28 February 2008

Shooting in the dark

As Dr Grumble arrived at work yesterday he bumped into Mr Pilkington in the car park. Mr Pilkington is a surgeon and arrives early, usually well before 07.30, and it's only on Fridays when the traffic is least heavy that Dr Grumble arrives at the same time. Yesterday Mr Pilkington was clutching five recently laundered white coats. "I hope you're putting those in the bin," joked Dr Grumble. White coats have, of course, been banned. Mr Pilkington is clearly not going to take any notice. He muttered something about the rot setting in when the hospital laundry closed. There's nothing new about any of this. White coats have always been fomites.

Dr Grumble is following the gallimaufry of new rules. As winter sets in, he has had a few comments about his short sleeved shirt. Hospitals tend to be hot but not consistently so and there have been times when Dr Grumble has shivered in his new attire.

The lifts in Dr Grumble's hospital are inadequate to say the least. Dr Grumble climbs the ten flights to his office each morning and on his way up he bumped into Dr Davey, a gastroenterologist. Dr Davey commented that Doc G had no tie. Ties too are now banned. Dr Davey is plainly another one who is not exactly content with the new dress code for doctors. Nor is Professor Parrot. Mr Bozek, a urologist, has even wondered if it is just another way of clipping the wings of doctors. Why the government is out to get doctors is puzzling. If you want to make the NHS the focus of an election campaign you ought to keep doctors on side. The public still trusts doctors.

There are many other workplaces where staff have to keep scrupulously clean. Dr Grumble has visited some. If, for example, you visit a pharmaceutical manufacturing plant you will be given a place to change, a locker and pristine white overalls. This is what Dr Davey says he needs for his endoscopies. Dr Grumble also performs endoscopies. When he was being trained he used to change into greens. There was a changing place and a locker. Now he just has a plastic apron. Some of the cases are highly infectious. Dr Davey wears his suit trousers and puts on a green top. He changes in the toilet. There's nowhere to put his valuables. In this garb he does 'topping and tailing'. In other words he pokes instruments down peoples' gullets and, well, up the other end. It's not, to Dr Grumble, pleasant work but Dr Davey probably enjoys it. It's not, by its very nature, clean work. Faecal material abounds. Some of it very probably occasionally gets onto Dr Davey's trousers. And then he goes to the ward and at the end of the day home to his newborn baby. It's not nice.

There seems to be a concerted campaign to blame doctors for MRSA and C. difficile. But how much is the government to blame? Who took away the ready provision of clean white coats? Surely contaminated clothes should stay in the hospital and be washed there and not taken out into the community? And who forced doctors to do safari ward rounds trekking from ward to ward because there was never enough flexibility to accommodate patients on the right ward? And who shoehorned extra beds into already crowded wards? And who is responsible for there being too few side rooms so that patently infectious cases cannot be easily isolated? And who is responsible for Dr Davey having to change in the toilet and wearing his suit trousers while dealing with faeces? And who is responsible for beds occupancy being so high that many beds have more than one occupant in 24 hours? If you were looking for a way to spread infection you couldn't find a better one. Skimping and cost cutting is costing us and our patients dear.

The solutions proposed by Gordon Brown's man at the ministry are about as effective as blowing against the wind. Dr Grumble wonders what evidence there is for them. He's not alone. Here's what the Lancet says:

So, on what basis did the Health Secretary make his recommendations? The working group resorted to “informed common sense”—a level of evidence just above guesswork.

Hospital infections are an important issue. We shouldn't be solving them by shooting in the dark.

This post was first published on 29th September 2007. Dr Grumble was concerned at the time about the government's silly initiatives tending to focus the blame for hospital infections on doctors. Since then we have had an even sillier initiative - the ludicrous deep cleaning that is costing us a small fortune. There are indications for deep cleaning but generally dirty hospitals is not one of them. They just require proper cleaning. The post has been republished to coincide with the latest news on C difficile deaths. The news is not good.

1 comment:

PhD scientist said...

Oh dear (the C Diff reports) - really not looking forward to my parents getting old and frail.

I'm sure we went through all this the last time this post was up, but the no ties, bare to the elbow, alcohol gel and deep clean all sound like the wrong emphasis, as you imply.

Is it just distraction tactics, do you think, Dr G? The "conversation" is not to be about the bigger systemic problems (see below), so a nice sounds-bite friendly cosmetic solution and some catchy phraseology will do?

From listening to my various medical cronies I had "hoisted in" the following collection of comments /suggestions on this sort of topic:

More space (reopen closed wards?) to get beds further apart and allow more (relative) isolation. Reduce bed occupancy. More ward staffing to get sick old folk to the commode in time when needed.

And for the doctors.. (cf endoscopy):

Uniforms. Laundries. Changing rooms.

As we have previously commented, this stuff would not be allowed in Dem Vaterland.