I am grateful for the opportunity to update members on the actions taken by NHS Lothian in response to an infection incident at the Royal infirmary of Edinburgh.
On 19 March, NHS Lothian wrote to all patients who had aortic valve replacement operations in the six-month period between September 2018 and March 2019 to advise them of a low infection risk arising from their surgery. Those precautionary letters, which were sent to 186 patients, were triggered by the following events.
On 19 February, we were advised by Health Protection Scotland, through the normal channels, of a patient who had contracted a mould infection, who had undergone cardiothoracic surgery at the RIE. On 20 February, NHS Lothian established an incident management team to investigate the matter and set the healthcare infection incident assessment tool at red, due to the severity of the illness and public concern.
On 26 February, NHS Lothian followed that by, rightly, instigating a retrospective review of all patients over an 18-month period. From that exercise, 186 patients were identified for whom there was a low infection risk. Measures were put in place to contact those patients by letter and to provide them with contact information to use for any follow-up questions that they had on receipt of that letter. To date, a total of 26 patients who received letters have contacted NHS 24, of which 19 have been passed on to the board for further discussions. Additionally, information has been provided to local general practitioners and cardiologists about symptoms to be aware of and to give guidance on appropriate testing and onward referral, should that be needed.
On the infection itself, three types of mould infection have been identified, which have affected six patients. Sadly, some of those patients have died. No further cases have been identified since November 2018, but I know that the whole chamber will join me in offering our sympathy and condolences to the families and friends affected.
The three types of mould identified are Lichtheimia corymbifera, Exophiala dermatitidis and Aspergillus. None is commonly found in hospitals.
NHS Lothian proactively undertook an extensive investigation of the incident and, as it should, sought the help of Health Protection Scotland, which visited the hospital at the board’s request and is providing comprehensive expert support to it. The detailed investigation is being undertaken by the lead infection control doctor, together with NHS Lothian’s director of operations and its director of technical service. Health Protection Scotland has visited the wards and theatres involved.
A comprehensive question set relating to ventilation within the cardiothoracic theatres was devised by the lead infection control doctor and lead infection control nurse, with some additional questions from Health Protection Scotland. The response to those questions has satisfied the infection control team and the director of facilities that the ventilation within the theatres concerned is operating within the acceptable parameters for air pressure, air changes and air flow, and no concerns are noted relating to filters.
In addition, of course, NHS Lothian has taken the further steps that we would expect it to take to minimise the risk of further infection spread, including additional and specialised cleaning and environmental decontamination with hydrogen peroxide vapour in all relevant wards and theatres, a review of practice, and air and water sampling from both the environment and specialist equipment.
As a precaution, last week, four planned elective surgeries at the hospital were cancelled to allow for additional preventative measures to be implemented. On 26 March, elective operations recommenced in two of the four theatres, subject to the additional preventative work, and the other two theatres will be operational when the additional cleaning and air sampling and other measures have been completed. All patients whose operations were cancelled have now had their operations rescheduled over this week and next week.
I completely understand that this will have been a worrying time for the patients who have been contacted by the board. However, let me repeat that the board was right to undertake a review of cases and to inform the patients whom it identified as a result of that exercise. Those precautionary steps were the right ones to take, as they were designed to minimise risk and to provide a clear pathway for those with concerns to access services as easily and efficiently as possible.
This is the right time for me to say again that, in Scotland, we have learned valuable and wide-ranging lessons from the tragic experience at the Vale of Leven hospital more than a decade ago. It is important to recognise the significant improvements in patient safety that have been made and sustained in those 10 years. Healthcare-associated infection outbreaks are rare and, although it is important to respond when they occur and to recognise that they are of critical importance to the individuals and the families affected, such outbreaks affect a very small proportion of the 1.2 million in-patient and day cases that are treated every year in Scotland.
Following the introduction of the national infection prevention and control manual, the assessment, reporting and escalation of outbreaks is a far more robust process. Infection prevention and control teams undertake active surveillance of certain organisms and, therefore, can identify outbreaks after finding just one or two cases. As part of outbreak investigations, boards undertake active case finding to look for cases retrospectively and prospectively. The current precautionary steps that NHS Lothian is undertaking resulted from an extensive review of the records of thousands of patients who have had many different types of surgery carried out since the beginning of 2015. That demonstrates that NHS Lothian is taking a rigorous approach to ensuring patient safety.
Overall, NHS Lothian has a strong record. Figures published on 12 February this year show that, over the four-year period from January to March 2014 to July to September 2018, the board’s hospital standardised mortality ratio fell by 2 per cent at the Royal infirmary of Edinburgh, by 10.4 per cent at the Western general hospital and by 13.6 per cent at St John’s hospital.
In addition, since 2014, there have been steady reductions in the rates of staphylococcus aureus bloodstream infections and Clostridium difficile infections in NHS Lothian. With regard to infections that are associated with caesarean sections and hip arthroplasty, NHS Lothian’s performance is on a par with that of the rest of Scotland. Since 2007, there has been a 98 per cent decrease in positive results for MRSA from testing, which compares well with the 93 per cent decrease in Scotland overall.
Clearly, we can improve processes to make our hospitals as safe as they can be, which is what the Scottish public have every right to expect. As my colleagues on the Parliament’s Health and Sport Committee noted recently, there are lessons for us to learn from recent incidents in NHS Greater Glasgow and Clyde, particularly about the importance of robust communication between infection prevention and control teams and estate staff. Such communication is particularly important during maintenance or repair work on the NHS Scotland estate, when extra control measures need to be put in place to reduce the risk of infection.
When I updated Parliament on 26 February, I announced that I had commissioned an independent review to look at the design, build,
“commissioning, construction, handover and”
on-going
“maintenance of the Queen Elizabeth university hospital and how such matters contribute to effective infection control.”—[Official Report, 26 February 2019; c 10.]
In order to ensure appropriate membership of the review committee, the independent chairs of the review, Dr Brian Montgomery and Dr Andrew Fraser, have been taking advice from experts on who will be best able to contribute, as well as analysing and reflecting on the work that has been done to date. From that, they will determine the review’s precise remit and the resources and support that will be required. We expect the independent chairs to consult on a draft remit shortly.
In addition, we are strengthening the roles that individual NHS Scotland infection prevention and control team members play and the expert service that they provide. Next week, to provide further reassurance on the efficacy and robustness of our approach, our chief nursing officer will meet board healthcare-associated infection leads to reinforce their responsibilities with regard to infection prevention, emphasising the mandatory surveillance requirements contained in the national infection prevention and control manual and ensuring that boards have local mechanisms in place to implement the manual reliably and sustainably.
I recognise that no patient wants to receive a letter similar to those sent by NHS Lothian last week, but I hope that what I have outlined today provides reassurance that such letters form part of a proactive and precautionary infection control and risk management system here in Scotland. Not all healthcare-associated infections are preventable, but we have dedicated professionals and a rigorous system, focused on limiting and controlling them. The system is alert to potential infection risks and how to assess and manage them and consistently looks to improve.