Case 31 Healthcare acquired infection?

Mrs Sanderson is a 58-year-old lady with a long history of alcohol dependency. She presents to the medical take with a vague history of lethargy, malaise and nonspecific abdominal pain coming on over the last month or so. Her GP’s letter states that the main trigger for admission is a heightened level of concern amongst Mrs Sanderson’s family, most notably her daughter Jane who worries that Mrs Sanderson’s already chaotic lifestyle is now at breaking point. Dr Jennings, an ST2 in core medicine, clerks Mrs Sanderson upon her arrival in hospital.

Mrs Sanderson appears lethargic and malnourished but does not display any focal neurology. She admits to drinking approximately 200 units of alcohol per week, typically as wine. She last drank 14 hours previously. She complains of generalized abdominal tenderness but on examination, the abdomen is soft and nontender with normal bowel sounds. Mrs Sanderson is sweaty and a little tremulous. She is unsteady on her feet. Observations show that Mrs Sanderson is apyrexial with a blood pressure of 115/56 and a regular pulse of 92. The chest is clear and a small area of erythema is noted over Mrs Sanderson’s lower thoracic spine although the skin does not appear to be broken. The admitting nurse has undertaken bedside urinalysis which shows the presence of leucocytes and nitrites.

What is the differential diagnosis, what investigations would you arrange and what treatment would you institute?

Dr Jennings sends routine blood tests including inflammatory markers and orders a chest radiograph. The urine specimen is sent to the laboratory for microscopy, culture and sensitivities. Whilst waiting for the blood results, Dr Jennings prescribes intravenous Pabrinex® and benzodiazepines in view of the significant alcohol history and apparent malnutrition. She elects not to commence antibiotics in the absence of cardiovascular compromise or clear urinary symptoms.

Blood tests show elevated inflammatory markers (ALP and CRP) with a modest elevation in the white cell count with a neutrophilia. Tests of hepatic synthetic function are normal. In addition to the neutrophilia, the full blood count demonstrates a low platelet count and a normocytic anaemia (7.6 g/dl). Mrs Sanderson’s last recorded haemoglobin had been 10.3 g/dl (with a macrocytosis).

What further tests would you consider in relation to the anaemia?

Dr Jennings requests a blood film and haematinics. The next day, the urine specimen is reported as showing mixed growth and haematinics show reduced serum iron, increased ferritin and elevated total iron binding capacity. The consultant considers these results to be consistent with iron deficiency and orders an inpatient OGD (in view of the alcohol excess) to be followed by a CT colon examination. On day 2, Mrs Sanderson is less tremulous and gives a more coherent history. She continues to describe a generalized abdominal discomfort but is able to eat, drink and mobilize.

An OGD shows mild gastritis without varices. The CT colon examination is undertaken as an inpatient and it demonstrates a normal bowel but widespread disc destruction and established vertebral body osteomyelitis throughout the thoracic and upper lumbar spine. Blood cultures are taken which confirm the presence of an MRSA bacteraemia.

What should be done now?

Mrs Sanderson is commenced on intravenous vancomycin and has an echocardiogram performed which is normal. The Trust triggers the Serious Incident Requiring Investigation (SIRI) process in accordance with local and national guidelines. The bacteraemia is reported to the Department of Health through the Health Protection Agency.

A root cause analysis is undertaken locally which reveals a 24 hour admission to hospital four months prior to this presentation when Mrs Sanderson had fainted whilst shopping. Records show that she had been given two litres of intravenous saline whilst observed in the Clinical Decision Unit. No documentation was found in relation to the insertion or care of an intravenous cannula.

In respect of the current admission, minor procedural irregularities are noted in relation to a lack of cutaneous skin screening on admission in line with Trust policy. It is felt that the MRSA bacteraemia was probably acquired many weeks prior to admission, most likely related to the poor state of Mrs Sanderson’s skin and the pressure damage noted over the lower thoracic spine. However, the investigation team were unable to rule out a connection with the cannula inserted in the Emergency Department when she had been admitted after the faint.

Expert opinion

Although staphylococcal bacteraemia usually has an aggressive course and is associated with a high mortality, it can on occasion present much more indolently as on this occasion. The diagnosis was made fortuitously on account of Mrs Sanderson’s CT colon examination: this examination was only undertaken so quickly as she remained an inpatient for other reasons, and it could be argued that a conventional colonoscopy examination would in fact have been more appropriate.

The MRSA bacteraemia was investigated according to the formalized process put in place by the Strategic Health Authority as part of a national effort to reduce the burden of staphylococcal bacteraemia.

In this case, it may be that the hospital had nothing to do with the acquisition of the bacteraemia. The use of devices (intravenous cannulae, urinary catheters etc.) may well have been appropriate although there is a dearth of information on Mrs Sanderson’s brief admission with the faint. At best, failure to deliver care in accordance with the Trust’s own standards (MRSA screening on admission, poor documentation around cannula insertion) leaves an impression of suboptimal care.

Legal comment

As described in section one “negligence” is a breach of a duty of care. The doctors employed by the Trust will not be deemed to have acted negligently if they have acted in accordance with the opinion of a responsible body of medical practitioners, skilled and practised in that art.

In this case, whilst the root cause analysis has identified some aspects of the patient’s care which were in contravention of the Trust’s guidelines, even if staff had acted in accordance with the Trust’s guidelines, the outcome may still have been the same. Moreover, the Trust’s guidelines are only a guide to staff. Non-compliance is not necessarily evidence of suboptimal and negligent care. But if the Trust’s guidelines are evidence-based or a reiteration of national guidelines or professional protocols, this lends weight to an expectation that a doctor should act a specific manner, and unless there is a good reason, a failure to do so is outside of the accepted responsible body of professional practice.

Solicitors acting for patients will often request copies of the Trust’s guidelines or protocols as evidence of proper standards of care. The trend will continue as the National Institute for Health and Care Excellence makes further recommendations. Trust and national guidelines, however, while considered indicative of an accepted course of clinical practice, are not the benchmark for professional standards. Nevertheless, a clinical negligence claim pleaded on the basis that guidelines or protocols have been transgressed without good reason makes a strong case (Part 1, Section 1, Failure to follow protocols). But it should not be forgotten that before a patient is entitled to compensation, it must be proved that, on the balance of probability, the failure of the Trust staff to act in accordance with the guidelines was the direct cause of the patient’s injury. In this case it seems likely that the MRSA was acquired weeks before hospital admission and so the Trust would have a causation defence.

NHS Trusts are required to register with the Care Quality Commission and comply with CQC standards. Some of these standards relate to infection control. Executive directors and operational managers are responsible for ensuring that staff know what is expected of them and for ensuring that the Trust complies. By means of a risk register, the Trust can monitor any difficulties in implementing guidelines. If there are problems, an action plan should be devised to overcome them.

The Corporate Manslaughter and Corporate Homicide Act 2007 introduced a new criminal offence for public authorities. A named executive director may be guilty if it is found that he or she was a controlling mind in an organisation whose decisions have beyond reasonable doubt caused a death.

The standard of proof both for this offence and for manslaughter by medical negligence is high, and so convictions are infrequent.

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