Childcare and Social Services.

[Fiona]

This is how such questions are dealt with scientifically. The scoring systems do not rely on experts to administer, trained staff do this more consistently.

Well I think you better tell NICE then

[Fiona]

As for identifying apriori who will be damaged. Cannot be done ever I hope: what a world it would be if we could accurately predict psychological intactness according to a formula.

My point exactly: can't be done

But developing and testing questionnaires for teachers/SW/parents etc to identify children likely to be suffering from depression/anxiety/ADHD/etc: no reason that should be impossible

No reason at all. Still unethical to administer them without parental consent, however. Don't see how it helps in any case. People get anxious and depressed for an awful lot of reasons.

[seren]

OT: I heard someone today refer to NICE as the National Institute for Cock-ups and Excuses.

The other day I rang them about a technology they should know about and they claimed complete ignorance of it. It appeared they were looking at their own website to find information- which of course I had already done. You're not a NICE bod, are you, Pebble? I don't mean to offend....

[Pebble]

Selecting out the statements that you agree with is not the same as assesing the evidence and determining whether in toto the recommendations reflect your preconceived ideas:

Control precautions (all Category 1b)
Action to be taken on identification
of a case of VISA/glycopeptide-intermediate
S. aureus (GISA) or VRSA

e

The laboratory should immediately notify the relevant

clinician and infection control personnel.
e

The infection control team should immediately

identify where the patient is and where the patient
has been during all of the current admission,
including transfers from other healthcare
facilities.
e

The relevant national surveillance organization,

e.g. Health Protection Scotland, Health
Protection Agency in England and Wales, and
the Health Protection Agency (Communicable
Disease Surveillance Centre) in Northern Ireland,
should be notified.
If the patient is still an inpatient
e

The number of healthcare workers caring for

the patient should be reduced. This will cause
problems for those who are allocated to care
for the patient. These healthcare workers will
need support.
e

Healthcare workers with chronic skin conditions,

e.g. eczema or psoriasis, should not be
involved in direct care of the patient.
e

All staff caring for the patient should be made

aware of how the organism is transmitted and

the precautions necessary to prevent this.

e

The patient should be cared for in a single room

with toilet facilities and a wash hand basin.
e

The patient and visitors must understand the

need for isolation.
e

Fans should not be used to control the patient’s

temperature.
e

Appropriate infection control procedures

should be implemented:
1. Standard precautions should be used.
Gowns/disposable aprons and disposable
gloves should be worn by all those entering
the patient’s room. Clean, non-sterile
gloves and gowns/aprons are adequate.
Consideration should be given to use of theatre-
style greens in addition to protective
clothing to ensure that healthcare workers
do not take uniforms home to launder.
2. Disposable masks and eye protection should
be worn by carers for procedures likely to
generate aerosols/splashing. Use of closed
suction systems will help to reduce
aerosols.
3. Hand hygiene should be performed with
an antibacterial preparation before and
after patient contact. Visibly soiled hands
should be washed with soap prior to
disinfection.
4. Non-disposable items that cannot be easily
cleaned or disinfected (e.g. sphygmomanometer
cuffs) should be dedicated for use
only by the infected/colonized patient.
5. Patient charts and records should be kept
outside the isolation room.
6. Linen should be treated as infected. It must
be discarded into alginate bags within the
patient’s room and a secondary bag outside
the room.
7. All waste should be discarded into a clinical
waste bag inside the room, and bags should
subsequently be disposed of according to
hospital policy.
8. Transfers of colonized/infected patients
within and between institutions should be
avoided unless essential, and the receiving
institution should be made aware of the patient’s
colonization/infection status prior to
transfer.
9. After discharge, the room in which the patient
was cared for should be cleaned according
to local disinfection policy, with
special attention given to horizontal surfaces
and dust-collecting areas. Hot water
and detergent are usually satisfactory. Curtains
should be changed.
10. Compliance with infection control procedures
should be monitored.
Screening (all Category 1b)
Patients
e

Nose, axillae, perineum, skin lesions and manipulated

sites of the index case and all other
patients in the unit should be screened for carriage
of VISA/GISA or VRSA.
e

The infection control team should review the

admission history of the patient and determine
if screening needs to be extended to other
areas and other units alerted.
Staff
e

Agreement with staff on the need for screening

should be sought.
e

Nose, axillae and perineum of healthcare

workers and others with close physical contact
with the case should be screened for carriage
of VISA/GISA or VRSA.
e

Healthcare workers who maintain contact

with the patient will require weekly screening.
This may require significant support for
these staff.
e

Feedback of results and maintenance of confidentiality

should be considered.
Eradication (all Category 1b)
e

Eradication of colonization/carriage of patients

and healthcare workers should be attempted
(see section on eradication of MRSA
carriage).
e

Colonized staff should be excluded from work
until eradication of carriage is achieved.

That is why it is called a package!

The point I was trying to make, is that the very arguments you are advancing to assert that SW is beyond research methodology has been rehearsed adnauseum in this setting. No single aspect of the package outlined is defensible in isolation, but the package of measures has been shown time and time again to work. Further if the education drive, resporting mechanisms and policing of the package of care slips as has been shown to occur if left to the local staff, then infection levels rise again.

[Pebble]

OT: I heard someone today refer to NICE as the National Institute for Cock-ups and Excuses.

The other day I rang them about a technology they should know about and they claimed complete ignorance of it. It appeared they were looking at their own website to find information- which of course I had already done. You're not a NICE bod, are you, Pebble? I don't mean to offend....

Nope! Not attempting to defend NICE at all, but even they sometimes get it right! The concept is correct, its execution leaves an awful lot to be desired (e.g. alzheimer's treatment)

[Fiona]

Nope! Not attempting to defend NICE at all, but even they sometimes get it right! The concept is correct, its execution leaves an awful lot to be desired (e.g. alzheimer's treatment)

Model on NICE for medicines.

The point I was trying to make, is that the very arguments you are advancing to assert that SW is beyond research methodology has been rehearsed adnauseum in this setting. No single aspect of the package outlined is defensible in isolation, but the package of measures has been shown time and time again to work. Further if the education drive, resporting mechanisms and policing of the package of care slips as has been shown to occur if left to the local staff, then infection levels rise again.

And the point I was trying to make is they have re-invented the wheel. You don't do complexity, do you Pebble?

Only in the past 5 years has research shown clearly how attention to hand washing and other hygeine measures combine to virtually abolishe hospital acquired infection.

That is not true according to the links you yourself provided. I was not quoting the bits I agree with. I was quoting the bits which show that hygiene in hospitals is important, as has been known for more than 100 years: and the bits which showed that other factors such as staff shortages and overcrowding are also important; as I said and as you did not. And we do not need research to know this because it is already known. By the average 10 year old actually. it is no wonder I am not persuaded by your approach, Pebble. First you did not support your assertion with any evidence at all: then the evidence you do post does not support what you say. It supports what I say: that you can put in a package of measures, without evidence if you already know the answer.

I have been reading back over this thread. I notice you don't actually answer any questions. It annoys me, so I am going to ask some again

1. How do you suggest a social worker should determine which child is at risk or is being abused?
2. What do you think should be done with a referral such as that made by the doctor in my example?
3. Which independent observer do you think should judge whether statutory measures are required if not the court?
4.. Are you indeed such a selfless person that the threat of losing your job would make precisely no impact on your decision making?
5. Do you really believe that the police got convictions solely on the basis of confessions and intuition before recent innovations in techonology?
6. Do you think that the over-representation of black people in stop and search figures is a good thing? And if not, why not?
7. Do you or do you not accept that the diagnosis of ADHD and the prescription of ritalin should only be done by a child psychiatrist or a paediatrician with expertise in ADHD, as NICE says?
8. Can you consider the possibility that NICE is a monumental waste of money? That in fact it is not science based, but rather a marketing and cost control body ?
9. do you understand that in the question I posed it is not a question of whether poverty or drug misuse is the confounder, only?

In any given family there may be poverty, drug misuse of one or both parents, single parenthood, alcohol misuse by another family member. domestic violence. sibling abuse. sexual abuse, alcohol abuse, social isolation, poor housing, bullying, learning difficulties which may be situational or innate, poor hygiene, criminality, and on and on and on. Your immediate idea of investigating two issues is silly, Pebble. Folk are just more complicated than that. Even if you can sort out all of those things you will still find that some children are abused and some are not: some are resilient and some are not.

Can you see why I do not see you as very scientific? You opened with blind prejudice and a great deal of ignorance and so far as I can see you have spent the rest of the time defending you profession. I have done the same but you attacked social work on no information whatsoever: I at least attack your profession from some basic experience. Far from being able to make progress in the way you suggest I honestly believe you would take us further and further from reality. Some things just are not science

[Pebble]

[quote=Pebble;31162]My worry with Govt. invovlement is that the imperative to do something, leads to actions that are not evidence based. Yes we know there are problems, many opinions exist as to the best solution but the evidence for what is effective is so limited that this cannot be parcelled up into an adequate package for action, so 'experts' opinions are relied upon. Solutions are agreed upon and become the new orthrodoxy, what is not done is to rigourously identify that which is proven, that which appears supported by objective observation, that which is one of many competing theories that could fit with the available observations and that which is pure guess work. Further, we are interefering with personal freedoms here, we must at the very least set up a progam that will challange the assumptions we are making to determine which are subsequently supported, which are not, and to ruthlessly root out the junk opinions.quote]

It supports what I say: that you can put in a package of measures, without evidence if you already know the answer.

Here exactly is my point: indeed the point I started with. Of course the package is comprised of commonsense measures. The impact of applying these measures then must be studied. Over time one can root out that which is unnecessary and identify further additions required to enhance efficacy. This can only be done when one has standardized practice, and identified those aspects that meet minimum criteria for inclusion in the package. For many years individual aspects of the 'common sense' approach have been tried and failed to significantly impact the infection rate. Only having studied the impact of implementing the packages as whole units could it be demonstrated that outcomes improved, and that it was worth in effect forcing staff to accept external direction and policing of their behaviour on a day to day basis to bring about improvement. The worry I started with (predjudice to use your words) is that simply applying the 'common sense' approach without then studying the outcome is where danger lies: whose common sense? based on what belief system? what evidence?

I have been reading back over this thread. I notice you don't actually answer any questions. It annoys me, so I am going to ask some again

1. How do you suggest a social worker should determine which child is at risk or is being abused?

That would be specultation; I am not against use of a common sense approach; I only insist that its elements should be codified and tested to measure the level of efficacy achieved by and given approach. So that comparisons can be made, and false theories debunked.

2. What do you think should be done with a referral such as that made by the doctor in my example?

More speculation. I do not know the details of the case, and am not a gynaecologist. As a guess vaginal bleeding is uncommon in 9 year old girls. But presumably she could be starting puberty. So that would be the first thing to establish.

3. Which independent observer do you think should judge whether statutory measures are required if not the court?

Courts have a rather limited remit. Fine for individual cases, but in the long run you must continually gather data to confrims or refute the efficacy of your care approach. Such data must be analysed independently somewhere along the line, since we all tend to believe our own data.

4.. Are you indeed such a selfless person that the threat of losing your job would make precisely no impact on your decision making?

No. But I would be extremely loathe to ever use my tenure as the explanation why I would or would not do something. If I get to that point, then I no longer believe in the system I am working for, and will try to change it.

5. Do you really believe that the police got convictions solely on the basis of confessions and intuition before recent innovations in techonology?

Finger printing is not exactly new. A couple of hundred years ago confessions were held to be the highest level of evidence, however extracted. While the development of policing methods led to analyzing whether someones confession/withness statements fitted with known facts. I think most would agree that confessions remain central to police work even today. Not my area of expertise so I shall say no more. If you have evidence otherwise, please produce.

6. Do you think that the over-representation of black people in stop and search figures is a good thing? And if not, why not?

Not sure where this comes from: you presumably think I am a racist!

7. Do you or do you not accept that the diagnosis of ADHD and the prescription of ritalin should only be done by a child psychiatrist or a paediatrician with expertise in ADHD, as NICE says?

Yes and No. I think the area is sufficiently difficult and the longterm effects of widespread use of ritalin insufficiently understood, that more work is required to know if on balance it's long term use is justified. If it worked, and the population it worked on can be identified by a check list of symptoms and behaviours, and less highly qualified people can be shown to administer these assessments more rigorously than psychiatrics and paediatricians. Why insist on them making the diagnosis, if in that senario others have been shown to do it better.

8. Can you consider the possibility that NICE is a monumental waste of money? That in fact it is not science based, but rather a marketing and cost control body ?

Is NICE too expensive - Yes. Is it objective - No. Is it consistent - No. Is it a COMPLETE waste of money - No. Again the package approach. It is clear that many treatments used by the medical profession are a waste of time and money. Some one must codify and determine what is useful and what is not. This must be done in a co-ordinated fashion, because spending money on one treatment reduces available time and money for other treatments. Further the huge variations in access to quality care giving the best outcomes cannot be tackled by a piecemeal approach. NICE certainly needs to leard lessons from its behaviour to date. But the fundamental concept is wholly justifiable.

9. do you understand that in the question I posed it is not a question of whether poverty or drug misuse is the confounder, only?

I never suggested that it was the only confounder. Merely using the pair as a method to demonstrate how one approached confounders. Your then give a list of confounders. To suggest that the presence of counfounders puts things beyond scientific enquiry is just mad. The same argument has been put to suggest that double blind trials are useless because there are so many differences between individual patients, how can you allow for all those effects? Randomisation!

Can you see why I do not see you as very scientific? You opened with blind prejudice and a great deal of ignorance and so far as I can see you have spent the rest of the time defending you profession.

What profession?

I have done the same but you attacked social work on no information whatsoever:

What attack?

I have shown my original position for reference.

[Pebble]

I know who Lister is, thanks. He continued with the carbolic spray for a long time before he accepted that cleanliness in hospitals did the same job far better.




Ditto

You obviously have a different information source on Lister than I do:

http://web.ukonline.co.uk/b.gardner/Lister.html

"Having tried methods to encourage clean healing, with little, or no success, Lister began to form theories to account for the prevalence of sepsis. He discarded the popular concept of direct infection by bad air and postulated that sepsis might be caused by a 'pollen-like dust'. Although, there is no evidence to suggest he believed this dust to be living matter he was close to the truth."

"When, In 1865, Louis Pasteur suggested that decay was caused by living organisms in the air, which on entering matter caused it to ferment, Lister made the connection with wound sepsis.
A meticulous researcher and surgeon, Lister recognized the relationship between Pasteir's research and his own. He considered that microbes in the air were likely causing the putrefaction and had to be destroyed before they entered the wound."

"Although his methods initially met with indifference and hostility, doctors gradually began to support his antiseptic techniques.
In 1870 Lister's antiseptic methods were used, by Germany, during the Franco-Prussian war saving many Prussian soldier's lives. In Germany, by 1878, Robert Koch was demonstrating the usefulness of steam for sterilizing surgical instruments and dressings."

"German surgeons were beginning to practice antiseptic surgery, which involved keeping wounds free from micro-organisms by the use of sterilized instruments and materials."

"A simple operation of wiring a fractured kneecap, entailing deliberate convertion of a simple fracture into a compound fracture, often resulted in generalised infection and death. On October 26 1877, Lister, for the first time, carried out the operation under antiseptic conditions."

Doesn't sound to me like some one who was against cleandiness!

Where is you information from?

[Fiona]

Ok, Let me have a look at your original statement, because it raises some good questions

[quote=Pebble;31517]

My worry with Govt. invovlement

If you do not think Government should be involved in child protection who do you think should be involved instead? Where do you think the money should come from, if not from taxation?

is that the imperative to do something, leads to actions that are not evidence based.

This is exactly what happened in the hospital hygiene issue, as shown in the links you posted. The actions taken were not based on evidence, as the report repeatedly states. The evidence of effectiveness was post hoc, only. Having said that, I repeat that the measures taken were effective because the answer was already known. You say that common sense knowledge must be tested, and of course that is true if it is nothing more than common sense: but in this, as in many cases, the common sense was underpinned by more than 100 years of clinical experience. The effectiveness of good hygiene in controlling infection was established in exactly the same way as has now been done again: by showing that it works.

The role of this "research" is two-fold. 1. It provides a fig-leaf for those who caused the problem, by implying that their decisions were reasonable and could not have been predicted to lead to an increase in hospital based infection, because the knowledge was not there: this is a lie. 2. It places the blame on hospital staff for a lack of personal hygiene, though it clearly shows that many factors are involved: for example lack of handwashing facilities; shortage of staff; inadequate cleaning etc etc etc. All of those are the result of ideology and cost/benefit analyses carried out by people who know nothing of the complexity of the organisation and who are ultimately driven by the bottom line of a balance sheet. Cost/benefit analyses do not have to be like that, but they very often are.

The research was not undertaken by impartial researchers unaffected by politics or ideology: it was done because the rates of hospital acquired infection were so shockingly high that they could not be denied: something had to be done, indeed. And whatever was done must not demonstrate that policies held to be sacrosanct were in fact disastrous. The researchers were used by interest groups in exactly the same way as social workers, so far as I can see.

Yes we know there are problems, many opinions exist as to the best solution but the evidence for what is effective is so limited that this cannot be parcelled up into an adequate package for action s so limited that this cannot be parcelled up into an adequate package for action, so 'experts' opinions are relied upon. Solutions are agreed upon and become the new orthrodoxy, what is not done is to rigourously identify that which is proven, that which appears supported by objective observation, that which is one of many competing theories that could fit with the available observations and that which is pure guess work. Further, we are interefering with personal freedoms here, we must at the very least set up a progam that will challange the assumptions we are making to determine which are subsequently supported, which are not, and to ruthlessly root out the junk opinions.

Unlike hospital hygiene the solutions in child protection are not already known, so you are right. Let me accept what you appear to be saying: let us shut up shop until research can give us a "package of measures" which are evidence based. Let us imagine that we work together to do that. Where shall we start? Well you say we know there are problems. perhaps we should start with defining them. So let us define child abuse. Since, as you so rightly said, this is culturally determined, it changes all the time. But I am sure that a good researcher can come up with a definition we can all accept, which will remain consistent over time, and which can be objectively measured.
So assuming we can do that, we now need to consider the scale of the problem, do we not? Oddly this has also proved quite intractable to research. For example, most of us would at least agree that where someone deliberately kills a child, that is evidence of child abuse. And a lot of effort goes into determining cause of death when someone dies unexpectedly: and those figures are recorded. So there should not really be a problem at least in this most objective of areas. Yet it seems that there is.

http://www.nspcc.org.uk/Inform/resea..._wda48218.html

http://www.unicef.at/fileadmin/medien/pdf/repcard5e.pdf.

Never mind, I am sure we an solve this for both child deaths and whatever other things we include in our objective definition of child abuse, once we get it. Of course there are problems with statistics too.

http://www.jimhopper.com/abstats/#s-intro

But we are all aware of those, so we should be able to solve them quite simply: especially since we will be completely free of pressure from those who pay our wages while we do this, won't we? And from the media when bad cases of child abuse come to light: we will just explain that we cannot do anything cos we are busy making an evidence base, and it would be wrong to act till we have it. I think you will have to be the person who explains this to them: I, as a social worker, have conspicuously failed to convince either group: but researchers are so much better at this.

So we have an agreed definition and we have found out the scale of the problem. Let us get to the real meat and decide on what to do about it. Of course we could decide we should not do anything at all: but let us suppose that that is not what society wants, for the moment. Let us suppose they would like child abuse to stop. Well prevention is better than cure so we need to research all the factors which contribute to make a person abuse a child. What might we look at? Well previous research gives us some clues: first, and most importantly perhaps, we should abolish poverty. That is apparently the most effective measure we can take. Mental illness is another biggy so we better ensure that adequate resources go into that too. Drug and alcohol misuse are implicated so we have to make sure those problems are dealt with. Poor housing is a problem so the housing stock will have to be radically improved. Parents who have themselves been abused are more likely to abuse so we need to find ways of identifying them and then provide evidence based therapy for all who need it. Criminality is also a factor so we need to put resource into crime prevention, and marital breakdown is a problem so we need to support people to stay together...oh wait - domestic abuse is also known to be a very big indicator so ....well we can sort that out with therapeutic interventions I am sure. Once we have done all that and of course addressed all the other factors which have a bearing we can evaluate the effectiveness of all this: and we can do a cost/benefit analysis to see if it is all worthwhile.

I am going to take a wild guess here: I do not think society will want to spend all this just to prevent child abuse. Call me cynical.

So what else can we do? Well we can accept that all those things are the most important factors in child abuse but leave them as they are. So we conclude that a certain amount of child abuse is to be expected and leave it at that. That is the rational thing to do. For myself, I do not think society is going to be very comfortable when they are told that children who die in plastic bags in bath tubs are the choice they have made, but, again, you can explain this properly. Good luck with that. We can still act after the fact and jail the perpetrators if we can find them. Of course we do not know about most child abuse: and where a child dies in the home it is often not possible to say who did it: but that is true of most crime and we live quite unhappily with the fact. This is no different.

But I do not think society will be very happy with that either, somehow. I suspect they will want "something to be done". So what is left? Well we know that even in the most adverse circumstances (ie when suffering from some or many of the factors we have identified as risk factors) some people abuse their children and some people don't. We agreed earlier that we cannot predict which ones, however, so that is not a lot of help. If we could then we could set up a research programme. We could try things which might help (as the hospitals did with hygiene) and we could evaluate which of those things were effective. But we have a problem. We have to respect individual liberty. If we did not have that constraint then we could specify criteria and identify all the people with some or many of the risk factors we have so painstakingly identified: and we could make them undergo whatever we think might be effective ( with proper hypotheses and theoretical bases and pilot studies and anything else research finds necessary); we could randomly assign them to to those different programmes; and we could evaluate the outcomes and see which ones were "effective" ( after we have identified what "effective" means, of course). And we would know what works best and we could do that. Better, we could make everybody go through those programmes, again randomly assigned: that would give us a much bigger data base. I like it!!
But there is individual liberty, thank dog, so we cannot do that . And without that we have no way of judging what is effective, because we do not know which people are going to abuse children.

So what if we just take people who have already abused children? Even though we cannot identify the vast majority of them we do identify some. Course some of them are in jail; and some are subject to pesky legal orders which prevent them from going near any more children. But there are some who are not so constrained. Perhaps we could have a new law akin to a drug treatment order whereby they are allowed to live with children so long as they participate in our programmes? Then we could measure how many on which programmes abuse again, and that would tell us what is "effective". Hmmm. Our programmes are only going to take up a wee part of the day. How will we control for variables outside those programmes? This is a problem because our sample is going to be very small indeed, especially since there are so many forms of abuse and we have no idea what significance those differences have: so we will need to randomise all the different forms across all the different programmes:and the factors in play vary such a lot too: if one in the drug-misusing/paedophiliac/single parent group gets clean that could really distort the results. Well perhaps we can do this time and again over a very long time? No that won't work either, I fear, because external circumstances change a lot over 20 years.

Sorry I am stumped. But then I am not a researcher. I am sure you can think of much better ways to do this. Meanwhile I will get on with my job :)

[Fiona]

As to Lister: he pioneered antisepsis but he was not involved in the development of asepsis. I am unable to find my original source but these illustrate my point. Lister used the carbolic spray and it was reported that he did not think asepsis was particularly important for a long time

http://www.bookrags.com/research/ant...a-scit-051234/

By 1880, based on the work of Lister, infections and particularly post-surgical infections continued to decline. Within a generation antisepsis was refined to asepsis, meaning the absence of harmful organisms. Asepsis is achieved mainly through [COLOR=#67AD06 ! important][COLOR=#67AD06 ! important]sterilization[/COLOR][/COLOR]. German physician Ernst von Bergmann (1836-1907) made a major breakthrough in asepsis when he introduced steam sterilization of surgical instruments in 1885.

http://www.questia.com/library/encyclopedia/surgery.jsp

The Birth of Modern Surgery
With the introduction of antiseptic methods, surgery entered its modern phase. Louis Pasteur established the fact that microbes are responsible for infection and disease. Using this knowledge, Dr. Ignaz Semmelweis reduced postpartum infections (puerperal sepsis) in the wards of Vienna's lying-in hospitals by urging doctors to wash their hands between patients. In the 1860s Joseph Lister introduced the use of carbolic acid as a cleansing and disinfecting agent, and his results in reducing infection were dramatic. It was found later that the carbolic acid spray that Lister used to cleanse the air about the patient was unnecessary, but the antiseptic treatment of instruments and other articles in contact with the patient continued until antisepsis was gradually replaced by the aseptic methods employed in modern hospitals. Before the discovery of antisepsis by Lister, about 80% of surgical patients contracted gangrene.
Ernst von Bergmann is credited with introducing steam sterilization under pressure for treating instruments and all other medical equipment used for a surgical patient. William Stewart Halsted, the famous surgeon at Johns Hopkins Hospital, introduced sterile rubber gloves when the hands of his fiancée became irritated from constant washings and antiseptics. The development of methods of anesthesia, especially the discovery in the 1840s of the value of ether, has also been of immeasurable value.

[Pebble]

As to Lister: he pioneered antisepsis but he was not involved in the development of asepsis. I am unable to find my original source but these illustrate my point. Lister used the carbolic spray and it was reported that he did not think asepsis was particularly important for a long time

[/LEFT]

The more I read about this chap the more I think those criticizing him are missing the point. He may have built on the German work on asepsis, and may have quite rightly realized that asepsis on its own was not suffieicnt for safe surgery, but to say that he was against asepsis seems entirely unfounded.

http://www.fullbooks.com/Beacon-Ligh...lume-XIV6.html
Listerism has been unjustly alleged by
a few to be unworthy of the appreciation in which it is held by the
great majority of medical men of all countries; simple cleanliness, it
has been urged, is quite as efficient as the full Listerian precautions.
This is begging the question, for simple cleanliness, "chemical
cleanliness," is all that Listerism purports to accomplish. The use of
antiseptics has been decried in the interest of asepticism, as if the
whole purpose of antisepticism were not to secure asepsis. Lord Lister
is entitled to the full credit of establishing the aseptic surgery of
the present day, in spite of the facts that his doctrine followed rather
than preceded his early improvements, that aseptic procedures have been
brought nearer perfection elsewhere than in his own country, and that
the whole system rests on foundations laid by Pasteur.


http://campus.udayton.edu/~hume/Lister/lister.htm

Here Lister was able to spend more time teaching as well as furthering his research. Lister was not always met with complete acceptance and had to train his colleagues as well as the nursing staff in Edinburgh to his new methods. The nursing profession was improving a great deal at this time with the work of Florence Nightingale and her schools, however the surgeons and other physicians were set in their ways. They saw Lister's excessive cleanliness and particularly his carbolic acid sprays during surgery as a waste of time and effort. The spray burnt their hands and eyes, and cleaning tools and linens a wasted effort.
Lister did not only continue to change and experiment with new methods of asepsis, but had other influences as well.

In January 1860, Joseph and Agnes moved to Glasgow where he was appointed Regius Professor at the university there. Lister was met by extreme filth and unfavorable conditions in his wards in Glasgow, and lack of cooperation from his colleagues in keeping the area clean. Lister had noticed in Edinburgh that keeping the area clean seemed to decrease the risk of infection, although he had no answer for why this made a difference.

As to your longer reply, that will take a little work, but I think we are beginning to address the same issue rather than parallel ones now.

[Fiona]

I am not criticising him, Pebble. I made an aside that he did not at first accept the importance of general cleanliness, as is perfectly understandable. He accepted the subsequent work which showed this and also the new techniques of sterilisation etc.

[Pebble]

Lister used the carbolic spray and it was reported that he did not think asepsis was particularly important for a long time



[/left]

That looks fairly critical to me!

[quote=Fiona;31555]

If you do not think Government should be involved in child protection who do you think should be involved instead? Where do you think the money should come from, if not from taxation?

Not what I said. I expressed my concern that govt. often failed to follow through with the necessary validation of their action.

This is exactly what happened in the hospital hygiene issue, as shown in the links you posted. The actions taken were not based on evidence, as the report repeatedly states. The evidence of effectiveness was post hoc, only.

The actions taken could not be fully underpinned by the highest quality of evidence, but were strongly supported by the evidence accepting that any individual aspect was open to criticism as not fully validated. Not the same as your oversimplification.

The effectiveness of good hygiene in controlling infection was established in exactly the same way as has now been done again: by showing that it works.

Not what the MRSA report says. Yes hygiene important but insufficient:

[FONT='AdvTrebu-R','serif']

[/font]
Fidteen full publications between[1982 and 2002 were adduced by the Societyof Healthcare Epidemiology of America (SHEAR','serif']Working Party 26,40,42,87, 98 in support of the value[/font]
]of active surveillance]85, 91 ]Several of these reports[/font]
[provided particularly significant additional[/font]
[information. Jernigan et al. demonstrated a 15.6-[/font]
[fold reduced rate of transmission (95% confidence[/font]
[interval 5.3 - 45.6, P <0.0001) from patients who[/font]
[were known to be MRSA carriers by surveillance[/font]
[cultures compared with those whose screening results[/font]
were not available.[/87 Later re-analysis of the[/font]
data showed that the effect was similar if patients[/font]
[who were only colonized with MRSA were studied[/font]
[relative risk 11.9, 95% confidence interval 3.25
-47.5, P< 0.00014).[

or

[]Secondly, on a Dutch ICU, Vriens[/font]
[et al. ]found a 38-fold greater rate of transmission[/font]
[]from unisolated unknown positive patients nursed[/font]
[]with universal precautions compared with identified[/font]
isolated positive patients cared for with[/font]
gown, mask and gloves.]

[A recent study in an 850-bedded community[/font]
[]hospital in Italy with endemic MRSA 50% of the[/font]
S. aureus ]infections being meticillin resistant)[/font]
[]reported the effects on MRSA bloodstream infections[/font]
[of introducing patient screening, targeted[/font]
enhanced contact precautions, feedback of MRSA[/font]
[rates to ward staff, and mupirocin clearance of[/font]
]MRSA carriage. A sustained fall in the incidence[/font]
[of MRSA bacteraemia was observed from 0.64 to[/font]
[]0.30 per 1000 admissions. Historical controls[/font]
[]were used, but the baseline was established over[/font]
[]18 months, screening and interventions were progressively[/font]
]introduced over 30 months, and this[/font]
was followed by a 24-month observation period.[/font]
]This reduction occurred despite rising usage of[/font]
[]central venous catheters. Interestingly, a rise in[/font]
[the rate of MSSA central venous catheter infection[/font]
[]was noted (0.81 to 1.59 per 1000 admissions, relative[/font]
[risk 1.96, 95% confidence interval 1.32[/font][FONT='AdvPS44A44B','serif']e[/font][FONT='AdvTrebu-R','serif']2.93,[/font]
[P <0.001),

[/font]

The role of this "research" is two-fold. 1. It provides a fig-leaf for those who caused the problem, by implying that their decisions were reasonable and could not have been predicted to lead to an increase in hospital based infection, because the knowledge was not there: this is a lie.

Need to read reports again there is much more meat to them that this.

2. It places the blame on hospital staff for a lack of personal hygiene, though it clearly shows that many factors are involved: for example lack of handwashing facilities; shortage of staff; inadequate cleaning etc etc etc.

No it specifically shows that hygiene alone cannot solve the problem.

The research was not undertaken by impartial researchers unaffected by politics or ideology: it was done because the rates of hospital acquired infection were so shockingly high that they could not be denied:

Much of this work was done in Sweden and Holland where this was not a large problem: why?

Unlike hospital hygiene the solutions in child protection are not already known, so you are right.

Agreed this is a much tougher nut.

Let me accept what you appear to be saying: let us shut up shop until research can give us a "package of measures" which are
evidence based.

No. I specifically said that one may have to act without an evidence base, but that the actions muct be underpinned by programs to acquire that evidence.

So let us define child abuse. Since, as you so rightly said, this is culturally determined, it changes all the time. But I am sure that a good researcher can come up with a definition we can all accept, which will remain consistent over time, and which can be objectively measured.

Just like the MRSA problem. MRSA colonisation was known to occur without causing patients any harm, MRSA caused deaths but was it just killing those who were destined to die anyway or was this a real additional problem? Years of research answered just that question.

So lets think of a parallel. Fractures in children occur. Many are not down to abuse. But serious abuse often leads to fractures. If we could show that there was a significant association between serious abuse and fractures, would the elimination of childhood fractures whatever the causse become a legitimate target. After all who wants a child with a broken bone?

Nw is that the only sort of abuse? Of course not, but other managable surrogates will exist.

Never mind, I am sure we an solve this for both child deaths and whatever other things we include in our objective definition of child abuse, once we get it. Of course there are problems with statistics too.

No one said statistics were perfect. But just because statistics can be abused, is no reason for dismissing statistics.

And from the media when bad cases of child abuse come to light: we will just explain that we cannot do anything cos we are busy making an evidence base, and it would be wrong to act till we have it.

I am simply suggesting that one codifies the actions taken and audit the outcome to determine which programs are effective.

Well previous research gives us some clues: first, and most importantly perhaps, we should abolish poverty. Mental illness is another biggy so we better ensure that adequate resources go into that too. Drug and alcohol misuse are implicated so we have to make sure those problems are dealt with. Poor housing is a problem so the housing stock will have to be radically improved. ....

I am going to take a wild guess here: I do not think society will want to spend all this just to prevent child abuse. Call me cynical.

I think you instinct is spot on here. Is that a reason for giving up?

So we conclude that a certain amount of child abuse is to be expected and leave it at that. That is the rational thing to do. For myself, I do not think society is going to be very comfortable when they are told that children who die in plastic bags in bath tubs are the choice they have made, but, again, you can explain this properly.

Now there is a message I would shout from the roof tops. Chldren are dying / suffering because you (general public) are too mean to pay for adequate support for the disadvantaged. Would need very solid evidence to show that this was the uncounfounded causative factor.

We could try things which might help (as the hospitals did with hygiene) and we could evaluate which of those things were effective. But we have a problem. We have to respect individual liberty. If we did not have that constraint then we could specify criteria and identify all the people with some or many of the risk factors we have so painstakingly identified: and we could make them undergo whatever we think might be effective ( with proper hypotheses and theoretical bases and pilot studies and anything else research finds necessary); we could randomly assign them to to those different programmes;

OK the premise here is that one must do something. Fine, but what you do is set up a number of packages of 'diagnosis', 'surveillence', 'prevention' and 'intervention' to pilot the various ideas people have. Then record and compare outcomes. Of course, direct randomisation is not possible, but f the same approach in different situations produces a consistent outcome, and this is not true of other packages, then that one is trialed further, and if results are consistent. It can ultimately be adopted as evidence based.

So what if we just take people who have already abused children? Even though we cannot identify the vast majority of them we do identify some.

Numbers too small, would only use this group to help understand the factors that led to child abuse in the first place. As is already being done but not in a veery systematic way.

II return to my quote: I have bolded the link points. I am critizising Govt failure to follow through. Not their need to or right to act.

My worry with Govt. invovlement is that the imperative to do something, leads to actions that are not evidence based. Yes we know there are problems, many opinions exist as to the best solution but the evidence for what is effective is so limited that this cannot be parcelled up into an adequate package for action, so 'experts' opinions are relied upon. Solutions are agreed upon and become the new orthrodoxy, what is not done is to rigourously identify that which is proven, that which appears supported by objective observation, that which is one of many competing theories that could fit with the available observations and that which is pure guess work. Further, we are interefering with personal freedoms here, we must at the very least set up a progam that will challange the assumptions we are making to determine which are subsequently supported, which are not, and to ruthlessly root out the junk opinions that lead to fiasco's such as the satanic abuse nonsense in Scotland a few years ago.

[Fiona]

That looks fairly critical to me!

Well I already know you have an idiosyncratic way of reading things

Not what I said. I expressed my concern that govt. often failed to follow through with the necessary validation of their action.

Not like any other body, eh?

The actions taken could not be fully underpinned by the highest quality of evidence, but were strongly supported by the evidence accepting that any individual aspect was open to criticism as not fully validated. Not the same as your oversimplification.

Correction: their oversimplification

.Little evidence exists

and

In the absence of randomised controlled trial data and on the basis of the descriptive studies outline above and a strong theoretical rationale, recommendations for the control of these organisms remain the province of existing best practice and professional opinion

and

evidence to support specific interventions is lacking

Not what the MRSA report says. Yes hygiene important but insufficient:

I can't read your next bit, but I did not say it was only hygiene if that is what you imply: I said that the effectiveness of good hygiene was established in the same way as it was before. I also mentioned the control of antibiotic over-prescription in a previous post; and if I did not mention screening it was an oversight.

You, on the other hand, said

Only in the past 5 years has research shown clearly how attention to hand washing and other hygeine measures combine to virtually abolishe hospital acquired infection.

That is what I was responding to. So tell me how "screening" is a hygiene measure if you are using ordinary english?
http://www.google.co.uk/search?hl=en...ition&ct=title

Need to read reports again there is much more meat to them that this.

No, I dont think I will bother, unless you show me what you mean

No it specifically shows that hygiene alone cannot solve the problem.

Yes it does: yet that is what you took from it ( see above). Not that I blame you since it is implicit in how the thing is written

Much of this work was done in Sweden and Holland where this was not a large problem: why?

No idea. Do you? It is irrelevant to why this report was produced

< snip>

No. I specifically said that one may have to act without an evidence base, but that the actions muct be underpinned by programs to acquire that evidence.

Where? I saw this

]My point - in respect of child abuse specifically, was that there should be clear evidence to back action.

and this

Where injury or neglect is already suspected, then the weight of evidence is central. Unless the family members or others are prepared to 'confess' or act as witnesses the situation becomes very difficult. Indirect evidence must be very strongly supported by very high quality research from more than one source,

(my bold)

If you qualified later I missed it, and I aplogise.

Just like the MRSA problem. MRSA colonisation was known to occur without causing patients any harm, MRSA caused deaths but was it just killing those who were destined to die anyway or was this a real additional problem? Years of research answered just that question.

I do not understand this. MRSA was defined: the effect of it might not have been known but the increase in hospital infection was known. That was the additional problem. It is actually nothing like child abuse: I do not think MRSA is culturally determined. But I am interested to learn if I am wrong.

So lets think of a parallel. Fractures in children occur. Many are not down to abuse. But serious abuse often leads to fractures. If we could show that there was a significant association between serious abuse and fractures, would the elimination of childhood fractures whatever the causse become a legitimate target. After all who wants a child with a broken bone?

You have completely lost me. I genuinely have no idea what you are talking about. Earlier we agreed that child abuse is culturally determined. As I noted in the case of child murder there are things we can agree are abuse, and I would think that deliberately caused fractures are in the same box, since both murder and grievous bodily harm are generally frowned on. "Deliberately caused fractures" and "serious abuse" are effectively a tautology. Would the elimination of childhood fractures be a legitimate target? Nice idea. I imagine everybody in the world is trying to achieve that; and they probably always have. After all, who wants a child with a broken bone? But, you know something? Accidents happen.

<snip>

No one said statistics were perfect. But just because statistics can be abused, is no reason for dismissing statistics.

And I did not say that. As the article I linked painstakingly pointed out, it is a reason for treating them with caution. Do you disagree with that?

I am simply suggesting that one codifies the actions taken and audit the outcome to determine which programs are effective.

And I am simply asking how

I think you instinct is spot on here. Is that a reason for giving up?

Er.....who is giving up?

Now there is a message I would shout from the roof tops. Chldren are dying / suffering because you (general public) are too mean to pay for adequate support for the disadvantaged. Would need very solid evidence to show that this was the uncounfounded causative factor.

Agreed

OK the premise here is that one must do something.

If that is your premise, fine. It is not mine

Fine, but what you do is set up a number of packages of 'diagnosis', 'surveillence', prevention' and 'intervention to pilot the various ideas people have. Then record and compare outcomes. Of course, direct randomisation is not possible, but if the same approach in different situations produces a consistent outcome, and this is not true of other packages, then that one is trialed further, and if results are consistent. It can ultimately be adopted as evidence based.

Do you honestly believe this has not been done? Have you never heard of "Headstart" or even "Surestart"? Children's centres? Family Centres? And a million other projects of the same sort? They do not produce conclusive results. They cannot.

But I am happy to concede that they are not well set up in the terms you set out. So tell me: let us imagine we have a "diagnostic" package. How is it to be used? Do you envisage it should be administered to the whole population and then we should wait and see how many false positives and false negatives we get? I do not think that is realistic and I do not think people would be happy to take a compulsory test. Do you? Seems a bit "big brother" to me and I thought we were both against that kind of thing

Are you seriously suggesting we should put the whole population under suveillance? Or the whole population of a street, if it is a pilot?

Let us imagine that one idea for prevention and intervention is home visits by a social worker. This is not fanciful: it is one of the things the Scottish Office acknowledges in the review I linked earlier: and I happen to believe it is right. Are you really sure you want every home in the country (or half of them if we are doing controlled trials)to be visited by a social worker regularly? Cos I am really sure I do not.

Numbers too small, would only use this group to help understand the factors that led to child abuse in the first place. As is already being done but not in a veery systematic way.

Exactly. The numbers are too small. That is why statistics don't work. That is why the research is inconclusive. That is in fact why the research is crap. We are not a universalist service. We deal with small numbers and that is all there is to it

[Pebble]

Fiona, too much to take in there in one go. But taking parts of statements out of context and asserting that that defines my position is part of the problem.

Lets look at the hygeine argument:

Hospital hygiene measures had indeed been in place for many years. These were known as 'universal precautions' it was evident that this was insufficient for certain situations: e.g. outbreaks of diarrhoea type illnesses. Here 'enhanced contact packages' were required. When it came to endemic infections like MRSA the required precise balance between these approaches was unknown. It was evident that universal application of the 'enhanced contact package' (gown, gloves and mask) was not practicable or desirable. Demonstration that MRSA carriage rate was strongly associated with MRSA sepsis rate, led to concepts that if one identified all those who were carriers and applied the enhanced approach to them this greatly reduced the MRSA sepsis rate. Thus surveillence measures became and extension of the 'hospital hygiene' package.

You are of course absolutely right there is more to it than just the hygiene measured that I have focused on. The point I was addressing at the time (context is important) is that many staff were very resistent to being directed in respect of the frequency of hand washing, the wearing of gowns, gloves and masks, the isolation of patients with suspected contact, the laborous auditing of all these actions, with endless education sessions on the same boring topic. Thus creating an evidence base that was capable of overcoming this natural resistance to change was a vital step. Yet because of the complexity of the issues invovled no breakthrough trials were possible. Many of the trial results seemed on the surface contradictory, but it was evident that whole package approaches did consistently show that MRSA sepsis rates could be sustainably reduced in most settings. This was demonstrated in many centres throughout the world and finally the burden of evidence was sufficient that although there are still those who argue that what they are being asked to do is unproven, these people are now a very small minority. Introduction of the packages with a degree of enforcement has been successful in taming one of the most intractable problems in UK hospitals in a very short time frame.

The crux of the argument I was trying to address, is that even if something cannot be proven absolutely to be true, if the burden of evidence for efficacy is high enough and the outcome desirable to society, one can justify actions that require a certain amount of interference with individual freedom. I am not suggesting one takes children away from parents on this basis, but alters the contract between family and state, to work toward a new appreciation of what society expects of individual families in terms of their childcare obligations.

Now you are right to assert that I did not bother with other aspects of the package (search and destroy policies; antibiotic management systems etc) but they were not relevant to the point I was trying to make.