the big story

Published: 12/08/2004, Volume II4, No. 5918 Page 10 11

As the MRSA bug threat grows, Alison Moore examines the government's heightened resolve to deal with a problem that has been blamed on everything from poor hygiene to hospital design

Last month, NHS trusts found themselves ranked in a particularly uncomfortable league table.

A week before the annual starratings were announced, the government published figures comparing rates of the deadly 'superbug' MRSA (methicillinresistant staphylococcus aureus) in every acute trust in England.

Nationally, it showed that infections caused by MRSA are rising - up 3.6 per cent on last year.

For the individual trusts at the bottom of the rankings, it reflected some major public concerns.A public meeting in Enfield in April saw health secretary John Reid tackled for the best part of an hour on the subject of hygiene at the local Barnet and Chase Farm Hospitals trust - fourth from the bottom of the table for general acute hospitals.

It was an hour that clearly stuck in Mr Reid's mind. In a webchat with Sun readers last month he told them about the hundreds of people he met at that meeting 'who were angry that their local hospital was not up to the standards of cleanliness they expected'.

As a result, the trust is now subject to 'cleanliness visits' by the local MP as well as patients - something that Mr Reid told Sun readers he would like to see more patients getting involved in.

Earlier that month, Patients Association president Claire Rayner hit the headlines when she claimed she would only return to hospital if she was 'at death's door', following her personal experience of the bug.

But this is not just a media furore.

MRSA is becoming a major killer: about 800 deaths a year are officially attributed to it, but many experts believe the true figure is far higher.

Announcing the tables, which followed a damning National Audit Office report on the scale of the problem, Mr Reid was clear about one thing: 'Hospital managers will be judged on their performance in reducing MRSA infection rates.'

To what extent should individual trusts be blamed for their MRSA rates? Is it all down to shoddy hygiene, as Ms Rayner alleged? And what is the government doing to support trusts battling to bring down their rates?

Certainly, the variation between trusts is huge. Some trusts have rates six or seven times higher than their peers, and some large trusts are dealing with more than 150 cases annually.

Some of the differences can be explained by the type of hospital.

When the figures for all hospitals are examined, nine of the 11 hospitals with the highest rates are specialist. Hospitals that take referrals from other hospitals may be importing patients who are already infected. In addition, such hospitals may be taking blood samples more often as their patients tend to be sicker, therefore they pick up more positive cultures, pushing their rates up.

Ted Baker, medical director of Guy's and St Thomas' Hospital trust, which has the worst rate of of all specialist and general trusts, says as many as 30 or 40 per cent of its MRSA cases may be 'imported' as the patient arrives with them - in some cases, specifically transferred to be treated at the hospital.And many of the specialist hospitals with the highest rates of MRSA would point to the operations they carry out as well - organ transplantation, for example, or renal work.

But the huge variations between general acute hospitals raise some difficult issues, not just for the trusts themselves but for future government policy.Of the 10 general acute trusts with the worst rates of MRSA, nine are in the south. This shines a light on one of the key battlegrounds for trusts with high rates of MRSA: the tension between keeping patient capacity rates high for maximum efficiency, and keeping beds empty for long enough for thorough cleaning to take place.

On top of this, patients are likely to be in contact with more people during a typical stay, increasing the chances they will be exposed to infection, and patients may be coming in from the community already infected. Trusts with high bed occupancy rates may also find it more difficult to close wards or bays if there are cases of MRSA.

Research for the National Audit Office report confirms the point, showing lower bed occupancy is associated with lower MRSA rates.

Now the government is attempting to play its part in bringing down future rates of MRSA by ensuring new buildings bring down the risk.

Of 15 strategic outline cases for new developments agreed last month, all bar one meet a new 'best practice' target to provide 50 per cent single rooms. The single rooms will allow barrier nursing of MRSA-infected patients who currently cannot always be separated from other patients because hospitals are running at close to capacity and lack the side wards needed. European countries typically have much lower rates of MRSA - and much higher numbers of single rooms.

Other aspects of hospital design may also need to be addressed - more hand-washing stations, for example. The Commission for Architecture and the Built Environment has also called for better ventilation to help fight superbugs. The Future Healthcare Network and NHS Estates hope to produce guidelines for hospital design that will minimise infection, based on evidence from Britain and abroad.

Bromley Hospitals trust halved its MRSA rate when it moved from old premises into a new hospital.One factor was the availability of single-bed rooms to allow easy isolation of patients.

University Hospital of North Staffordshire trust - with one of the highest rates in the country - says its elderly buildings are part of the problem and sometimes people with MRSA can't be isolated because there are not suitable facilities.

North Middlesex University Hospital trust is bottom of the general acute league table. But medical director Dr Yasmin Drabu points out that isolating patients can also be bad for morbidity. She tries to separate elderly MRSA patients from other patients, while keeping them grouped together.

Many of the worst-hit hospitals are increasing their spend on cleaning services. North Middlesex has increased its contract by£600,000. But the link between overall cleanliness and MRSA is not clear.

Some hospitals with the highest MRSA rates have done well in cleaning inspections. Addenbrooke's Hospital in Cambridge - second bottom in the combined league tables - has been rated green in patient environment action team inspections for the past two years, for example.

Probably the simplest and most important weapon in any individual trust's war on MRSA is convincing staff, patients and relatives to wash their hands thoroughly. Here, alcohol hand-rubs for nurses, UV cream so staff can see when they have cleaned their hands properly, and education campaigns for public and staff have been key.

But Royal College of Nursing health protection adviser Sue Wiseman says further action is urgent. She says infection control should be made a mandatory part of training for all NHS workers.

She would also like to see infection control teams given greater powers - so that bays and wards are closed on their recommendation, for example.

Separating trauma and elective surgery may allow some containment of MRSA: elective patients can be screened in advance and appropriate action taken.

Treatment centres may be able to eliminate MRSA through these measures.

But trusts are unlikely to be able to reverse the MRSA trends on their own. The NAO report suggests patient choice could contribute to infections, as could pressure under payment by results to increase the number of patients treated. If MRSA rates keep rising, the government may need to examine its own conscience.

Infectious enthusiasm: how Hereford hit a low

Hereford Hospitals trust has the lowest MRSA rate of any district general hospital, at just 0.04 per 1,000 bed days.But much of what it is doing is simple good practice that could be followed by any hospital in the country.

There is a stress on basic hygiene and hand washing, and this is included in health and safety training for consultants.Alcohol gel is readily available to clinical staff and there is a strongly supported antibiotic prescribing policy.MRSA patients are barrier-nursed in side rooms - made possible because the hospital is a new build with suitable rooms.

The hospital is now considering an education campaign to get visitors to wash their hands and is going to screen elective patients for MRSA colonisation so they can be treated before surgery.

As a district general it does not have many patients referred from other hospitals and has a relatively low staff turnover, which makes education easier.

But the secret of its success may be the importance the trust places on the issue.

'Infection control is high on the trust's agenda, ' says director of nursing and quality - and designated director for infection control - Helen Blanchard, who describes the approach as 'investing to save'.

Playing dirty

The 50 per cent single rooms target for new hospital developments is just one measure being brought in by the Department of Health to combat MRSA.

Other pledges are that:

the Healthcare Commission will review hospitals' cleanliness and infection control;

from April 2005, acute trusts will have a target of reducing MRSA year-on-year;

patients will be able to phone hospital cleaning services from their bedside;

alcohol rubs will be available at all 'staffpatient contact points'.

General acute trusts' MRSA rates 2003-04

Lowest rate

Hereford Hospitals trust

Harrogate Health Care

Peterborough Hospitals

Isle of Wight Healthcare

Southport and Ormskirk Hospital

Milton Keynes General Hospital

North Tees and Hartlepool

Royal Bournemouth and Christchurch Hospitals

Essex Rivers Healthcare

St Helen's and Knowsley Hospitals

Highest rate

North Middlesex Hospital

Epsom and St Helier

Weston Area Health

Barnet and Chase Farm Hospitals

Ealing Hospital

Lewisham Hospital

Birmingham Heartlands and Solihull Teaching

Frimley Park Hospital

West Middlesex University

Royal United Hospital Bath

MRSA surveillance system: results. www. dh. gov. uk (What's New,14 July)