Published: 07/10/2004, Volume II4, No. 5926 Page 41 42 43 44

Healthcare-acquired infections are making big headlines for the media - and even bigger headaches for trusts. Andy Cowper looks at how the war against MRSA is being waged at a national and local level

If a reminder were needed how near healthcare-acquired infections are to the top of the priority list, health minister John Hutton got one during the Department of Health en masse visit to West Yorkshire in September.

Consultant Dr Nick Scriven, while helping Mr Hutton to try an emergency breathing aid, told the minister to first wash his hands in alcohol gel as part of infection control procedure.

HAIs also hit the news in July, with Patients Association chair (and ex-nurse) Claire Rayner's public declaration that she hired a private nurse to care for her husband at home following a fall as she felt the risk of him contracting an HAI in an NHS hospital was too high. She had been infected with MRSA three years ago.

MRSA (methicillin-resistant staphylococcus aureus) is now the name on everybody's lips.

The staphylococcus aureus bacteria occur naturally in 25-30 per cent of healthy people's noses and on their skin. Where no illness is caused to the carrier, this is termed 'colonisation'.

MRSA infections can arise when bacteria breach the skin of people with weak immune systems. In healthcare settings, and particularly hospitals, there is a natural concentration of such people. The risk of HAI is heightened when the skin is broken (by an IV line, or bedsore, or post-operative scar or wound).

MRSA is not the only HAI, but it is widely prevalent. The National Audit Office estimated in 2002 that MRSA costs the NHS£1bn a year, and could be killing around 5,000 patients a year. It also found that around 15 per cent of HAIs could be prevented by better application of good practice, releasing resources of£150m for alternative NHS use.

Healthcare-acquired, opportunistic infections of this kind tend to be highly contagious and not easily treated once infections are under way.

Another potential problem in healthcare is the legionella bacteria in water systems (cooling towers and showers). All UK healthcare providers' water systems are meant to be flushed with biocide regularly. When they are not, problems arise.

Staphylococcus, streptococcus and E coli can also cause common infection problems.

In August 2004, the Department of Health published league table figures comparing MRSA rates in every acute trust in England. Nationally, it showed that infections caused by MRSA are rising - up 3.6 per cent on last year (The Big Story, pages 10-11, 12 August). Some trusts have rates six or seven times higher than their peers, and some large trusts are dealing with more than 150 cases a year.

The Department of Health is trying a number of solutions to infection control problems, including a target of 50 per cent provision of single rooms in new hospital developments. In addition, the Healthcare Commission will review hospitals' cleanliness and infection control.

Acute trusts are now obliged to display infection rates publicly, and from April 2005 will have a target of reducing MRSA yearon-year.

Patients will be able to phone hospital cleaning services from their bedside, and ward cleaners will report to matron. In addition, alcohol rubs will be available at all 'staff-patient contact points'.

Dr Phil Luton of the Health Protection Agency's Porton Down research facility says: 'We are now doing more monitoring, and more monitoring finds more cases. People live longer now. We do more intensive surgery on the more elderly, whose immune systems are weaker, so some of the challenge is down to demographics.

'Antibiotic resistance has been a natural phenomenon since Alexander Fleming discovered penicillin, ' he notes.

Dr Luton highlights the general drive in the NHS to only use antibiotics where they are essential, because 'as resistance grows, obviously antibiotics are less effective.'

Richard Wise is professor of clinical microbiology, City Hospital trust, Birmingham, and chair of the government's specialist advisory committee on antimicrobial resistance. He is also a non-executive director of the Health Protection Agency.

'Infection control is now being regarded seriously, in particular by management, who are now charged with ensuring it has a high profile in their trusts, ' he says.

'I think the problems that cause HAI remain difficult ones. It is about the appropriate design of wards and most of all having all staff, from senior consultant to trainee porter, minded to take appropriate measures of hygiene.

There will be no quick fixes.'

In July, the National Audit Office issued Improving Patient Care by Reducing the Risk of HAI: a progress report. The document is introduced by Florence Nightingale Museum director Alex Atwell, who reflects on the nurse's legacy as a self-styled 'passionate statistician'.

Ms Nightingale's analysis of statistical data led her to identify the importance of improving sanitation, and her Notes On Hospitals emphasise the importance of comparative statistics in locating problems.

Professor Alan Maynard of the York health economics consortium often quotes Ms Nightingale's dictum on the quest for information about hospitals - whether their patients depart 'relieved, unrelieved or dead'.

Professor Maynard is also chair of York Health Services trust, one of the six acute pilot sites in the 2003 'cleanyourhands' campaign.

'I wrote about infection control and the associated costs 15 years ago in a York health economics discussion paper, published for the NHS, ' he says. 'It got a fair bit of coverage at the time. The truth is that we do not really know the scale of the costs: the NAO figures are the best estimates We have got.

It is just pathetic that we haven't really cracked this yet.'

Antibiotic over-use has led to greater numbers of strains of resistant infectious organisms.

Professor Wise points out that: 'In January 2004,£12.8m was made available to put an antibiotic pharmacist in every acute trust, with the aim of enhancing prudent prescribing.

That is being rolled out and about half of all trusts have them so far.'

Even trusts with excellent policies on infection control can have problems. Helen Scott, editor of the British Journal of Nursing and a former nurse currently training to return to practice, recounts a story about visiting a relative in a major London trust known for its infection control policies and programmes.

'I saw a healthcare assistant put on some gloves, and then go between a number of patients without any cleaning of the gloves - so she was protected from infection, but the patients certainly were not.'

Professor Wise regards this as a demonstration of the 'continual educational deficit'. 'You have got to teach people about infection control from their induction into health service - and That is something for the NHSU, which is addressing this issue at present, ' she explains.

Another key problem is the number of infection control nurses. The national ratio is of one infection control nurse to every 347 NHS beds. Professor Wise describes this as 'worryingly low, and should be closer to one to 200. The Department of Health's current target is one to 250 beds, but now that the government is imposing information gathering about infection control, the number of IC nurses must be reassessed.'

Royal College of Nursing health protection adviser Sue Wiseman agrees that further action is needed: she thinks that infection control should be made a mandatory part of training for all NHS workers.

Activity levels and overcrowding are two other key issues.

At a time when raising rates of activity has been essential to meeting the 'P45 targets' from Whitehall, the problems of HAI have been compounded by the very high bed occupancy rates of acute trusts, and the pressure to move patients through the system quickly.

Guy's and St Thomas' Hospital trust (which has the worst rate of all specialist and general trusts) medical director Ted Baker thinks that up to 40 per cent of its MRSA cases may be patients who arrive already infected. The trust also deals with a particular casemix that makes them more likely to be treating those who are vulnerable to MRSA.

Many hospitals with high rates of MRSA also carry out complex and invasive operations such as organ transplantation or renal work.

The isolation of patients with MRSA has traditionally been thought important to prevent the spread of the disease - as the physical environment can become infected - 'hot' - with MRSA. Once this has happened, the bacteria are very hard to eradicate. This is in part an issue of hospital design. Ironically, the wards that bear the name of Florence Nightingale (who campaigned for better cleaning in the 1850s and 60s) can compound the problems of infection control, as they make isolation harder. Older buildings are also often harder to clean.

When Bromley Hospitals trust moved from old premises to a new hospital, its MRSA rate halved, and one factor was the availability of single-bed rooms to isolate infectious patients. The Commission for Architecture and the Built Environment has also called for better ventilation in healthcare settings, which could help to address many HAI problems.

The relative ease of isolating patients has traditionally been regarded as a reason why HAI rates are significantly lower in the independent sector.

Sally Taber of the Independent Healthcare Forum has said: 'Hospitals operating in the independent sector take the risk of HAIs seriously. Their experience is typically very different to NHS hospitals.'

However, others point out that the independent sector has traditionally dealt with few patients with 'high-risk' conditions and that most are probably wealthy and thus more likely to be relatively healthy.

A caveat regarding isolation for MRSA patients recently appeared in the 4 September issue of the British Medical Journal. Dr Ben Cooper and colleagues published a review of past studies, which found little evidence that isolation measures are effective.

They found that 'major methodological weakness and inadequate reporting in research into the effectiveness of isolation measures mean that many plausible alternative explanations for reductions in MRSA cannot be excluded.'

However, their point was more complex: they also said that they did see evidence that isolation could reduce the spread of MRSA substantially. 'A lack of evidence of an effect associated with specific measures recommended in national guidelines should not be mistaken for evidence of lack of effect.'

They suggested that 'isolation measures recommended in national guidelines should continue until further research establishes otherwise'.

The article concluded that researchers needed to investigate exactly how isolation measures should be used in the future.

Professor Wise observes that this piece 'shows that answers are complex'.

Another area, perhaps less immediately obvious, is that of staff clothing. Inadequate laundering can lead to uniforms remaining contaminated after a laundry process. Staff should be provided with information on safe laundering of uniforms that should include:

laundering work clothes alone, and not with personal items of clothing;

laundering at the maximum wash code permissible (preferably a minimum of 60C);

ironing or tumble drying to further reduce micro-organism levels;

storing clean uniforms in a manner that reduces the risk of contamination.

Legal aspects of HAI also need to be addressed. Risk managers will already have become aware of cases where patients or their relatives embark on litigation as a result of HAI, claiming negligent care on behalf of a hospital. The legal definition of negligence, according to defence solicitor Andrew Andrews of Bond Solon, is 'an act or omission which leads to foreseeable harm' - the relevance of such a definition is self-explanatory in infection control.

Successful approaches to changing staff behaviour will require systems thinking. Human behaviour is difficult to alter, and the disinfection of hands between every patient is a habit which needs to be both ingrained and facilitated in a variety of ways.

Technology approaches are also a part of the required strategy to reduce HAIs. However, Professor Wise cautions against a 'technology only' approach. 'A lot of companies have been tending to jump on the MRSA bandwagon, with new textiles, air filters and anti-MRSA door handles and hinges.'

He mentions the marketing of 'antiinfection' brass door handles and even hinges to replace stainless steel (as it is claimed that infectious bacteria survive for a shorter time on brass). 'To my knowledge there is no proven efficacy of these in healthcare', he comments.

'True, heavy metals such as copper do have anti-microbial effects, but managers would be well advised to look for evidence rather than taking at face value statements which might be more about marketing.'

He continues: 'I am unaware of validated evidence suggesting a possible benefit to patients from the right door handle. If there is no evident benefit to patients, you have to say that the clinical application is not proven.

'It is more important to concentrate on basics like proper hand washing and proper disinfection for all equipment, including the lowly stethoscope.'

Alcohol rubs are another element in the armoury. The National Patient Safety Agency recently issued instructions that alcohol rubs are to be made available by every bed.

This was reinforced by NHS chief executive Sir Nigel Crisp, whose recent chief executive's newsletter requested everyone to make available at all beds alcohol gel for hand disinfection.

However, Professor Maynard feels the 'rush to alcohol' as a panacea may not have as strong an evidence base as some think.

'The cleanyourhands pilots - which we took part in at York - were not evaluated systematically.

It was casual observation rather than good scientific observation: the trials were done too slowly and they were poorly designed.

'The results did seem to indicate that it reduced infections on two wards, and we are now proceeding to try and extend it (particularly the alcohol gel) to the rest of the hospital.'

In other developments, the makers of the antimicrobial fibre Microban (who brought you the plastic chopping board) have been looking at coating metals and fabrics for the healthcare market with their product.

Properly cleaned hospitals, where infection control is a priority and not an extra, may not seem an obvious goal.

Yet the changes in design and most importantly, staff behaviours are essential. Perhaps the campaign slogan should look back to Hippocrates' oath - the first duty of a clinician.

'Primum non nocere' - first, do no harm.

Low rates, high standards

With a DoH report in July declaring it has the lowest rates of MRSA in the country, infection control is clearly a high priority for Hereford Hospitals trust, writes Nitasha Kulashreshtha .

It has representation on a wide range of committees, from health and safety and risk management to the policy advisory group. The trust's infection control committee is chaired by a senior microbiologist - other members include the chief executive, the director of nursing and senior clinicians.

The infection control team interacts via formal education and informal meetings with all categories of staff, including domestics and porters, through to the clinical staff or nurses, physiotherapists and medical staff.

Senior infection control nurse Gillian Hill leads the small team and covers audit, policy implementation, education and surveillance. The team uses laboratory-collected data for recording alert organisms, including HAIs. In the near future the trust is looking to implement a more comprehensive IT based system called the ICnet. This follows recommendations for the DoH to look into IT systems for the collection of infection control data.

All new clinical staff receive a comprehensive induction programme, which includes an Bacteria bashing:

senior infection control nurse Gillian Hill.

overview of infection control within the organisation, risk reduction and a list of resources and contacts for future reference.

Ms Hill explains: 'All staff receive an annual infection control update, which discusses developments in infection control, and we also educate on a number of other courses including intravenous bolus therapy, intravenous cannulation and woundcare courses. We hold an annual infection control study day, open to all clinical staff, both in and outside the organisation. We hold awareness days, have informal teaching in clinical areas and knowledge-based competitions.'

A colour-coding system for cleaning equipment ensures hygiene levels are at the right level in different contexts. Monthly audits are carried out by ward sisters while spot-check audits are done by the infection control team.

The trust has had alcohol hand rub located at the foot of every bed for the last two and half years. Hand washbasins are located in every four-bedded bay within the new private finance initiative-built hospital and by every bed in high-risk areas such as the intensive therapy unit.

Patients with an HAI are isolated in a single side room with en-suite facilities. All staff having contact with the patient wear protective clothing and undertake stringent hand hygiene, using the alcohol hand gel after leaving the room.

What is MRSA? A fact sheet from the Centre for Disease Control giving background information about MRSA as well as details of prevention and control and laboratory testing practices.

www. cdc. gov/ncidod/hip/ARESIST/ mrsa. htm#1

November 2003 Royal College of Nursing MRSA guidelines for nursing staff covering how MRSA is transmitted, the national guidelines, control precautions, treatment and staff health issues.

www. rcn. org. uk/publications/pdf/ mrsa. pdf

MRSA - you can make a difference

Online course for all those who come into regular contact with patients. Designed to be a learning resource to help intensive care nurses train others.

www. mrsa. no. com

The problem in the UK Results of the first three years of the Department of Health's mandatory MRSA surveillance system in acute trusts in Bug on the web: MRSA resource sites England.

www. dh. gov. uk then

Publications, Publications statistics then search for MRSA Scottish report A report on MRSA blood infections in Scottish acute hospital trusts (April 2003 to March 2004).

www. show. scot. nhs. uk/scieh

Welsh reports

An archive of recent reports of the staphylococcus aureus bacteraemia surveillance scheme.

www. wales. nhs. uk/sites/page. cfm? orgid=379&pid=5362

Northern Ireland reports

Includes data collected on a quarterly basis from 'acute trusts' from April 2002 to March 2003.

www. cdscni. org. uk/publications/AnnualReports/MRSA. asp

Winning Ways: working together to reduce HAI in England

This national plan review sets out the action necessary to control HAIs.

www. dh. gov. uk/assetRoot/04/06/46/89/04064689. pdf

Improving patient care by reducing the risk of hospital-acquired infection: a progress report National Audit Office, July 2004.

www. nao. org. uk/publications/nao_reports/0304/0304876. pdf

Strategies for control World Health Organisation, 1996.

www. who. int/emc-documents/ antimicrobial_resistance

Comparison of international practices National Audit Office, September 2003.

www. nao. org. uk/publications/nao_reports

How have Dutch hospitals brought MRSA under control? Eurosurveillance, March 2000 www. eurosurveillance. org/em/v05n03/0503-222. asp

Jim Young

Education, education, education: Southport and Ormskirk

Southport and Ormskirk Hospital trust achieved one of the lowest rates for MRSA, according to the DoH. Nurse consultant Martin Kiernan is responsible for the management of the infection control nursing team but shares responsibility for infection control with consultant microbiologist and infection control doctor Dr Judith Bowley, writes Nitasha Kulashreshtha .

Currently the trust uses a paper-based system for recording HAIs. In future it plans to move some of these to a speedier PC form of data collection. At the moment the trust is undertaking surveillance of MRSA, all bacteraemia cases, all patients admitted to critical care areas and some targeted surgical site surveillance and has recently appointed a part-time surveillance nurse to help to collect more reliable data.

To combat HAI, infection control education has been made mandatory for all staff and is an integral part of the induction programme for the past six years. Following initial induction, infection control is a part of the trust's long-established risk management update training. Each nurse is supposed to attend it once a year. The hospital has also recently established a link-worker scheme for infection control that is open to all grades of staff and not just for nurses.

The hospital has its own in-house hotel services team that works towards keeping the trust clean. The cleaning has never been outsourced. New initiatives in the past few years have helped in minimising the risks of environmental contamination to patients and include the introduction of task teams, housekeepers and the in-house HEAT (hygienic environment action team) inspections. The task team is from the hotel services department and entails two members of its staff spending half a day each week on each ward deep-cleaning the clinical equipment, for example bath hoists, manual handling equipment, commodes, drip stands etc.

The HEAT inspections are carried out by matrons, infection control, facilities and hotel services staff and are also accompanied by a member of the patients group. HEAT inspections are built on the government's patient environment action team process and deal with cleanliness of equipment.

Generally, all patients with MRSA or other organisms with a potential for cross-infection are isolated in single rooms, except for spinal injury cases. Bed managers work very closely with infection control staff to ensure optimum use of the side-room facilities, frequently using the 24-hour infection control nurse on-call system. The director of estates has recently redesigned the layout of a proposed unit in order to provide more en-suite isolation facilities.

Each patient admitted has his or her MRSA status checked on admission and is placed in a side-room if practical. In the event that this has not been done, the infection control team will still be aware of the patient's presence the next day as the information department e-mails a list all of the known positive patients in the trust.

Martin Kiernan comments: 'We try to get over to staff that they are responsible for protecting the patients. The problem with infection control is that the person responsible for the poor practice in spreading infection from one person to another very often does not see the effects on that person as it may not manifest for several days or even weeks.

'So we try to encourage staff to make the connection between poor practice and the effects of it.'

All come out in the wash: Lewisham Annette Jenas is senior nurse for infection control, Lewisham Hospital trust. She points out the importance of regular monitoring of hand-washing compliance. Her trust's approach (based on the work of Diddier Pittet in Switzerland) measures compliance by observing staff at work for 20-minute periods.

A percentage is calculated of the number of times staff were observed washing or decontaminating their hands from the number of time they should have washed or decontaminated hands (hand hygiene opportunities).

An initial baseline score of 25 per cent is obtained in most areas. Observation is followed by feedback to staff and training as required. Subsequent scores of compliance regularly exceed 70 per cent.

Ms Jenas notes that: 'Observation does change the behaviour of staff, but increasingly staff are trained to observe their own teams. The application of peer pressure has proved very effective.' Yet she also warns that 'there are still some staff who do not wash or decontaminate their hands when they should, and it can be extremely difficult pointing this out.'

She lists the following as key to a hand hygiene campaign:

identify and support leaders and champions of campaign;

have a clear policy and make it visible;

provide the best hand hygiene products you can afford;

take non-compliance seriously for all staff;

start hand hygiene education at induction;

regularly review progress and applaud successes.

HSJ survey: what infection control experts really think

Consultants are still giving HAIs too low a priority, according to a snapshot survey of infection control nurses.

The poll, conducted in association with the Infection Control Nurses Association, found that on average respondents thought that consultants scored just 4.8 out of 10 on prioritising the issue. However, this compared to just 3.3 a year ago. Looking back 12 months a quarter of respondents gave consultants the lowest score possible.

In contrast, nurses scored their trust's executive team at 6.2, up from 5.0 the year before - both scores only slightly lower than the priority they thought fellow nurses gave it.

A third of respondents also believed that patient awareness of infection had risen significantly in the past 12 months, with only 5 per cent reporting no increase in interest at all.

Their confidence in the DoH's own league tables on MRSA was very low, at just 3.3 out of 10. There was equally unpromising news for Whitehall in the responses on resources. Asked: 'How confident are you that this year you can achieve a full programme of infection prevention with your current resources?', respondents rated this just 5.0 Asked: 'In the past 12-18 months, which single change in your trust has made most difference in combating HAIs?', respondents listed full staffing levels, engaging matrons/ head nurses, clinician and administrative support, robust training programmes and mandatory training for all staff.

Technology solutions also came up, with many votes for the increased use of alcohol gel mentioned by virtually all respondents. Publication and distribution of revised infection control manual were also mentioned. Better quality paper hand towels were also noted, as was a 'mandatory hand hygiene training for all staff, supported by in-house video available to all'.

However, one big caveat should be noted in the following words from a respondent: 'Over the past 18 months, our trust has reduced the cleaning contract. This has resulted in cheaper products being used, but more worryingly, in a significant reduction in the number of cleaning hours. There has been an appreciable decline in the standards of hygiene since, and this is continuing.'