How have Welsh hospitals with high occupancy rates reduced their MRSA rates by 60 per cent? asks Theresa Judge
MRSA infection rates can be reduced very significantly if an emphasis is placed on prevention, the culture within hospitals is changed, and strong leadership is provided, according to a specialist in Wales who has succeeded in reducing MRSA rates by 60 per cent over the past five years.
Dr Ian Hosein says his success is due to bringing "quality management principles into the heart of a discipline [ infection control] that has traditionally been a reactive one".
He is working in similar conditions to Irish hospitals. In his hospitals, bed occupancy rates - a key factor in MRSA levels - are routinely up to, and even above, 100 per cent.
Senior personnel from the HSE charged with reducing Ireland's very high MRSA rates will meet Hosein during a fact-finding trip to Wales next week.
Hosein, who is director of infection prevention and control in the Cardiff and Vale Trust, says he was the first to put the word "prevention" into the job title. He says he has applied his qualification in business management to devising a new approach to infection control.
Using terms such as "total quality management", "strategic marketing" and "relationship marketing", his approach appears to be based on improving co-operation between hospital managers, doctors and infection control specialists, raising staff morale by building relationships and providing leadership that people can believe in.
He says, for example, that in the nine hospitals he is responsible for, with some 2,300 beds and 1,400 staff, "compliance with hand hygiene improved because staff members felt that they were being listened to and we were addressing their needs".
Staff had previously been surveyed as to how they could be helped to wash their hands more frequently.
He says his approach is based on working with the resources available in the present rather than focusing on "wish lists".
He would recommend that Ireland appoint a director of infection prevention and control to provide the leadership required.
Continuous discussion of resources and taking a purely "technical route" as Ireland appears to be doing, he says, could undermine staff confidence and morale, which are crucial to preventing spread of infection.
However, Hosein stresses the importance of integrating all the different sectors of hospital management. "It must be integrated because if, for example, staffing levels are insufficient, hand hygiene will not be optimal because of the stress levels of staff."
While MRSA rates have been reduced dramatically in Hosein's trust, overall levels in Wales and the rest of the UK are on a par with our own and, along with Greece, are the worst in Europe.
The European countries that report the lowest MRSA rates are the Netherlands and the Nordic countries.
In between these two extremes, northern European countries generally have lower rates than southern states such as Spain and Italy.
There is a stark contrast between the figures for Ireland and the Nordic states.
The number of MRSA bloodstream infections in Ireland last year was 592 and will be in the region of 600 again this year. In Norway, with a population of 4.6 million, there were four bloodstream infections last year, and in Denmark there were 11.
The reality for Irish hospitals today is that very high occupancy rates, of more than 95 per cent, and a lack of isolation facilities - both the results of under-investment in the health service - mean it is impossible to tackle the problem in the way that the Netherlands does, for example. There, if MRSA is detected in a unit it will be immediately closed.
In the Netherlands, a person seen as at risk of MRSA is automatically put into a single room until they are screened. This cannot happen in most Irish hospitals because they do not have isolation facilities.
As a result, while Irish MRSA guidelines state that "at-risk" patients should be put in single-bed units until they are screened, the guidelines acknowledge that in most hospitals this will not be possible.
Dr Robert Cunney, a consultant microbiologist at the National Health Protection Surveillance Centre and an expert in MRSA, says it is important to acknowledge that a lot of work has been done over recent years and this has resulted in our MRSA rate stabilising.
He adds, however: "Unfortunately it has levelled off at a very high level." The number of infection control nurses has doubled from 33 to 70, and the number of microbiologists has also doubled to 30 since 2001.
In addition to 52 extra infection control staff sanctioned by the HSE this year - although none of these posts has yet been advertised - the intention is now to employ 60 more, including surveillance scientists and antibiotics pharmacists, he says.
"We are a long way short of international standards in terms of staffing levels, but it is fair to say that we are getting there," says Cunney.
Within two years, he believes we should be close to European norms in terms of staffing.
Cunney says the lack of isolation facilities is "a definite problem" that will take a long time to address. In Britain this has been recognised, and a five-year target has been set to ensure that a minimum of 50 per cent of all patients are in single-bed rooms and that no wards should have more than four beds.
Cunney says Britain's five-year target reflects the fact that it is starting at a much higher level than we are.
A survey in the Republic in 2003 found that only about 6 per cent of beds were in single rooms and if private hospitals were excluded, the figure would have been even lower. In 2003 some hospitals had no single rooms at all.
The use of single rooms has been shown to reduce contamination, and staff are more likely to comply with hand hygiene measures.
Britain has also now set a target of bed occupancy rates of lower than 85 per cent, which is also a norm across northern Europe. In the Netherlands the bed occupancy rate is about 80 per cent.
In contrast, Irish hospitals cannot afford to leave one bed in a two-bed unit unoccupied for a few days so that a suspected MRSA patient can be isolated because of a never-ending queue in A&E departments and the prospect of having to cancel elective admissions if beds are not available.
Cunney says an EU-wide study has identified five key factors in keeping MRSA rates low. These are active surveillance and screening of patients for MRSA, ready access to isolation facilities, appropriate level of staffing, use of barrier precautions and alcohol hand gel, and the prudent use of antibiotics.
The most important point is that action on one or two of these areas alone will not tackle the problem; all five have to be addressed, he adds.
He points to progress being made on establishing a national surveillance system for healthcare-associated infections - Ireland is one of the few EU countries that does not have such a system.
MRSA is just one of many healthcare-associated infections.
Cunney says we "do well in terms of national surveillance" as we participate in an EU-wide surveillance system of antimicrobial resistance, known as EARSS, which gives reasonably accurate figures on MRSA nationally. EARSS data is collected from laboratories.
He says some hospitals are able to have a surveillance system for healthcare associated infections, but "a lot of hospitals" do not have sufficient resources, as staff spend their time "firefighting" dealing with infections.
Yet it has been shown that good surveillance systems reduce infections in the long run and are cost-effective.
In Germany, for example, such hospital surveillance has been standard for many years, and this is also the case in many northern European states.
He says the irony in Ireland is that hospitals with good screening procedures detect more cases and can then be "unfairly labelled" when, in fact, good surveillance leads to better infection control.
Cunney says there has been very good progress over recent years on hand hygiene. Where he works at Temple Street hospital in Dublin, the amount of alcohol hand gel used has doubled over the past two years.
He says initiatives are also being taken to try to reduce our use of antibiotics, which is "well over the EU average". A pilot programme with GPs in Cork is to be extended nationwide.
Cunney also stresses the importance of ensuring that "all healthcare workers see infection control as their responsibility, and not just the preserve of infection control nurses and microbiologists".