For a healthcare professional working in the NHS of today, it is virtually impossible to be unaware of the high public profile that MRSA has in the media generally. It clearly has to be accepted that some of the media have a political agenda in keeping such issues in the public domain, and others may feel that they are providing a genuine public service by raising it's profile.
There are indeed some healthcare professionals who point out - possibly with some justification - that the issue of MRSA per se. does not actually justify this high level of public concern, particularly when it is compared with other potential difficulties that could beset a hospitalised patient. It is generally conceded that iatrogenic problems are a significant danger to patients in hospital. (Public Health Laboratory Service 2002)
To some extent, MRSA can be considered the public face of the bigger issue of Healthcare associated infections (HCAIs). Newspapers will refer to the problem of MRSA on our wards when it is, in reality, only a partial aspect of the whole issue of the problem of cross-contamination of patients. (Hiramatsu 1997)
This dissertation sets out to explore all of the viewpoints by examining the literature and critically assessing their justification and validity.
The first issue that we need to explore is that of verified incidence. The Government, through the Department of Health, commissioned an investigation to look at aspects of NHS expenditure. (Public Accounts Committee 2000). This committee came to the conclusion that HCAI's already account for over 8% of all of the acute hospital admissions in the UK.
This fact alone has a number of direct sequelae, not least of which is the prolongation of a patients stay in hospital, with all its attendant costs. It also follows that if infected patients have to stay in hospital longer then this must inevitably increase the likelihood of other patients contracting HCAI's themselves. (Centers for Disease Control and Prevention 2001).The same study gives us other information in this regard. it costs the financial burden at about 1 billion and also equates this with about 3.6 million bed-days lost
The history of HCAI's
Hippocrates made the relatively profound statement that If you wish to become a physician, always follow the maxim, first do no harm (Carrick 2000). It is obviously the case that modern medicine bears little resemblance to that practised two millennia ago, but the maxim clearly still applies.
Nearer to the present day, Florence Nightingale paraphrased Hippocrates' words with the phrase "It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm". (Nightingale F 1859). In the context of this dissertation her words were particularly poignant as she was referring to the infections that were rife in her hospital due to the sanitary arrangements.
At almost exactly the same time that Nightingale was writing, on the other side of Europe, Dr Ignaz Semmelweis (Semmelweis,1861) was coming to the realisation that it was hospital staff who were largely responsible for the dreadful death toll of puerperal fever in the maternity units that he was responsible for. His seminal observation was that puerperal fever claimed the lives of 25% of the mothers who delivered in hospital but only 5% of those who delivered at home. (Playfair,1847).
By a complex series of exclusion experiments he was able to discover that by getting the hospital staff to wash their hands between seeing the patients he reduced the death rate by a staggering 96%. In a measure that echoes across the centuries, his insistence on all his colleagues washing their hands between patients made him very unpopular and subsequently marginalised by his clinical colleagues. (Birte Twisselmann 2003)
What is the actual documented position
For reasons outlined above, we clearly can't turn to the media for an accurate representation of the actual size of the current problem. One of the most authoritative of recent papers on the subject is by Cooper (et al 2004) who provided a fairly comprehensive literature search. Their prime objective was to consider the effectiveness of the various methods of containment of MRSA infection in a hospital setting. The paper actually gives us a great deal of useful information. It points to the fact that, on a global scale, the incidence of MRSA continues to rise. (Turnidge et al 2000)
The National Audit Office report (2004)equally gives us a slightly more detailed picture. It shows that figures clollected from the Dept. of Health's own mandatory reporting system had indicated that there was an 8% increase in Staph Aureus infections between 2002 and 2004, of which 40% were MRSA infections - the 2004 figures almost reaching 20,000 infected patients. This actually makes the rate of infection in the England amongst the worst in Europe. (Cuevas et al 2004)
Other sources quote the UK infection rate as being about 30,000 hospital acquired infections per year (Morton et al 2003) which they quote as being representative of a 9% infection rate. They also add the information that, of these, about 5,000 will die. It is important to make the distinction that the authors do not suggest that the 5,000 who will die, will do so as a result of the MRSA infection. There is the other element that patients who are severely debilitated (and therefore at greater risk of dying) are more likely to contract MRSA. (Alvarez et al 1985)
How to control the spread of HCAI's
There have been three major types of intervention to try to limit the spread of the HCAI's :
Hand hygiene among healthcare workers, (Donowitz LG. 1987)
Restriction of antibiotics, (Morris AH 2002)
Detection and isolation of infected or colonised patients. (Graham M. 1990),
Most of the current national guidelines tend to specify the latter as the single most important measure (Rhaman et al 2000)
With regard to control there appear to have been a number of attempts at prophylaxis. Some hospitals have stopped screening their new admissions and adopted a policy of antiseptic baths and staphlocidal cream the apply to the nose of the patient. (Hori et al 2002) I
t has to be observed that s many microbiologists are of the opinion that nose cream does little to affect the overall incidence of MRSA in the hospital. (Chambers 2002). Some articles have suggested the use of prophylactic antibiotics for all admissions, (Nottingham Health Authority 2000). but there is a general consensus that such a measure would actually encourage the emergence of greater numbers of resistant strains. (Coello et al 2004)
Some hospitals are now running pre-surgery MRSA assessment clinics to identify infected patients and to treat them prior to surgery (Teare et al 1997) Again, it has to be noted that there is little in the way of firm evidence-base for these measures. (Weinstein 1999) Some healthcare professional are publicly calling for a number of controlled trials to examine these various measures to see if they are either cost-effective, or actually effective at all. (Kluytmans et al 1996)
Handwashing is another of the mainstays of prevention of cross-contamination of infection. The actual evidence to support the efficacy of handwashing is both plentiful and largely beyond dispute (Donowitz 1987). One of the bigger problems that is encountered is the fact that many healthcare professionals are very resistant to the idea of handwashing ( there are echoes here of Semmelweis) (Simmons et al 1990). It appears that the theory is generally known, but either lax practice or just simple laziness is largely responsible (Kretzer et al.1998).
The Kretzer paper considered the various types of behavioural interventions that could improve the compliance in the handwashing behaviour patterns of various healthcare professionals. They explored and evaluated strategies such as near-patient handwashing facilities combined with lectures and poster campaigns. They found that the single most effective strategy was the conversion of the team leaders in each discipline who would then tend to lead by example. Even this, though was not sufficient on its own as each single measure was effective, but only for a short time if not constantly reinforced. (Tibballs 1996)
We cannot leave this particular section without making mention of the paper by Jarvis (1994). This paper is an impressive tour de force of the issues that pertain to the effectiveness of handwashing. It effectively sets the evidence baseline in the subject and although it is now more than a decade old it is still frequently referred to in many of the modern papers.
The government has tried to tackle the problem with a number of different initiatives. One of the most far reaching was their Government White Paper New Guidelines to cleaner hospitals (NICE, 2004). This was introduced to parliament by Dr John Reid the Health Minister(Reid 2004). Who made the public commitment to reduce the incidence of MRSA infections to 50% of their 2004 levels by 2008. It follows from what we have already discussed that the cost to the NHS is huge and therefore it also follows that the potential savings (not only in purely financial terms) are equally significant.
The paper that we used as the source for the costs earlier also provides information on savings in the form of the following statement:-
Implementation of all the measures suggested by the NPSA would release 147 million and save about 450 lives once target compliance rates have been met. (Public Accounts Committee 2000)
Part of the reason for the disparity between the cost figures and the savings figures is the huge cost of actually implementing the measures that have become necessary in order to actually provide a significant reduction in the transmission rates of infections (Grimes et al 2002)
Nursing issues are largely paramount in this particular subject. By the very nature of their work, nurses have the ability to transfer pathogens from one patient to another more readily than perhaps any other healthcare professional (Cooper et al 2004).
In this field in particular, (like most others in medicine), a good evidence base is vital for the instigation of good, rational decisions.
Evidence-based medicine is often defined as being:
Evidence-based health care is the conscientious use of current best evidence in making decisions about the care of individual patients or the delivery of health services. Current best evidence is up-to-date information from relevant, valid research about the effects of different forms of health care, the potential for harm from exposure to particular agents, the accuracy of diagnostic tests, and the predictive power of prognostic factors. (Sackett, 1996).
Another definition which is equally valid could be that evidence-based healthcare:
Takes place when decisions that affect the care of patients are taken with due weight accorded to all valid, relevant information. (Merry 1998)
A review of the various methods of control has suggested that there are very few studies on which good evidence-based decisions can actually be made (Barakate et al 2000). Most national guidelines recommend patient isolation as the mainstay of control of the spread of MRSA.
As a major part of the nursing-based procedures, handwashing has a vital part to play. In this respect the paper by Boyce JM & Pittet D (2002) is probably regarded as the gold standard. It reviews all of the available published work in the area. It points to the fact that there is an important distinction to be made between reputable peer reviewed papers and those that are simply published.
Of particular relevance to us in this dissertation is one aspect of their paper which examines the apparent resistance of nursing (and other ) staff to handwashing procedures.(Kretzer et al 1998) Some healthcare professionals appear to consider that handwashing is something of a nuisance. (Teare 1999). Simple measures such as posters and verbal reminders do not appear to have any long-lasting influence as lax habits can soon re-emerge (Teare et al 1999)
We opened this dissertation with a comment about the media perception and portrayal of the MRSA problem. Fairly typical, perhaps, of the type of newspaper coverage that we have seen in recent months is an article (Guardian 2005). It is written with a degree of invective and superlative which is rarely seen in the more measured peer-reviewed journals. It refers to superbugs and government complacency and refers to a mass of statistics and quotes without any attribution at all. It quotes a Chief Nursing Officer (Beasley 2005) as stating that the Government has not done all that it could on the issue.
There is no doubt that we took our eye off the ball," Ms Beasley told NHS managers on the closing day of the NHS Confederation conference. "I think people got complacent. I think clinicians get complacent as the population did. It is not true to say there is nothing we could have done earlier. I think there was.
In the context of this dissertation we note that Ms Beasley is quoted as with the following statement:
Ms Beasley blamed media headlines for sparking public fears over an issue that was first identified more than a century ago. Now when people go to hospital they were as concerned about acquiring a hospital infection as the treatment they were about to receive, she said.
But she admitted the issue was not a figment of the media's imagination. People who contracted the superbug after undergoing hip replacements were often left disabled for life, she said.
This is probably typical of the rather scare-mongering type of reporting that is commonly seen in the media and clearly will colour the vast majority of the public's perception of the issue.
A rather different aspect of the issue is seen in an equally scare-mongering, but slightly more measured piece in The Times (Wise 2004). In this article a solicitor writes to encourage patients to sue hospitals if they contract MRSA infection. It is sadly written in the traditional ambulance chasing style of sue everybody in sight and therefore is full of facts and figures that are not attributed to any source and is (at best) extremely one-sided.
We do not propose to quote from the passage here as, frankly, it does very little to further our knowledge of the subject other than to document the fact that public opinion will clearly be swayed by such articles.
Public perception issues
This issue has to be intimately linked to the previous one as, arguably, the single most important influence on public perception is the media in general. (Kuhse et al 2001)
The question of just how to judge the public's perception of the MRSA issue is difficult as it is clearly not easy to actually define just exactly who are the public. There are, however, a number of sources that can throw some light on our investigations. The BBC has recently had a number of discussion programmes in which the public can air their views and it is probably reasonable to assume that these may be taken as fairly representative of the public as a whole.
In February of this year Michelle Roberts chaired a discussion and phone in on BBC Radio 4 (Roberts 2005). It has to be said that the tone of the programme was neither sensationalistic nor inflammatory, but it did appear to contain a reasonably balanced content.
One of the main points that was raised was the public perception that MRSA somehow equates with dirt, filth and inefficient hospitals. >From the literature that we have discussed, this would not appear to be supported in fact. (Weeks et al 1999)
There were several comments that every death from MRSA is a death too many, with the clear implication that it is a simple problem to keep MRSA out of hospitals. The expert opinion that was voiced said the 9% of patients admitted to hospital would be found to have MRSA but it was not clear just how many of these were infected before they arrived in hospital - simply because pre-admission screening just is not done on a big enough scale. (Cooper et al 1999)
Another point made was that only about 15% of infections were estimated to be prevented by such measures as hand-washing. This is actually rather more optimistic than research suggests. Larson (2004) points to the fact that about a 9% reduction in infection rates is realistically achievable year on year.
The other point that arose from the discussion was the fact that it was not generally recognised that MRSA was a bacteria that occurred normally outside of hospitals in the community and that it was not a product of aberrant hospital procedures. There is little point in examining the public perception in any further detail as it clearly is not based on any type of rational evidence base. It is also sometimes difficult to explain to the non-scientifically orientated person elements of basic science with any degree of success. (Akerman N 2004)
Having made the point, there is one area where the public perception has been explored, and indeed used to advantage, is the so-called patient element in the area of cross-contamination.
The Public Accounts Committee (2000) produced a fascinating study when it was investigating the measures that could be employed to combat HCAIs. Their interviewers found that patients would expound their views strongly to the interviewers when asked if they would challenge a doctor or nurse who did not wash their hands, but when the same interviewers observed a contrived situation, the patients would rarely actually raise the subject.
The authors concluded that the only consistent exception to this was when self- interest was perceived to be at stake. In terms of hard figures, this particular study found that of a cohort of more than 350 patients, 74% replied that they felt that they (as patients) should be involved in the process of helping staff to conscientiously observe hand washing measures. Of these 53% said that they felt confident enough to actually ask staff if they had recently washed their hands but over 80% said that they would ask the same question if the same member of staff was just about to touch them. (Dubbert et al 1990).
It could therefore just be that one of the more effective measures of ensuring healthcare professional's compliance of handwashing procedures is actually (and paradoxically) to educate the public (Gibbs, G 1988)
The Infection Control Nurse
We have already made reference to the Government White Paper "Towards cleaner hospitals and lower rates of infection" (NICE 2004). This particular report is significant in our considerations for a number of reasons. It documents the fact that the government has invested 68 million in instituting measures to improve the cleanliness of hospitals which is over and above any monies that have been invested by the various NHS trusts throughout the country. It also refers to the fact that
control of infection is patchy throughout the UK and that there are excellent examples of good cleanliness and infection control in the NHS, a new campaign is needed to bring everywhere up to the same standard. Control of infection is to be put "at the heart of inspection regimes".
Significantly it acknowledges the fact that the MRSA problem is growing and points to the report from the National Audit Office (NAO 2004) which makes the comment:
"despite putting systems and processes in place and strengthening infection control teams to improve the prevention and control of hospital acquired infection, the NHS does not have enough information on the extent of hospital acquired infection".
This is certainly in line with many of the papers that we have quoted above.
It calls for the appointments of Infection Control Nurses in each DGH who is charged with the responsibility of overseeing the various measures that are put in place to try to control infection. Part of the remit of the Infection Control Nurse is also:
Educating and training in infection control to all groups of staff and compliance with guidance on issues such as hand hygiene and hospital cleanliness.
The same report (NAO 2004) also makes a number of other recommendations including:
The Department of Health (DoH) should carry out research into bed management and isolation in conjunction with the Health Protection Agency (HPA); that the DoH works with the HPA to hurry up the development of a national mandatory surveillance of hospital acquired infection to produce comparable data and that infection control is a key component in undergraduate training.
The Infection Control Nurse is now becoming a frequent sight on the hospital wards (Malone, B 2005) and there is now an Association of Infection Control Nurses which is formed under the auspices of the RCN. Earlier on this year the Association called for the next Government to:
Invest in hundreds of thousands more nurses' uniforms, require employers to build adequate staff changing and laundry facilities and introduce 24-hour cleaning teams in all acute hospitals if they are to successfully tackle MRSA (Nye et al 2005)
The association has also called for the adoption of ten points for effective infection control, namely:-
1) Mandatory infection control training at the time of induction for all health and social care staff working in both the NHS and the independent sector should be introduced across the four UK countries. An annual update, with protected study time to allow staff to attend, should be made mandatory.
2) A standardised infection prevention and control education module should be developed at a UK-wide level by an expert multi-disciplinary group and must become a compulsory component of all multi-professional undergraduate health care programmes.
3) 24 hour cleaning teams should be introduced in all acute health care facilities and be rapidly deployable by senior nursing staff especially for high risk areas such as ICU and emergency care settings.
4) Matrons, senior nurses, sisters/charge nurses or registered managers must have the mandated power, authority and necessary protected time to ensure health care establishments are clean and decontaminated in line with UK standards
5) There must be sufficient provision of staff uniforms for all staff and students commensurate with the number of shifts worked and there must be provision of adequate onsite changing facilities for all staff. All acute health care services must provide adequate and timely laundering arrangements for staff uniforms.
6) The implementation of the ward housekeeper role should be rolled out across the UK and be supported by additional funding, rather than by changing existing nursing establishments.
7) Employers should be mandated to introduce straightforward, confidential and highly visible systems which allow patients, visitors and staff to report safely and/or challenge poor practice, incidents and mistakes involving infection control and cleanlinss.
8) Clinical need and clinical advice given by infection control teams or senior clinical nurses must be paramount in determining how MRSA and other health care associated infectious outbreaks are managed.
9) The Government should re-emphasise its commitment to ensuring that the ring-fenced ward environment budgets of 5000 and the associated ward manager credit cards announced by the Secretary of State for Health in 2000 are adequately resourced, delivered and extended across the whole of the UK.
10) Employers should ensure that there are appropriate, easily accessible and widely available evidence-based infection prevention and control policies for all staff groups, and appropriate and understandable guidance for all patients and visitors.
Discussion and Conclusions
The whole area of MRSA spread in the literature, appears to be largely centred on the issue of handwashing (Jones et al 2000). The whole subject is very succinctly summed up in an article produced by Department of Health (NPSA Study 2004) with the comment:- The quantitative results are subject to uncertainty in several parameters notably the extent to which increased hand hygiene can reduce HCAI rates. A conservative base rate reduction of 9% was chosen based upon available literature (Larson 2004)( Pittet et al 2000) The effects of changes in this key parameter were explored using a sensitivity analysis. This suggests that the interventions will be cost saving even if the reduction in hospital acquired infection rates was as low as 0.1% (NPSA Study 2004)
It would appear that despite the rhetoric and pronouncements coming from various national and governmental bodies, that the whole issue of HACIs is actually being taken very seriously. The Government has commissioned reports and studies and published them (see above) and has appeared to have put in place a number of initiatives (which we have discussed) together with considerable resources, both in terms of money and personnel, in order to try to bring the whole issue under control.
It is clearly a matter of debate as to just how much all of these measures are as a result of clinical need, and just how much is actually due the perception on the part of the politicians, that public awareness of the problem is growing and therefore their success in containing the problem will have a direct impact on the public's perception of them.
It can obviously be argued, from a cynical viewpoint, that all these measures may not have been instigated unless public awareness had been aroused in the first place. From the point of view of the politician, it has to be acknowledged that such considerations are indeed paramount, but from the point of view of the healthcare professional, such debates are largely fruitless. What is clearly more important is just how effective the various measures are in eradicating the problem, insofar as it impacts on patient well-being, morbidity and mortality. (Marks-Moran & Rose 1996)
The last major concept that perhaps we should consider is that raised by a Dutch Professor of Infection Control, Andreas Voss (2004). He takes as his starting point a quote from the article by Cooper ( an author who we have quoted above).
The lack of evidence of an effect associated with specificmeasures should not be mistaken for evidence of lack of effect
This is largely due to the fact that, as we have already observed, although there have been a number of trials on the subject, because of the ethical and practical difficulties involved, it has proved far from easy to get a good evidence-base in this area. (Muto et al 2003).
The author points to the fact that the major confounding difficulty is the fact that it is virtually impossible to establish good randomisation procedures, in the way that perhaps one would if one was constructing a drug trial. Another point that he makes is that trials are at their most useful when they control for, or investigate only one variable. This is almost impossible with trials involving infective parameters as they are almost universally complex and multifactorial.
The professor therefore takes the rather unscientific, but clearly pragmatic, view that
I still have some faith in the strength of common sense, microbiologicalexperiments, and careful observation of success and failurewhen evaluating infection control measures.
The lack of evidence that this review finds should not be used to support arguments that efforts to control MRSA are costly and ineffective. This would be incorrect and harmful.
This concept is of great importance, not only to the healthcare professional but to the patient as well. This should not stop the quest for good evidence based practice, but common sense and experience must also be allowed to play a part if the evidence base is simply not there. (Sherertz et al 1996)
The author points to the fact that it is not generally helpful to assess each of the possible control measures in isolation, in order to try to evaluate the usefulness of each individually. He suggests that it is the additive effect of all of the control measures that is actually important.
Any chain of events is only as strong as the weakest link. It therefore follows that the most intensive isolation procedure can be rendered useless by one nurse who forgets to wash her hands, equally rigorous hand washing is ineffective if a hospital if the patient arrives from the community already infected. (WIP 2003)
Although the Cooper paper is commendable in its efforts to try to establish an independent evidence base for each individual component of the chain, its failure to actually achieve this should be interpreted only as a reflection of the difficulty of addressing the problem and not as a measure of proof that the measures do not work. This is actually a very important point which goes to the heart of any critical review of the literature on clinical matters. The author's general thrust is that one should not be tempted to throw the baby out with the bath water. To quote Professor Voss verbatim:
The lack of evidence,as reported by Cooper et al, is not a convincing argument forchanging successful infection control strategies such as theuse of the search and destroy strategy. While waiting for hard evidence we should have faith that we are doing the right thing.
In conclusion we should observe that the issues of MRSA infection is of major importance in the NHS of today. We cannot fully assess the true impact of these issues without taking account of the realities of public perception and just how effectively this is actually influenced by the various media outlets to which the public is exposed. (Dale BA 2004)
As we have shown, some of these media outlets are clearly responsible and attempt to provide a balanced argument to inform the public on the actual issues involved. Others are blatantly biased and are little more than mouthpieces to publicise one particular viewpoint or another. It is quite clear from our investigations into the subject, that it is actually very rare to find a media source that actually quotes an authoritative source that can be critically verified. It is therefore very important that a serious researcher into the subject would view such pronouncements with extreme caution.
The final comment taken from a report from the Public Health Laboratory Service. Nosocomial Infection National Surveillance Scheme (PHLS 2000.) speaks for itself
The effect is so great that, if "handhygiene" were a new drug, it would be accepted without question.
In itself, that comment speaks volumes.
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