The UK has one of the highest rates of HCAI, and in November 2004 the NHS Chief Nursing Officer, Christine Beasley, provided NHS Trusts with the latest facts and figures about MRSA.
- What is MRSA?
- What does MRSA do?
- How is MRSA passed on?
- What measures can stop MRSA?
- How many people pick up MRSA in hospital?
- How do MRSA rates in the UK compare to those in other countries?
- How many have patients have died of MRSA in England?
- How much does MRSA cost the NHS?
- Why can't the Government provide better statistics on MRSA deaths?
- Do MRSA rates differ between NHS Trusts?
- Is the increase in MRSA a result of poor levels of cleanliness?
- How much does the NHS spend on cleaning?
- Hasn't privatised cleaning in the NHS meant standards have dropped?
- Who monitors cleaning standards?
- Can MRSA be passed on from uniforms and jewellery?
- How are you engaging staff in tackling cleanliness and infection control?
- What about empowering patients?
- What research is being carried out to tackle MRSA?
- Why are we not taking the "search and destroy" approach as in Holland and Denmark?
- How many isolation rooms the UK have?
- How many isolation rooms do we need?
- Won't it be prohibitively expensive to care for patients in single rooms?
- Is there a shortage of infection control nurses? What is the Government doing about this?
- What impact do government targets and high occupancy rates have on MRSA rates?
- What action is taken to monitor MRSA levels in patients when they are discharged from hospital?
- What does the future hold?
- What is MRSA?
MRSA stands for methicillin-resistant Staphylococcus aureus. It is a strain of Staphylococcus aureus, bacteria that can cause infections. MRSA has become resistant to the powerful antibiotic drug methicillin.
However, the term is slightly misleading because MRSA is also resistant to other powerful antibiotics. In fact, around 40% of cases of Staphylococcus aureus in the UK are resistant to methicillin and other antibiotics.
- What does MRSA do?
MRSA does not normally pose a risk to healthy adults or children. In fact, around one third of people are thought to carry it in their noses or on their skin, often referred to as being 'colonised'. But those who are healthy and carry it do not have any symptoms.
The bacteria only becomes a problem if the bacteria gets into the body for example through burns, surgical wounds, or the entry point for catheters or intravenous drips.
MRSA and SA can cause boils and abscesses, the skin infection impetigo, septic wounds, heart-valve infections, food poisoning, pneumonia and toxic shock syndrome.
- How is MRSA passed on?
MRSA is mainly passed on via the hands of healthcare workers, from surfaces to patients or between patients.
- What measures can stop MRSA?
There is no one simple solution to stop MRSA.
One of the most important measures, though, is getting healthcare staff to wash their hands more frequently. International studies show that infection rates are reduced by between 10% and 50% if staff regularly clean their hands.
Other measures include:
- changing dressings using disposable gloves;
- isolating infected patients;
- pre-planning visits of infected patients to other departments;
- placing infected patients in the last slot for operations or X-rays.
- How many people pick up MRSA in hospitals?
There were 7,647 MRSA bloodstream infections from 2003 to 2004, an increase of 3.6% in England over the last year.
But this represents only part of the total picture. There are also, for example, surgical site infections, ulcers and other wound infections. However, the Health Protection Agency does not currently collect these figures.
- How do MRSA rates in the UK compare to those in other countries?
The prevalence of hospital acquired infections and MRSA in hospitals varies widely within the EU.
The rate of HCAI is 9% in England compared with 7% in the Netherlands, and 8% in Spain and Denmark. Rates in France are between 6-10% and 5-10% in the United States.
There has been a significant increase of MRSA in Austria, Belgium, Germany and the UK during 1998-2003. The rate of MRSA increased most quickly in Germany (8% to 18% and Austria (5% to 14%). The rate in the UK is stable following a fast rise of MRSA in the 1990s.
There are countries with very low rates of MRSA, such as the Netherlands, which has the lowest rate of MRSA in Europe. Earlier this year, Chief Medical Officer Sir Liam Donaldson visited the country on a fact-finding mission.
MRSA has become more of a problem in the UK for a number of interrelated reasons. These include the fact that the strains responsible for most infections in the UK are well adapted to spreading between patients. Also, we have a higher proportion of patients who are susceptible to this infection.
- How many have patients have died of MRSA in England?
National Audit Office (NAO) estimates there have been 5,000 deaths a year attributable to hospital-acquired infections.
However, this figure has to be treated with caution because it is based on US figures from the 1980s.
The Office for National Statistics (ONS) study found that MRSA was mentioned as a contributory factor in 800 death certificates in 2002.
But it is worth remembering that some 70 million people went to hospital from 2002 to 2003 including 11.4 million in-patients.
And there were 539,200 deaths in England and Wales in 2003 from all causes.
- How much does MRSA cost the NHS?
It is estimated that 100,000 people a year pick up some form of infection while in hospital, costing around £1 billion a year.
- Why can't the Government provide better statistics on MRSA deaths?
Patients who die with MRSA are often already seriously ill with another medical condition. Therefore, it is difficult to say with any certainty if they would have recovered if they had not caught MRSA.
Death certificates ask for the 'underlying cause of death'. It is up to the doctor how many conditions, other than the underlying cause, he or she thinks should be recorded. MRSA may contribute to death, but it is unlikely to be the first event in the sequence.
However, the Chief Medical Officer's report "Winning Ways" called for an audit of deaths from healthcare associated infections which will be introduced from 2006, and therefore, better data should be available in the future.
Proposed changes should enable death certification to be done electronically. Information from patient records will be linked electronically to the registration, with the consent of a family member, registering the death. This will help identify cases where MRSA or other hospital acquired infections played a role.
- Do MRSA rates differ between NHS Trusts?
Over the last year, the rate of MRSA in some general acute trusts has increased, while the rate in some specialist trusts had decreased.
However, there are limits in comparing NHS Trusts with each other because the rate of MRSA can be affected by a number of factors, such as types of patients treated and the predominant strain of MRSA.
- Is the increase in MRSA a result of poor levels of cleanliness?
Common sense indicates that cleanliness contributes to controlling infection. However, preventing infections is very much more complex and requires more than just cleanliness. This is why good infection control procedures, such as cleaning hands in between patients, are so important.
Some surveys are not helpful in that the study design can be flawed and some methods used do not separate out MRSA from other much more common environmental 'bugs' that have no significance for health infections. These surveys give the impression that MRSA is present when it is not.
- How much does the NHS spend on cleaning?
Our 2002 to 2003 figures indicate that the NHS spent £460 million on cleaning. The NHS Plan injected £68 million extra national investment over and above what trusts have spent locally since 2000.
- Hasn't privatised cleaning in the NHS meant standards have dropped?
The 2003 Patient Environment Action Teams (PEAT) inspections revealed that although many Trusts with out-sourced services had a very strong performance in terms of cleanliness, the private sector has not always performed as well as in-house cleaners. We have recently asked all Chief Executives to check their cleaning contracts to make sure that they can deliver the high quality services we want and that the contracts are flexible enough to meet patients' expectations.
Competitive tendering was seen as too cost driven and not quality driven and we know that cleaning staff at ward level became separated from the ward team and services became fragmented. We know that the key to infection control is sound leadership at ward level and this is why Matrons will have more influence over the way cleaning is organised. To help with this the Chief Medical Officer Sir Liam Donaldson has requested that NHS Estates draw up a new model cleaning contract emphasising quality standards, not lowest cost.
- Who monitors cleaning standards?
National cleaning standards for hospitals have been in place since 2001 and a National Healthcare Cleaning Manual was issued to the NHS for the first time in 2005.
Patient Environment Action Teams (PEAT) inspect hospitals and report to the Healthcare Commission on cleanliness, tidiness and food services - they have reported year on year improvements to cleaning services since 2000. PEAT visitors are volunteers, drawn from NHS managers, nurses (including infection control nurses), patient and patient representative organisations and the general public.
Each NHS Trust has a Director of Infection Protection to oversee cleanliness, and matrons and ward housekeepers ensure standards are met on a daily basis.
As part of 'Towards Cleaner Hospitals And Lower Rates Of Infection' cleanliness and infection control will become part of the annual inspection regimes and patients will be involved in local inspections of cleanliness at their hospitals - these results will be made public.
- Can MRSA be passed on from uniforms and jewellery?
We are not aware of any evidence that uniforms are a significant source of hospital infections.
As for jewellery, staff should remove wrist and hand jewellery at the beginning of each shift before disinfecting their hands.
- How are you engaging staff in tackling cleanliness and infection control?
The requirement in Winning Ways is for each Trust to designate a Director of Infection Prevention and Control is helping to change the culture.
In September, we brought together matrons, facilities managers, infection control nurses, the Royal College of Nursing (RCN), the Royal College of Midwives (RCM), the Infection Control Nurses Association (ICNA), Association of Domestic Managers (ADM), the Hospital Infection Society (HIS), Unison and the Healthcare Facilities Management Association (HeFMA) to work to develop a Matron's Charter to help matrons in their key role.
The NHS is successfully introducing Ward Housekeepers; staff who can be a constant presence on wards to assist patients and help out with some of the domestic chores such as cleaning and serving food.
Prior to the NHS Plan, Department of Health did not collect data on how many Trusts employed Ward Housekeepers. Since 2000, over £14million central funding has been invested in developing this role and over 53% of larger (over 100 bed) hospitals now have housekeepers in post - over 5,000 in total.
A series of activities aimed at ensuring that cleanliness is at the forefront of everyone's mind is underway.
The National Patient Safety Agency's "Clean Your Hands" campaign is in action across the NHS. This will empower patients and their carers to challenge NHS Staff to ensure they have washed or disinfected their hands before touching them. The campaign will help acute Trusts to implement the provision of anti-bacterial hand gel at all staff-patient contact points.
The new audit tool developed with the Infection Control Nurses Association will help NHS staff monitor and improve infection control. This will help NHS staff assess compliance on policies on hand hygiene, decontamination of patient equipment, linen and waste handling, clinical practice, the environment and ward kitchens.
We will collect the views of stakeholders for views on lines of accountability for domestic and house keeping staff. We will also consider whether the use of a direct line for patients to contact domestic services would help promote cleaning.
- What about empowering patients?
The "Clean Your Hands" campaign very much encourages patients to challenge staff about cleanliness.
Other areas being examined include establishing a direct line to contact domestic services to report problems, producing better patient information leaflets, and publishing infection rates to help patients exercise choice.
- What research is being carried out to tackle MRSA?
Some £3 million has been earmarked for research and development into MRSA.
Drugs are being developed and tested in clinical trials to treat strains that are resistant to vancomycin and teicoplanin.
Chief Medical Officer Sir Liam Donaldson has asked the Government's medicines watchdog (the MHRA) to fast track the latest products for hospital use. Research on new methods of cleaning is also being done.
- Why are we not taking the "search and destroy" approach as in Holland and Denmark?
Countries such as the Netherlands and Sweden have a low prevalence of MRSA and have been able to maintain a "search and destroy" policy for MRSA. This means that they can screen more patients for MRSA than we do in the UK and either treat the patient to remove MRSA before surgery etc or take other action such as putting them in an isolation ward. These measures are easier in countries with a low prevalence of MRSA and a higher proportion of single rooms or small bedded wards. However, their overall levels of HCAI are similar to the UK.
- How many isolation rooms the UK have?
Across the NHS, around 23% of beds are in single rooms and 15% of beds in acute hospitals are in single rooms.
For the latest hospitals put forward for approval, 8 out of 12 planned to have 50% single rooms. The others were asked to review their plans, and now all but one plan to have 50% single rooms.
- How many isolation rooms do we need?
It is not easy to be precise because the need for an isolation room varies with the type of patient being cared for.
- Won't it be prohibitively expensive to care for patients in single rooms?
Hospital infections are expensive, so anything that helps us to prevent them is valuable.
Evidence from other countries show that single rooms have other safety advantages, such as reducing medication errors.
- Is there a shortage of infection control nurses? What is the Government doing about this?
There are more qualified nurses working in the NHS than ever before, as at September 2003 there were 386,359 NHS nurses, an increase of 67,500 since 1997. The NHS Plan, manifesto and 'Delivering the NHS Plan' targets for increasing the NHS nursing workforce have all been achieved early and the NHS Plan target for increasing nurses and midwives entering training has been achieved.
The National Audit Office report 2004 acknowledges that there has been a rise in the number of infection control nurses. In 1998 the ratio of infection control nurses was one nurse to 535 beds. The ratio was one nurse to 347 beds as of June 2003.
- What impact do government targets and high occupancy rates have on MRSA rates?
It is possible for hospitals to meet targets and have low MRSA rates.
For example, from 2003 to 2004 Sheffield Teaching Hospitals NHS Trust, Harrogate Health Care NHS Trust and Taunton and Somerset NHS Trust achieved waiting list targets and maintained low rates for MRSA.
The NHS runs at high occupancy because it is treating more patients and cutting waiting lists.
Although there are potential risks to extensive movements of patients in hospitals and high bed occupancy rates, it is important to recognise risks can be managed through simple measures, such as good infection control surveillance systems.
- What action is taken to monitor MRSA levels in patients when they are discharged from hospital?
A significant amount of work has been undertaken on this but unfortunately it has not produced a viable way forward. However, this will be a priority for the committee on surveillance being convened by the Health Protection Agency.
The Healthcare Associated Infection Surveillance Steering Group sub-group looked at surveillance of caesarean sections and identified practical problems with implementing surveillance in the community. One particular problem was access to hospital records in the community.
Problems and complexities of post discharge surveillance are well described in the scientific literature and there is a need to improve the evidence base. In autumn 2003, the NHS Research Methodology programme issued a call for tenders on methods for identifying and classifying surgical wound infection after discharge from hospital. Unfortunately none of the applications were suitable and an expert paper was commissioned from the Depart of Health Sciences University of York and should be available shortly. This will be used to inform the Health Protection Agency's committee.
- What does the future hold?
The outlook for dealing with MRSA is good. There are ways of controlling it through improved hygiene and isolating patients, and research is ongoing into new drugs. One such drug, called Aurograb, is currently under trial in the UK.
However, other resistant strains are appearing. VRSA, or vancomycin-resistant Staphylococcus aureus, has acquired resistance to vancomycin, a drug considered the last line of defence.
The UK has already seen several cases of GISA, or glycopeptide intermediate Staphylococcus aureus, a kind of halfway house between MRSA and VRSA, which has developed a resistance to antibiotics of the vancomycin family.