This site is intended for health professionals only

Infection control: think clean to tackle MRSA

Sarah J Fairclough
RGN
Epsom and St Helier University Hospitals
NHS Trust

In February 2005, the National Statistics Office reported that the number of death certificates that mentioned Staphylococcus aureus had increased annually between 1993 and 2003 in England and Wales, solely because of the rise in methicillin-resistant Staph aureus (MRSA). The statistics proved sobering enough to hit the national headlines. Fortunately, trusts can take steps to hold back, or even reverse, the rising tide of MRSA and other nosocomial infections. However, nurses shouldn't be fighting this rising threat alone; everyone in the NHS - from consultants to cleaners - needs to make a concerted effort to prevent the further spread of these almost ubiquitous organisms. Building on the advice of Christine Beasley, the Chief Nursing Officer, this article aims to encourage you to think about how you work and whether you could make any changes to improve overall cleanliness within the healthcare environment.

The sobering statistics
The National Statistics Office revealed that:

  • The number of death certificates mentioning MRSA increased by 19% between 2002 and 2003.
  • The age-standardised MRSA mortality rate in males increased from 14.8 per million of the population in 2002 to 16.3 per million in 2003.
  • Among females, the rate increased from 7.0 to 8.5 per million respectively.

Laboratory reports of MRSA increased by only 7%, however, so part of the recent rise probably just reflects increased reporting. Nevertheless, MRSA is undoubtedly becoming more common and imposes increasingly heavy clinical, managerial and economic burdens. For example, hospital-acquired infections cost the NHS up to £1bn a year.(1) And it's not just hospitals that need to worry: over the past three years, the Health Protection Agency has identified approximately 100 cases of community-acquired MRSA (CA-MRSA) in the UK; one patient actually died after acquiring the bug within the community.(2) The USA has already been experiencing a rise in CA-MRSA for some time,(3) and it seems that the UK is now following in its footsteps.
Ironically, official statistics suggest that hospitals are becoming cleaner, compared with 2000 at least. Currently, around half of all hospitals have "good" or "very good" levels of cleanliness. In most others, cleanliness is "acceptable". Fewer than 3% of NHS trusts put in a "poor" cleanliness performance. Nevertheless, the Department of Health (DH) aims to improve standards, and some of the initiatives implemented within hospitals can also be transferred into communities. Environments such as GP surgeries and sports centres, where more vulnerable people are present or infection is more easily transferable, could benefit from observing many of the same principles of cleanliness standards.
However, cleanliness alone is unlikely to be sufficient to reduce MRSA rates. As a result, a growing number of initiatives aim to tackle MRSA, including the "clean your hands" campaign led by the National Patients Safety Agency and a new cleaning contract published by the DH. The DH plans to publish each hospital's infection rates, make matrons responsible for cleanliness, and promote handwashing among healthcare workers. To help meet the last objective, a growing body of evidence - discussed later in this article - suggests that alcohol rubs improve compliance with hand hygiene and are easily implemented in busy wards and surgeries.

Think clean
In one of the most recent initiatives, nurses, doctors, consultants and cleaners from 939 hospitals participated in the Think Clean Day at the end of February. As part of this, the NHS distributed promotional material to each hospital encouraging the trust to audit a ward or department and address any cleanliness problems that emerged. The organisers, which included local trusts, the DH, UNISON and the Royal College of Nursing, hoped that the day would prompt trusts to examine their current performance critically and sustain their action against infections over the longer term.
These steps should help the NHS reach the Secretary of State for Health's ambitious target of halving the number of MRSA blood infections in NHS hospitals by 2008. The National Audit Office (NAO), for example, suggests that better application of good practice could prevent around 15% of all hospital-acquired infections, which would release £150m for alternative use. Other authors suggest that better-quality care could prevent about one-third of healthcare-associated infections.(4)
"Hospitals need to be kept clean all day, every day, and we have already put in place national standards and monitoring procedures which will deliver real improvement," said Christine Beasley on Think Clean Day. "Everyone, no matter how junior or senior, can play a part. I hope that all staff will take the opportunity to think about how they work, and whether there are any changes they could make that would improve the cleanliness of our hospitals."

A spreading problem
Over the last few years, numerous factors conspired to encourage the spread of MRSA and other bacteria responsible for nosocomial infections. On average, the human body is home to at least 1,000 species of bacteria. Most of these are innocuous. Others can cause disease when drugs or illness compromise immunity. MRSA is, for example, carried unintentionally by patients, visitors and healthcare staff, who can spread it around the hospital and surgery. MRSA and other nosocomial bacteria usually cause symptoms in people already weakened by illness. Indeed, intensive care units (ICUs) tend to be the most susceptible departments to nosocomial infections.(5) In one ICU, MRSA was present on almost 17% of available bed days.(6)
Similarly, this tendency to infect the vulnerable means that the elderly are especially prone to contracting MRSA. In 2003, according to the National Statistics Office, MRSA mortality rates in those aged 85 years and over reached 437.1 and 220.8 deaths per million of the population for males and females, respectively. In contrast, among people under 45 years of age, there were 0.9 and 0.6 deaths per million among males and females respectively.
Pressure on trusts to meet performance targets probably also contributed to the inexorable spread of MRSA. To meet the targets, trusts often need to maximise patient throughput. As a result, bed occupancy tends to be high. According to the NAO, 71% of trusts report bed occupancy levels as being higher than the 82% target that the DH aimed to achieve by 2003/04. This, the NAO comments, could undermine good infection control. Furthermore, patients increasingly moved between wards and even different hospitals.(1) The trend towards earlier hospital discharge, day surgery and the increasing transport of patients between facilities is also likely to have an impact on the greater spread of infections in the community. Even patients' case notes may contribute to the spread of infection - a potential problem in both primary and secondary care. In one study, which randomly sampled 228 current inpatients' notes, bacteria were grown from 227.(7) Although most were environmental, nine cases grew Staph aureus. Numerous other clinical and logistical factors contribute to the spread of MRSA and other nosocomial organisms. These examples suffice, however, to underscore a key point: winning the war against MRSA means advancing simultaneously on several fronts.

Improving hand hygiene
Improving hand hygiene is one of the most important measures in the fight against MRSA. To make the advances needed, all healthcare professionals - both within hospitals and in the community - need to ensure that complying with hand hygiene is simple and effective. They also need to ensure that healthcare professionals can implement the approach rapidly on a busy ward, clinic or GP surgery. This may mean improving hand-cleansing facilities and offering a range of materials other than  soap.(4)
 
Effective measures
Alcohol hand rubs offer one alternative to soap. Indeed, alcohol hand rubs quickly and effectively decontaminate hands without water and can be applied by the bedside. As the author of one study comments: "In intensive care units, less time-consuming hand-rubbing might replace standard handwashing and overcome the barrier of time constraints".(8) The same applies to other busy wards, clinics and surgeries. Within primary care, practice nurses and GPs may find that using alcohol rubs is a far more convenient, practical and effective method for maintaining hand hygiene than requiring access to a sink, soap, water and towels to undertake traditional handwashing. Alcohol hand rubs also tend to be less irritant to skin than soap.(9)
This combination of ease and efficacy means that alcohol hand rubs increase compliance with hand hygiene by around 25%.(6) For example, in a study of three paediatric intensive care units, compliance with hand hygiene was as low as 23%. After introducing the hand gel as part of a quality improvement initiative, compliance increased to approximately 37%.(10) The 40% compliance rate emphasises, however, the need to continue improving hand hygiene.

Campaign of cleanliness
In another study, an educational campaign in medical, surgical and paediatric ICUs increased compliance with hand hygiene from 38% to 55%. The campaign had little impact on handwashing, however, with only 30% of healthcare workers washing their hands. However, the campaign increased the proportion who rub their hands with an alcohol-based formulation from 5% to 22%. Nurses and nursing assistants showed a particularly marked increase in compliance, although the campaign seemed to have little impact on compliance among physicians.(8) Nurses now have an unprecedented opportunity to educate their physician colleagues about the importance of good hand hygiene and cleanliness generally.

Conclusion
Until recently, preventing hospital-acquired infections was a low priority for most trusts. For example, there was just one infection control nurse for every 347 beds. MRSA's growing clinical, economic, managerial and political importance forced hospital hygiene back up the NHS's agenda. As mentioned above, a combination of strategies and products should be enough to counter the spread of MRSA.
Despite the political will to counter nosocomial infections, in the war against MRSA and other resistant bacteria we're not - to paraphrase Churchill - at the end. We're not even at the beginning of the end. But the current focus on MRSA means that we may be at the end of the beginning - provided that everyone plays their role.

References

  1. National Audit Office. Improving patient care by reducing the risk of ­hospital-acquired infection: a progress report. London: NAO; 2004.
  2. Health Protection Agency. Available from URL: http://www.hpa.org.uk
  3. Rosenberg J. Methicillin-resistant Staphylococcus aureus (MRSA) in the community: who's watching? Lancet 1995;346;8968:132-3.
  4. Rickard NA. Hand hygiene:promoting compliance among nurses and health workers. Br J Nurs 2004;13:404-10.
  5. Newsom SWB. MRSA - past,present, future. J R Soc Med 2004;97:509-10.
  6. Thompson DS. Methicillin-resistant Staphylococcus aureus in a general intensive care unit. J R Soc Med 2004;97:521-6.
  7. Bebbington A, Parkin I, James PA, Chichester LJ, Kubiak EM. Patients' case-notes: look but don't touch. J Hosp Infect 2003;55:229-301.
  8. Hugonnet S, Perneger TV, Pittet D. Alcohol-based handrub improves compliance with hand hygiene inintensive care units. Arch Intern Med 2002;162:1037-43.
  9. Bissett L. Can alcohol hand rubs increase compliance with hand hygiene? Br J Nurs 2002;11:1072, 1074-7.
  10. Harbarth S, Pittet D, Grady L, et al. Interventional study to evaluate the impact of an alcohol-based hand gel in improving hand hygiene compliance. Pediatr Infect Dis J 2002;21:489-95.

Resources
National Statistics Office
W:www.statistics.gov.uk
National Audit Office
W:www.nao.gov.uk
Department of Health
W:www.dh.gov.uk/Home/fs/en
Chief Nursing Officer
W:www.dh.gov.uk/AboutUs/HeadsOfProfession/ChiefNursingOfficer/fs/en