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Clean up your act

MRSA strikes fear in the minds of hospital patients but a more stringent approach to cleaning would reduce the number of hospital-acquired infections.

CleanupMethicillin Resistant Staphylococcus aureus (MRSA) is a term to strike fear in the minds of hospital patients and is vexing health professionals.

There is good reason for concern. In recent years, the number of cases of MRSA and other hospital-acquired infections has been rising steadily. MRSA rates have increased from 7,250 in 2001 to 7,647 2004, while the incidence of other infections has risen by 1,378 to 19,311 in the same period.

John Reid has given the task of solving the problem to Christine Beasley, the recently appointed Chief Nursing Officer. It could prove to be a thankless job. Hospital-acquired infections, including MRSA, are caused by many complex factors: there is no simple, or single, solution.

Making headway
Evidence is emerging that some hospitals are making real headway in bringing infection rates down. University College Hospitals in London are reporting a 50 per cent drop in wound infections after surgery. This has been achieved by consistent delivery of an agreed strategy within the trust.

All hospitals need to share best practice more effectively. The message seems to be that local ownership of the problem is crucial. However, there are some factors that are difficult to control locally.

In the drive to cut costs in the 1980s, many cleaning services were put out to tender with the contract usually awarded to the cheapest bidder. Before this, most hospital cleaners were employed directly by the NHS. The result was a loyal and fairly stable, albeit low paid, workforce.

Throughout my career in the NHS, including three years at the Royal Marsden Hospital and seven in Lambeth, I experienced the value of a dedicated cleaning workforce. Each ward, or department, had regular cleaners who were very much a part of the team.

When contracting firms came in, usually offering poorer wages and conditions, in many hospitals the cleaning workforce became more casualised, less stable and often the sense of being a team member was diluted or lost.

While it is possible for a reputable private company to provide a good and thorough service, it is crucial that NHS Trusts get better at building clarity around standards and consistency in contracts, as well as monitoring cleaning contractors.

It is also crucial that the senior nurse at ward or departmental level has real authority to oversee the quality of the cleaning staff without having to jump through hierarchical hoops to get decisions. Private contractors are not going away, of that we can be sure, but how the NHS actually manages contractors needs to sharpen up.

The other difficulty lies in the sheer volume of activity passing through NHS hospitals. When I was a staff nurse in the 1970s, we had bed occupancy rates of between 75-80 per cent and there was slack in the system. Average length of stay was much longer, so fewer patients moved through the available beds.

When a patient was discharged you had time to clean each bed mattress and locker with appropriate disinfectant. At the weekends, when things were less hectic, I remember spending hours in the sluice room washing the wheels of dressing trolleys and intravenous drip stands. This was part of routine nursing duties.

Today however, average occupancy rates are much higher - usually around 95 per cent - and there is little slack in the system. In addition, length of stay has plummeted, with more patients passing through the beds. No sooner has one patient leaves a bed, a new patient fills it immediately. This scenario leaves hard-pressed nurses little time to undertake the duties of basic hygiene management on the ward.

All the incentives in the NHS are geared towards squeezing more patients through the available beds and making unit costs as efficient as possible. This may look good economically, but this relentless traffic can increase the risk of infection.

The issue of hand-washing between patients is also crucial in solving the problems. Many hospitals are now putting hand wipes in boxes by each patient's bed, making it easy to clean hands before attending to each individual.

Can patients help?
There was a hue and cry when some hospitals suggested that patients and their visitors might also have a role in reminding staff to clean their hands. Some staff felt this was inappropriate.

The public is now far more aware of the problems of hospital-acquired infections so why shouldn't patients have a role in reminding the agency staff nurse to clean their hands before changing a wound dressing? Better-informed patients can help improve things.

On a deeper level, hospitals need to ensure that all staff are well trained in maintaining best practice in the use of aseptic techniques. This becomes even more crucial in areas of high activity, for example, acute medicine, surgical wards, intensive care units and operating theatres. Many routine interventions are invasive and risky; the insertion of an IV line or a urinary catheter, to name but two.

Before patients even get into hospital there is much that can be improved by prescribers in primary care. GPs and nurse prescribers have a key role in patient education. Too often a patient with an acutely inflamed throat will go to the GP demanding antibiotics, when in many cases such use is pointless.

It is tempting to ease time pressures, reach for the scrip pad and acquiesce to patient demand. However, strains of bacteria are becoming increasingly resistant to antibiotics through overuse. Each time we use antibiotics inappropriately, the risk of treatment resistance increases.

The guidance from the Department of Health emphasises that reducing MRSA and other hospital-acquired infections is complex and requires top-level teamwork. If nurses, doctors, allied health professionals, ancillary staff and patients do not work together effectively then success in this area is unlikely.

Hospital chief executives should also be working with staff to find solutions. The average NHS chief executive has a radar screen that is crammed with competing blimps, but it is vital that MRSA remains high on the agenda. Many deaths caused by such infections are actually avoidable; there are solutions.

In today's world, public scrutiny of the NHS is increasing and public expectations are high. If the public does not see a visible reduction in avoidable risk in the medium term, then I doubt that the Chief Nursing Officer will remain in her exalted post!

The Author
Ray Rowden is a Health Policy Analyst and registered nurse

2nd September 2008


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