About one in 10 patients admitted to hospital develops an infection. However, this figure varies depending on the type of hospital and the patient category, writes Hilary Humphreys
Vulnerable, elderly ill patients are more likely to get infection and hospitals with a complex caseload, eg those with national or regional specialities, may have a higher infection rate than smaller hospitals.
Infection rates in intensive care units (ICU) are higher than on general medical or surgical wards, because patients in ICU are very ill, they require a number of invasive procedures, eg ventilation on an artificial lung, and require continuous care by nurses and doctors.
When comparing infection rates, it is important to check that similar data is being collected and that due allowance is made for risk factors associated with infection.
A low infection rate in one hospital may be correct but alternatively could be due to infections that are missed. A high infection rate may be due to a more thorough surveillance system with better diagnosis, and or a complex patient population at high risk of infection.
MRSA has attracted considerable attention recently, but it is just one of many bacteria capable of causing infections in hospital. Because strains of MRSA are resistant to many useful antibiotics, there are fewer options for treatment, but it is still possible to effectively treat MRSA.
Hospital infections are expensive for the health system, for patients themselves and their families. In addition, these infections result in pain and considerable distress for the patient and even death. Patients with hospital infection remain in hospital longer, require a greater number of investigations such as X-rays, need more interventions such as surgery and require the use of antibiotics to treat infection.
Apart from these costs, there are indirect costs; an infected patient occupies a bed that might otherwise be used to admit another patient from the A&E department or an elective admission for surgery. Infected patients return to the workforce later than non-infected patients, and they and their families incur their own costs such as travel to hospital. In 1999 it was estimated that the cost of hospital infections in the National Health System in England alone amounted to £1 billion.
It is difficult to estimate what are the costs to the Irish health system but it has been estimated that a 15 per cent reduction in infections would result in potential savings of between €10-20 million at 2001 costs. This is probably an underestimate.
Hospital infections are not new and have been recognised as a significant problem worldwide for many decades. Although not visible to the naked eye, bacteria are innovative, replicate once every 20 minutes and can adapt easily in terms of causing infections and developing antibiotic resistance. The patient population is also increasing in age and in complexity. Cancers, which were untreatable 20 years ago, are now capable of being cured and a greater range of organs can be transplanted in to older patients.
The use of antibiotics, much of it appropriate, contributes to antimicrobial resistance, as bacteria develop resistance relatively quickly, even when exposed to very new antibiotics.
Many of our hospitals are unsuitable for the modern care of the large numbers of complex patients in the system. Too many public patients are cared for in too small a space with insufficient single rooms for patient isolation.
The design, construction and the layout of our healthcare facilities have not kept pace with advances in medical care such as in cancer chemotherapy and intensive care.
Ireland compares unfavourably with other European countries when measured against rates of MRSA in bloodstream infections, collected under the European Antimicrobial Resistance Surveillance Scheme. Our figures are significantly higher than those in the Netherlands and in the Scandinavian countries.
The reasons for this include a different philosophy to hospital infection, ie the importance of preventing infection in hospitals has always been higher on the healthcare agenda in those countries, better hospital facilities for patient care, more specialists to prevent infection, better use of antibiotics and higher staffing ratios.
Patients looked after in inadequate cluttered facilities by too few staff are more likely to get infected than those cared for in adequate space by medical, nursing and other staff, who are not constantly working under intense pressure.
Major reductions in hospital infections, including those caused by MRSA, are not possible overnight. However, improvements will lead to less patient suffering and death, lower healthcare costs and the more effective use of hospital beds.
Interventions to reduce or control hospital infections must be multi-faceted and should include efforts to promote the appropriate use of antibiotics; better compliance with hand-hygiene recommendations such as the National Hand-Hygiene Guidelines recently launched by the Minister for Health; improved cleanliness of the hospital environment as emphasised by the recent hospital audit, the results of which are awaited; the education of all healthcare staff on simple infection prevention measures; and the provision of suitable facilities and space for patients.
Overcrowding in our hospitals with patients waiting for admission on trolleys in A&E departments or patients on trolleys transferred to already full wards is a serious impediment to making progress.
It is estimated that about a quarter to a third of hospital infections are preventable but the remainder are inevitable. In the 21st century, we have very sick elderly patients, requiring complex treatments, all very prone to acquiring infection in hospital. For these reasons also, it is unlikely that MRSA and other hospital-acquired infections will be completely eradicated from our hospitals.
Hospital infection and its prevention have been of concern to microbiologists and infection control nurses for many years.
It was not a priority until recently when patients and the public began to complain, specifically about MRSA. Irish hospitals are handicapped from making significant improvements because of insufficient numbers of personnel with expertise and experience in the area, ie microbiologists and infection control nurses, and inadequate space for the care of our patients, including isolation rooms.
Cleaner hospitals and compliance with hand-hygiene guidelines will help and are important measures in infection prevention, but more radical measures are required.
Until we see the prevention of hospital infection as an intrinsic component of a quality approach in our hospitals, we will continue to see patients with preventable hospital infection, including MRSA.
Quality processes in industry such as in the agri-food sector, where we can trace the product from its original source to the consumer, and in IT, where there is restricted access and the provision of a very clean manufacturing environment, represent a paradigm for what is required in our health sector.
While this cannot be achieved immediately, patients and the public have a right to expect such a commitment to change with the necessary resources, over the medium and long term.
Ultimately this will benefit everybody; patients and their families, all those working in the health service, the Department of Health and Children, and in the long term, the Exchequer.
Hilary Humphreys is professor of microbiology at the Royal College of Surgeons in Ireland and consultant microbiologist to Beaumont Hospital, Dublin