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Speech summary - Chris Beasley

'It is clear there is no single solution to driving down infection and we need a whole package of measures to combat MRSA.

"This event will help share practical advice from many different staff and many different hospitals. I am optimistic that with the contribution of all staff in the NHS, from chief executives all the way up to those working on the ward, and with the right activities and measures in place, we can make a difference and bring about a significant improvement in patient care."

"This is a long journey and not just something that can be fixed overnight"

The CNO said there was already considerable good work being done by the NHS to prevent and control infection.

"It is important that we share this practice across the NHS. Following today and building on existing work I want to see a range of measures agreed that will make the biggest impact on tackling MRSA."

She said the Department of Health and NHS were in "absolutely no doubt" that patients and the public still found the issue of MRSA and other hospital associated infections a real area of concern.

"There is no point in saying they should not be worried. They are and we have to do an awful lot to make sure that we get people back into a position of confidence.

"It does take time. This is a long journey and not just something that can be fixed overnight. Nevertheless we are committed to improving the situation and it is very important to the patients that use our services, and to us too, that we make real measurable progress."

Speech summary - Professor Gary French

"Trusts and Government must work together to ensure that more compliance with good practice reduces infection"

Prof French delivered a perspective from a trust that has the second highest rate of MRSA and second highest number of MRSA bacteraemias in the country - but has halved its rates over the past year.

He said that although MRSA has been around for a long time it has only really caused a clinical problem in the  UK  since the beginning of the nineties, exacerbated particularly by the appearance of two new clones of the infection.

Prof French said that the NHS knows how MRSA is brought into hospitals, how it spreads and how to control it and that now the NHS needed to screen, identify and isolate patients at risk of bringing MRSA into healthcare organisations, if possible, before admission.

At Guy's and  St Thomas ', and other trusts, it is becoming common for pre-admission clinics to be held where patients are screened before being admitted. If they are found to be carriers they are decontaminated or admission is delayed, said Prof French.

There are many other ways to prevent and control infection that are happening across the country such as using alcohol hand gel, better designed hospital environments, better care of central vascular lines or peripheral vascular lines to reduce MRSA bacteraemia and better use of antibiotics.

"There is a debate about the publication of league tables. Are MRSA bacteraemia rates, which tables are presently based upon, a reasonable measure of infection control?

"I'm becoming convinced they are a very powerful tool. Because it is the publication of these that has led to a major impact on corporate support of infection control procedures and the political interest centred on them.

"Certainly in our own trust it has had a tremendous impact and changed our priorities."

In 2003 Guy's and St Thomas' trust set up its own infection control group and in the 12 months that followed there was a 50 per cent fall in the numbers and rates of MRSA bacteraemia. In addition, isolates of MRSA from clinical sites have also reduced by almost half in the past year.

Prof French concluded: "So in the UK we have MRSA rates that are too high. But this can change. Trusts and Government must work together to ensure that more compliance with good practice reduces infection. When we do things better, as we have at my trust, we have reductions."

Speech summary - Prof Don Goldmann

"What has to be done is a comprehensive, all or nothing gambit at trying to deal with this problem"

"In the  USA  rates of MRSA bacteraemia are high, increasing and somewhat comparable to the  UK ," said Prof Goldmann.

He said there was a high variationin the rates of MRSA in single countries amongst hospitals, which he believed was mainly attributable to variation in practice, and that variation in health care was almost always an opportunity for learning and improving care.

Prof Goldmann said: "You have to know about the MRSA burden in each hospital and this involves more than just screening upon admission.  It means screening patients who have been there for a while in a period study of colonisation.

"If you don't understand the true magnitude of the burden, not just clinical, you probably can't have an informed debate as to what should be done."

Prof Goldmann said it required the resource-intensive need to screen cultures but was worth the investment.

He said the hospitals that were orderly and clean, and had reduced their infection rates, were generally better organised.

Another way to look at the problem was through Hazard Analysis Critical Control Point, or Failure Mode and Effects Analysis.

These take a system, map it out and look for the failure prone points in the system of care. Once identified as a failure prone point, action can be taken to prevent failures.

Prof Goldmann concluded: "Piecemeal efforts fail. We tend to take a piecemeal, one-at-a-time approach. What has to be done is a comprehensive, all or nothing gambit at trying to deal with this problem.

"This involves audit and feedback of data regarding compliance of key process of care. It means caregivers have to know today, not two months from now, how they are performing. Behavioural change methods are totally under utilised in most healthcare institutions. This isn't just a matter of teaching and thinking how to influence. There are models of behavioural theory, social norms, and self-efficacy that we dismiss often as soft science but are critically important to changing the hearts and minds and practices of our caregivers. Multi-disciplinary collaboration is important. Infection control teams must not be the only ones blamed.

"This is a leadership problem and the only way it is going to get solved is if a true multi-disciplinary collaboration amongst people who do not normally work together. It's critical. 

"Rapid cycle tests should be formed. The question isn't what are we going to do in 18 or six months in the  UK  to address this problem. Ask yourself what are we going to do next Monday? Am I going to screen 10 patients or two patients to try and improve some aspect of care?

"It's not just a question of knowing what you want to do but it's having the will and knowledge to do it that is going to count."

Questions for speakers

Delegates discussed the role that patients can play in reducing transmission of infection. Claire Rayner, president of the Patients Association, had a list of 10 things patients could do to help the NHS, which was later distributed to delegates.

It was also felt that there was a need for smart marketing, targeting patients and staff about what the NHS is doing around infection control and to drive behavioural change in trusts.

Other key themes were the need for greater leadership from senior staff and that, while MRSA was a priority, other healthcare-associated infections existed and need to be addressed.

Speech summary - Dr John Boyce

Dr Boyce spoke about the various strategies implemented at the  Hospital of St Raphael ,  New Haven, Connecticut , for controlling MRSA.

He said despite considerable evidence that surveillance cultures could help control MRSA, there was controversy about whether or not it was useful and practical.

 New Haven  took a staged approach and reaped the benefits.

Initially a surgical intensive care unit (SICU) and the haematology/oncology ward were selected to start active surveillance cultures. The unit and ward had ongoing transmission of MRSA with infections, despite implementing precaution policies and alcohol-based hand rub. All patients admitted to the two units were screened on admission and weekly thereafter. Colonised or infected patients were isolated.

Results for nine months showed more than 800 patients were admitted - 89 per cent had an admission culture tested as recommended.

Out of those, 4.5 per cent had MRSA (and a history of it) and the same number of patients was positive for MRSA (without history).

So in taking the cultures the hospital detected 50 per cent of all the patients admitted to the ward and unit with MRSA.

A comparison of a baseline six-month period before the culture surveillance revealed there was a significant drop in MRSA infections in the unit and ward.

A crude cost analysis showed about $11,400 was spent on testing the cultures, which prevented 10 infections at $10,000 - $15,000 per infection, which suggested the culture surveillance was cost-effective.

"This staged process detected patients with MRSA, resulted in more prompt isolation of these patients and significantly reduced the infection rates," said Dr Boyce.

The hospital also screened stool specimens for MRSA as patients with loose or liquid stools that contain MRSA are likely to be sources of transmission.

In 2003 more than 1,500 patients had one or more specimens submitted, about 10 per cent had MRSA - 62 per cent of those had no history of MRSA. Of them 75 were inpatients - with only 15 in isolation.

This policy detected people with unknown MRSA colonisation and were isolated sooner than if this initial test had not been performed.

In some hospitals in the  USA  patients that have a history of colonisation or MRSA infection are assumed to be positive for MRSA for the rest of their life and are automatically put back in contact precautions.

Over a period of years this process requires isolation of patients that do not carry MRSA any more.

At the  Hospital of St Raphael  staff identified people that returned there and those without a positive test in the six months before being admitted were cultured.

If three cultures were negative the patient was removed from MRSA contact precautions. At least 20 per cent of patients were removed from contact precautions following negative results.

This benefited patients and meant that the hospital experienced less pressure on isolation rooms.

Speech summary - Dr Margreet Vos

The  Netherlands  has had major success in keeping MRSA out of its hospitals.

One of the leading places for developing effective strategies to achieve this is the Erasmus University Medical Centre in  Rotterdam .

In 2002, at a neighbouring hospital, there was a sudden increase in the cases of MRSA among patients and healthcare workers, rising from an average of 400 to 1,200 cases. One of the main causes was the introduction of a new strain of MRSA. But it was not recognised as MRSA and in 2002 it, and other strains, were detected elsewhere.

At the 1,200-bed  Erasmus Medical Centre University Hospital ,  there were about 20 positive cases of MRSA per year. In 2002 this rose to 70.

Now in 2004 there is no MRSA in the outbreak hospital and other incidents are quickly eradicated using search and destroy.

"This is proof that you can come from a high endemic level then to hardly any MRSA. Many cultures are now taken from patients and healthcare workers and you don't see any outbreaks," said Dr Vos.

Dr Vos said one of the main reasons for success was search and destroy which involves the early detection, early identification and early containment of infection and encompasses patients, healthcare workers and the healthcare environment.

The critical success factors in the  Netherlands  highlighted by Dr Vos were:

Dr Vos said: "Search and destroy is not evidence-based - it is a package of measures. I can't give you the evidence base. But these are measures that do work. Search and destroy lacks evidence but this is not an argument to stop successful strategies."

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Speech summary - Dr Alison Holmes

"These are institutional barriers which need to be broken through and we need to work across the organisation"

Dr Holmes described ways to achieve effective infection control.

At her trust issues have been addressed around line care where related bloodstream infections are reported now as a clinical adverse incident. In addition, pharmacists are used in an IV to oral programme to reduce the lines used.

"One area we need to focus on is targeting our bloodstream infection surveillance in our high-risk areas such as renal services and neonates. It's also critical we get people onto AV fistulas as soon as possible. The risk is 32 times as high with a line compared to an AV fistula."

The trust Dr Holmes is employed by, Hammersmith Hospitals NHS Trust, has 98 per cent bed occupancy rates which, coupled with stringent A&E targets, makes any issues around cohorting patients very difficult.

There are also many other pressures on isolation rooms and considerations such as gender-mix and staffing levels.

"These are institutional barriers which need to be broken through and we need to work across the organisation.

"We also have to address some professional barriers and to reinforce the importance of infection control, particularly in clinical careers.

"There are lots of policies and ideas of what we can do. We have major institutional barriers. However, we need to acknowledge that this is the system we are working in and we need to focus on changing the organisation's behaviour, culture and its power-base and actually embed infection control in the fabric of the organisation and put it at the forefront of clinical care.

"The other thing that is very important for credibility is that you must be addressing your local issues. It must be driven by local patients needs.

Patient care is the driver, not bacteria.

"More research is required in how to optimise our healthcare organisations to effectively promote and deliver infection control and keep our patients safe."

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Question and answer session with international panel

Delegates discussed the variation in bed occupancy in the  UK , which is very high at around 98 per cent, and in the  Netherlands , which is around 80 per cent, and the difficulties around isolating patients and healthcare workers with MRSA when occupancy is so high.

Dr Boyce said: "In the  US , there was a fear that if all high risk patients and healthcare workers were screened there would be so many with MRSA that there would not be enough isolation rooms and the whole infection control programme would be scrapped.

"So in places where there is a high occupancy rate and not enough room to cohort them, but to get the programme started, we elected to choose those areas of the hospital where there were some private rooms or least disruption to patient care. By doing this in a few high-risk areas we have been more successful than if we had tried to do it all across the hospital at the same time."

Speech summary - Prof Brian Duerden

Prof Duerden discussed what the Department of Health and staff at every level of the NHS from ward to board could do now to start implementing better practice and reduce rates of MRSA and other healthcare-associated infections.

He said that the medium-term programme was that the Department of Health would provide some infrastructure guidance on the sort of infection control arrangements needed in all types of trusts and defining roles and responsibilities.

In the spring, the National Electronic Library for Health will launch a virtual infection control manual - a one-stop-shop of information for healthcare workers.

"The short-term, which is what we are building on today, is to involve the infection control teams with management, using audit, producing an action plan, adopting the sort of clinical guidelines and protocols we have been hearing about today and implementing local focused surveillance so we know what the situation is at unit and specialty level."

Prof Duerden outlined 10 actions for improvement.

He said: "A lot of this is already in place but we are trying to emphasise it is the total package. It only works when the whole lot is brought together. So, although some things are in place, it's a case of looking at the gaps."

The 10 actions for improvement, under the headlines of people, knowledge and practice, were:

People:

Knowledge:

Practice:

Group work

Delegates were asked to work in groups and discuss answers to four questions before presenting them to the conference.

What would success look/feel like in your organisation?

The main responses were user confidence in the trust and organisation, infection control embedded in clinical care, the hospital looks and feels like a better place for patients and staff, seeing all staff being responsible for keeping their environment clean and tidy, and getting infection control on the agenda of the trust board.

What are the key challenges you face in delivering the target?

Delegates felt that the challenge was crossing the boundaries between acute, primary care and the independent sector, particularly care homes. Cultural change throughout the NHS workforce was also cited - getting all NHS staff to translate action plans into action. It was also viewed as particularly important to deal with the public perception of MRSA and for the public to understand that MRSA is not the only healthcare-associated infection and that they have a role to play in driving down infections.

What are the actions you will take when you get back to your trust?

Here calls came for national guidance on infection prevention and control that could be implemented locally. Delegates agreed that making infection control training a core element of staff training was required.

More information on tackling infection and healthcare associated infections:

• Healthcare associated infection