Bottle of soapYvonne Peel

Hospital acquired infections, particularly methicillin resistant Staphylococcus aureus (MRSA), have been under the spotlight recently. At any one time it is suggested that 9% of the hospital population is affected by an infection acquired during healthcare.

This is a risk factor in any environment where vulnerable people are in close proximity for long periods, but its prevalence in the acute care sector has become the focus of attention. Government deadlines need to be met to demonstrate improvement.

A key policy document in this area was published in December 2003, "Winning Ways – working together to reduce Healthcare Associated Infection in England", by the Chief Medical Officer. Among many of the recommendations, trusts were told to appoint directors of Infection Prevention and Control (DIPCs). In practice, these tended to be consultant microbiologists. Other recent prominent initiatives and announcements have included the setting targets that trusts must reduce bacteraemia rates by 50% by 2008.

However, there are many issues about reporting MRSA:

  • Acute trusts possess a wide range of information systems in infection control and have many different ways of counting infections;
  • Data are reported centrally but feedback to hospitals is not in a helpful and timely form;
  • There is a general lack of confidence in the comparative robustness of trusts’ infection control data.

In this scenario, what strategy should doctors support?

Measurement and information collection

Many initiatives have been instigated by trusts and others – including hand-washing campaigns and deep cleaning programmes – and best practice is being established, but how are trusts to measure and demonstrate this improvement, and how can a comprehensive picture of the problem be gained?

The NHS must produce information on MRSA at hospital level. Some information is now being collected about MRSA bacteraemia infections, but not on the total numbers of patients affected by MRSA, and the impact of prolonging hospital stays, which reduces available beds and increases costs in terms of bed days and drugs.

There is a pressing need to develop better information about the impact on hospital resources of patients with MRSA. Information can underpin the targeting of efforts to tackle infections, provide doctors and others with arguments for investing in care arrangements, enhance the corporate understanding of the issue, and improve external reporting.

Improvement of data quality needed

The challenge is to link, at patient level, the data held about the infection by the infection control department with the admitted patient dataset held by every hospital’s Patient Administration System.

Admitted patient datasets represent a rich source of information about many aspects of care, including types of patients affected, the specialties in which they were treated and the operative procedures performed. This data can contribute to research and show the behaviour patterns and risk factors that affect the spread of infection. It can also be used to better understand the environment and conditions which increase the risk of healthcare acquired infections. In discussions with managers and clinicians, the measure of local impact has been seen as an important contribution to the debate.

But the link between infection control data and admitted patient datasets is not always straightforward. The number of creative ways in which hospital datasets are inconsistent is surprising. For example, the systems may use different patient identification numbers or may technically handle data or text fields in divergent ways. Some data sets may be created ad hoc and be difficult to interrogate.

However the successful synthesis of the two datasets can lead to new knowledge about the pattern of presentation of infected patients. Without linking the data, such patterns are not apparent. Additionally, the array of the additional cost associated with the longer stays of MRSA patients, compared with the lengths of stay of uninfected patients in hospital with the same underlying conditions or for the same operations, helps calculate the extra cost on the hospital that potentially could have been avoided.

Linking hospitals together

So far, an opportunity for infection control by benchmarking hospitals has been neglected. Once data quality has been addressed, comparable hospitals should share incidence, volumes and impact at specialty level. The selection of peer hospitals could be based on locality, similar numbers of transfers or the organisation of clinical specialties. The linkage, analysis and interpretation of these datasets at a sufficient number of hospitals will allow the development of risk adjusted tools that could better predict the probability of infections and greatly improve the reporting between hospitals of nosocomial infections.

Furthermore, the use of organisational audit and benchmarking can demonstrate areas of best practice that should be encouraged in all healthcare environments. Continuing trends can be demonstrated through robust data collection and audit to combat existing problems, deliver improvements and present any early warning systems of future problems.

Making the connection between infection control and admitted patient data helps to show the organisational impact of healthcare acquired infections and can give doctors and managers an organisational tool they can use to tackle the issue together.

Yvonne Peel