MRSA Incidence: Presentation
Deputy Gormley: Dr. Cunny says that two thirds of hospital infections are inevitable, which brings the figure for those developing infections in hospital down to roughly 6%. How does that compare to countries that are very good at managing infections, such as the Netherlands and Sweden, where best practice prevails?
Dr. Cunny: I do not have the exact figures to hand but we are roughly comparable. The overall average is approximately 10% but the rate varies from 5% to 15 % across different countries, types of hospitals and types of infections. Countries such as the Netherlands are closer to the lower end of the scale.
Deputy Gormley: Does Dr. Cunny know what the figures for Ireland are at present?
Dr. Cunny: Unfortunately, we do not know and that is one of the purposes of the major international study mentioned by Dr. Kelleher, in which we are participating next year. That study will help us to establish the baseline level of hospital acquired infections here. The beauty of the study is that when we are collecting data in Irish hospitals, similar data will be collected in hospitals in Northern Ireland, Scotland, England and Wales, thus enabling us to compare our figures with other regions and groups of hospitals within the United Kingdom.
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Deputy Gormley: Has Dr. Hynes any costings on measures to make it easier for hospitals to comply? What level of increased investment would be required?
Did she say that there is no direct correlation between overcrowding and MRSA rates or did I misunderstand her? I always believed that to be a significant factor.
I raised the issue of antibiotics last week. Some GPs seem more responsible than others in terms of prescribing antibiotics. There are doctors in my constituency who freely supply antibiotics and patients who complain when they are not prescribed for minor ailments. Should we not be more rigorous in our scrutiny of this matter because the real source of the problem is antibiotic resistance?
Dr. Hynes: We have conducted a gap analysis on the personnel required to make it easier and this has clearly indicated the levels of funding involved. While the pit is almost bottomless in terms of the fabric of hospitals and what can be done, we have agreed to invest an initial €20 million in 2006. The latter will be focussed on measures that can be put in place quickly. Not only should compliance be made easier for hospitals but we should also facilitate individual members of staff, including porters and allied health professionals as well as doctors and nurses. If we want them to clean their hands, we must make it easy for them to do so.
My remarks on the direct correlation with overcrowding referred to cleanliness rather than infection rates. For example, St. James’ Hospital, which has one of the busiest accident and emergency units and highest occupancy rates in the country, managed to achieve good results. On the Deputy’s question on overcrowding, logic dictates that patients who are close together are more likely to infect each other. Hospitals that have high occupancy rates but insufficient isolation units will face greater difficulties in keeping infected patients separated. That is a problem with regard to infections.
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Deputy Gormley: Is Dr. Cunny saying hand washing is vital but environmental cleanliness is not?
Dr. Cunny: One must know what is required to control hospital acquired infections. Factors include hand hygiene, environmental hygiene, control of antibiotic use, staffing levels, laboratory resources, infection control infrastructure and surveillance programmes. No single component will control MRSA.
The United States focussed on hand hygiene for many decades but it did not work. MRSA rates in the US increased and their problem is bigger than ours because they did not address all the factors. The countries that have succeeded took a multidisciplinary approach and tackled all the problems at once, and we must do the same. The SARI progress report has identified this in its priorities for next year and onwards.
On trying to correlate the results of the hygiene audit with MRSA rates in individual hospitals, the problem is that we have no national system for measuring MRSA in individual hospitals. We have a system that allows one to calculate the overall national figure for the number of MRSA bloodstream infections. That does not detail the rate in individual hospitals or tertiary referral centres. One does not know how many infected patients were transferred from other hospitals, came in from the community or acquired it in the hospital. A hospital that is aggressively testing for MRSA will detect more cases while a hospital with inferior surveillance will detect fewer cases and will look better. It comes back to information for action. We need better data, but first we need the resources to gather it.
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Deputy Gormley: There seems to be inconsistency among general practitioners in the prescription of antibiotics. What is the current position? Are there data on it?
Dr. Kelleher: We provided data to the committee in advance of this meeting. Rates are higher than the EU average and must be addressed seriously. It is an issue of behaviour affecting all of us. People take a child to a GP with earache or a sore throat and expect to come away with an antibiotic prescription. It takes 15 minutes for a GP to persuade them not to go on a course of antibiotics but it only takes a minute to write the prescription. We in the profession have a responsibility to get that message across and develop guidelines for our staff on such matters as prescriptions and washing hands.
I will answer a couple of important questions. Professor Drumm has clearly stated we must address the resources in our system and how we deal with the community side of primary care. Having read the transcript from last week we must address how we support people coming out of hospital with MRSA and other infections. We also learnt from last week’s transcript that we must get the message to everybody in the health services that they must spend more time passing on information about infections so patients understand them and can take appropriate action. People must tell patients what is happening.
The patients’ association told the HSE they wanted to help us and we are grateful for that. It was suggested they should be represented on our groups and we must explore that in our meeting with them in January. Dr. Hynes and I will meet them again on Friday to discuss actively progressing that idea. They are keen to have a voice in the process and we are keen to hear that voice. That meeting will be very important in directing us on the way forward.
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Deputy Gormley: Dr. Kelleher said he has data on the prescribing of antibiotics. Does that compare prescription rates from GP to GP or what sort of data is available?
Dr. Cunny: There are two types of data available. The first is national level data that we report as part of a Europe-wide surveillance system where we can compare our overall level of antibiotic use, and patterns of antibiotic use across the Continent. That is how we know that our overall level is not the highest in Europe. Ireland is among a group of countries in which levels are a little above average but are not as high as those in some countries, such as Spain or France. There is also individual prescription level data available through the GMS scheme that is fed back to individual GPs generally through GP units within the old health board structure or GP tutor groups. It is the tutor groups model that is being used in the pilot work going on in the southern region, which is being rolled out to other regions as well, of giving GPs feedback on their own prescribing patterns. The work done in the southern region has been very successful in that the GPs can examine their own prescribing patterns and identify where they are overusing particular types of antibiotics or problems with particular types of patients. The focus has been on addressing many of the cultural issues and the way patient demand, or perceived patient demand, for antibiotics should be addressed. That model appears to be successful but the next stage is tying it in with patient and public education. That will be a major focus of the joint meeting we will have with our colleagues at the end of this month in Armagh in terms of drawing on the success they have had in this area in Northern Ireland.
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Deputy Gormley: When the Lorenzo system is in place, will Dr. Cunny be able to get that prescription data back quickly? Is part of the process that he will be able to know that very quickly?
Dr. Cunny: The difficulty with the prescription level data is that it is only available for the GMS scheme. There is no data at prescription level for non-GMS antibiotic use but work is being carried out at the national centre for pharmacoeconomics in St. James’s Hospital, which is examining overall GMS prescribing n a quarterly basis. At local level, that data is also fed back to individual GPs and that is where it makes the difference. Feeding back the data to individual GPs means they can then use it to modify their own prescribing if necessery.