We Americans can learn a great deal from our friends in the United Kingdom if we simply take the time to pay attention. For today’s lesson, we’re most grateful to Dr. Stephanie Dancer, Consultant Microbiologist at the NHS Lanarkshire, and fellow blogger The Ferret Fancier; the former for her work and permission to republish her presentation here, and the latter for bringing this whole thing to our attention. While the topic at hand is most directly about infection control and the best way to defend against the spread of methicillin-resistant Staphylococcus aureus (MRSA), the lessons and implications go well beyond infectious disease and take us on a short trip down the Road to Hellth.
For those of you who may not be in tune with such things, MRSA is a potentially harmful strain of bacteria that often infects wounds or breaks in the skin. It is highly resistant to treatment by conventional antibiotic therapy. MRSA bacteria are responsible for a substantial percentage of hospital-acquired skin infections, and such infections can be extremely expensive and difficult to treat. The bacteria can also be encountered among relatively healthy people in the larger non-hospital community – and is often spread as a result of sharing razors, sports equipment and other items that come in contact with the skin. As is the case with many health problems, this is one that we’ve largely created for ourselves through the ubiquitous and often indiscriminate use of antibiotics for everything from scratches to animal feed. Nevertheless it’s important to try to limit its spread because our treatment options for MRSA-related illness are rapidly disappearing.
We strongly encourage all of our readers to go through Dr. Dancer’s excellent slide show on the topic of MRSA embedded above. But for the benefit of any of our readers who may be time-constrained and/or impatient we’ll provide a short synopsis and make a couple of observations.
Soon after it became apparent the MRSA was a problem that would not go away, medical researchers began to think about how it might be possible to limit the spread of this organism in the hospital. One strategy that was formally investigated in the late 1990s was the enhanced use of hand washing among healthcare personnel. In 2000, Dr. Didier Pittet and his colleagues in Geneva Switzerland launched a study in which they carefully observed the hand washing practices of in-hospital providers and actively promoted hand hygiene, especially with the use of bedside alcohol-based gels, and tracked the impact on MRSA infections over time. One result was that while the hand cleaning rates among nursing and support personnel improved significantly over the three year study period, hand cleaning among doctors did not. A second result was that both hospital-acquired infections and the MRSA transmission rate fell substantially. The impact of this study was immediately felt around the world, as hospitals everywhere proceeded to launch intensive hand-cleaning programs of their own.
As people are wont to do in such cases, healthcare and political leaders everywhere began to look for ways to improve upon the hand washing crusade. “After all”, they reasoned, “if a little hand washing is good, more is better, right?” Administrators in the United Kingdom took the leadership bit between their teeth and began to run hard and fast.
As illustrated by Dr. Dancer, they launched into a fairly astonishing variety of interventions including the production of posters, life-size cardboard cutouts of admonishing nurses, audits, conferences, flyers, “hand-hygiene coordinators”, badgers badges, UV detectors, TV monitors, additional sinks, disinfectant dispensers, warning letters, flashing signs, committees, sniffer dogs, more audits, and lots of additional managers and administers to name just a few. In 2007 and 2008 three separate government departments came out with MRSA-related guidelines dictating that healthcare providers had to eliminate their personal use of wristwatches, jewelry, neck ties, white coats and pens or pencils in outside pockets. They were further instructed to go “bare below the elbow, and forbidden to leave work in their uniforms. Finally, on January 29, 2009 the government in Scotland really took the gloves off. It established a “zero tolerance policy” for providers who failed to wash their hands, complete with the threat of firing.
“A ‘zero tolerance policy’ for NHS staff who fail to wash their hands was today declared by the Scottish Government.
And the public will be able to check superbug infection rates and levels of hand cleanliness for each hospital under the new measures.
The latest moves in the battle against hospital infection were announced today by health secretary Nicola Sturgeon.
A ‘one-stop shop’ is to be set up to give public access to all published information on hospital infection rates and hand hygiene compliance.
This will be available on a website which will be established by the end of the month.
The ‘zero tolerance’ approach has been set out by the Scottish Government’s chief nursing officer, Paul Martin, in a letter to all health board chief executives.
Figures earlier this month showed varying levels of compliance for hand hygiene.
The target level for compliance in Scotland is at least 90%. Overall, this target is being exceeded, at 93%.
But within this total, compliance levels vary from 95% for nurses to 84% for medical staff.
Ms Sturgeon said: ‘Hand hygiene is a simple, but essential, part of our drive to tackle infections in hospitals, for everyone from consultants to clerical staff.
‘That’s why we are now adopting a zero tolerance approach to non-compliance by NHS staff to ensure we build on the great progress that has already been made.’
The new drive includes an eight-week advertising campaign.”
Not to be left out, politicians “across the pond” in the U.S. have taken up the cause. In April of 2011, Sen. Jeffrey D. Klein and Democratic colleagues in the New York state legislature sponsored S4909, which mandates a “Health Care Practitioner Hygienic Dress Code” that is similar to the rules imposed in the U.K. At the time of this writing Senator Klein’s bill is still in committee, but infectious disease specialists have questioned its clinical value:
“The New York legislation “sort of verges on hysteria,” said James L. Cook, MD, chief of the Section of Infectious Diseases, Immunology and International Medicine at the University of Illinois College of Medicine in Chicago. “You’ve got to decide. Do you want to use the evidence? … There is nothing to suggest that anything you find on someone’s article of clothing is likely to be transmitted to a patient.”
Apparently undeterred by any potential criticism, however, the bill’s sponsors are continuing to forge ahead. Indeed, when asked to comment, Senator Klein even took an approach ironically reminiscent of Star Trek’s “Dr. Leonard McCoy:
“’I’m an attorney, I’m not an MD,’ said Klein, a Democrat who represents the Bronx. ‘This is a simple and noninvasive approach to alleviating the infections that are taking place in hospitals and which are a serious problem — not only in New York, but across the country.’”
This really brings us back to Dr. Dancer’s presentation. What does the medical evidence say about the top-down measures being imposed – as they invariably are – by the vast government bureaucracies governing healthcare these days? In a nutshell, it amounts to this:
- Bare below the elbow? “Bare below the elbow improves wrist washing.” Unfortunately, there is no evidence that this provides any medical benefit.
- Using alcohol gel? “No effect on MRSA.” It also does not appear to have any impact on the control of C. difficile infections or transmission of pathogens in the ICU.
- Rabid hand cleaning vigilance? MRSA infection rates in hospitals have declined over the same period of time that these programs have been placed into effect, but so have efforts to enhance screening for MRSA, reduce infections caused by IV lines, and improve topical care. No one has yet sorted out how the benefits of hand cleaning compare with the impact of all these other interventions. Interestingly enough, despite all of these measures, infection rates of methicillin-susceptible Staphylococcus aureus have not changed at all. This suggests that the progress we’re making with respect to reducing MRSA-related infections mat well have nothing whatsoever to do with hygiene, but everything to do with more judicious use of antibiotics in the hospital.
Dr. Dancer then goes on to make a very good case that hospital overcrowding and a heavy load of bacterial contamination on the surfaces of everything one touches in NHS hospitals probably more than make up for any benefits garnered from all of this “zero tolerance” nonsense. After all, what good does it do to clean your hands in the very next thing you touch is already contaminated? In one study 5% of the fingertips of healthcare workers were contaminated with MRSA: 6% after clinical contact, 7% after environmental contact, and 4% after no specific contact. In fact, preliminary data shows that simply hiring additional cleaners can reduce the bacterial load in rooms by 33% and cut the rate of MRSA infections in half. Why haven’t the politicians and bureaucrats mandated that this be done routinely in NHS hospitals? Because it’s expensive relative to simply ordering doctors and nurses to do things that are highly visible, but have little or no real impact on infection rates.
Let’s not kid ourselves. There’s still an enormous amount that we still don’t know about the best way to do many things in healthcare. Any physician who’s been in practice more than ten years can point to a host of “facts” (s)he learned about the cause and treatment of illness that are now known to be completely wrong. And when it comes to making improvements, the obvious is often faulty. It was “obvious” that electronic medical records would save the healthcare system billions each year in time and money; our experience thus far has been disappointing to say the least, (with the NHS again leading the way). It was “obvious” that having the government fix the price of healthcare goods and services for the past 40 years would lead to healthcare cost containment. We all know how that turned out. And now it’s “obvious” that an unaccountable board of unelected “experts” like ObamaCare’s Independent Payment Advisory Board can magically control the cost of Medicare without reducing benefits, quality or access to care.
So let’s learn one thing from our British cousins, shall we? When it comes to a clearly medical problem such as infection control, the best thing our political and bureaucratic leaders can possibly do is politely ask the medical community to: (1) seriously research the problem; and (2) implement medically valid solutions based upon their findings. Don’t pass laws. Don’t generate regulations. Don’t specify behavior or procedures. Just ask the medical community to do the best it can. Then go right back to placing your own economic, ethical and political house in order.
That one task alone should keep you fully and completely occupied.