A review published in The Lancet Infectious Diseases finds that the inability to control the meticillin-resistant Staphylococcus aureus (MRSA, or “super-bug”) is partly due to hospital overcrowding and understaffing. Dr. Archie Clements (School of Population Health, University of Queensland, Australia) and colleagues argue that a vicious cycle continues with increased inpatient hospital stays, bed-blocking, and further failure to control the infection.
In high income countries, efficiency and cost-cutting measures have changed the structure of health-care systems. Australia has seen a decrease of 40% in public hospital beds per head, but a 20% increase in patient throughput (from 1982 to 2000) and a 14% increase the total number of patients treated (from 1995 to 2000). Most of these changes are the product of same-day admissions and discharges. The outpatient movement has also affected the UK, USA, and Canada, countries which have reported a decline in inpatients relative to outpatients. A higher rate of patient admissions in the UK coupled with bed reductions has resulted in 71% of health trusts surpassing the 82% target set by the government. “The drive towards greater efficiency by reducing the number of hospital beds and increasing patient throughput has led to highly stressed health-care systems with unwelcome side-effects,” write the authors.
Clements and colleagues also predict a worsening of conditions in high-income countries due to population growth and aging. In addition, the health-care workforce is reducing in these countries as fewer people select nursing as a career. The nursing supply is also getting older: the average age of nurses in the USA in 1983 was 37.4 and in 2004 was 46.8. The researchers add that, “Understaffing is both an ongoing and long-term future problem with severe consequences for hospital patients.”
The relationship between infection rates and health-care worker to patient ratios is quite clear. According to one analysis, over 25% of health-care-acquired infection (HAI) in intensive care units could have been prevented if hospitals had at or below 2.2 patients per health-care worker. Additional papers have revealed that increases in HAIs have moderated any cost-benefits gained from re-designing the workforce using agency staff or having fewer full-time staff.
In order to reduce the spreading of MRSA, it is necessary for hospital staff to frequently wash their hands. Handwashing compliance, according to several studies, is low among nurses and even worse among doctors. When staff is short and workloads are high, compliance is further reduced. Hospitals try other methods of controlling MRSA, such as isolating infected patients or grouping them by cohorts who are treated by specific health-care workers; however, these strategies fail because of the same reasons: overcrowding and understaffing.
The presence of MRSA infected patients, who usually have extended hospital stays, results in fewer beds available for new admissions and outs additional stress on both the affected wards and the wards to which new patients are sent. Sometimes the number of MRSA patients exceeds isolation capacities and “bed-blocking” occurs – when multi-bed rooms are used for isolation prohibiting the use of both occupied and unoccupied beds. “MRSA also contributes directly to staffing deficits when health-care workers are excluded as a result of colonisation, detected via routine or outbreak screening,” indicate the authors. Problems can become nearly unmanageable as outbreaks overload hospital staff. Patients staying longer and becoming severely ill substantially increase the workloads of nurses involved in HAI management.
In order to control, prevent, and reduce MRSA outbreaks, cost-effective infection control strategies at the national level must be implements. Successful programs have resulted in low rates in The Netherlands and Scandinavia and a decline or at least stabilization in Australia and the UK. “Although the burden of HIA is enormous,” write Clements and colleagues, “it has been estimated that 15-32% of cases can be prevented and economic loses reduced.”
“Overcrowding and understaffing have had a negative effect on patient safety and quality of care, evidenced by the flourishing of health-care-acquired MRSA infections in many countries, despite efforts to control and prevent these infections occurring…There is an urgent need for detailed study of the relative effects of acute short-term and chronic long-term resource constraints on the dynamics of MRSA infection and a concurrent requirement for developing resource allocation strategies that minimise MRSA transmission without compromising the quality and level of patient care,” conclude the authors.
Overcrowding and understaffing in modern health-care systems: key determinants in meticillin-resistant Staphylococcus aureus transmission
Archie Clements, Kate Halton, Nicholas Graves, Anthony Pettitt, Anthony Morton, David Looke, Michael Whitby
The Lancet Infectious Diseases (2008); 8: 427-34
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Written by: Peter M Crosta