Hospital Overcrowding, Understaffing, and MRSA Incidence - A Vicious Cycle

Overcrowding and understaffing in hospitals lead to a failure of meticillin-resistant staphylococcus aureus (MRSA) control programmes, which in turn leads to increased inpatient hospital stay, bed blocking, and further infection control failure. These are the conclusions of authors of a Review in the July edition of The Lancet Infectious Diseases, authored by Dr Archie Clements, School of Population Health, University of Queensland, Australia.

The structure of health-care systems is changing in high-income countries because of a drive towards increased efficiency and cost-cutting. In Australia, for example, there has been a 40% decrease in public hospital beds per head yet a 20% increase in patient throughput between 1982 and 2000;and a 14% increase in the overall number of patients treated between 1995 and 2000. Same day admissions and discharges are responsible for the majority of these changes. Restructuring in the UK, USA, and Canada has also resulted in less patients being dealt with as inpatients and more as outpatients. In the UK, higher patient admission rates together with bed reductions have led to 71% of health trusts exceeding the government target bed occupancy of 82%. The authors say: "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."

These issues are likely to be intensiï¬ ;ed by the ageing trend in high-income countries and growth of populations. Also, fewer people in high-income countries are choosing nursing as a career, which will diminish the size of the health-care workforce. Workforce ageing is also a problem—in the USA, average-age of nurses has increased from 37.4 years in 1983 to 46.8 years in 2004. The authors say: "Understaffing is both an ongoing and long-term future problem with severe consequences for hospital patients."

Health-care worker to patient ratios have a signifficant association with observed infection rates, with one study showing that over a quarter of health-care-acquired infection (HAI) in intensive care units could be avoided with a ratio at or below 2.2 patients per health-care worker. Other studies have shown that the beneï¬ ;ts of re-engineering the workforce to save money by using agency staff and reducing the number of full-time workers is cancelled out by increased incidence of HAIs in these circumstances.

Handwashing is vital for reduction of MRSA transmission yet many studies show compliance in nurses is low and in doctors even lower. Compliance falls further during periods of understaffing and high workload. Other MRSA control strategies, including isolation of colonised or infected patients, and cohorting—where patients are cared for by speciï¬ ;c, nominated health-care workers—break down in the face of overcrowding and understaffing.

The extended hospital stays of many MRSA infected patients makes hospital beds unavailable for new admissions. This puts pressure on the capacity of the affected ward and the wards to which new patients are diverted. In situations in which incidence of MRSA exceeds the capacity of isolation facilities, multi-bed rooms might be used for isolation, preventing the use of both the occupied and unoccupied beds, a phenomenon termed 'bed-blocking'.

MRSA outbreaks can compound problems of understaffing in hospitals through their effect on staff workloads and availability. Nursing workloads for those involved in HAI management have been shown to rise as a result of both patient length of stay and severity of illness arising from infection. The authors say: "MRSA also contributes directly to staffing deï¬ ;cits when health-care workers are excluded as a result of colonisation, detected via routine or outbreak screening."

Implementation of cost-effective infection control measures at the national level can help control, prevent, and reduce MRSA outbreaks, as shown by both low rates in The Netherlands and Scandinavia, and the recent stabilisation/decline in Australia and the UK following widespread implementation of such measures. The authors say: "Although the burden of HIA is enormous, it has been estimated that 15-32% of cases can be prevented and economic loses reduced." Strategies to reduce hospital overcrowding, such as diversion of patients to community settings where possible, need to be fully explored.

The authors conclude: "Overcrowding and understaffing have had a negative effect on patient safety and quality of care, evidenced by the ï¬';ourishing 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."