14 July 2008

MRSA: How we lost control

Dr Grumble can remember when doctors (but not managers) had a real concern about MRSA. He can remember having his orifices swabbed to make sure he was not a carrier. Microbiologists of that era felt that MRSA was something that we could and should control. Dr Grumble can remember how seriously the problem was taken. There was concern in the lab and concern on the wards.

Swabbing of the Grumble orifices has not happened for decades. In fact it didn't happen for long because doctors found to be carriers were not allowed to work and pretty soon so many were sent off work that the managers felt that we were making too much fuss. At that time Dr G used to work up to 168 hours a week so losing a doctor was equivalent to losing 4 staff working normal hours.

How they used to screen NHS staff.

So how many of the staff are carriers now? Dr Grumble cannot tell you what the figure is for his hospital because, as far as he is aware, nobody knows. Nobody looks any more. We can't keep MRSA out of our hospital. The patients arrive with it and they have to be treated. Probably the staff have it and probably they spread it to their households. And probably they spread it from hospital to hospital. An Australian healthcare worker was believed to have brought an epidemic MRSA strain from Victoria to London to cause the 1982 outbreaks.

Dr Grumble, as some will know, left clinical work for 6 years. Over twelve years ago he returned to do a locum in a deprived district general hospital. When you leave and return changes hit you. And he can remember noticing, not without some horror, that the authorities had in the intervening 6 years given up the battle against MRSA. Patients with MRSA were being nursed in open wards and lip service only was being paid to barrier nursing. The hospital was a mad frenzy of busyness. MRSA was low on the list of priorities. There were not the resources to do things properly. Given the lack of resources the loss of control of MRSA was not really the fault of those at the coalface. They had not been given the tools they needed to tackle the problem.

Could things have been any different? The answer is yes.

A costly consequence of failure to deal with MRSA.

The figures below show the proportion of isolates of Staphylococcus aureus which are methicillin resistant in selected European countries (1999-2002 figures):
United Kingdom 44.5%
Netherlands 1%
Sweden 0.7%
Norway 0.2%
Quite a difference. Now why should that be?

Dr Grumble once tried to transfer a Dutch patient to a hospital in the Netherlands. When he tried to negotiate this he could detect the shock at the other end of the telephone when the Dutch staff realised they might have to take an inpatient from the UK. They would not even begin to consider this until he had been screened for MRSA - which is not part of our routine. In the Netherlands and parts of Scandinavia in most hospitals they have an aggressive MRSA search and destroy policy. They even screen exposed healthcare workers. It can be done. It works. It should have been done in the UK. Dr Grumble can remember those that understand these things shouting their concern from the roof tops. Nobody took any notice. And, unsurprisingly, these same people then seemed to just give up. You do. You get worn down if the management ignores you. And when the cat is out of the bag is there any point any more? It's odd that the management are now running around like beheaded chickens telling us off about this problem.

Can the management be blamed? After all, controlling MRSA would be costly. Of course they can and should be blamed because almost every analysis that has ever been done has shown that it is cheaper to control MRSA than to let it run wild. The cost of caring for patients infected with MRSA is so great that it makes screening look cheap.

A management failure to search and destroy.

Doctors are not much to blame for this. Those that knew lobbied hard. But loan voices can do nothing. The fault was with managers, managers who failed to heed the warnings of doctors, experts who knew what they were talking about. And now these same people are blaming the doctors for this. It makes Dr Grumble angry, very angry indeed. The ignorance of these people about the history of all this is breathtaking.

By the way there are more practising doctors in the Netherlands than in the UK - 57% more (2004 figures). Do you think that might help? Not from the viewpoint of managers. After all it's doctors that are to blame.

This post was first published on 3rd November 2007. It attracted some interest from Chris Vallance at the BBC who asked Dr Grumble if he would be interviewed on the radio. Dr Grumble declined. Others then expressed doubts about the truth of Dr Grumble's story. Anybody in medicine who is as old as Dr Grumble will know that the story is essentially an accurate account of how the battle against MRSA was lost in the UK a very long time ago. At that time no member of the public had ever heard of MRSA. Nor, probably, had any NHS managers. They weren't interested. They weren't listening to the concerns of doctors. By the time they were forced to listen it was too late.

Dr Grumble's story has to be true. Otherwise how can anybody account for the different prevalence of MRSA in the cleaner countries of Europe?


Medifix said...

Brilliant, it’s true no one could be older than Dr Grumble to know anything about MRSA.

I have been working to help prevent the spread of this infection since 1989, informed managers, and published articles and wrote to politicians on how they could reduce the spread and prevent this threat entering the community. They all looked at me as if I come from another planet and mad. My hypothesis and fear is now real and is getting worse than I imagined. Helpless, I have now stopped talking about this topic but maintain a website to talk about my fear and help educate people.

Seeing some young lad die right in front of your eyes and you as a doctor unable to do anything is similar to a helpless non-swimmer letting some one drown in a swimming pool.

"God, help us fight this battle that we may never win”

madnhswife said...

A few weeks ago I and my husband (who works in an NHShospital) were in a hospital in northern Italy to pay a bill for our granddaughter who had needed treatment there a couple of years ago and the invoice had taken a long time to arrive (well - it IS Italy, even though they speak German in that locality!). As we left my husband was looking puzzled and then his face lit up. "I was trying to work out what was different" he said. "It SMELLED like a hospital should smell." When our granddaughter was there as an in-patient it was immaculate. Our daughter who is a nurse-in-training was impressed. It was like it used to be here - squeaky clean.
To my knowledge there isn't an MRSA problem there. And another thing - when you need treatment it is there, waiting in their open-access emergencies and admissions department. But they found a lot of people were turning up with silly problems they could have dealt with themselves (just like here) - so now you are asked to pay 15 Euro per incident yourself. Given the quality and speed of the care it is well worth every cent and the number of wimps and time-wasters has dropped. Sounds good to me.

A medical student said...

We still get swabs when we enter our clinical year. And those who are tested positive for MRSA will undergo eradication before they are allowed clinical exposure.

Anonymous said...

italy A & E will see genuine cases with no wait and no fee in clean friendly surroundings, which contrasts big time with the squalor of the nhs, they may i suppose charge a nominal fee to timewasters (i have not seen this) but for sure genuine cases do not get charged

so MRSA isnt all to do with GPs giving antibiotics to those with chronic ear ache? thought not

Dr Grumble said...

How interesting medical student. This does not seem to happen at the medical school where Dr Grumble works. And it doesn't happen at either of the two medical schools where Dr Grumble's children study. Are you going to tell us which medical school you are at?

Anonymous said...

my boyfriend has it so bad in his feet, its wierd the wounds are healed on the outside, but on the inside at his bones is where the most damage is being done!!! im scared to death i dont want to loose him to something that he got becuase of an oyster bed cut