Peter Lapsley: A gap to be closed?

Peter LapsleyIt seems clear that the determined campaign to prevent healthcare-acquired MRSA within the NHS is paying substantial dividends. The financial year from April 2010 to March 2011 saw a reduction of 22% in reported cases of MRSA bacteraemia, and a 50% reduction against those reported for the year 2008/9.

That “determined campaign” has included pre-op assessments for elective patients and isolation for emergency admissions until their MRSA test results have been seen; improved cleaning of floors, toilets, and beds; requiring health professionals to wear short sleeves and no ties; to wash carefully before and after examining or treating patients, before and after touching potentially contaminated equipment or dressings, after bed-making and before handling food; frequent use of fast-acting antiseptic solutions such as hand wipes or gels; wearing disposable gloves for any contact with open wounds, handling needles, or inserting drips; and isolating patients known to be or suspected of MRSA infection.

The gaping hole in these defences has to do with families and friends who visit in-patients. At best, there is a wall-mounted gel dispenser at the entrance to the ward and a modest notice asking people to use it. Whether they do so or not appears to depend upon their seeing and understanding its importance and then on personal choice. In two one-week admissions as an in-patient in the past 18 months, I saw no evidence of insistence on visitor cleanliness or of any patient checking with his or her visitors that they had used the gel before entering the ward. Such apparent indifference is unacceptable.

It cannot be beyond the wit of hospital authorities to devise protocols to reduce to a minimum the risk of importation of MRSA by visitors. It could start with a prominent notice on the patient’s pre-admission papers or even an eye-catching separate leaflet – explaining the dangers of MRSA and the NHS’s determination to minimise the risk, and providing guidelines for visitors – as few as possible; that they must wash carefully before the visit, wear clean clothes, and use the gel when they arrive; that fruit and other gifts should be cleaned or washed; that visitors should avoid physical contact with patients as far as possible; and that neither staff nor patients should hesitate to ask visitors whether they have used the gel. Gel dispensers could be sited by the nurses stations with the staff briefed to insist on their use. And the staff could have the authority courteously to turn away visitors about whose cleanliness they have doubts.

On cruise boats on the Nile, where stomach upsets are endemic, no passenger may enter a dining room without first washing his or her hands with gel, and there is always a member of the crew by the door to ensure compliance. If they can do it, so can we – and we must.

Peter Lapsley is patient editor of the BMJ.