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Methods

The SARI Infection Control Subcommittee drafted the survey questionnaire (Appendix Figure A) that focused on the major recommendations in the guidelines (eg, antibiotic stewardship and MRSA surveillance). The questionnaire was forwarded to the chief executive officers of 59 acute care hospitals in Ireland in early 2007. Reminders (by e‐mail and telephone) were sent to hospitals that did not reply before the deadline. Results were analyzed by use of Excel (Microsoft).

Results

Of the 59 broadly representative acute care hospitals that were forwarded the questionnaire, 49 (83%) responded. These included 27 general hospitals that served a mixture of city and rural populations (mean, 212 inpatient beds; range, 76–474 inpatient beds), 10 academic tertiary care hospitals that served primarily city dwellers but also referrals from general hospitals (mean, 493 inpatient beds; range, 220–753 inpatient beds), 9 specialist hospitals (mean, 159 inpatient beds; range, 80–210 inpatient beds), and 3 adult private hospitals (mean, 142 inpatient beds; range, 120–164 inpatient beds). The specialist hospitals included 4 maternity hospitals and 3 pediatric hospitals. The results of the survey are summarized in the Table. Of these 49 acute care hospitals, 43 (88%) reported local barriers to implementation that were the result of poor hospital infrastructure, inadequate laboratory resources, inadequate staffing, the unavailability of single rooms or isolation rooms, or bed occupancy rates of 90% or more.

Table.  Results of a 2007 Survey of 49 Irish Acute Care Hospitals on the Implementation of National Guidelines for the Control and Prevention of Methicillin‐Resistant Staphylococcus aureus (MRSA) Infection

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Only 1 (2%) of the 49 acute care hospitals believed that their infrastructure was adequate to allow full implementation of these national guidelines. Twenty‐four hospitals (49%) believed that their infrastructure was adequate to allow only partial implementation, and 24 hospitals (49%) believed that their infrastructure was inadequate. Only 3 hospitals (6%) believed that their laboratory resources were adequate to allow full implementation. However, 34 hospitals (69%) believed that their laboratory resources were adequate to allow only partial implementation.

Of the 49 acute care hospitals surveyed, 4 (8%) reported that the staffing for infection control and prevention was adequate; 26 hospitals (53%) believed that staffing was only adequate to allow partial implementation, and 15 hospitals (31%) believed that staffing was inadequate to allow even partial implementation. Three hospitals (6%) believed that the availability of single rooms was adequate to allow full implementation of the guidelines, and 26 hospitals (53%) believed that the availability of single rooms was inadequate to allow implementation. Only 3 hospitals (6%) believed that their high rates of bed occupancy did not impact the implementation of the guidelines.

Discussion

There are still major challenges in Ireland to the full implementation of national MRSA guidelines. It is of concern that 8% of the hospitals surveyed did not have educational programs on hand hygiene, even though national guidelines on hand hygiene were launched along with the MRSA guidelines.

Of the 49 acute care hospitals surveyed, 16 (33%) did not have a written policy on antibiotic use, and only 17 (35%) had an antibiotic stewardship program. In a 1999 study on MRSA in Ireland by the Department of Health and Children, less than half (41%) of the hospitals studied had a written policy on antibiotic use.⁴ Although there has been some improvement in the Republic of Ireland since, we believe that all hospitals should have a written policy on antibiotic use.

The majority of hospitals believed that a high rate of bed occupancy compromised their ability to implement the guidelines. Compared with the Netherlands, where bed occupancy rates are approximately 70%,⁵ bed occupancy rates in Irish hospitals are much higher (85% in 2006 and greater than 90% in some individual hospitals).⁶

In a recent European study, the ability to isolate a patient colonized with MRSA in a single room was identified as an independent predictor of a low prevalence of cases of MRSA colonization or infection, but the uavailability of single rooms was identified as an independent predictor of high prevalence.⁷ In our survey, the ratio of single‐patient rooms to total beds was greater than 1:3 in 88% of the hospitals surveyed, with only 29% of hospitals having the recommended 2.9 meters of space between beds in multiple‐patient rooms.³ Although there is still some controversy over the ideal proportion of single rooms in acute care hospitals, having all patient rooms be single‐patient rooms has become the standard for new hospital buildings in the United States.⁷ In Europe, the hospitals are composed of a mixture of single‐ and multiple‐patient rooms; multiple‐patient rooms generally have 2 or, at most, 3 beds per room. A minimum of 50% single rooms is now the standard in the United Kingdom.⁸ A draft of the Irish infection control building guidelines recommends that all inpatient accommodations in newly built acute care hospitals be single‐patient rooms, and it specifies what a standard single‐patient room should look like (R.C., written personal communication, September 2008).

Although the eradication of MRSA in colonized patients is generally considered a major component of MRSA infection control and prevention strategies, the scientific data are not robust enough to justify the use of decolonization therapy for all cases of MRSA colonization. A recent literature search found that only 4 of 211 hits were articles that met the criteria for evaluation, and the beneficial effects of MRSA decolonization therapy were largely seen among patients who underwent cardiothoracic or orthopedic surgery, not general surgery.⁹ There may be an argument for routine MRSA decolonization therapy for intensive care unit patients, because of the presence of high‐risk patients in the immediate vicinity.

It is a concern that almost a quarter of the hospitals that responded did not include infection control and prevention in the hospital strategic service plan and that almost a third of the hospitals that responded still did not produce an annual infection control plan. The majority of hospitals that responded indicated that hospital infrastructure, laboratory resources, infection control staffing, and the availability of single rooms were all deficient and that bed occupancy rates were high. International comparisons of the effectiveness of efforts to control outbreaks of MRSA infection suggest that the hospital infrastructure in which the outbreak occurs (eg, bed occupancy rates) and the level of commitment of authorities to control the outreak may help explain why countries with similar approaches to infection control and prevention have different rates of MRSA infection.¹⁰

Although our survey clearly identified that the lack of physical resources had impeded the implementation of national guidelines for the control and prevention of MRSA infection in acute care hospitals in Ireland, other areas of concern, such as staffing, can also be addressed; for example, current staffing levels could be increased, or, in the short term, medical, nurse, or pharmacy specialists could be appointed. National strategies must ensure that all hospitals have an educational program on hand hygiene and that audits be carried out regularly. Antibiotic stewardship programs are essential for the control and prevention of MRSA and other infections (eg, Clostridium difficile infection). An easily accessible policy of antibiotic use should be available in each hospital, and it should be updated regularly. All hospitals should be encouraged to use eradication therapy for high‐risk MRSA carriers and for patients who have been responsive to this type of therapy before (eg, patients who underwent orthopedic surgery). All hospitals must include infection control and prevention as part of their strategic service and must produce an annual infection control plan.

Finally, as revealed in our survey, the local factors that have impeded the implementation of national guidelines for the control and prevention of MRSA infection (eg, poor hospital infrastructure and inadequate laboratory resources) need to be addressed in Ireland and elsewhere. It is unclear whether hospitals in other European countries comply (either partially or almost completely) with their own national guidelines. Because national policies are similar (ie, based on best practice), the different capacities of hospitals to implement such national policies may partly explain the different rates of MRSA infection found in hospitals.