Less hospital beds can mean more infections

28 October 2008

The University of Ulster's Joseph Cunningham investigates the link between hospital overcrowding and infection levels and considers possible solutions

The report into the outbreak of Clostridium difficile (C. diff) at Maidstone and Tunbridge Wells Hospital Trust¹, carried out by the Healthcare Commission, and the number of deaths in this trust is an indictment of conditions of care in British hospitals. At the time of its release various commentators spoke of this as a one-off, something that was not typical. However, a similar report by the Healthcare Commission² report one year earlier on a C. diff outbreak in Stoke Mandeville revealed the same issues. A recent outbreak of C. diff in a Northern Ireland trust with the related deaths of 54 patients since July 2008, 40 of which happened since January 2008, shows that basic issues in the management of beds and care may still have to be addressed. The number of deaths in Northern Ireland linked to C. diff has jumped five-fold since 2001.

It is indisputable that the use of antibiotics for vulnerable patients upsets the fauna of the intestine, allowing C. diff to proliferate, but when that infection, through the process of cross-infection, affects non-vulnerable patients, eg. those not being treated with antibiotics, then, arguably, hospitals are putting patients at risk. A common feature of all the reports into outbreaks of C. diff is the high level of bed occupancy. The report into Maidstone and Tunbridge Wells showed photos of the overcrowding and the unsanitary conditions.

A count, for the word 'occupancy', in the report into the Maidstone and Tunbridge Wells Hospital Trust³ outbreak shows that it occurs approximately 34 times. Long sections of it are devoted to the overcrowding of wards. One of the recommendations is that greater priority should be given to 'factors that affect the ability of staff to control infection, including the environment, cleaning, the movement of patients, and levels of bed occupancy'. But how do staff and trust boards control occupancy? Admit fewer patients or increase the number of beds? It is doubtful if hospitals have sufficient side-room beds for the isolation of patients who may be a risk of infecting other patients.

The government's performance targets have resulted in additional pressures on already hard pressed cleaning staff, doctors, nurses, and other clinical personnel. But the government and the Department of Health has been slow in meeting its own targets on bed occupancy levels. The Department of Health had hoped to achieve 82% bed occupancy levels by 2003-04 but in the year 2004-05, 20% of acute English trusts had bed occupancy levels of 90%, and 70% had occupancy levels over 82%. Bed occupancy, in simple terms, is also a measure of overcrowding in hospitals. It is likely that hospitals with a mean bed occupancy of 90% have, at times, occupancies of over 100%, meaning that there are actually more patients than beds.

The hospital bed has been falling out of favour. The pressures to reduce public spending in the 1980s and the notion that day surgery and better care in the community for chronic conditions has resulted in cuts in acute beds to the point where it may be unsafe. This type of thinking is typified in, for example, Appleby⁴, who, in 1997, predicted that by the year 2003, maternity length of stay would be measured in hours not days, acute surgical patients would be out of hospital within one day, and that patients' average length of stay would be negative at the turn of the century. The anti-bed lobby is also reflected in some statements from ministers, which encourages the growth of private sector beds at the expense of growth in the public sector. Professor Alison Pollock has estimated that there has been a decrease of 10,000 NHS beds in order to make way for the private sector.

Between the years 1987/88 to 2004/05, the numbers of all speciality beds in England fell from 297,341 to 181,784 (38.8%); general beds declined by half, and day only beds rose by more than a third. At the same time, the average length of stay got shorter and the number of patients increased. England now has fewer hospital beds per head of the population than any other European country.

Two recent research papers provide convincing evidence for the relationship of healthcare acquired infection (HCAI) and bed occupancy levels. Clements, Halton, Graves, et al⁵, in a comprehensive review of literature looking specifically at MRSA, concluded that 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' (page 431). Borg, Suda and Scicluna⁶ used a time series analysis between MRSA rates and bed occupancy rates over a 65 month period. They demonstrated that excessive overcrowding tended to coincide with a significant increase in the rate of MRSA. Both these papers have added more evidence to a growing body of literature showing links between high levels of bed occupancy and HCAI.

There is a counter argument that many patients are admitted with HCAI and that they were not acquired in hospital. But there are studies to show that this may not be the case. The only way it could be verified that patients are admitted with HCAI would be if patients were screened on admission and this preventative practice has not been adapted by most English hospitals but is now being initiated in Scotland. However, it is likely that as more and more patients are discharged from acute facilities with HCAI, these infections will become endemic in the community. This will probably be noticed first in care homes for the elderly, with larger numbers showing positive for HCAI.

There has been great emphasis on measures such as shortening lengths of stay, Independent Treatment Centres where minor operations and investigations can be carried out, and day surgery. Perhaps it is time to look at whether Britain has the stock of beds within its acute sector to provide safe care where the dignity of patients can be respected. The RCN, which provides excellent guidance for nurses on issue such as hand washing, laundering and cleaning, acknowledges⁷ that there is a number of risk factors, such as higher bed occupancy, higher numbers of patients, inadequate management, poor teamwork, low staffing, and heavy work loads, causing a fall in the quality of care. That too many NHS psychiatric beds have been decommissioned has been accepted. Perhaps the same is true of the acute sector.

1 Healthcare Commission (2007) 'Investigation into outbreaks of Clostridium difficile at Maidstone and Tunbridge Wells NHS Trust, October 2007', London: Commission for Healthcare Audit and Inspection
2 Healthcare Commission (2006) 'Investigation into outbreaks of Clostridium difficile at Stoke Mandeville Hospital, Buckinghamshire Hospitals NHS Trust, July 2006', London: Commission for Healthcare Audit and Inspection
3 Healthcare Commission (2007) 'Investigation into outbreaks of Clostridium difficile at Maidstone and Tunbridge Wells NHS Trust, October 2007', London: Commission for Healthcare Audit and Inspection
4 Appleby J (1997) 'The English patient', Health Services Journal, 10th April, 36-37
5 Clements C, Halton K, Graves N et al (2008) 'Overcrowding and understaffing in modern health-care systems: key determinants in methicillin-resistant Staphylococcus aureus transmission', Lancet Infect Dis 2008; 8: 427-34
6 Borg M A, Suda D, Scicluna E (2008) 'Time-Series Analysis of the Impact of Bed Occupancy Rates on the Incidence of Methicillin-Resistant Staphylococcus aureus Infection in Overcrowded General Wards', Infect Control Hosp Epidemiol 2008; 29: 496-502
7 King's College London, 'The Impact of Organisation and Management Factors on Infection Control in Hospitals: a Scoping Review', sponsored by the Royal College of Nursing, University of London