Bed occupancy and overcrowding as determinant factors in the incidence of MRSA infections within general ward settings

doi:10.1016/S0195-6701(03)00153-1

Journal of Hospital Infection

Volume 54, Issue 4, August 2003, Pages 316-318

https://doi.org/10.1016/S0195-6701(03)00153-1 Get rights and content

Abstract

Methicillin-resistant Staphylococcus aureus (MRSA) incidence and bed occupancy rates at St Luke's Hospital, Malta, were assessed over a 24-month period. A significant positive correlation was established $(r=0.463; P<0.05)$ between new cases of MRSA infections and overall levels of bed occupancy. This would imply that overcrowding may be a relevant factor in MRSA spread within hospitals, even in non-intensive care settings.

Introduction

There are an increasing number of studies that indicate a relationship between the incidence of methicillin-resistant Staphylococcus aureus (MRSA) in the hospital setting and levels of staffing amongst healthcare workers, in particular nursing personnel.¹ The body of evidence towards this relationship appears to have been accumulated mainly from studies in intensive care environments, both adult² and paediatric.³ However, there is little information as to whether the same relationship also applies in the non-intensive care settings of general hospital wards.⁴

Section snippets

Methods

St Luke's Hospital is the only tertiary care facility in Malta, a country having a population of 375 000. The hospital is a 900-bed facility with most general wards incorporating mainly four and eight-bedded bays with larger areas partitioned into two-bedded bays. Single rooms with en-suite facilities are rare. Because of its unique status in the country, and therefore the inability to cap the number of admissions at any one time, St Luke's Hospital experiences significant fluctuations in bed

Results

Over the 24 months of the study an average of 41.7 new cases of MRSA was reported per month (range: 17–61) with a mean monthly bed occupancy rate of 76.3% (range: 73–86%). A significant positive correlation (Figure 2) was established between the bed occupancy rates per month and the number of new MRSA cases identified $(r=0.463; P<0.05).$ Conversely, no statistically significant relationship could be ascertained between MRSA incidence and length of stay per month—mean 7.2 days (range: 4.7–8.6

Discussion

A correlation between workload indices and hospital-acquired infections has been demonstrated in several studies. Vicca showed that nurse understaffing contributed significantly to the spread of MRSA in an adult intensive care setting.² Mathematical modelling has identified relative staff deficit to be significantly associated with likely transmission of MRSA.⁵ Fridkin et al. demonstrated that when the patient:nurse ratio in the surgical intensive care unit increased above a certain threshold

Acknowledgements

I thank the Department of Health Information (Malta) for providing bed occupancy and stay data, Ms Elizabeth Scicluna for her epidemiological input and Prof. B. D. Cookson (PHLS Central Public Health Laboratory, London, England) for his helpful suggestions.

References (10)

A.F. Vicca
Nursing staff workload as a determinant of methicillin-resistant Staphylococcus aureus spread in an adult intensive therapy unit
J Hosp Infect
(1999)
G.E. Bignardi et al.
Workload may be related to the spread of MRSA and other infections
J Hosp Infect
(2000)
C.C. Kibbler et al.
The effect of increased bed numbers on MRSA transmission in acute medical wards
J Hosp Infect
(1998)
M. Farrington et al.
Effects on nursing workload of different methicillin-resistant Staphylococcus aureus (MRSA) control strategies
J Hosp Infect
(2000)
R.W. Haley et al.
The role of understaffing and overcrowding in recurrent outbreaks of staphylococcal infection in a neonatal special-care unit
J Infect Dis
(1982)

There are more references available in the full text version of this article.

Cited by (92)

The effect of patient volume on mortality and morbidity of extremely low birth weight infants in Taiwan
2023, Journal of the Formosan Medical Association
To assess whether the number of extremely low birth weight (ELBW) infants treated annually in neonatal intensive care units (NICUs) in Taiwan affects the mortality and morbidity of this patient population.
This retrospective cohort study included preterm infants with ELBW (≤1000 g). NICUs were divided into three subgroups according to the annual admissions of ELBW infants (low, ≤10; medium, 11–25; and high, >25). Perinatal characteristics, mortality, and short-term morbidities were compared between groups.
A total of 1945 ELBW infants from 17 NICUs were analyzed (low-volume, n = 263; medium-volume, n = 420; and high-volume, n = 1262). After risk adjustments, infants from NICUs with low patient volumes were at a higher risk of death. The risk-adjusted odds ratios (aOR) for mortality were 0.61 (95% CI, 0.43–0.86) in the high-volume NICUs and 0.65 (95% CI, 0.43–0.98) in medium-volume NICUs, compared with infants admitted to low-volume NICUs. Infants in medium-volume NICUs had the lowest incidence of prenatal steroid exposure (58.1%, P < 0.001) and were associated with the highest risk of necrotizing enterocolitis (aOR, 2.35 [95% CI, 1.48–3.72]), severe intraventricular hemorrhage (aOR, 1.55 [95% CI, 1.01–2.28]), and bronchopulmonary dysplasia (aOR, 1.61 [95% CI, 1.10–2.35]). However, survival without major morbidity did not differ between the groups.
The mortality risk was higher among ELBW infants admitted to NICUs with a low annual patient volume. This may emphasize the importance of systematically referring patients from these vulnerable populations to appropriate care settings.
Spill Over Effects of Inpatient Bed Capacity on Accident and Emergency Performance in England
2020, Health Policy
The English National Health Service (NHS) has failed to meet the four-hour waiting time target to admit, transfer or discharge 95 per cent of patients attending Accident and Emergency Departments (A&E) since 2013. A growing number of patients requiring inpatient care are waiting on trolleys longer than four hours before admission to a hospital bed. This study examines the role of bed occupancy in the deterioration of A&E performance in the NHS. Longitudinal panel data methods are used to analyse hospital data (n = 72,129,886) for 143 Trusts from 1^st June 2016 to 31^st October 2019. The average bed occupancy rate across the study period was 93.2%. A 1% increase in bed occupancy was associated with a 9.5 percentage point decrease in the Trusts’ probabilitay of meeting the waiting target, and an approximately 6 patient increase in four hours to 12 -hs trolley waits per 1,000 admissions. These relationships became more pronounced with rising bed occupancy levels above a 90% threshold. Bed occupancy is associated with significant negative spill-over effects on A&E performance. We estimate a minimum investment in 3,861 additional inpatient beds across the NHS to improve A&E performance in England. Relevant lessons can be derived for health care systems that have observed similar trends in increasing bed occupancy and deteriorations in A&E performance, including Ireland, Canada and Israel.
Characteristics of nursing homes with comprehensive antibiotic stewardship programs: Results of a national survey
2020, American Journal of Infection Control
Antibiotic stewardship in nursing homes (NHs) is a high priority owing to intense antibiotic use and increased risk of adverse events. Updated Centers for Medicare and Medicaid Services regulations required NHs to establish antibiotic stewardship programs (ASPs). This study describes the current state of NH ASPs.
A nationally representative survey of NHs was conducted in 2018. ASP comprehensiveness, infection preventionist (IP) training, participation in Quality Innovation Network-Quality Improvement Organization (QIN-QIO) activities, and facility and staff characteristics were analyzed using weighted descriptive statistics and multinomial regression models.
Of 861 NHs, 33.2% (6-7) had “comprehensive” ASP policies, 41.1% (4-5) had “moderately comprehensive” ASP policies, and 25.6% (≤ 3) had “not comprehensive” ASP policies. Data collection on antibiotic use was most reported (91.4%), and restricting use of specific antibiotics was least reported (19.0%). Comprehensive ASPs were associated with QIN-QIO involvement; moderate and comprehensive ASPs were associated with IP training and high occupancy.
Immediately following Centers for Medicare and Medicaid Services regulation changes, a majority of NHs had moderately comprehensive or comprehensive ASPs. Rates for each policy and infection control-trained IPs increased from previous studies.
NH ASPs are becoming more comprehensive. Infection control training and partnerships with QIN-QIOs can support NHs to increase ASP comprehensiveness.
Superintendence of antimicrobial resistance observed in bacterial flora isolated from human faecal carriage in Vellore, India
2017, Saudi Journal of Biological Sciences
Citation Excerpt :
Worldwide, there are increasing problems with multiresistant bacteria. The most important drug resistance today is caused by methicillin-resistant Staphylococcus aureus (MRSA) (Udo et al., 2001; Borg, 2003), vancomycin resistant enterococci (VRE) (Calfee et al., 2003; Kuriyama et al., 2003) and Enterobacteriaceae with extended-spectrum beta-lactamases (ESBL). The common aerobic pathogens isolated from the chronic wounds are S. aureus, coagulase negative Staphylococcus (CONS), S. epidermidis and Streptococcus spp.
A frequent cross-sectional study was conducted to determine the patterns of antimicrobial resistance in 296 bacterial strains isolated from in-patient faecal samples of Government Vellore Medical College and Hospital, Vellore. Isolation and identification of bacterial strains were done using enrichment media, selective media, and biochemical tests. Antimicrobial susceptibility testing by the disc diffusion method and minimal inhibitory concentration method was conducted and the strains were subjected to extended spectrum beta-lactamases screening. Antibiotic sensitivity pattern of Staphylococcus spp. showed oxacillin resistance. Almost all the strains were sensitive to linezolid, vancomycin, gentamycin and chloramphenicol. In gram negative isolates ciprofloxacin and tobramycin showed better sensitivity and ceftazidime showed a higher percentage of resistance by MIC. Out of 250 isolates, Enterobacteriaceae showed positive for 86/250, 82/250 and 94/250 isolates and 3/10, 4/10 and 4/10 non-Enterobacteriaceae isolates were found to be positive for CTX-M gene, TEM gene and SHV gene, respectively. This study helps to assess/analyse the relation between the spectrum of microorganisms present in various grades of faecal carriage and their susceptibility pattern in this part of the Vellore town.
Hospital organisation, management, and structure for prevention of health-care-associated infection: A systematic review and expert consensus
2015, The Lancet Infectious Diseases
Despite control efforts, the burden of health-care-associated infections in Europe is high and leads to around 37 000 deaths each year. We did a systematic review to identify crucial elements for the organisation of effective infection-prevention programmes in hospitals and key components for implementation of monitoring. 92 studies published from 1996 to 2012 were assessed and ten key components identified: organisation of infection control at the hospital level; bed occupancy, staffing, workload, and employment of pool or agency nurses; availability of and ease of access to materials and equipment and optimum ergonomics; appropriate use of guidelines; education and training; auditing; surveillance and feedback; multimodal and multidisciplinary prevention programmes that include behavioural change; engagement of champions; and positive organisational culture. These components comprise manageable and widely applicable ways to reduce health-care-associated infections and improve patients' safety.
What's trending in the infection prevention and control literature? From HIS 2012 to HIS 2014, and beyond
2015, Journal of Hospital Infection
Citation Excerpt :
The question of whether all patients should be given a single room was the subject of a recent BMJ debate.38 Single rooms are associated with lower rates of healthcare-associated infection, some patients report high levels of satisfaction, and the reduction in interruptions during patient contact leads to fewer ‘mix-up’ errors.39–45 On the other hand, caring for patients in multi-occupancy bays is associated with a reduced risk of adverse events, patients in single rooms often report less social contact and feelings of isolation, and bays require a lower staffing ratio.45–49
This is an informal review of some of the trends in the infection prevention and control literature since the last Healthcare Infection Society (HIS) conference in late 2012. Google Trends was used to investigate how the volume of interest in various infection control topics had changed over time. Ebola trumped all the others in Google searches, reflecting a surge of publications in the literature. Aside from Ebola, other trends in the infection prevention and control literature covered in this article include Middle East Respiratory Syndrome (MERS) coronavirus, universal versus targeted interventions, faecal microbiota transplantation, whole genome sequencing, carbapenem-resistant Enterobacteriaceae, and some aspects of environmental science. The review ends with an attempt to predict some of the trends in the infection prevention and control literature between now and the next HIS conference in 2016.

View all citing articles on Scopus

View full text

Article preview

Journal of Hospital Infection

Abstract

Introduction

Section snippets

Methods

Results

Discussion

Acknowledgements

References (10)

Nursing staff workload as a determinant of methicillin-resistant Staphylococcus aureus spread in an adult intensive therapy unit

J Hosp Infect

Workload may be related to the spread of MRSA and other infections

J Hosp Infect

The effect of increased bed numbers on MRSA transmission in acute medical wards

J Hosp Infect

Effects on nursing workload of different methicillin-resistant Staphylococcus aureus (MRSA) control strategies

J Hosp Infect

The role of understaffing and overcrowding in recurrent outbreaks of staphylococcal infection in a neonatal special-care unit

J Infect Dis

Cited by (92)

The effect of patient volume on mortality and morbidity of extremely low birth weight infants in Taiwan

Spill Over Effects of Inpatient Bed Capacity on Accident and Emergency Performance in England

Characteristics of nursing homes with comprehensive antibiotic stewardship programs: Results of a national survey

Superintendence of antimicrobial resistance observed in bacterial flora isolated from human faecal carriage in Vellore, India

Hospital organisation, management, and structure for prevention of health-care-associated infection: A systematic review and expert consensus

What's trending in the infection prevention and control literature? From HIS 2012 to HIS 2014, and beyond

Short reportBed occupancy and overcrowding as determinant factors in the incidence of MRSA infections within general ward settings

Abstract

Introduction

Section snippets

Methods

Results

Discussion

Acknowledgements

J Hosp Infect

J Hosp Infect

J Hosp Infect

Effects on nursing workload of different methicillin-resistant Staphylococcus aureus (MRSA) control strategies

J Hosp Infect

The role of understaffing and overcrowding in recurrent outbreaks of staphylococcal infection in a neonatal special-care unit

J Infect Dis

Short report
Bed occupancy and overcrowding as determinant factors in the incidence of MRSA infections within general ward settings