key: cord-009788-bc6sc2rc authors: Ferguson, J. K. title: Preventing healthcare‐associated infection: risks, healthcare systems and behaviour date: 2009-09-17 journal: Intern Med J DOI: 10.1111/j.1445-5994.2009.02004.x sha: doc_id: 9788 cord_uid: bc6sc2rc More than 177 000 potentially preventable healthcare‐associated infections (HAIs) occur per annum in Australia with sizable attributable mortality. Organizational systems to protect against HAI in hospitals in Australia are relatively poorly developed. Awareness and practice of infection control by medical and other healthcare staff are often poor. These lapses in practice create significant risk for patients and staff from HAI. Excessive patient exposure to antimicrobials is another key factor in the emergence of antibiotic‐resistant bacteria and Clostridium difficile infection. Physicians must ensure that their interactions with patients are safe from the infection prevention standpoint. The critical preventative practice is hand hygiene in accord with the World Health Organization 5 moments model. Improving the use of antimicrobials, asepsis and immunization also has great importance. Hospitals should measure and feed back HAI rates to clinical teams. Physicians as leaders, role models and educators play an important part in promoting adherence to safe practices by other staff and students. They are also potentially effective system engineers who can embed safer practices in all elements of patient care and promote essential structural and organizational change. Patients and the public in general are becoming increasingly aware of the risk of infection when entering a hospital and expect their carers to adhere to safe practice. Poor infection control practice will be regarded in a negative light by patients and their families, regardless of any other manifest skills of the practitioner. The Quality in Australian Health Care Study (QAHCS) 1 estimated that 5.5% of hospital admissions were affected by healthcare-associated infection (HAI), with an estimate at that time of 155 000 infections per annum across Australia. These figures are consistent with other Australian estimates of between 7.7% 2 and 5.7% 3 and the total estimate of 177 392 infections per annum from the Australian Commission on Safety and Quality in Healthcare review. 4 The QAHCS documented death in 4.9% of all adverse events (including infections) and permanent disability in 13.7%. Although there has not been a systematic study of this size conducted subsequently in Australia, there is no evidence that rates of HAI have decreased and HAI remains a major healthcare safety issue. 1 The most common patient HAI involves the urinary tract, respiratory tract, surgical sites, intravascular catheters and bloodstream. It is estimated that up to 70% of HAI could be prevented if infection control procedures were followed. 5 Patients increasingly concern themselves with risk of infection when entering a hospital and expect their carers to adhere to safe practice. Poor infection control practice will be regarded in a negative light by patients and their families, regardless of any other manifest skills of the practitioner. Modern healthcare generates a wide range of infection risks for patients through practices that severely compromise host defences against infection and promote colonization by pathogenic hospital strains of bacteria. Patients are frequently confined in crowded, difficult to clean environments, where they may undergo invasive procedures, be fitted with prosthetic devices, and require broad-spectrum antibiotics or immunosuppressive therapies. These conditions provide ideal opportunities for the adaptation and spread of pathogenic microorganisms, such as methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile, vancomycin-resistant enterococci and multi-resistant Acinetobacter species. Pathogens circulating in the general community also enter the hospital and exploit the crowded conditions to spread rapidly within the hospital population. Examples include community-type MRSA, norovirus and severe acute respiratory syndrome (SARS) virus. 4 Some infections are also caused by an admitted patient's own bacterial flora (endogenous infections), due to processes that compromise defences against invasion and infection. Until recently many clinicians have not considered themselves to be at risk from infection by working in healthcare. 'Standard Precautions' formerly termed universal precautions (Table 1 ) are designed to reduce HAI risk for both patients and staff in all healthcare settings, independent of the infectious status of a person. 6 When adhered to closely, they largely eliminate the risk of blood-borne virus (e.g. HIV, Hepatitis B or C) transmission during healthcare without the need to document the infection status of individual patients. There are well-documented cases of blood-borne virus infections in healthcare staff that have resulted from lapses in Standard Precaution practice (e.g. following avoidable needlestick injury or mucosal splash). 7 The worldwide SARS epidemic provided a stark reminder of risk from pathogenic respiratory illness. In Canada, Hong Kong, Singapore and elsewhere, healthcare staff were at the highest risk of contracting SARS and significant mortality resulted. 8 Other respiratory illnesses such as influenza and respiratory syncytial virus are also frequently spread among staff by infected patients and major morbidity may result. A recent review concludes that tuberculosis remains a very important occupational risk for healthcare staff in low and middle income countries and for staff in some high-income country facilities. Risk appears particularly high when there is increased exposure combined with inadequate infection control measures. 9 Organisms such as MRSA that are spread mainly by contact (touch), colonize and infect healthcare staff with varying ease dependent on the characteristics of the strain. A review of 127 investigations of hospital MRSA and the involvement of healthcare staff indicated an average of 4.6% of healthcare staff to be carriers of MRSA with 1 in 20 (5.1%) experiencing MRSA infection. Risk factors for staff included chronic skin disease and poor infection control practice. Staff were implicated as the cause of several MRSA clusters. 10 New virulent strains of community-type MRSA have been isolated in most Australian states, causing outbreaks within families, facilities and communities. 11 MRSA infected or colonized patients admitted to hospital increase the risk of MRSA spread to healthcare staff and their families. A recent report highlighted the impact of community-type MRSA on a paediatric clinic in the United States; 16 of 45 staff experienced skin infections and one staff member died from MRSA infection. 12 A conventional division specifies three modes of infectious illness dissemination -contact (direct, indirect, common vehicle and vector), droplet and airborne spread; however, in reality a continuum of patterns exist for each pathogen. Table 1 provides examples of agents predominantly spread by each mode and protective measures that are required to reduce cross-transmission. 13 The hands of healthcare staff are the single most important factor in the transfer of pathogens from patient to patient (contact spread). 14 Colonized patients and staff are the main reservoirs of hospital-adapted pathogens, shedding these organisms into their immediate surroundings. The transfer of these pathogens (usually through direct or indirect contact) to a normally sterile body site or onto an invasive medical device enables an infection to occur. Healthcare-associated infection that result from exposure to infected aerosols (droplet or airborne transmission) are less frequent. Infections spread by the droplet respiratory mode can also be transmitted through contact spread as many of these infective agents remain viable on hands and surfaces for extended periods. For instance there is compelling evidence that respiratory syncytial virus cross-infection in paediatrics is reduced by increasing compliance of healthcare staff with hand hygiene. 15 Agents that cause respiratory infection are designated as either spread by droplet or airborne routes (see Table 1 ) largely based on epidemiological studies; however, this division is artificial to some degree. The process of coughing or sneezing creates droplets of varying size that may be expelled at high velocity across distances up to 6 m, which may facilitate distant transfer of any respiratory infective agent. Furthermore, in low-humidity (e.g. air conditioned) environments, larger droplets may evaporate to form droplet nuclei that remain airborne for extended periods. Whether true airborne transmission of infection occurs depends on such variables as the infectious dose of an agent, the delivered dose to the recipient and what degree of pre-existing immunity the recipient has. The microbes that are most efficiently disseminated by the airborne mode (e.g. tuberculosis, measles, varicella) remain viable in droplet nuclei and have a very low infectious dose in a susceptible individual. In low-humidity environments, influenza more usually spread by 'droplet' may also be spread over short distances via the airborne route as shown from animal studies. 16 Healthcare staff and other patients must be protected from infectious fine particle (<5 mM) aerosols that are capable of transmitting infection at low doses †Active screening and isolation for methicillin-resistant Staphylococcus aureus-colonized patients/staff is not performed at some Australian sites as it is considered to be an ineffective measure. However, all evidence-based international standards and guidelines support the practice in patients demonstrated to have moderate to high risk for carriage. Active screening for other MROs (e.g. vancomycin-resistant enterococci) is still controversial and varies widely in practice. In large part, screening should be confined to patient populations at highest risk from morbidity (e.g. intensive care, haematology and solid organ transplant patients). It is tempting to ascribe the failure to prevent HAI to individual human factors alone -lapses and active failures by doctors and other healthcare staff; however, these lapses occur in a healthcare environment that often fails to facilitate safe systems of care. For instance lack of training or credentialing in standard infection control practices, understaffing and lack of availability of alcoholbased hand rub make adherence to safe practice less likely. To protect patients more effectively, it is crucial that systems of management and care in hospitals are improved such that (i) lapses or active failures are less likely to occur and (ii) there are safeguards to prevent injury in the event of a lapse. A basic premise is that humans are fallible and errors are to be expected. Systems that provide barriers and safeguards must be improved to reduce the capacity for human error to cause an adverse event. 17 Most existing healthcare systems still have significant potential to create risk for patients and staff from HAI. There are many relatively hidden and important deficiencies (latent unsafe conditions) that contribute to significant HAI risks. Table 2 catalogues Australian healthcare systems, their status of development and examples of latent unsafe conditions with an assessment of the HAI risk from each of these. The risk assessment is a subjective synthesis of the likelihood of an unsafe condition or event coupled to the potential severity of outcome in line with the NSW risk assessment process. 18 In addition to system change, organizational culture change, that is, the establishment of new norms of behaviour driven by leaders in management and clinical care who have been convinced of need for urgent change is needed. 19 Leaders must provide explicit, unequivocal support for infection control policy and its implementation. They must ensure that all necessary enablers such as bed-side alcohol-based hand rub and universal staff training are in place. Sufficient epidemiologists and infection control professionals are required to effectively manage and implement infection control surveillance, audits and training. Once these measures are in place, there is also a role for social marketing campaigns to healthcare staff and patients to increase awareness of HAI and its prevention. Physicians as leaders, role models, patient advocates and educators play a crucial role in efforts to improve safety of healthcare. A persuasive, detailed case for clinician-led reform was made by Scott et al. recently in this journal. 20 Physicians are uniquely placed to drive clinical practice reform that embeds specific evidence-based patient safety practices across all relevant patient groups. As argued by Scott et al., to achieve this, significant changes in clinical workforce organization, teamwork, patient participation, interventional supervision, clinical governance and information technology for monitoring performance are required. Systems design principles, using approaches derived from industry, can help to make clinical care safer and less variable and improve safety. The active involvement of clinicians in these changes is paramount. At an individual level, physicians can make a difference by: • Participating in the orientation and performance man- 21 Three large studies have demonstrated that multimodal programmes to achieve sustained increases in hand hygiene compliance have been associated with reductions in HAI, including MRSA. [22] [23] [24] A national initiative commenced in 2008 to improve hand hygiene, focusing on education, provision of alcohol-based hand rub at every bedside, reliable, regular audits of compliance with effective feedback to staff and management, and measurement of patient infection outcomes (healthcare-associated S. aureus bloodstream infections). The programme is modelled on the five moments for hand hygiene programme developed by the World Health Organization. A central message is to clean your hands before and after every patient contact. In observational audits, medical staff are often demonstrated to have the poorest hand hygiene adherence and thereby expose their patients to significant risk. As leaders, mentors, educators and patient advocates, physicians must urgently adopt a best practice of hand hygiene throughout their practice settings. System aspects include making sure that hand alcohol-based hand rub is available for use at each bed-side and practice setting. Just as the culture change that normalized the use of seat belts was essential to improvements in road safety, sustained changes in compliance with hand hygiene will only arise out medical support for a pervasive organizational (and perhaps regulatory) approach to culture change. Other elements of the hospital ward round may create significant risk to patients and staff due to lack of compliance with Standard Precautions. In particular, portable equipment (e.g. stethoscope) taken to the bedside must be cleaned or disinfected prior to contact with a patient or their environs. A good system of care on ward rounds is to provide a separate ward round trolley equipped with alcohol-based hand rub and large alcohol-impregnated wipes for disinfecting stethoscopes and other equipment. Such a trolley can also hold the patient clinical files and provide a surface for writing, avoiding cross-contamination with the patient environment. Asepsis encompasses techniques, including disinfection, that reduce the potential for microorganisms to contaminate sterile body sites during invasive procedures. As an example, studies of central intravascular lines document significant reduction in risk from infection when optimal aseptic practices are systematically adopted. A care 'bundle' that includes performance of hand hygiene by the operator prior to insertion, application of effective skin antiseptic, allowing it sufficient time to work, wearing sterile protective apparel, and using a large sterile drape for the insertion site virtually eliminates intensive care central line-associated bloodstream infection. 25 Prior patient exposure to antimicrobials is a key risk factor for colonization and infection due to antibioticresistant bacteria and C. difficile infection. These infections usually add to the infectious burden rather than just replacing existing cases of infection caused by less resistant pathogens. Evidence from community and hospital practice shows that use of systemic antimicrobials is often indiscriminate or ineffectively targeted against the likely or proven pathogen. Antimicrobial stewardship programmes attempt to improve prescribing to reduce unnecessary use and promote effective directed antibiotic treatment in line with guidelines and demonstrated incidence of antibiotic resistance. Successful stewardship programmes have been shown to reduce not only resistance rates in hospitalized patients but also morbidity, mortality and cost. 26 The Australian Commission on Safety and Quality in Healthcare has recently established a project to improve antibiotic stewardship in Australian hospitals. 27 Key practice points include 27, 28 • Potentially septic patients need appropriate investigation prior to antibiotic treatment -at least two blood culture sets from different peripheral sites, other microbiology as indicated • Empiric antimicrobial choice and dose for septic patients should be based on recommendations from Therapeutic Guidelines: Antibiotic or local Infectious Diseases/Microbiology expert advice -inadequate initial therapy is a demonstrated risk factor for adverse outcomes • Indications for antimicrobial treatment and duration should always be documented • Patients who are on antimicrobials need regular evaluation to determine: need for ongoing treatment and/or need to target (or direct) treatment against a demonstrated pathogen (select alternative agent, consider correct dose, switch to oral, modify treatment plan including duration of treatment) • Follow recommended surgical antibiotic prophylaxis (right drug, right dose, right timing -administer within 60 min of procedure commencement, no post-operative doses) • Evidence-based computerized decision support systems facilitate better prescribing and lower bacterial resistance. Immunization of healthcare staff helps protect the individual and also reduces risk from vaccine preventable disease in patients. For instance high uptake rates of annual influenza immunization by healthcare staff in aged care facilities has been shown to reduce mortality in their elderly patients. 29 All healthcare staff with direct patient contact need to ensure that their immune status is optimized for hepatitis B, tuberculosis, measles, chickenpox, influenza and pertussis. Medical staff should visit their staff health service annually to update their immunization and have their immune status checked as required. The Australian Immunisation handbook defines many situations in which patients who are over 65 years and younger patients with various chronic medical conditions should receive additional regular immunizations. These include patients with splenectomy or hyposplenism. Various surveys of these patients indicate that compliance with immunization guidelines is poor. 30 All physicians should implement systems of care to identify their at-risk patients to enable opportunistic immunization as recommended. Measurement of the incidence of major types of HAI is an essential component of control programmes. 1 Bloodstream infections, surgical site infections, intensive care infections, infections and colonizations due to multiresistant organisms are usually documented by routine surveillance systems and reported to State and National bodies. Clinical teams should receive regular feedback about HAI, antibiotic resistance and usage in their patients. Current levels of HAI in Australian hospitals are unacceptable and lead to preventable morbidity. Physicians can drive widespread system and practice change towards safer care using existing knowledge about quality improvement. The impact of such changes will be evident from HAI surveillance data and will serve to increase the community's trust in the healthcare system. The Quality in Australian Health Care Study The prevalence of nosocomial and community-acquired infections in Australian hospitals Effect of healthcare-acquired infection on length of hospital stay and cost Reducing Harm to Patients from Healthcare Associated Infection: The Role of Surveillance. Sydney, NSW: Australian Commission on Safety and Quality in Healthcare The preventable proportion of nosocomial infections: an overview of published reports Infection Control Guidelines. Table 2.1 Standard precautions for infection control in health care settings. Canberra, ACT: Department of Health and Ageing Occupationally acquired human immunodeficiency virus (HIV) infection: national case surveillance data during 20 years of the HIV epidemic in the United States Consensus Document on the Epidemiology of Severe Acute Respiratory Syndrome (SARS) Risk of tuberculosis infection and disease associated with work in health care settings Health-care workers: source, vector, or victim of MRSA? Community-associated methicillin-resistant Staphylococcus aureus (MRSA) in Australia Methicillin-resistant Staphylococcus aureus and skin infections among personnel at a pediatric clinic Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings Hand hygiene: a frequently missed lifesaving opportunity during patient care Nosocomial respiratory syncytial virus infections: the 'Cold War' has not ended Transmission of influenza A in human beings Human error: models and management Severity assessment code matrix Leading Change Improving quality and safety of hospital care: a reappraisal and an agenda for clinically relevant reform Hand hygiene and patient care: pursuing the Semmelweis legacy Significant reductions in methicillin-resistant Staphylococcus aureus bacteraemia and clinical isolates associated with a multisite, hand hygiene culture-change program and subsequent successful statewide roll-out Effectiveness of a hospital-wide programme to improve compliance with hand hygiene Efficacy of an alcohol/ chlorhexidine hand hygiene program in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection An intervention to decrease catheter-related bloodstream infections in the ICU Antimicrobial stewardship Australian Commission on Safety and Quality in Healthcare Therapeutic Guidelines Limited Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial Influenza and pneumococcal vaccine coverage among a random sample of hospitalised persons aged 65 years or more Ten commandments of infection prevention for physicians 1 . Always disinfect your hands with alcohol-based hand rub BEFORE and AFTER touching a patient or performing a procedure. Set the example for your team and expect others to follow your lead.2. Dress well for safer care -abandon ties and lanyards, bare your arms to the elbow -no wrist watches or jewellery.3. Insist on the provision of alcohol-based hand rubs at the patient bedside and in your clinic/rooms. 4 . Take alcohol-impregnated wipes on your ward rounds to disinfect equipment, such as stethoscopes and pulse oximeters between use on every patient. 5. Ensure your team follows a standard, methodical, sterile (aseptic) approach for all invasive procedures (especially IV line insertion).6. Invasive devices are potentially dangerous -remove them as soon as you can (within 3 days for peripheral cannulae). 7. Target antimicrobial therapy -consult Therapeutic Guidelines: Antibiotic for the most appropriate agent(s), dose, route and duration.8. Be the first on your team to have the influenza vaccine every year and make it known to others.9. If you're not receiving regular, relevant feedback about healthcare-associated infections like MRSA involving your patients, then you're missing out -insist on it. 10. Look beyond the obvious when seeking source(s) of infection. Surgical wound and device-related infection may be present even in the absence of visible local inflammation.