Old problems, new partners
With the release of the World Health Organization’s Antimicrobial Resistance Global Report on Surveillance, Cathryn Murphy believes it opens the way to build infection control capacity through novel approaches, including exploring new partnerships with medical industry.
The very recent World Health Organization Antimicrobial Resistance. Global Report on Surveillance provides Australia with a timely and salient reminder of its urgent need to stop further development and spread of antimicrobial resistance.1
Infections and especially healthcare associated infections (HAIs) caused by multiple resistant organisms (MROs) have been problematic in Australian hospitals since the early 1980s.2 Foremost they cause harm to patients and can contribute to or cause their death. Further they place significant drain on an already overburdened Australian health system through additional length of stay, treatment costs, reallocation of limited resources and disruption to hospital throughput, ie productivity.3
Even after four decades of formal infection prevention and control (IP&C) programs HAIs remain problematic and unabated, begging the question of “what now?”4 While no single intervention will likely make an immediate or radical impact on HAI prevention, control or reduction, those familiar with international advances in IP&C research may recognise there are some previously unrecognised opportunities to build infection control capacity through novel approaches.
This article discusses one such approach; the potential value of exploring new partnerships with medical industry as a legitimate and necessary additional resource to bolster local IP&C efforts.
The Australian infection control and microbiology communities as well as government and professional bodies responsible for patient safety and quality of healthcare have invested incalculable effort in attempts to reduce HAIs, more recently targeting MROs.5-8 Healthcare education worker (HCW) education, early identification, and isolation of patients with use of Contact Precautions have been the mainstays of managing patients positive for significant MROs. 9-12 This approach has inherent deficiencies as reported recently by an Australian infection control expert.13 Under the direction of the national government, hospitals and acute care settings in both the public and private sectors are vigorously promoting and monitoring hand hygiene and stringent control and use of antimicrobial agents ie. antimicrobial stewardship, in what may prove to be our most crucial efforts against MDROs and HAIs.14-16
Australia’s approach, like that of other countries with similar healthcare infrastructure, economic prosperity and mature systems of IP&C, is unfortunately failing in its mission. On a microbiological level we are observing increased levels of resistance among a wider range of organisms.1,15,16 Ironically at the same time we are finally able to observe, measure, analyse and report HCW compliance with basic infection control measures in a standardised way.17-19 For other measures, such as compliance with basic isolation process we are not yet routinely measuring either locally or nationally, we rely on research findings from our international peers.11 The news is not good on either front with Australian HCW hand hygiene compliance at around 70% but even as low as 61%20 for some specific HCW groups, and internationally compliance with isolation measures estimated to be around 28.9%.21 These realisations about poor hand hygiene practice and incorrect patient isolation are especially concerning as they highlight perhaps two of the Australian healthcare system’s greatest vulnerabilities for further MRO resistance. Our systems of infection prevention and control are not preventing MROs as well as they should. Nor are they necessarily controlling them.
Antimicrobial Resistance Global Report on Surveillance was published by the World Health Organization on 20 April 2014. It is WHO’s first report to look at antimicrobial resistance, including antibiotic resistance, globally and provides the most comprehensive picture of antibiotic resistance to date, with data from 114 countries.
“Over the past decade IC&P partnerships between clinicians, researchers, governments, professional associations and global public health agencies have flourished domestically and internationally. These partnerships result in wider, more rapid distillation of IC&P thinking and sharing as well as far-reaching distribution of findings and experiences.”
“There is much that the Australian healthcare system and specifically the IP&C community could learn from medical industry beyond just their latest product or value-added offerings.”
Over the past decade IC&P partnerships between clinicians, researchers, governments, professional associations and global public health agencies have flourished domestically and internationally. These partnerships result in wider, more rapid distillation of IC&P thinking and sharing as well as far-reaching distribution of findings and experiences. Global improvements in hand hygiene associated with the World Health Organization’s Five Moments of Hand Hygiene undisputedly illustrate the positive outcomes from partnerships. The US Keystone initiative and work around preventing catheter-related bloodstream infections, surgical site infections and ventilator-related pneumonia spearheaded by Pronovost and peers are other examples where patients prosper through partnership.22-25
Compared to our like international colleagues the Australian IP&C community makes modest investment in partnerships.26 One glaring oversight has been the almost total exclusion of medical industry and device manufacturers in any formal partnerships targeting HAI prevention. These groups are indisputably commercially driven and will always remain so. Many, especially the large multi-national companies have rich and long histories of finding efficiencies and eliminating error in their internal systems. They have been recognised as exemplars.27 They are held accountable by relevant legislative and regulatory instruments as well as formal, professional Codes of Conducts. They account according to relevant internal governance structures and they are constantly seeking innovation by investing in research and development. There is much that the Australian healthcare system and specifically the IP&C community could learn from medical industry beyond just their latest product or value-added offerings. Anecdotally, it is reported that Australian IC&P practitioners are becoming increasingly distant from medical industry. This is demonstrated by unavailability for appointments and referral instead to colleagues specifically charged with procurement. Other ICPs cite “conflict of interest” as an all-purpose way of avoiding contact. Some display general disinclination to actively engage with industry at industry-sponsored events including tradeshows associated with the annual national infection prevention conference hosted by the Australian College of Infection Prevention and Control.
Typically due to significant internal propriety investment in research and development, in-depth knowledge of the infection control ‘market’ and high level business, communication, marketing, presentation and strategic skills medical industry potentially provides the Australian IP&C community with a wealth of otherwise untapped resources beyond the usual offerings such as sponsorship of speakers and events. International partnerships with medical industry such as those implemented more than a decade ago by the Association for Professional in Infection Control and Hospital Epidemiology (APIC) provide excellent models of HAI prevention progression through strategic partnership. Since around 2012, medical industry including manufacturers of hand hygiene solution have been involved in and partially funded the WHO’s Hand Hygiene program through their Private Organizations For Patient Safety programme (http://www.who.int/gpsc/pops/en/). Their involvement is open and transparent with details publically available. Their involvement at the heart of global public policy making enables them to nimbly respond to changes in public policy which subsequently drive market demand. ICPs enjoy the fruits of this partnership by being provided with options to implement new hand hygiene formulations, new methods of delivery and new automated systems of measuring compliance. In the absence of this partnership it is likely that medical industry’s “time to market” with suitable new products consistent with recommendations would be greatly extended. In the interim, MROs continue to adapt and evolve, always taking the lead in the battle against them.
There are many other benefits of partnerships and several other potential partners for ICPs however medical industry appears to be the most logical, one of the most easily available and one of the most proven. Provided they are ethical, legitimate, open, transparent, well-thought out and highly visible, medical industry partnerships have the great potential to be mutually beneficial.28-35 Lacking these types of partnerships may continue to frustrate Australia’s efforts at HAI prevention. It will most definitely retard our ability to halt MRO progression. These reasons alone should act as catalysts for ICPs to seek new partners in prevention.
Cathryn Murphy PhD
As Executive Director of Infection Control Plus Pty Ltd, Cathryn Murphy PhD provides independent consulting services to a range of clinical, public policy and commercial clients throughout the world. In more than 25 years working in Infection Control and Prevention Cath’s career has covered senior positions within the clinical, government, non-government and professional associations within Australia and internationally.
For more than twenty years Cath helped shape infection control domestically as an Executive member and then President of both her state and national Infection Control Associations. She was a foundation member of the Asia Pacific Society of infection Control (APSIC) and an invited member of the World Health Organisation’s Expert Technical Infection Control Group. Since 2004 she has been a senior partner in Infection Control Plus.
- World Health Organization. Antimicrobial Resistance. Global Report on Surveillance. Geneva: World Health Organization; 2014.
- McLaws ML, Gold J, King K, Irwig LM, Berry G. The prevalence of nosocomial and community-acquired infections in Australian hospitals. The Medical journal of Australia 1988;149:582-90.
- Merollini KM, Crawford RW, Whitehouse SL, Graves N. Surgical site infection prevention following total hip arthroplasty in Australia: a cost-effectiveness analysis. Am J Infect Control 2013;41:803-9.
- Cheng AC, Woolnough E, Worth LJ, Pilcher DV. How should we interpret hospital infection statistics? The Medical journal of Australia 2013;199:735-6.
- Australian Commission on Safety and Quality in Health Care. Safety and Quality Improvement Guide Standard 3: Preventing and Controlling Healthcare Associated Infections (October 2012). Sydney: ACSQHC; 2012.
- Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards. Sydney: ACSQHC; 2011.
- Cheng AC, Turnidge J, Collignon P, Looke D, Barton M, Gottlieb T. Control of fluoroquinolone resistance through successful regulation, Australia. Emerg Infect Dis 2012;18:1453-60.
- Commission. AGP. Hospital-acquired infections Public and Private Hospitals Productivity Commission Research Report. Canberra: Australian Government Productivity Commission.; 2009.
- Spelman DW. 2: Hospital-acquired infections. The Medical journal of Australia 2002;176:286-91.
- Karki SMMIH, Leder KMFMPHP, Cheng ACMFMPHP. Patients under Contact Precautions Have an Increased Risk of Injuries and Medication Errors: A Retrospective Cohort Study. Infection Control and Hospital Epidemiology 2013;34:1118-20.
- Anderson DJMDMPH, Weber DJMDMPH, Sickbert-Bennett EPMS. Commentary: On Contact Precautions: The Good, the Bad, and the Ugly. Infection Control and Hospital Epidemiology 2014;35:222-4.
- Ferguson JK. Preventing healthcare-associated infection: risks, healthcare systems and behaviour. Intern Med J 2009;39:574-81.
- Godsell M-R, Shaban RZ, Gamble J. “Recognizing rapport”: Health professionals’ lived experience of caring for patients under transmission-based precautions in an Australian health care setting. American Journal of Infection Control 2013;41:971-5.
- Gottlieb T, Nimmo GR. Antibiotic resistance is an emerging threat to public health: an urgent call to action at the Antimicrobial Resistance Summit 2011. The Medical journal of Australia 2011;194:281-3.
- Coxeter P, Looke D, Hoffmann T, Lowe J, Del Mar C. The antibiotic crisis: charting Australia’s path towards least resistance. Aust N Z J Public Health 2013;37:403-4.
- Looke DF, Gottlieb T, Jones CA, Paterson DL. Gram-negative resistance: can we combat the coming of a new “Red Plague”? The Medical journal of Australia 2013;198:243-4.
- Macbeth D, Murphy C. Auditing hand hygiene rates for quality and improvement. Healthcare Infection 2012;17:13-7.
- Grayson ML, Russo PL. Problematic linkage of publicly disclosed hand hygiene compliance and health care-associated Staphylococcus aureus bacteraemia rates: comment. The Medical journal of Australia 2012;197:212-4; author reply 4.
- Graves N, Barnett A, White K, et al. Evaluating the economics of the Australian National Hand Hygiene Initiative. Healthcare Infection 2012;17:5-10.
- Syed A, McLaws ML. Doctor, do you have a moment? National Hand Hygiene Initiative Compliance in Australian hospitals? Medical Journal of Australia 2014;200:1-4.
- Dhar SMD, Marchaim DMD, Tansek RMD, et al. Contact Precautions: More Is Not Necessarily Better. Infection Control and Hospital Epidemiology 2014;35:213-21.
- Berenholtz SM, Pham JC, Thompson DA, et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol 2011;32:305-14.
- Brooke BS, Meguid RA, Makary MA, Perler BA, Pronovost PJ, Pawlik TM. Improving surgical outcomes through adoption of evidence-based process measures: intervention specific or associated with overall hospital quality? Surgery 2010;147:481-90.
- Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725-32.
- Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf 2005;31:243-8.
- Murphy CL. Using Collaboratives to Develop a Consensus Model of Elements of Australian Prevention and Control Programs. American Journal of Infection Control 2009;37:E92.
- Collins JCPJI. Built to last : successful habits of visionary companies. New York: HarperBusiness; 1994.
- Nahai F. Disclosing conflicts of interest to maintain ethical integrity. Aesthet Surg J 2011;31:591-3.
- Milligan E, Cripps AW. Conflicts of interest: a review of institutional policy in Australian medical schools. Med J Aust 2011;195:156.
- Limb M. Links between non-profit foundations and companies pose potential conflicts of interest. BMJ 2011;342:d2490.
- Liesegang TJ, Schachat AP. Enhanced reporting of potential conflicts of interest: rationale and new form. Am J Ophthalmol 2011;151:391-3 e5.
- Kachuck NJ. Managing conflicts of interest and commitment: academic medicine and the physician’s progress. J Med Ethics 2011;37:2-5.
- Fins JJ, Schlaepfer TE, Nuttin B, et al. Ethical guidance for the management of conflicts of interest for researchers, engineers and clinicians engaged in the development of therapeutic deep brain stimulation. J Neural Eng 2011;8:033001.
- Farmer BM, Nelson LS. Conflicts of interest on pharmacy and therapeutics committees at academic medical centers. J Med Toxicol 2011;7:175-6.
- Caplan AL. Is Industry Money the Root of All Conflicts of Interest in Biomedical Research? Ann Emerg Med 2011.
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