Preventing and controlling healthcare associated infections
Saturday, 20 April, 2013
Reflecting on Standard 3, at least half of all healthcare associated infections are considered to be preventable and can cause extensive harm and have significant resource costs, writes President of the Australasian College for Infection Prevention and Control, and Co-Director for Sterilization and Infection Control, Southern Health, Elizabeth Gillespie BN, RM, ORMgt, CICP, MPubHlth(Melb).
At least half of all healthcare associated infections are considered to be preventable and can cause extensive harm and have significant resource costs.
Standard 3 of the National Safety and Quality Health Service Standards is aimed at assisting organisations develop, establish and improve their programs for infection prevention and control. There are six broad criteria within this standard that provide direction to safe and effective care. A guide has been developed, that can be used in conjunction with the standard, to assist organisations to demonstrate a quality improvement program is in place, which is facility wide.
The standard is structured to engage the health service executive, senior managers and clinicians through a governance framework and risk management approach to infection prevention and control. Protecting the public from harm and improving healthcare is the focus by preventing and controlling healthcare associated infections.
Preventing and controlling healthcare associated infections
The Australian Commission on Safety and Quality in Health Care (the Commission) have developed the National Safety and Quality Health Service (NSQHS) Standards 1 in consultation with jurisdictions plus a wide range of organisations, including the former Australian Infection Control Association (AICA). This was undertaken prior to the establishment of the Australasian College for Infection Prevention and Control in 2012.
The primary aim of the 10 standards is to protect the public from harm and improve the quality of health care. Standard 3 in the series of 10, pertains to preventing and controlling healthcare associated infections and the Commission has also released a guide to assist health services align their quality improvement programs when using the NSQHS standards.2
Clinical governance refers to the system by which managers and clinicians share responsibility and are held accountable for patient care. The prevention and transmission of infectious agents must be a priority in every healthcare facility. To achieve this, the NSQHS Standards provide the framework to drive continuous quality improvement and promote a non-punitive culture.
Standard 3 is intended to reduce the risk for patients of acquiring healthcare associated infections by using evidence based strategies. Mechanisms exist that can reduce the rate of infections. However, as there is no single cause of infection, there is also no single solution. A range of strategies is required together with a collaborative approach. The standard is intended to equip organisations to effectively manage infections if they occur.2 The mechanism by which the standard aims to achieve the prevention and control of healthcare associated infections is through broad management options using the following criteria:
Governance and systems for infection prevention, control and surveillance,
Infection prevention and control strategies,
Managing patients with infections or colonisation,
Cleaning, disinfection and sterilisation
Communicating with patients and carers.
Each year in Australia there are about 200,000 healthcare associated infections; at least half these infections are preventable and they are sometimes a cause of serious harm. Healthcare associated infections are the most common complication-affecting patients in hospitals. The important sites of infection are the bloodstream and surgical sites. The excess length of stay due to a surgical site infection is between 3.5 and 23 hospital bed days. The total number of bed days due to surgical site infection for a one-year period was estimated to be 206,527 bed days. 3
Healthcare associated infections may also have significant resource costs, as they prolong hospital length of stay and add to morbidity for patient care.4 Each year in Australia, there are estimated to be more than 12,000 bloodstream infections associated with healthcare. Studies have demonstrated that between 17 - 29% of patients with hospital acquired bloodstream infection die while still in hospital.5
It is well recognised that to address infection prevention and control issues effectively, requires a facility wide program and is everybody’s responsibility.4
The Commission’s guide provides suggestions to assist with meeting the standard and is clear that these suggestions should not be interpreted as mandatory requirements.
The criteria addressed within Standard 3 are outlined below:
Governance and systems for infection prevention, control and surveillance
This criterion is aimed at ensuring the presence of a governance framework that incorporates executive responsibility. The framework is outlined in the Australian guidelines for the prevention and control of infections in healthcare3 and promotes the development of strategies to assist the infection prevention and control program to decrease infection. Ideally this would be incorporated into the quality and safety plan of the organisation. To be successful, the infection prevention and control program requires leadership and support from the executive, senior managers and clinicians.2
Risk management is an integral part of a successful infection prevention and control program in reducing harm arising from infection. Development and regular review of policies and monitoring systems should be based on a risk assessment to determine actions relevant to the particular health service. Policies should be endorsed by the executive of the health service.2
In most settings, clinical indicators are used to monitor performance and evaluate and improve processes. Indicators relating to infection prevention and control should demonstrate a continuous quality improvement plan is in place. Quality activities must be implemented and regularly reviewed, with measurement, action, evaluation and feedback occurring. Examples of strategies to demonstrate compliance might include surveys of the workforce for awareness of protocols and guidelines, records of completion of in-service education that incorporates practice changes, improved usage rates of products such as chlorhexidine washes for patients in high risk areas or improved antibiotic prophylaxis compliance for antibiotic type, duration and timing when compared with national and international benchmarks.
The infection prevention and control program should encompass every part of the healthcare facility. Monitoring recommended practice and measuring against benchmarks can provide the baseline for improving infection control practice outcomes.
Safe and high quality infection prevention and control practice contributes to continual improvements in the quality of healthcare provided in any setting. These practices occur at the organisational, staff and patient levels. One example from Southern Health in Victoria is the introduction of a hand hygiene program for the operating suite. This involved the development of a specific operating suite hand hygiene tool. Over 4 years a statistically significant improvement in hand hygiene compliance was observed along with a reduction in deep wound infections for cardiothoracic surgery.6
Integrating monitoring and review processes into policies and procedures enables data to be collected. Performance indicators can be developed from this data, such as compliance with protocols and use of infection prevention and control products. This has been demonstrated in an intensive care unit where a reduction in Methicillin-resistant Staphylococcus aureus (MRSA) was able to be sustained7 and hand profiling was used to engage medical leaders in a program of effective hand rub technique.8
Standard 3 requires health services to provide evidence of regular review, monitoring, audit or assessment. The frequency of these activities is determined through the use of a risk management assessment, the scope of the organisations activities or services and retention rates of their workforce.2 For instance, a small facility where the workforce is stable and compliance is high may interpret regular review as every 2 years. However, a large facility with high turnover of staff, who move within departments on rotation, may interpret regular review as at least annually. Both process measures and outcome measures can be utilised to drive improvements.
Infection prevention and control strategies
Infection control is a health and safety issue that requires both managers and clinicians to be responsible for providing a safe environment for patients and the workforce. Successful measures such as the implementation of work practices that prevent the transmission of infectious agents may involve using a tiered approach of routinely applying strategies to minimise risk and effectively manage infectious agents where standard precautions may not be sufficient on their own.
An example of this might be auditing the implementation of transmission-based guidelines. This can be used to confirm the appropriate use of resources in conjunction with the minimisation of risk to transmission of infection. Another example is the review of microbiological monitoring of endoscopes that resulted in the use of process controls rather than product controls for quality assurance of this reusable medical equipment. Education of personnel, utilisation of competency standards and strict adherence to the manufacturer’s instructions for cleaning and disinfection became the process controls used to demonstrate endoscope quality assurance.9
Managing patients with infections or colonisation
Standard precautions are applied to everyone, regardless of their perceived or confirmed infectious status since all people potentially harbour infectious agents. Implementing standard precautions minimises the risk of transmission of infectious agents from person-to-person, even in high-risk situations. Standard precautions are used by the workforce to prevent or reduce the risk of transmission of infectious agents from person-to-person and are applied as an essential strategy for minimising the spread of infections. Transmission based precautions are required where there is a risk of transmission, with patients suspected or confirmed to be infected with agents transmitted by contact, droplet or airborne routes. These are tailored to the particular infectious agents involved and its mode of transmission and may involve a combination of practices. If successfully implemented, standard and transmission-based precautions prevent any type of infectious agent from being transmitted.2
Appropriate prescribing of antimicrobials to prevent and manage healthcare associated infections and improve safety and quality of care is the intent of this criterion. The emergence of antimicrobial resistant bacteria is closely linked with inappropriate antimicrobial use. Studies demonstrate up to 50% of antimicrobial regimes are inappropriate.2 Australian hospitals have a higher overall rate of inpatient antimicrobial use and it’s recognised that further work is required to optimise the use of antimicrobials in our hospitals. 4
An antimicrobial stewardship program is an effective approach that involves a combination of a range of complimentary strategies and interventions that work together to achieve optimal usage. The program is usually incorporated with treatment guidelines and consideration of local incidence of antimicrobial resistant pathogens.2 It should be multidisciplinary and where possible involve the expertise of infectious diseases physicians, medical microbiologists, infection control personnel and pharmacists. However, there are reports of programs that specifically involve nurses to provide mechanisms for improving antimicrobial stewardship.10,11
Effective antimicrobial stewardship programs have been shown to reduce inappropriate antimicrobial use, improve patient outcomes and reduce adverse consequences. Together with hand hygiene and workforce immunisation, antimicrobial stewardship is regarded as one of the most important strategies to reduce and prevent healthcare acquired infection.4
Cleaning, disinfection and sterilisation
This criterion includes the cleaning, disinfection and sterilisation activities for re-useable equipment and instrumentation used in the health service. Consistency with the Australian guidelines for the prevention and control of infections in health care together with international and Australian Standards12 is essential for reprocessing re-useable equipment and instrumentation.
The criterion also addresses environmental cleaning and identifies key areas where quality and safety outcomes can be demonstrated. It is important that management oversees the systems and process for the maintenance of a clean, hygienic environment. The criterion links with the governance and systems criteria of Standard 3. Examples of innovations to support environmental cleaning are the use of fluorescent markers13 and newer cleaning technologies 14. These examples demonstrate mechanisms that utilise quality systems to improve practice.
This criterion requires the use of risk management principles to implement systems. The implementation of a traceability system to enable identification of patients on whom reusable medical devices have been used is required to be in place. Competency training of the workforce who decontaminate and reprocess reusable medical devices is also a requirement of this criterion.
Communicating with patients and carers
This criterion may include the provision of consumer specific information on the management and reduction of healthcare associated infections, ensuring it is available at the point of care. Improved communication, awareness of risk and risk minimization in relation to healthcare associated infections should be demonstrated for this criterion. Patient infection prevention and control information needs to be evaluated to determine if it meets the needs of the target audience.
An example might include consumer participation on a committee where infection control consumer information is reviewed and updated. It is important to identify existing processes for inclusion of consumers and carers in decision making about safety and quality activities around infection prevention and control. Accepting feedback from consumers making complaints and taking action on that feedback are simple but effective ways to make ongoing improvements within existing processes.
The NHMRC recommend that healthcare facilities support local research for specific cases of infection, outbreaks or preventative strategies and adopt relevant research findings that reduce or prevent healthcare-associated infections.5
If risk management within an organisation is to be effective, there needs to be appropriate infrastructure and culture. A logical and systematic approach to implementing the required steps and embedding risk-management principles into philosophy, practices and business processes of an organisation, rather than it being a separate activity or focus. Addressing infection prevention and control issues requires a multi-component, facility-wide program and is everybody’s responsibility. A systematic approach that has been shown to be effective is the use of care bundles. In the United States the bundled approach was considered to have saved 100,000 lives. The program was multi-component and responsibility was seen to belong to everyone. 15 Locally, a team used a bundle of care to reduce colorectal infections.16
Two-way communication between management and healthcare workers is an important factor in increasing support and then compliance with infection prevention programs. Change is more likely to be achieved where there is a shared understanding of the role of patients, healthcare workers and organisations in achieving the best possible outcomes.4
The safety and quality improvement guide for preventing and controlling healthcare associated infections provides an extensive range of examples to assist health service organisations demonstrate how they meet the criteria of the standards. They are designed with the aim of protecting the public from harm and improving healthcare. Standard 3 is specific to preventing and controlling infections. The aim of this standard is to promote a quality improvement program that is facility wide and has the capacity to prevent and control infection issues effectively.
Subsequent to the resignation of Elizabeth Gillespie as President, Marija Juraja, President Elect has been appointed as President for the balance of the 2012 – 2013 term of office.
Marija is the Clinical Service Coordinator (CICP) - Infection Prevention & Control Unit at the Queen Elizabeth Hospital in Adelaide, South Australia and has been involved in infection prevention and control for over 20 years. Since 2003 she has been a member of the previous Infection Control Association of South Australia and the president for the last 7 years. She was also a part of the National Consultative Steering Committee that began the journey for the new college.
Marija has worked at both the local network, state, national and international level, as an ICP. She has been involved in promoting and marketing infection control as a Conference Convenor/committee member for three state conferences and now for the new college. She has also worked collaboratively in providing marketing support to build clinician and organisational capacity, to develop core competencies for the ICP and general healthcare worker and to further opportunities for research and product development.
Marija’s qualification include RGN, Grad Cert Nurs, Grad Cert Inf Ctrl, CICP.
1. Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards. Sydney. ACSQHC, 2011
2. Australian Commission on Safety and Quality in Health Care. Safety and Quality Improvement Guide. Standard3: Preventing and Controlling Healthcare Associated Infections (October 2012). Sydney. ACSQHC, 2012.
3. Australian Commission on Safety and Quality in Health Care. Preventing and controlling healthcare associated infections Standard 3 Fact sheet http://www.safetyandquality.gov.au/ wp-content/uploads/2012/01/NSQHS-Standards- Fact-Sheet-Standard-3.pdf Last accessed January 2013
4. Cruickshank M, Ferguson J, editors. Reducing harm to patients from healthcare associated infection: The role of surveillance. Australian Commission in Safety and Quality in Health Care, 2008.
5. NHMRC. Australian Guidelines for the Prevention and Control of Infection in Healthcare. Commonwealth of Australia. 2010.
6. Bellaard-Smith E, Gillespie E. Implementing hand hygiene strategies in the operating suite. Healthcare Infection 2012;17:33-37
7. Gillespie E, ten Berk de Boer F, Stuart R, Wilson J. A sustained reduction in the transmission of methicillin-resistant Staphylococcus aureus in an intensive care unit. Crit Care Resusc 2007;9:161- 165
8. Gillespie E, Kotsanas D, Wilson J, Buist M, Stuart R. hand profiling: A novel tool used to demonstrate hand hygiene technique. Healthcare Infection 2009;14:153-157
9. Gillespie E, Kotsanas D, Stuart R. Microbiological monitoring of endoscopes: 5-year review. Journal of Gastroenterol Hepatol 2008;23:1069-74
10. Gillespie E. Rodrigues A, Wright L, Williams N, Stuart R. Improving antibiotic stewardship by involving nurses. AJIC 2012 Oct 13 [Epub ahead of print]
11. Stuart R, Wilson J, Bellaard-Smith E, brown R, Wright L, Vandergraaf S, Gillespie E. Antibiotic use and misuse in residential aged care facilities. Intern Med J 2012;42:1145-9
12. Standards Australia. Cleaning, disinfecting and sterilizing reusable medical and surgical instruments and equipment, and maintenance of associated environments in health care facilities. AS/NZS 4187:2003
13. Gillespie E. Standard for using a fluorescent marker. AJIC 2012;40:85-6
14. Gillespie E, Wilson J, Lovegrove A, Scott C, Abernethy M, Kotsanas D, Stuart R. Environmental cleaning without chemicals in clinical settings. AJIC 2012; Nov [Epub ahead of print]
15. McCannon CJ, Schall MW, Calkins DR, Nazem AG. Saving 100,000 lives in US hospitals. British Medical Journal. 2006;332(7553):1328-1330.
16. Bull A, Wilson J, Worth L, Stuart R, Gillespie E, Waxman B, Shearer W, Richards M. A bundle of care to reduce colorectal surgical infections: an Australian experience. J Hosp Infect 2011;78:297-301.
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