The patients' perception of infection prevention and control in healthcare
The strategies healthcare facilities have in place to manage healthcare acquired infections need to take the patient into consideration, writes Marija Juraja.
Approximately five to 10 per cent of patients in hospitals will have a healthcare acquired infection (HAI) and they are just as common amongst residential aged care facilities such as nursing homes, rehabilitation facilities and special accommodation placements i.e. respite centres (Spelman, D. 2002). In Australia it is estimated there are 180,000 HAIs annually and that over two million additional beds are taken up by HAI patients (Australian Government Productivity Commission 2009). The impact of a HAI also has a ripple effect onto the facility, with reduced bed capacity, loss of income and increased medical expenses.
The patient journey into healthcare can be simple or, as many find it, very complex, with multiple people and interventions. When patients are admitted into the healthcare system, their journey should begin with a clear understanding of why they have been admitted, their treatment plan, and the length of their hospitalisation/recovery. As many patients and staff will tell you, this is not often the case. Issues that impact on this happening are the level of understanding by the patient, the language barriers, the patient’s co-morbidities, poor discharge planning and the acquisition of a HAI.
On attending the last Community and Hospital Infection Control Association (CHICA) national conference in Ottawa Canada this year, there were several presentations providing evidence of system failures and the outcome with a HAI. Sir Liam Donaldson’s presentation gave some great examples of the patients and their journey through healthcare, their misfortunes and where the system failed them. He stated though that there is a changing emphasis on HAIs and the public is now becoming more engaged in the process from hospital to community as it personally affects more people.
One case he presented was a 30-year-old male patient admitted with damaged cartilage in his knee, requiring surgery. The surgical wound became infected with Methicillin resistant staphylococcus aureus while he was an inpatient. The patient’s infection progressed despite antibiotic treatment and ultimately he had a below-knee amputation. On asking the patient about his journey through the system to this end point, the patient said: “the doctors and nurses didn’t wash their hands or wear gloves when touching his wound; the bathroom wasn’t cleaned frequently, and he never saw the cleaners change the mop or water between rooms.” The patient also stated: “I’m not bitter of what happened but I wasn’t aware that I could ask or what I should be asking with the things that were happening or that I was seeing” (CHICA 2013).
Last year, at the inaugural Australasian College for Infection Prevention and Control national conference in Sydney, recent research by Emma Burnett was provided on the patient’s perception of HAI and it found, again, that it was the system and process that failed the patient. In her research, she found that patients had limited understanding of infection or risk of transmission, that they lacked the appropriate information, and were fearful and distrusted the system. She also found the media were one of the main sources of information for patients (Burnett, E. 2013).
Various care bundles or strategies have been introduced into healthcare to reduce the risk of HAI. One strategy has been embedding the culture of hand hygiene.
“Infection prevention and control should be a key goal in any organisation, as should patient safety and quality of care.”
Hand hygiene over several years has been focused at healthcare workers (HCW), but to drive changes the patient needs to be engaged in the process. Recent studies and conference presentations have highlighted that several years ago few patients would have challenged HCW on their hand hygiene, but this perception is shifting as the focus moves to the patient and community awareness. Alcohol hand rub (ABHR) is now freely available across the continuum of healthcare to the community. The challenge in any facility is ensuring access to hand hygiene while minimising the risk to patients/residents with potential ingestion.
A recent hospital consumer complaint stated: “ ..it was good to see the ABHR available and used at the end of my bed. I saw the nursing, medical staff and visitors using the rub. It wasn’t until day nine of my admission, when all the tubes and paraphernalia was removed and I could get out of bed and use the bathroom, that I realised that not once had I washed my hands or even been offered anything when I used the bottle.” Again, in this case, it clearly demonstrates how systems can fall over when the closest and most obvious isn’t even considered in patient care or even challenged by the patient.
At the CHICA 2013 conference there was a presentation by a patient Mr Bill Beattie who had presented to his local hospital with diarrhoea after taking a course of antibiotics for cellulitis from a cut on his arm. He tested positive for Clostridium difficile. He spent several weeks to months in hospital and several times in the Intensive Care Unit. He made several observations while in hospital and on reflection stated: “he wasn’t isolated in the Emergency Department and that precautions weren’t implemented even though he had diarrhoea; there was a lack of communication from medical staff; the nursing staff were disorganised and constantly forgetting things which delayed them returning to his room due to having to remove and replace the personal protective equipment; he wasn’t offered any opportunities for hand hygiene when he was bed bound (same as the previous patient story) and that information provided to the patient needs to be kept simple and constantly repeated.”
Even when he was discharged home finally after undergoing a faecal transplant, he still didn’t understand Clostridium difficile, even though he had been given a fact sheet. This impacted on him psychologically as he felt like a leper and a potential vehicle for furthering the spread of disease. He limited his visitors, he distanced himself for months from the family at home, including his very elderly parents (both in their nineties). He was fearful in passing this to his family and possibly causing the demise of his elderly parents.
These insights from the patients highlight several important points that patients do understand basic infection control principles and value appropriate communication. Patients need to be given information that is reinforced throughout their journey including their inpatient care and post discharge care (CHICA 2013). As patients are technologically savvy and use search engines such as Google to find information, this can be more stressful as there is so much information and it is not always appropriate and can be conflicting. Fear and fear of retribution for speaking up or challenging behaviour by the patient will begin to decline and challenging will become the norm as they are further educated and empowered.
Infection prevention and control should be a key goal in any organisation, as should patient safety and quality of care. This requires leadership from within the organisation from the highest level of governance the Chief Operating Officer, the facility Manager and/or Nursing Director. It should be supported further by the Infection Control Practioner/Professional and all facility staff from the medical/nursing staff through to the cleaners and maintenance staff (ACSQHC 2011).
I will leave this question for you to reflect on by Sir Liam Donaldson from the CHICA 2013 conference “are patients and their experiences embedded at all levels of your organisation?”
Marija Jane Juraja
RN, Grad Certificate IC,
CICP ACIPC President
Marija currently holds the position of Coordinator, Infection Prevention & Control at The Queen Elizabeth Hospital, SA. She is a registered nurse, with extensive experience in infection prevention, surveillance and control. She has a Graduate Certificate in Infection Control from Adelaide University. She is currently an Adjunct Lecturer at The University of South Australia. She is the current president of the Australasian College for Infection Prevention and Control. She has published and co-authored several articles and guidelines and presented at national and international conferences. Marija is the college representative on the Healthcare Associated Infection’s Implementation Advisory Committee at the Australian Commission on Safety & Quality in Health Care and a council/board member of the National Coalition of National Nursing Organisations.
1.Spelman, D. Hospital Acquired Infections. MJA 2002; 176: 286-291.
2.Australian Government Productivity Commission. Chapter 6 Hospital- Acquired infections. Public and Private Hospitals – Productivity Commission Research Report. 2009.
3.Community and Hospital Infection Control Association (CHICA) National Conference June 1-6th 2013, Ottawa Canada. http://www.chica.org/index.php
4.Burnett, E. et al. Understanding factors that impact on public and patient’s risk perceptions and responses toward Clostridium difficile and other health-care associated infections: A structured literature review. AJIC 2013; 41: 542-548.
5.National Standard 3. Preventing & Controlling Healthcare Acquired Infections. Australian Commission on Safety and Quality in Health Care (ACSQHC) (2011), National Safety and Quality Health Service Standards, ACSQHC, Sydney.
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