A Multi-pronged Approach to Tackle HAI

Though evidence-based guidelines for prevention of infection are available, there are new challenges such as MRSA, VRE, MDR-TB, extended sprectum beta lactum producing bacteria.

Dr Vijay D'Silva

Infection that is not present, nor incubating at the time of patient's admission to hospital is called nosocomial infection. Around 5-10 per cent of hospitalised patients in any part of the world at any time have Hospital Acquired Infection (HAI). The most common among these are urinary tract infection followed closely by respiratory tract infection. The others are surgical site infection and bacteremia. The major risk factors for acquiring nosocomial infection are invasive procedures. Efforts to lower infection risks have been challenged by the growing number of immunocompromised patients, antibiotic-resistant bacteria, fungal and viral superinfections, and invasive devices and procedures.

Picture Courtesy: Getinge

Infection Control (IC) is a quality improvement activity. The best way to prevent infection is to have a multi-disciplinary approach which is evidence based and cost-effective. The most effective single measure in the control of HAI is hand washing
which is proven and cost effective. The standards of the Joint Commission on Accreditation of Healthcare Organisations require all accredited hospitals to have an active programme for surveillance, prevention, and control of nosocomial infections. Though evidence-based guidelines for prevention of infection are available, there are new challenges such as methicillin resistant staphylococcus aureus (MRSA), vancomycin resistant enterococci (VRE), multi-drug resistant tuberculosis (MDR-TB), extended sprectum beta lactum producing bacteria, multi- resistant gram negative bacilli, clostridium defficle and pseudomonas.

In order to prevent and control infection, there is a need for an IC programme. The programme needs to be given firm structure. The other most important component is commitment of hospital staff to IC practices. The laid down IC practices should be simple, cheap, user-friendly and strictly enforced, with more emphasis on prevention rather cure. The IC committee should be a multi-disciplinary group consisting of infectious disease doctor, the HOD of intensive care, pathology, microbiology, nursing, central sterile supply department, engineering, pharmacy, housekeeping and dietetics. The committee is a think tank which makes policies, standard operating procedures and analyses data. The actions are by IC team comprising a doctor, nurse and technician, who are ground level workers. The committee and the team should have commitment from top management and financial support. The following are some of the most important components of IC programme :

• Surveillance involves acquiring data of patients admitted with pre-existing infection and those acquiring the infection while in the hospital. This data needs to be analysed and the root cause analysis needs to be done to find out why the patients have acquired infection and necessary corrective action taken immediately. This should be an on going activity. In addition, investigation of an outbreak needs to be done thoroughly to control the infection at its source.
• The most common mode of transmission of infection to the patient is from the hands of the healthcare workers. Surprisingly, this is preventable and the simple solution is handwashing. Handwashing needs to be implemented in all clinical areas to be effective.
• The hospital needs to adopt standard isolation protocols when necessary. The majority of these will be contact isolation followed by blood and body fluid isolation and some respiratory isolation. The hospital needs to provide the infrastructure and facilities for these isolations and the staff needs to be trained for implementing the same. This will prevent the spread of infection from one patient to another.
• The need for reserved antibiotic policy cannot be emphasised more. Considering the rising incidence of antibiotic resistance and the emergence of multi-drug resistant organisms, there is an emergent need for restricting antibiotic misuse. The objective is to provide a mechanism that will facilitate the reliable and scientific administration of antibiotic for treatment and prophylaxis. The policy needs to be reviewed periodically, keeping in view the changing antibiotic resistance pattern to provide a scientific change.
• Hospital waste is the potential reservoir of pathogenic microorganism and requires appropriate handling. Hospital waste requires management at every step from generation, segregation, collection, transportation, storage and treatment to final disposal. Segregation of different catogeries of waste must be done at the source i.e. at the point of generation. Colour coded bags as per local norms should be used with appropriate labels. The final disposal of the waste is done as per the local waste management policy of the Government.
• The hospital and its surrounding needs to be covered by a periodic cleaning schedule to achieve the goal of keeping the environment free from garbage, dust and pest.
• Equipment decontamination and disinfection should be a routine protocol in all clinical areas.
• An efficiently run central sterile service department is the backbone of an operation theatre and also the hospital.
• Pre-employment screening and periodic medical check-up of all employees is an essential tool to prevent transmission of infection from employee to the patient. Though all employees are not involved in direct patient care, it is advisable that all all employees are aware of prophylaxis and safe work practices.
• A policy needs to be implemented for handling injuries due to sharps and needles. These may involve training to prevent injuries and investigations and prophylaxis if the injuries occur.
• One major mechanism for the introduction of MRSA into a hospital can be admission of a MRSA-colonised patient or staff. Determining the prevalence of these organisms will assist in defining the risk from admitted colonised patients. Timely identification will allow for prompt implementing of precautions, which should reduce risk of transmission.
• Soiled linen can become a source of microbial contamination which can lead to outbreak of infection. Hence, it is important that the contaminated linen is collected and transported to the laundry in such a route that it is never in contact with the clean items.
• Fresh filtered air, appropriately circulated, will dilute and remove airborne bacterial contamination, and also smell. High-efficiency filters must be provided in systems serving in OT/ cath lab, haematology/ oncology units etc.
• Training is the backbone of a successful infection control programme. It should involve all the staff including doctors, nurses, technicians, paramedical staff including housekeeping.
• Audit is the tool which will indicate the success or failure of the infection control programme. It should be done for each process on a periodic or random basis.

The writer is Director Critical Care Asian Heart Institute Mumbai
Email: drvijaydesilva@ahirc.com