Global control of health-care associated infections

Abstract

A global movement to control health-care associated infections, led by WHO, has been gathering pace over the past 3 years. Kelly Morris reviews the measures that are being taken in developed and developing countries to tackle this major threat to patient safety. Headlines about “super bugs” and “filthy hospitals” have grabbed the public's attention in the UK. But has this scaremongering helped to tackle the problem of health-care associated infections (HAIs) that at any given time affect about 1·4 million people worldwide? Around 5–10% of patients in hospitals in developed countries get HAIs, but the risk is 2–20 times higher in poorer countries. Now a global movement to tackle this aspect of patient safety is gaining momentum, notably driven by the WHO World Alliance for Patient Safety (WAPS). WAPS' Didier Pittet from University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland, notes that tackling the issue needs awareness and action from those in positions of power. “The implementation of evidence-based measures needs more clinical governance at a very high level, not only by infection control personnel and experts, but also by chief executive officers and politicians, and not just fire fighting but investing in the basics…only now is infection control coming onto the political agenda.” The first WAPS Global Patient Safety Challenge—Clean Care is Safer Care—started in 2005. Since then, 116 countries have signed up. First, a pledge is signed between a Ministry of Health and WAPS. Then the Ministry of Health undertakes an awareness campaign, from individual hospitals to society overall. WHO guidelines for hand hygiene have been adapted for local conditions in more than 200 countries, with 40 approaches to help hand-hygiene promotion. Examples include workplace reminders or the skills to produce low-cost, high-quality, local alcohol hand-rub. “What we've seen from the beginning is a promising new surveillance system, new human resources to build-up infection control and monitoring, and strategies to tackle HAIs”, says Pittet. WAPS also has pilot sites in each of the six WHO regions, to monitor the validity and outcomes of the guidelines and strategy in different settings. “The results already show improvement in hand hygiene in all eight sites so this proves the strategy works”, says Pittet. These data are compared with control hospitals, where hand hygiene remains stable until the initiative is introduced. Data on HAI rates are expected in the near future. This year, the second global challenge—Safe Surgery Saves Lives—has started, while the third challenge, in planning, is Tackling Antimicrobial Resistance. A particular focus of the first challenge is Africa, where WHO regional director, Luis Sambo, is passionate about patient safety. At the September regional committee for Africa in Yaounde, Cameroon, he called on individual countries to develop national policies, raise awareness, and prioritise actions for patient and health-care worker safety, including tackling HAIs, especially bloodborne pathogens. Of particular concern is the low rates of testing donated blood for HIV and hepatitis and the re-use of syringes and needles. In a report Sambo presented to the committee, he wrote: “Every patient has the right to treatment using the safest technology available in health facilities. Therefore, all healthcare professionals and institutions have obligations to provide safe and quality health care and to avoid unintentional harm to patients.” Next year, WAPS will launch the African Partnerships for Patient Safety, to initially improve hand hygiene and infection control. Results from a study of implementation of the WHO hand-hygiene strategy in a hospital in Bamako, Mali are now available, says Benedetta Allegranzi from WAPS. One major achievement has been the adoption of locally produced alcohol hand-rub, alongside education, observation, monitoring, and feedback. Baseline infrastructure was severely deficient, explains Allegranzi, with few sinks in patient rooms and no soap or towels. Initial data from July, this year, “brought very encouraging results about the feasibility and effectiveness of hand-hygiene promotion in a low-income country”, she notes. Within a year, with compliance increasing from 8% to 21·8%. An essential component was the support of key hospital management and staff, and now hand hygiene and monitoring are included in annual management plans. The Mali Government will expand the strategy and use of local hand-rub at national level. However, Sambo notes that illiteracy and cultural or societal norms for medical care are some of the barriers to involving civil society and patients in such strategies. Allegranzi agrees. She was first author of a 2008 review that reported that religious faith and culture can strongly influence hand hygiene behaviour in health-care workers and “must be taken into consideration when implementing a multimodal strategy to promote hand hygiene on a global scale”. Pittet notes that in higher-income countries, the focus can be on the different strategies to tackle individual organisms—eg, meticillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. But, he says, “what we know is if we improve overall education and awareness, and empower institutions and the Ministries of Health—the people in charge—we certainly have a lot more impact”. He points to the UK as an example where success with tackling HAIs, especially MRSA and bacteraemia, is because of overall infection prevention and control measures. Brian Duerden, UK Department of Health inspector of microbiology and infection control, comments that substantial improvements in HAI rates in the UK are “the result of the commitment of all involved in delivering health care and a changed attitude that makes patient safety a priority throughout the National Health Service [NHS]”. He describes the responsibilities at every level: government and relevant departments set standards and targets and manage performance; senior managers and boards provide the environment to promote safe health care and ensure implementation and audit; and all clinical and support staff have personal responsibility to deliver safe care through hand hygiene, clinical practice protocols for procedures with risk of infection, and maintenance of a clean environment. “Training in infection prevention and control is now mandatory for all NHS staff”, he notes, while “audit of key infection rates and compliance with policies and procedures is on the agenda at all levels from ward to board”. However, the situation in the USA is rather different. In 2007, Elaine Larson from Joseph Mailman School of Public Health, Columbia University, NY, USA, studied 40 hospitals before and after implementation of hand-hygiene guidelines by the Centers for Disease Control and Prevention. Afterwards, almost half of hospitals had no multidisciplinary programme to improve compliance, hand hygiene rates were an average 56·6%, whereas central line-associated bloodstream infections were substantially lower in hospitals with higher rates of hand hygiene. “I think that part of the problem is that simple, essential infection prevention strategies such as hand hygiene have not been ‘owned’ by all health-care providers”, says Larson. “They tend to depend upon technological advances such as antibiotics or newer devices and perhaps forget about the basics. In fact, hand hygiene is not even emphasised in an effective way in many medical schools.” The responsibility is seen to lie with infection control personnel rather than each care provider, Larson adds, and a sense of “blaming” an individual still exists, rather than seeing the solution as a team effort. “It is clear that when there is a culture of responsibility, such practices improve.” Larson points to the work of WAPS collaborator Peter Pronovost from Johns Hopkins University School of Medicine, Baltimore, MD, USA, who has demonstrated that “a more systematic, multidisciplinary approach is needed. This is especially the case for routine behaviours such as hand hygiene which can get tiring and for which there is little credit”. Pronovost's team has shown that a five-item checklist applied in over 100 intensive care units saved nearly 1500 lives and nearly US$200 million by eliminating central line-associated bloodstream infections. However, surveillance of hand-hygiene compliance and HAIs is not mandatory across the USA. Infection control is “everyone's responsibility”, concludes Duerden, since, as Pittet says, “infection control goes beyond the borders of hospitals”. A media focus on individual scare stories makes the public fearful, when they need to be “concerned and involved”, he says. Larson supports the greater community use of alcohol hand sanitisers, but notes that regular soap is usually adequate. The massive expansion of bactericides, such as triclosan, in consumer products may threaten their effectiveness in hospitals, and might even cause cross resistance with antibiotics. Ultimately, what Pittet hopes for is a top-level meeting between expert clinical scientists and top scientific journalists, to fully communicate what is important and effective and what is not. Didier PittetDidier Pittet is Professor of Medicine, Director of the Infection Control Programme at the University of Geneva Hospitals and Faculty of Medicine, Switzerland. He leads WHO's World Alliance for Patient Safety First Global Patient Safety Challenge “Clean Care is Safer Care”. In 2007, he was awarded the CBE for services to the prevention of health-care-associated infection in the UK. Full-Text PDF