ABSTRACT
Infection control (IC) is a necessary component of safe, high quality patient care and is essential for the well being of the patients and of the staff. Organizational structure is an essential component to the success of any public health program. Each level of the infection control program, from the person(s) charged with administrative support to the direct care provider at the patient's bedside, should share in the overall responsibility of preventing infection. An integrated structured infection control program should be organized and conducted with the participation from ground level to the national level.
INTRODUCTION
Infection control (IC) is a necessary component of safe, high quality patient care and is essential for the well being of the patients and of the staff. The fundamentals of infection control are applicable across all settings where healthcare is provided. These fundamentals need to be employed regardless of constraints in resources and support, as they are designed to protect the patients and provider against exposure to infectious microorganisms and against the morbidity and mortality associated with these infectious agents.
In order to achieve reduction in infection rates among patients and staff, an infection control program has to develop a scientific and specified organizational structure. As a first step, the infection control program needs to establish the appropriate organizational structure within each level of the healthcare system and to have defined roles and responsibilities for key personnel. This organizational structure is an essential component to the success of any public health program. Each level of the infection control program, from the national level through individual institutional administrative support to the direct care provided at the patient's bedside, each person involved shares the overall responsibility of preventing infection.
INCIDENCE
Healthcare associated infections (HAIs) have great impact on patients in terms of illness of greater severity than the original illness, prolongation of hospital stay, long-term disability and even death. Additionally, HAIs exert enormous unwarranted financial burden and increase personal costs on the patients and their families. Prevalence of HAI in developed countries varies between 3.5 percent in USA to over 10 percent in Canada and Switzerland. Incidence of HAI in US is approximately 5 to 6 percent with over 1.7 million affected patients with economic loss of almost $4.5 billion annually. HAI contributes to almost 1 million deaths per year in USA.
Infections in the newborns in developing countries are 3 to 20 times higher than in industrialized countries. Among hospital born babies these infections are responsible for 4 to 56 percent of all causes of death in the neonatal period,(3/4 in South East Asia and sub-Saharan Africa). In a prospective surveillance of 21,069 patients who were hospitalized in 55 intensive care units in 46 hospitals in Central and South America, India, Morocco, and Turkey showed high rates (22.5 infections per 1000 intensive care unit days) of device-associated infections.
Recent study on implementation of hand hygiene practices among the patients infected with novel H1N1 and contacts revealed that secondary attack rate among hand hygiene group (0.05) was much lower than control group (0.12). The study found that there was 58 percent reduction of transmission with hand hygiene group.
In a recent study by Manchanda et al on healthcare associated infections in pediatric ICUs from tertiary pediatric center in India suggests implementation and monitoring of infection control program is helpful in reducing HAIs in an Indian hospital also. The study conducted in 2008 to 2009 revealed central line-associated blood stream infections (CLABSI) were most common in the NICU (52%), ventilator associated pneumonia (VAP) was predominant in PICU (58%). Multidrug-resistant bacteria such as Acinetobacter baumannii and Klebsiella pneumoniae were the two most common organisms isolated in critically ill hospitalized children. During the study period the incidence of VAP and surgical site infections (SSIs) was reduced by more than half. The study concluded implementation of early and effective control measures and improve patients outcome as measured by reducing length of stay and mortality caused by these infections.
Another study by Singh et al on device associated infections among the patients admitted to a tertiary care center in South India revealed most common HAI in ICU was VAP with 4.8 per 1000 ventilator days, followed by CLABSI of 4.4 per 1000 central line days and CA-UTI of 3.9/1000 catheter days.
IMPLEMENTATION STRATEGY
Implementation of robust infection prevention program requires political will and support. Measurements of both process measures (delivery of care) and outcome measures are essential part of the prevention of HAI 3program. Diagnosis of HAI relies on clinical judgment and laboratory evidence. Since the early 1990s, infection prevention guidelines have been prepared by the United States CDCs Healthcare Infection Control Practices Advisory Committee (HICPAC). The main challenge to prevention of HAIs in the United States has been not a lack of guidelines but, rather, consistent implementation of recommended practices.
Multimodal strategy as recommended by WHO may be useful in improvement of patient safety by reducing the rates of hospital acquired infections. This includes chronological steps eventually forming a full cycle for continuous improvement of the program. These steps include system change, education, monitoring performance, reminders and safety culture. The system change in case of hand hygiene, for example, shall comprise of availability of alcohol base hand rubs at the point of care and access of safe, continuous water supply, soaps and towels. This should be followed by training and education which involves training of trainers followed by further dissemination of knowledge and practices to all categories of healthcare staff. A robust monitoring program using defined tools (e.g. WHO hand hygiene monitoring tools) and constant feedback to the healthcare staff are imperative for success of the program. Constant reminders, e.g. in form of poster, computer screen savers, printings on objects of daily use, are helpful to improve compliance of such programs in a healthcare setting. Implementation of HAI prevention steps are as follows:
STEP 1
- Identification of nodal centers (where such program is already instituted and monitored).
- Training of trainers.
STEP 2
- Designing of the program keeping in mind local issues—separated according to specific institutional requirements.
- Providing the level of care—primary, secondary, tertiary care centers or teaching hospitals.
- Designing of implementation tools.
- Designing of the monitoring tools.
STEP 3
- Pilot implementation of the program.
- Feedback from the participants and modifications.
- Decision on national and international benchmarking for various performance indicators.
STEP 4
- Full implementation of the program.
- Collection of data and constant feedback on live network.
- Continuous quality improvement.
4Antimicrobial stewardship program promotes the rational use of antibiotics and help in reducing emergence of multidrug resistance organisms (MDROs). Monitoring of usage of antibiotics is imperative for such program including prophylaxis for surgical site infections.
Sanitation and disinfection practices need improvement. National Rural Health Mission (NRHM) program has provided thrust in area of sanitation. However, disinfection practices needs further strengthening in terms of uninterrupted supply of disinfectants, education and training.
Safe injection practice are important in the prevention of transmission of blood borne pathogens. India has defined policy for biomedical waste management and disposable syringes and has implemented it to large extent. There has also been legislation (BMW Rules 1998) in place in this regard.
ORGANIZATIONAL STRUCTURE
There should be a designated Department for Infection Control at National, State and District levels to function as advisory, supervisory and policy making body. These should be multidisciplinary. As an alternative, a Department of Patients Safety could be formed in which infection prevention and control can be a key component.
Health Facility Level
The hospital director should be responsible for ensuring that appropriate arrangements (IC professionals and appropriate IC program infrastructure) are in place for effective infection control.
In large health facilities two groups are recommended, for example:
- Infection control committees (ICCs).
- Infection control teams (ICTs).
In smaller hospital, there should be infection control committees (ICCs) and an infection control nurse (ICN).
Hospital Infection Control Committees
Hospital infection control committees should be developed for all health care facilities. The IC committee should be made up of key personnel from the various health facility departments. It should act as a liaison between departments that are responsible for patient care and departments responsible for support (nursing, medicine, pharmacy, CSSD, housekeeping, central store, engineering, etc.). The Director of the faculty or his Deputy could be the Chairperson and members suggested are:
- Incharge of clinical departments.
- Head of Microbiology.
- Head of nursing services.
- Members of the infection control team.
- Incharge of the pharmacy.
- Incharge of support services/facility.
- Financial and administrative incharge of the hospital.
- Others as appropriate, e.g. occupational health specialist, laboratory professionals, surgeon, etc.
All infection control committees at all levels should consist of the staff available from those listed. The committee may co-opt any other members as deemed necessary.
Recommended Terms of Reference
- To approve the annual plan for infection control at the level of facility.
- To approve the infection control policies in the facility.
- To support the IC-teams and to direct resources to address problems as identified.
- To ensure availability of appropriate supplies needed for IC at the facility level.
- To facilitate and to support the training of the staff.
- To encourage communication among the involved discipline and among the different departments in the facility.
- To report outbreaks of nosocomial infections in the facility to the district and/or state level as required.
- Participate in outbreak investigations of nosocomial infections.To submit monthly reports to the district and/or state level as required.
INFECTION CONTROL TEAM
Infection control team should be established in each healthcare facility that have more than 30 beds. The infection control team should have the authority to manage an effective infection control program and should have full support from the director of the health facility. PHC facilities with no beds or with less than 30 beds, a nurse should be assigned the responsibility for implementation of infection prevention and control activities within the facility.
Infection Control Team Personnel
The Infection Control (IC) team should include a doctor and a nurse for the facility with 150 beds (or less). In facilities with more than 150 beds, the team should be formed of a doctor and a minimum of a nurse. All members of the team should be full-time employees dedicated to infection control activities. Some nurses, called “link nurse” or “representatives” affiliated with various departments should be assigned to the IC teams. An average of one IC nurse should be assigned for functional 150 to 200 beds.
Team Leader
- Infection control doctor (a clinician, epidemiologist or a microbiologist).
Members
- Infection control nurses (in large facilities, infection control microbiologists should also be included).
Terms of Reference
- To prepare an annual action plan for implementation of the infection control program and to get approval from the IC-committee.
- To implement a plan to ensure safety of practices.
- To advise the staff on all aspects of infection control needed to maintain a safe environment for patients and for staff.
- To supervise and to monitor daily practices of patient care designed to prevent infection.
- To formulate infection control policies within the health facility.
- To develop surveillance program for nosocomial infection.
- To identify problems in the implementation of infection control activities which need to be solved or referred to the hospital IC-committee.
- To develop an annual training plan for the healthcare workers and to submit the plan to the hospital IC-committee for approval.
- To implement the infection control training activities within the health facility.
- To ensure availability of supplies and equipment needed for infection control.
- To report outbreaks to the IC-committee and to investigate outbreaks within the healthcare facility.
- To submit reports on activities to the IC-committee.
Nursing Representatives or “Link Nurses”
Nursing representatives work in the different wards of the hospital and act as a liasion between the infection control team and all of the staff of the department or ward. Preferably, this nurse should be the head nurse of the department/ward.
- To convey the recommendations of the infection control team to the staff of the ward and to send feedback to the Infection Control team.
- To ensure implementation of infection control activities in the ‘Link Nurses’ department.
- To be responsible for reporting any infections in the department.
CONCLUSION
Majority of HAIs are potentially preventable by implementation of evidence based interventions. The priorities among the interventions for prevention of HAIs should be hand hygiene practices and comprehensive monitoring; antimicrobial stewardship program; sanitation and disinfection practices; safe injection practices and Surveillance System for HAIs.7
Studies have shown that at least 35 to 40 percent of all HAIs are associated with only six basic principles of infection prevention. The committee/teams should consider these while formulating and implementing the Infection Control techniques/processes.
- High compliance with hand hygiene.
- Use of standard precautions for every patient every time.
- Meticulous care of central vascular lines and other devices in critical patients.
- Appropriate handling of respirators/ventilators.
- Use of check list for surgical procedures.
- Selective use care of urinary catheters.