Infection Risk Assessment and Management1
BACKGROUND
Risk management in healthcare settings is not a new legally and/or socially ordained phenomenon as thought. It is noted in the history that about 4,000 years ago, the Babylonian Code of Hammurabi ordained those physicians who caused death or harm to their patients by malpractices.
“If a physician operates on a man for severe wound with bronze lancet and causes a man’s death or opens an abscess in the eye of a man with bronze lancet and destroys man’s eye then they shall cut off his fingers”.
In 1970s, in USA, there was an upsurge in malpractice suits that created crisis situations among healthcare providers, and this led to appointments of risk assessment professionals in healthcare institutions to prevent adverse outcomes of patient care.
It is the organization’s multidisciplinary approach, which is undertaken to mitigate the infection risk to patients, their family members and healthcare staff too. It is a multipronged multilevel approach which is done through various well- coordinated and knowledge-oriented stages. Infection and infectious agents in the environment and their potential impact healthcare setting.
The risk assessment has the following characteristics:
- It helps establish the starting point of well-developed infection control plan.
- It is an integral part of the plan.
- Infection control plan based on risk assessment makes the strong foundation.
- It helps in various program component activities like surveillance.
- It helps in better patient care and favorable outcome.
- It helps in meeting state and national regulatory requirements.
In order to achieve the control over hospital-acquired infections, every organization should have certain committed broad guidelines which explain the followings:
- The task of infection control and prevention is taken as team challenge rather than individual challenge.
- Periodic assessment of the program on predetermined criteria.
- Infection control program is a part of organizations’ patient safety and quality care program.
- Program covers organization’s external as well internal customers.
While doing the risk assessment, the following questions to be answered:
- What is likelihood of the risk to occur?
- What are the main risk factors and additional risk factors?
- Who all are at risk?
- What would be severity of risk?
- What would be its effects on the systems of hospital functioning?
- What is the source of infection?
- How does a particular infection spread?
- What measures are being followed to mitigate the risk?
IDENTIFICATION AND PRIORITIZATION OF RISKS
The healthcare environment is typically very dynamic and constantly changing internally as well externally. Though we have the disease transmission knowledge and various medical breakthrough, yet the infection remains the potential risk in healthcare settings even today. Though 30–35 percent of most of the healthcare-associated infections (HAIs) are preventable, yet there are certain infections which lead to threat to life; hence, the identification and prioritization of such infection risk is of immense importance. A few challenges are common globally in infection prevention and control, and these are multidrug resistance, deficient infection control program, public reporting of infection data, etc.
As the infection prevention and control program is not one kit for all problems type, risks of acquiring and transmitting infections vary tremendously. Identification of infection risk depends on various factors like characteristics of patients’ population, geographic area, type of services provided by organization (in critical care area, the risk will be more), patient volume and number of employees working in that particular organization.
The risks in the healthcare environment constantly change and may pose in many forms; for example, sharp injuries more common to nursing and other hospital staff, while device-related infections are more common to patients. The severity of risk varies from individual to individual and contributed by various factors like organisms virulence, host resistance, preventive measures, etc.
In order to identify and prioritize risk, the organization should do annual survey. This exercise will help the organization review the changes occurred in its external or internal environment. The annual audit should be conducted by the multidisciplinary team, which will provide large base for perspective individual member of the team. When the review is being done, due attention should be paid to existing and new procedures, technologies, patient population, services provided, vaccination status and population characteristics.
Prioritization may have different areas at different time of review, and the order of priority may change from time to time. The process should not be 3one-time done process, but be continuous process which is regularly reviewed and updated. For examples, new civil work in part of the hospital or decrease in nurse patient ratio will expose the nurses to more infection, because of prolonged contact and exposure time.
RISK ASSESSMENT PROCESS
Before the process of risk assessment is started, the study of key principles of patient categorization should be considered:
- Many of patients have inherent susceptibility to infections which may be due to any of the contributing factors like radiation, chemotherapy, diabetes, human immunodeficiency virus (HIV), etc. which lead to immunosuppression.
- Opportunity for bacteria to invade the system—unbreached skin becomes susceptible to invasion of bacteria, when it is incised in operation theater for surgery.
- Construction work in the healthcare facility.
- Activities resulting in releasing of dusts.
- Green/brown field project specifications.
- Before the process is turned into action, the purpose of the assessment should be made clear, and this could be one of the followings or in combination:
- Improvement in staff and patient safety.
- Identifying the training needs for the staff on IPC.
- Improvement in staff and patient work efficiency.
- Justifying the need to bring changes in present system of IPC.
- Avoidance of potential infection-related adverse events.
The risk assessment is a regular ongoing process and to be reviewed on an annual basis. The progress report can be taken to track priorities and achieved objectives of infection control program. The process takes the cyclical form as depicted in Flow chart 1.1.
4Planning consists of gathering the data from various sources and prepares standards based on findings. It also designs various types of evaluation forms. The knowledge of current status and issues should be at hand.
The team should be multidisciplinary including medical, nursing, paramedical, laboratory, engineering, quality and administrative as well. The effectiveness of the team depends on voluntary action and commitment towards the infection prevention and control.
Thoughtful discussion will stress up on risk identification and prioritization, as well as on charting out the infection control plan.
The current status is evaluated in the form of characteristics of population of the community, how the medical services are being driven, endemicity of infection, geographic and environmental characteristics, and lastly, other area- related and specific risks.
Each risk factor will be assigned with some specific value, which is done after considering sererity or impact, probability of event occurring, and lastly, current system. These considerations are tabulated in Table 1.1.
Scoring of risk is done by multiplying the individual scores.
The progress report is made, having various headings along with action plan (Table 1.2).
Once the detailed analysis is done, then gap identification is also done which will help get another step of planning, and this way the cycle continues.
RISK ASSESSMENT: METHODS AND TOOLS
Once the policy on assessment is decided, then the methods and tools are chosen which will be most suitable to the situation. These can be divided into two approaches: one qualitative and another quantitative.
Qualitative Approach
This methodology is based on the description and the observation made for any event, for which the risk is to be assessed. In this method, each process or step is given the priority marking depending on the severity of risk (minimum–1 and maximum–5). And based on the total score, the magnitude of the risk is assessed; for example, the qualitative tool is used to assess the risk of needle stick injury (Table 1.3).
The same qualitative analysis can be done for hand washing, urinary tract infection (UTI), etc.
Quantitative Approach
This method uses the numeric value for each risk, which may be in the form of severity or probability, and the value can be given either in ascending order or descending order, for example, most severe (5) to least severe (1) or based on probability like most probable (5) to least probable (1).
In order to obtain the total value of risk, the value of individual variable is to be added. The total score will prioritize the IPC program in the organization. The infection control committee should clarify each numeric value in terms of definition, lest it would create ambiguity, and desired result would definitely deviate. The clarity is obtained through defining and giving meaning to each value.
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Though there are various method and tools of the risk assessment, however, the selection of the most appropriate method is challenging task.
The selection of the tool should be based following assumptions:
- Will the staff understand and utilize the tool without any bias?
- Is the tool comprehensive for particular risk assessment?
- Can the tool be utilized in desired time frame?
- Is the tool practical and not the theoretical assumptions?
- How useful will be results obtained?
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Few are the following tools or methodologies, which are used in IPC in health care.
Organizations
7SWOT analysis: This is done by a team which identifies the strength, weakness, opportunities and threats for particular risk. Once the details of SWOT are obtained and each one given a numeric value to get final value of the risk. Based on final results, the risk can be prioritized.
TOWS analysis: Some organizations consider negative values first and for that they do opposite to SWOT analysis.
FMEA analysis: Failure mode and effects analysis is proactive tool, in which the team members participate and identify issues systematically. As the tool is preventive in nature, hence the problem can be stopped before occurring.
PPR technique: This is periodic performance review throughout the organization. PPR is done systematically by assessing, verifying and assuring compliance to the policy and standards set by organization.
RISK ASSESSMENT EVALUATION
The methodology of evaluation of risk assessment varies from organization to organization and in same organization from time to time. The timings of evaluation depend on following factors:
- Who are involved in the evaluation process?
- What is to be evaluated?
- How it is to be evaluated?
- On whom the evaluation is to be done?
If few activities are monitored strictly, then these may yield information which can be utilized in evaluation process:
- Use of contact precaution
- Performance of hand hygiene
- Compliance with cleaning activities
- Use of aseptic techniques while doing central line insertion
- Use of protective bundles.
The mitigation of infection is a continuous process, that is why the monitoring and evaluation also become continuous process. The main aim of HAI control is to control the cost of care management because many of HAI are preventable with appropriate methodology of prevention.
RISK MANAGEMENT PROCESS
Risk management can be defined as an organized efforts to identify, assess and reduce the risk to patient, staff, attendants and institutional assets.
This can also be defined as a systematic process, that is designed to reduce the incidence of preventable incidences to minimize financial loss to the institution, which may otherwise cause because of these incidences.
Further, the risk management process is of assuring the patients receive all the healthcare services, needed to which they are entitled and at the cost-effective 8level by reducing or eliminating untoward occurrences during care, that might lead to injury or illness to patient, caregivers, visitors and/or attendants.
The management process of risk in healthcare entities can be moved from:
- Identifying exposures to accidental loss, that may interfere with institution’s aims and objectives to
- Examining the suitable and feasible alternatives risk management techniques for dealing with these exposures to
- Selection of best risk management technique and implementation of best selected technique to
- Monitoring results of selected technique to determine desired results.
In order to redefine the process of risk management to reflect the reality in the process a system of 5Is is applied, Investigate/inform/influence/interpret/integrate.
- Investigate through close observation or examination and inquiring the chronology of the incidence systematically.
- Inform all findings should be presented in documented form.
- Influence means affected or altered by intangible or indirect means.
- Interpret all findings being present should be in understandable form.
- Integrate findings should be blend or unite in whole.
It is also stated that, objective of risk management is to select, coordinate and efficiently apply interdisciplinary skills to harmful uncertainties, which may reduce future value of organization. Add to this the “Big A” strategy is followed for anticipation of harmful event while giving patient care and be prepared to handle that possibility, if at all arises.
Example: While giving a dose of Penicillin G or group drug one should anticipate the drug allergy, even it not stated by the patient and be prepared to handle, if that arises.
RISK REDUCTION METHODS
For any organization to reduce the risk is of prime importance, as this would help to make its standing in the industry by noting the less incidences of infection as compare to others. To reduce the risk is a very organized and systematic task which involves all levels of the employee playing their role to the maximum. The risk reduction methods, which are being described, are not for patients only, but for healthcare staff also.
Following methods of risk reductions are commonly used by healthcare settings:
- Strict hand decontamination practices before and after direct patient care or activity, which lead to contact with potentially contaminated object.
- Following principle of bare below the elbow and removal of hand and wrist jewellery while giving patient care.
- Hand washing practices by all staff members.
- Use of plastic apron where, there are chances of getting clothes contaminated with blood or body fluids.
- Keep the finger nails short and clean.
- Use of appropriate method to decontaminate the medical equipment and devices between each use.
- With waterproof dressing cover all cuts and bruises.
- Protective gloves to be worn whenever there are chances of contact with blood, body fluids, contaminated skin and instruments.
- Regular training and education to all staff member regarding standard principles and procedures about decontamination and related practices.
RISK ASSESSMENT-BASED INFECTION PREVENTION AND CONTROL PROGRAM
For any healthcare organization, the risk can be divided into two sources, i.e. external risks and internal risks.
External risks: These are risks, which are from outside of the organization. For example, water borne infections from outside water bodies or respiratory infections in thickly populated communities.
Internal risks: These are risks, which are inside the organization in origin and may be caused by injury or infection, resulting in increased morbidity and mortality.
What may be the origin of risk the factors which are contributing to risk may be as follows?
- People having severe depression in immunity level.
- Patients undergoing high-risk surgeries like coronary artery bypass grafting (CABG), joint replacement, organ transplant surgeries, etc.
- Very young or very old and frail people.
- Patients in the intensive care units.
- People in rehabilitation centers.
Let us discuss the different risk-based program which an organization can undertake.
- Environment-related risks: There are various environmental issues which poses infection risk to the staff as well as patients. The design and construction of the facility can help in various way to reduce chances of infection by having planned construction, expansion or renovation, this planning may include the placement of hand washing facility, earmarked places for hand rubs, effective heating ventilation and air conditioning (HVAC) system, placement of positive and negative pressure rooms, etc. The team should consider the impact of construction on the infection control and develop the criteria along side.
- Staff-related risks: The staff is major contributor to infection, if they are not educated and motivated to follow infection control practices. Various factors like shortage, heavy attrition, unskilled manpower, overtime work, lack of motivation, insufficient support system put the staff or from the staff-related risks in the organization. These all factors lead to reduced compliance to basic activity of infection control, i.e. hand washing/hand rubs thus causing breach in aseptic technique.
- 10Procedure related risk: The risk of infection is relative in the procedures done in healthcare facility. Some are high risk, while some are low risk, but may be converted into high risk.The risk of infection can be reduced to maximum by following “Best practices” laid down by the organization in consultation with infection control committee. For examples, of best practices are like use of sterile equipment for procedures, strict compliance to hand washing practices, following infection control bundles, etc.
- Patient-related risk: Healthcare facility provides support to different kind of customers from age group, socioeconomic status, gender, etc. It is to note that any individual, who comes to the healthcare facility is potential point of infection risk. For example, patient transferred from other facility with intubation is risk. Another patient, who comes with community-acquired pneumonia is a potential infection risk to other patients.The vulnerability for risk of contracting infection varies from individual to individual and in the same individual from time to time based on various factors like:
- Age
- Comorbid conditions
- Compromised immunity
- Severity of illness
- Duration of stay
- Extremes of age
The infections, which are of concerns from patient point are ventilator- associated pneumonia (VAP), surgical site infection (SSI), catheter-associated urinary tract infection (CAUTI), and catheter-associated bloodstream infection (CABSI). These infections, if not corrected in time, may lead to further prolonged stay and financial burden on patients and their families.