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9 Chapter contained on Book Bennett and Brachman s Hospital Infection th Edition. Title of Chapter: Epidemiology and Control of Health Care Acquired Infections in Limited Resource Settings Author of this chapter: Victor D Rosenthal, INICC Founder and Chairman. Title of Chapter: Epidemiology and Control of Health Care Acquired Infections in Limited Resource Settings By Victor D Rosenthal BACKGROUND Among the principal precepts of medical ethics is the old mandate first, do no harm. During the first half of the 18 th century healers from all over the world voiced their concern over patient safety and their risks of acquiring infections in hospitals as part of an iatrogenic consequence. The concept of healthcare-associated infection (HAI) has been developed since then thanks to the work of enthusiasts such as Nightingale, (1) Semmelweis,(2) Pasteur,(3) Koch,(4) and Lister,(5) at the beginning of the Bacteriological Era. After hospital reforms and asepsis, the victory over HAI was short-lived, as infections did not only occur in obstetric and surgical patients, but also in medical patients. The source of infection was not only bacterial but viral as well, spreading infection via air. The dissemination of Streptococcus pyogenes raised clinical awareness during the first decades of the 20 th century, declining its importance after the introduction of sulphonamides and penicillin, and improved hospital hygiene methods. With the advent of serologic typing, the high incidence of cross-infection in scarlet and puerperal fever was finally elucidated.(6) It was not until the second half of the 20 th century, however, that infection prevention programs were structured and systematized in hospitals. Staphylococcus aureus became a focus of medical attention for hospital cross-infection in the late 1950s, but it was the emergence of phage 80/81 staphylococcus in the 1960s that caused notorious epidemics worldwide.(1) It soon became more evident that risks for HAI increased despite the growing sophistication on healthcare tools and procedures. Infectious diseases have been identified as the second most common cause of death in the world.(7) A wide diversity of factors strongly influences the occurrence and transmission of infectious diseases. Socio- economic factors, such as poverty, homeless, and high unemployment 1

10 rates, have been acknowledged to expand infections, including HAIs. Other factors, such as global travel, emergence of old debilitating and mortal diseases, and wars also play a substantial role in transmitting pathogens. Confronted with these threats, which are out of the direct medical scope, infection control professionals may feel overwhelmed by the challenge of reducing and controlling HAIs. HAIs have been shown to be among the main causes of patient morbidity and mortality worldwide. In studies from developed countries, it has been well-documented that HAIs are responsible for increasing hospital costs as well. (8-9) Because of the great vulnerability of critically ill patients, HAIs pose the most serious threats in the intensive care unit (ICU) setting. For that reason, device-associated HAIs (DA- HAIs), such as central line-associated bloodstream infection (CLA-BSI),(10-13) ventilatorassociated pneumonia (VAP),(14-16) and catheter-associated urinary tract infection (CA- UTI)(17) represent the most serious challenges to patient safety and quality healthcare in ICUs. In a review about CLA-BSI in limited-resource countries by Rosenthal, a number of structural and behavior reasons were associated with higher rates of CLA-BSI, and among their most common observations were overcrowded ICUs, insufficient rooms for isolation, lack of sinks, lack of medical supplies in general, including but not limited to alcohol hand rub, antiseptic soap, and paper towels.(18) In addition, a lack of supplies for the wearing of maximal barriers during catheter insertion, a lack of chlorhexidine for hand hygiene (HH) and skin antisepsis purposes, and a lack of needleless connectors (and the subsequent use of three ways stopcocks) were noted. Moreover, poor performances in infection control practices, such as using cotton balls already impregnated with antiseptic contained in a contaminated container, not covering the insertion site with a sterile dressing, storing drugs in open single use vials, reusing single use vials, leaving needles inserted in multiple use vials, taking fluids from 1000 cc container for dilution of parenteral solutions, and using tacky mats were paramount.(18) The World Bank classifies countries into four economic strata based on 2011 gross national income per capita: low income, middle income (subdivided into lower middle and upper middle), or high income. Together low income countries, lower middle income countries, and upper middle income countries economies are sometimes referred to as developing economies, developing countries, lower income countries, low resources countries, or emerging countries. In this chapter, they will be referred to as limited-resource countries. Limited-resource countries represent 144/209 (68.8%) countries of the world and >75% of the world population.(19) In high 2

11 Chapter contained on Book Bennett and Brachman s Hospital Infection th Edition. Title of Chapter: Epidemiology and Control of Health Care Acquired Infections in Limited Resource Settings Author of this chapter: Victor D Rosenthal, INICC Founder and Chairman. income countries, such as the United States, the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) (previously, the National Nosocomial Infections Surveillance [NNIS] system)(20) has provided standardized definitions for HAIs, thereby allowing prospective surveillance targeted on DA-HAIs rates per 1,000 device-days to be benchmarked against rates determined in different healthcare facilities worldwide. (21-23) Furthermore, using the CDC methodology, surveillance data for calculation of DA-HAI rates include specific risk factors, which is fundamental to detect and improve problems at hospital level. In the context of an expanded framework for HAI control, most of the relevant studies of ICU-acquired infections have been carried out in high income countries.(24) In the United States, HAIs are among the top 10 causes of death, being the main healthcare complication. A study from the United States reported that the number of annual deaths attributable to HAIs ranged from 44,000 to 99,000.(25) In different studies, most from developed countries, it has been shown that with effective HAI preventive interventions, many lives and extra costs can be saved. Findings in the scientific literature have shown that original CDC infection control programs that include HAI surveillance can reduce their incidence by >30%. (26) According to an estimate by the CDC in 2002, U.S. national costs for HAI were approximately $6 billion;(27) these extra costs can be reduced by 32% with the implementation of effective HAI prevention programs.(28) In different countries, national conferences were organized to examine the burden of HAI from a broader perspective. This issue became of primary importance in several countries, where medical institutions established committees to start the appointment of Infection Control coordinators in healthcare facilities, the implementation of infection control programs, and the organization of workshops to respond to the need for training in infection control. There have been good examples of global planning, such as during the severe acute respiratory syndrome (SARS) worldwide outbreak in 2003, which resulted in great mobilization of resources from the World Health Organization (WHO), in coordination with experts, pharmaceutical research and laboratories in national agencies worldwide. This global approach resulted in successful tracking and containment of spread. Additionally, the WHO in 2005 has launched a global health initiative related for HAI prevention, called Clean Care is Safer Care 3

12 with the aim of promoting HH worldwide.(29) Then in 2009, the WHO published its guidelines including a combination of previously published data, a new formulation for alcohol hand rub products, among several other recommendations.(30) In limited-resource countries, with the emergence of the International Nosocomial Infection Control Consortium (INICC) in 1998 in Argentina, which was expanded internationally in 2002, HAI surveillance and HAI prevention interventions were expanded worldwide. (31-35) INICC started to conduct surveillance by applying standardized definitions of the CDC-NNIS, and NHSN.(20-23) In order to raise global awareness and help reduce HAI rates, INICC has been dedicated to provide free tools, to measure HAIs and their adverse consequences and to measure and improve compliance with infection control practices.(31-35) INICC became the first international HAI surveillance program to measure, prevent and control HAIs be means of the analysis and feedback of outcome and process surveillance data collected by hospital collaborators worldwide; this system currently exists in hospitals in 46countries of Africa, Asia, Europe and Latin America (Argentina, Bolivia, Brazil, Bulgaria, China, Colombia, Costa Rica, Croatia, Cuba, Czech Republic, Dominican Republic, Ecuador, Egypt, El Salvador, Greece, India, Italy, Iran, Jordan, Kosovo, Lebanon, Lithuania, Macedonia, Malaysia, Mexico, Morocco, Nigeria, Pakistan, Panama, Peru, Philippines, Poland, Puerto Rico, Romania, Saudi Arabia, Serbia, Singapore, Slovakia, Sri Lanka, Sudan, Thailand, Tunisia, Turkey, Uruguay, Venezuela, and Vietnam).(31-35) Data from these hospitals has greatly expanded our knowledge of the epidemiology of and prevention of HAIs in limited-resource countries.(36-53) PRIORITIES FOR INFECTION CONTROL IN LIMITED-RESOURCE SETTINGS Allocation of national resources comes within the competence of governments, and decisions on funding are made according to different priorities. So, public health needs must compete for funding against other important national matters, many times more visible, including educational, environmental, political, social, economic, and other fundamental issues. Given the high visibility of improvements in a country's infrastructure, not so visible positive outcomes of HAI prevention programs may be left behind by policy-makers and managers of national programs. Thus, resources needed for the implementation of infection control strategies at the hospital level often are insufficient. However, even if underestimated, public health is primary for the successful 4

13 Chapter contained on Book Bennett and Brachman s Hospital Infection th Edition. Title of Chapter: Epidemiology and Control of Health Care Acquired Infections in Limited Resource Settings Author of this chapter: Victor D Rosenthal, INICC Founder and Chairman. functioning of other national priorities, affecting different social aspects, such as work and social well-being. Promoting global health, therefore, is beneficial to the population as a whole, and should be treated as a global priority not only in instances of epidemic diseases, but ideally, to cover every aspect of health and infection prevention. There are several factors that may render infection control initiatives ineffective, namely lack of attention and proper promotion of health improvement by agencies at national and international levels. Poverty and insufficient engagement by hospital administrators, governments and health ministers are among other negative factors. Moreover, professional infection control societies of nurses, physicians and laboratorians (if any) are not fully committed to the promotion of infection prevention. A major limitation on the progress of infection control has been lack of priority in the agenda of policy makers. Fortunately, the field of infection prevention and control of HAIs via surveillance programs has reached limited-resource countries during the last decade. Many problems remain unresolved, such as how to implement surveillance programs for the effective prevention and control of HAIs. A lack of a global perspective has limited the scope of organized strategies and research agenda, whose items revolve around minor questions and fragmented approaches, squandering considerable resources. Global initiatives focused on the prevention and control of HAIs have only emerged in the last decade. At present, different global health initiatives have been well-coordinated and have provided great benefit to recipients and donors. A list of priorities that addresses these issues and provide a framework for finding a solution for these needs in limited-resource settings was developed by a wide range of independent international organizations, including INICC, the WHO, the Joint Commission International (JCI), the International Federation of Infection Control (IFIC), the International Healthcare Worker Safety Center, the Asia Pacific Society of Infection Control (APSIC), Eastern Mediterranean Regional Network for Infection Control (EMR-NIC), Baltic Network for Infection Control and Containment of Antimicrobial Resistance (BALTICCARE), Southeastern Europe Infection Control (SEEIC), PanAmerican Association of Infection Control, The Infection Prevention & Control Africa Network (IPCAN), and others. 5

14 These priorities focus on raising awareness, fostering research, developing guidelines, promoting education, surveillance, prevention, and control of HAIand can be condensed into the following: 1. Assessment of facilities, infrastructure, supplies, and human resources dedicated to surveillance, prevention and control of HAIs. 2. Surveillance of DA-HAIs in ICUs (CLA-BSI, VAP and CA-UTI) and their consequences, such as mortality, extra length of stay (LOS), and cost. 3. Surveillance of surgical site infections (SSIs), and their consequences such as mortality, extra LOS, and cost. 4. Assessment of prevention strategies for CLA-BSI, VAP, and CA-UTI. 5. Assessment of prevention strategies for SSI. 6. Measuring the financial impact of complications and the cost effectiveness of interventions. 7. Studies related to improved antibiotic usage and management of antibiotic resistance. 8. Development, edition, promotion and distribution of guidelines to prevent and control HAIs (DA-HAIs, and SSIs). 9. Improving compliance with practices known to be beneficial, especially HH, appropriate staffing in healthcare institutions, and other components for HAI control and prevention programs. 10. Improving compliance with specific interventions proven effective for prevention and control of each specific DA-HAI. 11. Preventing occupational transmission of blood-borne pathogens. 12. Establishment of worldwide, national, regional and local networks to provide support and information, improve practices, and reduce the steep learning curve more efficiently and economically. 13. Surveillance and reduction of healthcare-associated transmission of epidemic respiratory diseases, such as influenza. MISSION, VISION, AND GOALS OF INTERNATIONAL ORGANIZATIONS DEDICATED TO SURVEILLANCE, PREVENTION AND CONTROL OF HEALTHCARE ASSOCIATED INFECTIONS AND SAFETY IN LIMITED-RESOURCE COUNTRIES 6

15 Chapter contained on Book Bennett and Brachman s Hospital Infection th Edition. Title of Chapter: Epidemiology and Control of Health Care Acquired Infections in Limited Resource Settings Author of this chapter: Victor D Rosenthal, INICC Founder and Chairman. International Nosocomial Infection Control Consortium (INICC): o o MISSION: We are an international scientific community that works interactively through a network aiming at reducing healthcare-associated infections. VISION: A society that recognizes the legitimate right of a hospitalized patient to be delivered safe healthcare. A society in which the scientific and medical community works for the safeguard of good infection control and surveillance practices. A society with the minimum incidence of HAIs. World Health Organization. First Global Patient Safety Challenge. Clean Care is Safer Care o o Goal of Clean Care is Safer Care: is to ensure that infection control is acknowledged universally as a solid and essential basis towards patient safety and supports the reduction of HAIs and their consequences. As a global campaign to improve HH among healthcare workers (HCWs), SAVE LIVES: Clean Your Hands is a major component of Clean Care is Safer Care. It advocates the need to improve and sustain HH practices of HCWs at the right times and in the right way to help reduce the spread of potentially life-threatening infections in healthcare facilities. Joint Commission International (JCI), o o o Mission: To continuously improve healthcare for the public, in collaboration with other stakeholders, by evaluating healthcare organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. Vision: All people always experience the safest, highest quality, best-value healthcare across all settings. As the international arm of The Joint Commission, Joint Commission International (JCI) has been working with healthcare organizations, ministries of health, and global organizations in >80 countries since

16 o Our focus is on improving the safety of patient care through the provision of accreditation and certification services as well as through advisory and educational services aimed at helping organizations implement practical and sustainable solutions. International Healthcare Worker Safety Center Mission: Protecting HCW. Millions of HCWs around the globe face a daily risk of contracting life-threatening occupational infections, such as HIV, hepatitis B, and hepatitis C, from occupational exposures to patients' blood and body fluids. The International Healthcare Worker Safety Center at the University of Virginia is dedicated to reducing this serious risk. International Federation of Infection Control (IFIC), o o Vision: To become the leading worldwide network facilitator between organizations and individuals active in the prevention and control of HAIs. Mission: To facilitate international networking in order to improve the prevention and control of HAIs worldwide. THE INTERNATIONAL NOSOCOMIAL INFECTION CONTROL CONSORTIUM (INICC) PROGRAM The INICC ( is a nonprofit, open, multicenter, international, collaborative program modeled on the U.S. CDC-NNIS/NHSN system. Founded in Argentina in 1998, it is the first international research network that includes prospective, targeted, outcome and process surveillance designed to identify and reduce HAI rates and their consequences in the participating facilities.(31-35) Its objectives are the following: To create a global network using standardized HAI surveillance definitions and methodology in order to reduce HAIs, their attributable mortality, bacterial resistance, length of hospital stay, and extra cost. To collaborate in the development, adaptation, promotion and edition of local guidelines for the control and prevention of HAIs. To enhance safety and quality of healthcare in every healthcare facility. To optimize antimicrobial use for prophylaxis or treatment. To stimulate, support, guide and advice on the development of research projects aimed at reducing HAIs. To train HCWs in order to improve their skills for scientific research. To foster relevant scientific evidence-based literature for the surveillance, prevention 8

17 Chapter contained on Book Bennett and Brachman s Hospital Infection th Edition. Title of Chapter: Epidemiology and Control of Health Care Acquired Infections in Limited Resource Settings Author of this chapter: Victor D Rosenthal, INICC Founder and Chairman. and control of HAIs by designing, coordinating, and publishing scientific research studies on the clinical and cost effectiveness of proved or new infection control interventions. INICC does the following activities with hospitals of limited-resource countries: 1- provides tools for and training for outcome HAI surveillance, 2- provides tools for and training for HAI process surveillance, 3- develops and provides charts and tables for feedback of HAI rates, 4- develops and provides charts and tables for performance feedback, 5- provides an infection control bundle with targeted interventions guided by risk factor analysis and cost-effective interventions guided by cost analysis, 6- provides education and training in infection control guidelines application, 7- provides secretarial and administrative support in entering data, 8- develops and sends charts, scientific data analysis and data interpretation to guide actions, 9- analyzes, edits, and shares data at scientific meetings and publishing in peer-reviewed journals, and 10- cooperates with hospitals and organizations worldwide in order to improve surveillance and control of HAIs. INICC sends a protocol to INICC members, who review it with their research committees and agree to full participation by signing a commitment letter and sending it to the INICC central office in Buenos Aires, which then processes data, and provides analyses and reports on a monthly basis, answers questions, and augments the tutorial with personal instructions when needed. Forms and software designed to record data and direct infection control activities are used for both control patients without HAI and patients with HAIs. These forms include age, gender, underlying diseases, and severity of illness score at the time of entrance to the ICU. On a daily basis, information regarding temperature, blood pressure, device-days, cultures taken, presence of clinical pneumonia, antibiotic use, and characteristics of any surrogate of infection is collected both for cases and controls. Thus, it is also possible to validate received data and analyze cases and controls in a prospective cohort nested study.(36-37, 40, 42-53) At the same time, process surveillance and performance feedback are done for HH compliance, vascular and urinary catheter care, mechanical ventilator care, and measures to prevent SSIs. Data collected for process surveillance purposes include HH compliance and key interventions to prevent CLA-BSI, CA-UTI, VAP and SSI, such as practices for insertion of the central line, skin antisepsis, placement of gauze on intravascular (IV) access insertion sites, 9

18 marking the date on the IV administration set, condition of the gauze, position of the urinary catheter regarding the leg and position of urine bag regarding the bed, among many others. INICC has reported HAI rates by country, (Tables 1-2) and in international global reports (Table 2), mortality rates (Tables 3-5), as well as extra LOS (Tables 6-8), and extra cost (Tables 9-10) from several participating hospitals that applied the INICC methodology.(31) THE INTERNATIONAL NOSOCOMIAL INFECTION CONTROL CONSORTIUM (INICC) MULTIDIMENSIONAL APPROACH The INICC multidimensional approach, designed to reduce HAI and mortality rates, cost, LOS, as well as bacterial resistance includes the following six activities: 1- bundle of infection control interventions, 2- education about outcome surveillance, process surveillance and infection control guidelines, 3- outcome surveillance of HAI rates and consequences, 4- process surveillance of infection control interventions, 5- feedback of HAI rates and consequences, and 6- performance feedback of infection control practices.(54-64) 1- BUNDLE OF INFECTION CONTROL INTERVENTIONS An infection control bundle consists of a collection of interventions based on scientific evidence and key recommendations for practice. The INICC multidimensional approach for includes an infection control bundle for the prevention of HAIs which is based on practical and cost-effective measures that are described the guidelines published by the Society for HealthCare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) published in 2008 (65-69), by the Association for Professionals of Infection Control and Epidemiology, Inc. in 2009 (70-71) by the WHO published in 2009,(72) by the CDC in 2011,(68) and by the JCI in 2012.(73) The hospital infection control team members are aware that these interventions are the most adequate practices for effective infection control; however, the actual application of each bundle element may not be consistent in routine patient care. For this reason, the infection control bundle serves as a means to ensure that all interventions are carried out consistently for all patients and at all times. The effective implementation of any infection control bundle depends on the full development of team work, since it is necessary to improve reliability levels.(74) The 10

19 Chapter contained on Book Bennett and Brachman s Hospital Infection th Edition. Title of Chapter: Epidemiology and Control of Health Care Acquired Infections in Limited Resource Settings Author of this chapter: Victor D Rosenthal, INICC Founder and Chairman. application of DA-HAI control bundles in the ICU setting provides specific evidence to support possible changes for additional improvements in patient safety. The effectiveness of the implementation of an infection control bundle is measured by recording full adherence to all bundle elements; if any of these elements is not included in the record; this is counted as incomplete implementation, unless the missing element refers to a specific medical contraindication. This focus on the application of all the elements contained in the infection control bundle enables HCWs awareness of the importance of compliance with the collection of elements, rather than with isolated interventions. Furthermore, this team-oriented, whole-method strategy provides a fundamental boost to improvement changes in the healthcare delivery system as whole. 2- EDUCATION Another crucial factor for an effective implementation of any infection control program is education of HCWs. It is essential that HH practices be deeply rooted and embedded in hospitals customs, traditions and culture. Education must at least include basic information that raises awareness of the risk involved in patient safety if healthcare delivery practices are not adequately performed. Each HCW needs to be grounded in updated infection control guidelines, implementation of bundle elements and surveillance methods. This requires regular, proper training in the correct procedures for infection control practices and safe care delivery. Consequently, instructions must be clearly provided to HCWs by means a uniform approach that focuses on the user and applies practical methods so as to avoid subjective and ambiguous interpretations. An education program should be targeted not only at HCWs, but also at observers and trainers. Education must be provided to all HCWs, whether to start the HH training or to update or check competence and learned skills. The education program should be led by a coordinator and sub-coordinators (managers or committee members) who select trainers and observers, based on their knowledge and experience in infection control, but also on their capability of leadership. Finally, the education program must be supported by and subjected to regular evaluations to improve teaching and learning methods. 11

20 3- OUTCOME SURVEILLANCE Outcome surveillance is the measurement of the rates and consequences of HAIs, including but not limited to, the following few variables: HAI rates, mortality, extra LOS, cost, microorganisms, and bacterial resistance rates. Outcome surveillance data also are analyzed through case-control studies to identify risk factors and determine extra cost and mortality. The results of HAI outcome surveillance allow infection control professionals to define the magnitude of the problem, identify devices with the highest risk, and provide the framework for plans to reduce infection risk, including the evaluation of the cost-effectiveness of specific infection control interventions.(26) In summary, outcome surveillance is the infrastructure for HAI management. Outcome surveillance of DA-HAI has become an integral feature of infection control and quality assurance programs in high-income countries, since risk adjustment by device use and duration of stay provides a more precise estimate of risk. (75-76) Standards for institutional surveillance have been adopted in the United States, (75) United Kingdom, (77) Australia, (78) Canada, (79) and Germany, (80) among other countries. These developed countries report rates as DA-HAI per 1,000 device days, which allows them to further analyze the impact of specific risk factors and guide their targeted interventions. In limited-resource countries, the general perception is that HAI rates are low and that compliance with infection control practices, such as HH recommendations, is high. However, it is frequent that no formal outcome and process surveillance is conducted at hospitals, hence the impossibility to confirm the scientific validity of such perception. Studies on HAI rates in limitedresource countries have been scarce, and in most instances, authors have reported percentage (cases over discharges or admissions) of HAIs, (81-86) or HAI rates are reported as number of infections per 1,000 patient-days, (81) rather than DA-HAIs per 1,000 device-days. Because the denominator of number of device-days is unknown, it is not possible to compare rates between hospitals, and reported rates are less useful for secular trend comparisons within the same hospital as well. This situation has changed markedly since 2002, as there has been an increase in studies that present DA-HAI rates per 1,000 device-days from limited resource countries.(36-37, 40, 42-12

21 Chapter contained on Book Bennett and Brachman s Hospital Infection th Edition. Title of Chapter: Epidemiology and Control of Health Care Acquired Infections in Limited Resource Settings Author of this chapter: Victor D Rosenthal, INICC Founder and Chairman. 53) As part of the INICC, DA-HAI rates per 1,000 device-days have been reported in many recent studies at the country (36-37, 40, 42-53) and global level.(32-35) As stated in two recent reviews by the WHO, by applying INICC outcome surveillance method, it is possible to benchmark HAI rates in limited-resource countries against high-income countries.(87-88) In turn, from 2003, there have been more scientific publications from limitedresource countries in which HAI rates are reported per 1,000 device days. (89-100) 4- PROCESS SURVEILLANCE Process surveillance consists of the regular supervision of a series of infection control practices involved in the routine patient-care. Similar to outcome surveillance, process surveillance is a standardized collection of data, but it is focused on the actual performance of infection control practices in the healthcare facility. These practices include the monitoring of compliance with HH recommendations, vascular catheter care, urinary catheter care, measures to prevent VAP (such as position of the head and type of secretion suctioning), and measures to prevent SSI (e.g., pre-surgical shower, hair removal, antibiotic prophylaxis, etc.). Surveillance of infection control practices is among the most important indicators evaluated at the hospitals facilities. Accompanying the other components of the multidimensional strategy to reduce DA-HAIs, process surveillance is crucial to provide a basis to focus on the areas needing more attention: first, it measures the actual situation of compliance with infection control practices and provides a general overview of HCW s perception and knowledge of the burden of DA-HAIs. Second, this evaluation and measurement permits the identification of problem areas in healthcare delivery, which is essential to implement localized interventions. Third, it also allows the measurement of the outcome of such interventions in relation to the other components of the multidimensional approach and their translation into improvements in infection control practices and reduction of DA-HAIs. In other words, the onset and the outcome of the whole multidimensional approach are evaluated through process surveillance. Process surveillance is conducted by an observer (usually an infection control nurse) who directly monitors HCWs practices by following a standardized protocol and completing specific surveillance forms at regular intervals.(31) These observations are conducted unobtrusively at 13

22 specific time periods distributed in three work shifts (morning, afternoon and evening). HCWs are not aware of the actual schedule of the monitoring, so to avoid or minimize the observer effect. Process surveillance data include key interventions to control and reduce the incidence of HAI, such as HH compliance, specific measures to prevent VAP (i.e., position of the head, cleanliness of tubes, aspiration technique), CLA-BSI (i.e., care practices for insertion site of the central lines, skin antisepsis, placement of gauze on intravascular access insertion sites, marking the date on the IV administration set, condition of the gauze dressing, by assessing the presence or absence of moisture, blood, gross soilage, and the appearance of the insertion site), CA-UTI (i.e., position of the urinary catheter regarding the leg and position of urine bag regarding the bed) VAP (i.e., position of the head of the bed, evaluation of time to wean patients off ventilation), and SSI (i.e., proper hair removal, optimal antimicrobial prophylaxis.) The INICC multidimensional approach, including process surveillance for vascular catheter, urinary catheter, and mechanical ventilator care has been effective in reducing associated HAIs in several previous studies conducted in limited-resource countries, such as CLA-BS,(54-57), VAP (58-61, ), and CA-UTI (62-64) among others. 5- FEEDBACK OF HEALTH CARE ASSOCIATED INFECTION RATES The goal of measuring HAIs through outcome surveillance is directly related to the need to communicate the results to HCWs, who are expected to bring about meaningful changes. This communication process entails providing HCWs with feedback of the incidence of HAI rates and their adverse consequences. The concept of using feedback of outcome surveillance is a powerful control measure in hospitals with limited resources, whose effectiveness has been reported from 1999 to 2002 in studies within individual Argentine hospitals before the inception of INICC in 2002.(54, 103) As part of the INICC multidimensional approach, data contained in completed outcome surveillance forms are submitted to the INICC Central Office in Buenos Aires, which in turn, sends monthly reports that contain the analysis of outcome surveillance data, such as microorganism profile, and monthly rates for each DA-HAI. Through this communication process, it is possible to evaluate the validity of each infection case, as data include the recorded signs and symptoms of infection and results of positive cultures, which can be matched with individual patients forms. Infection control professionals review the forms filled out in the ICU 14

23 Chapter contained on Book Bennett and Brachman s Hospital Infection th Edition. Title of Chapter: Epidemiology and Control of Health Care Acquired Infections in Limited Resource Settings Author of this chapter: Victor D Rosenthal, INICC Founder and Chairman. and are able to verify that criteria for infection are met accurately in each case. Additionally, the original patient data forms are further validated at the INICC Central Office, before data on the reported infection are entered into the INICC s database. To that end, queries may be submitted from the INICC office in Buenos Aires to the hospital s investigators, challenging those cases with suspected VAP, and data are uploaded after receiving the reply (validation) from the hospital teams. Finally, the INICC team performs consistency analyses of database, such as age, gender, dates, among other data, and reviews of medical records that compared data registered in forms and data in medical records. To foster the effective implementation of the multidimensional approach, and the adoption of each component, reminders of outcome surveillance in the workplace play a substantial role. These messages are aimed at pointing-out the basic information on the significance of HAI prevention. Such reminders include posters with the graphs and charts showing monthly changes in rates of HAIs and their adverse effects, such as extra mortality and extra LOS. The information contained in the remainders must be updated regularly. Reminders are to be displayed and disseminated all around the hospital settings in order to obtain a higher level of awareness. 6- PERFORMANCE FEEDBACK Providing feedback to HCWs in order to assess performance levels is one of the most motivating aspects of the INICC multidimensional approach from the perspective of HCWs. To know the outcome of their efforts reflected by the measurement of their practices and the incidence of HAIs can be a most rewarding or conscious-raising factor to ensure the effectiveness of the multidimensional improvement strategy. On a monthly basis and from the first month of implementation of the infection control program, the INICC Headquarters team prepares and sends to each participating ICU a final month-by-month report on compliance with healthcare practices based on the data compiled by the hospital infection control professionals at the participating ICUs. These charts contain a running tally of compliance with infection control practices by HCWs along with information on how improvements are being made in the compliance with key infection preventive intervention, comparing several variables, such as gender, HCW status, ICU type, contact type, and work shift. 15

24 Those charts are reviewed at monthly staff meetings and also posted in prominent locations in the ICUs in order to give performance feedback to the participating HCWs of the ICUs. HAND HYGIENE COMPLIANCE IN LIMITED RESOURCES SETTINGS. EARLIEST STUDIES SHOWING BENEFIT OF HH ON HEALTH CARE ASSOCIATED INFECTION RATE REDUCTION. The impact of HH (HH) before each patient contact for infection prevention was demonstrated 160 years ago when Semmelweis studied the relationship between improved hand antisepsis and reduced mortality from puerperal sepsis.(104) Since then, it has been proven that improved HH practice reduces HAI rates and antimicrobial resistance.( ) (108)HCWs commonly carry HAI pathogens on their hands.( ) Most pathogens responsible for HAIs are thought to be transmitted from patient-to-patient via HCW's hands.( ) Although improvement in the prevention interventions associated with invasive devices t aid in the prevention of HAIs, HH remains the cornerstone in the prevention of cross-infection among patients. However, HCWs compliance with good HH practice is low in most settings.(107, ) Most reports of successful interventions have been conducted in high-income countries; ( ) only a few have been conducted in settings with limited resources, such as Argentina and Mali. (103, 108, 118) HAND HYGIENE COMPLIANCE ASSOCIATED RISK FACTORS Monitoring HH is one of the key examples of process surveillance. Achieving higher adherence to HH guideline recommendations has been a difficult issue, which remains unresolved in many healthcare facilities worldwide.(119) Table 11 shows examples of HH in limitedresource countries. Low HH rates were reported in many studies in which HH compliance rates ranged from 9% to 75%. Lack of a mandatory national HAI control program, lack of a national HAI surveillance system, and lack of a national healthcare facility accreditation process in some countries probably contribute to low HH compliance. 16

25 Chapter contained on Book Bennett and Brachman s Hospital Infection th Edition. Title of Chapter: Epidemiology and Control of Health Care Acquired Infections in Limited Resource Settings Author of this chapter: Victor D Rosenthal, INICC Founder and Chairman. HH performance is influenced by different factors, and its promotion is particularly complex in limited-resource countries, because limited resources and culture-specific issues strongly influence practices.(120) Factors predicting poor HH adherence level include male gender,(103) type of HCW, (103, 122) type of ICU, ( ) and type of procedure, ( ), etc. Different studies have shown that there is a higher HH compliance by females.( ) Women usually wash their hands more frequently than men, and in many countries, females are the predominant gender in nursing. Guinan et al found a higher HH compliance by female students in middle and high school,(127) and another study found similar findings in the restroom of Penn Station in the Wirthlin Worldwide observational study in 1996.(128) In limited-resource countries, at least from Latin America, the cultural construction of the traditional role of women continues to be directed by the patriarchal model of family. According to this socio-cultural construction, the natural role of women lies in the catering for children and the ill. The influence exerted by gender in HH compliance should be regarded a strong factor that contributes to male HCWs lower internal motivation for HH healthcare in general (in contrast to females), and also to the unquestioned predisposition of women to be the predominant gender in nursing and related professions. This factor has not been fully acknowledged as a useful parameter for further research in the design of HH programs.(129) If HCWs are stratified by type of professional, HH compliance was found to be higher in nurses in different studies. ( ) In a study conducted by Rosenthal et al in 2005, performance was lower among physicians and ancillary staff compared to nurses.(108) Professional status also can influence HH compliance level.(122) Watanakunakorn et al also found differences in HH compliance rates in different work categories: resident physicians (59%), staff physician (37%), nurses (33%), and others (4%).(132) Avila et al. found subtle differences between nurses (67%) and ancillary staff (62%), (131) whereas Wurtz found a HH compliance rate of 33% for nurses, 35% for physicians, 25% for physiotherapists, and between 0 and 20% among technicians.(130) Some have found HH compliance differences between work shifts. Possible explanations include the fact that during day shifts ICUs may be more crowded and busy than during night 17

26 shifts. In 1982, Haley et al(121) showed that overcrowding and understaffing hindered HCWs efforts to perform HH as adequately and frequently as needed to prevent cross infection. Similarly, in 2001, O Boyle et al.,(120) claimed that lower adherence to HH was related to high level of intensity of work in healthcare settings,--which predisposed HCWs to a lower awareness of their actual HH performances--rather than to a lack of internal motivation. If related to understaffing, morning and afternoon (compared to night shift) are risk factors associated with poor administrative support, particularly in the context of limited-resource countries, as shown by Rosenthal et al in 2003, (103) in a study that evaluated the relationship between greater administrative support and higher HH adherence. In this respect, many different studies from developed countries have demonstrated that active administrative support is an especially important issue to deal with HH compliance, not only in making hospital infrastructure readily available for timely and properly HH performance, but also to focus on the adoption of systematical societal marketing methods that were proved effective in sustaining HH in clinical settings. (133) Although Watanakunakorn et al (132) found no HH compliance differences between work shifts, there were remarkable variations by unit, with compliance being 56% in ICUs, compared to 23% in non ICUs. Thus, the type of unit also has an influence on HH compliance. Watanakunakorn et al., also showed that prevalence of HH was higher in surgical (56.4%) and medical ICUs (39.2%) than in intermediate (30.0%) or general ICUs (22.8%). Newborns are the most vulnerable patients, which may explain higher HH compliance by HCWs in this type of ICU.(134) The type of contact also may influence HH performance: superficial contacts were significantly associated with lower compliance. This coincides with the findings of Lipsett, which showed that nursing groups were significantly less likely to perform HH in low-risk vs. high-risk situations. (122) INTERVENTIONS TO IMPROVE HAND HYGIENE COMPLIANCE The effectiveness of different interventions had been analyzed, and published from the early eighties by several investigators, such as: Contribution of supplies availabilityevaluated by Preston in 1981,(111) Mayer in 1986,(135) and Doebbeling in 1992;(105) 18

27 Chapter contained on Book Bennett and Brachman s Hospital Infection th Edition. Title of Chapter: Epidemiology and Control of Health Care Acquired Infections in Limited Resource Settings Author of this chapter: Victor D Rosenthal, INICC Founder and Chairman. Contribution of use of reminders and posters evaluated by Conly in 1989 (136), Graham and Simmons in 1990 (107, 114), Lohr in 1991 (137), Dorsey in 1996 (138), and by Avila- Aguero in 1998 (139); Contribution of use of monitoring and performance feedback by Mayer in 1986 (140), Conly in 1989 (113), Graham and Dubbert in 1990 (114, 141), Lohr in 1991 (137), Raju in 1991 (142), Berg in 1995 (143), Tibballs in 1996 (144), Larson in 1997 (145), Avila-Aguero in 1998 (139), and by Rosenthal in 2003 (103) and 2005(108); Contribution of administrative support by Larson et al in 1997 (145) and 2000 (145), and by Rosenthal in 2003 (146) and 2005 (108); Introduction of alcohol-based hand rub by Graham in 1990 (147); Effectiveness of education by Dubbert (148), Tibballs (144), Dorsey in 1996 (138), Larson in 1997 (145), and by Rosenthal in 2003 (103) and 2005 (108). Combining these various interventions, multidimensional approaches have been designed and implemented with successful results since the late eighties. In 1989, Conly (136) concluded that an educational and enforcement program was an efficient tool to achieve higher HH compliance. In 1990, Dubbert et al reached the same conclusions combining education, monitoring and performance feedback, (148). But, it was not until 1997 that Larson et al explicitly referred to a multidimensional strategy that considered several interventions in a study conducted in the United States.(149) Similarly, in 1998, Won et al. launched a multimodal campaign for HH promotion in a university hospital in Taiwan, which included lectures, written instructions, reminding posters on adequate HH techniques, monitoring, financial incentives, and performance feedback.(150) Likewise, in 2003 and 2005, Rosenthal et al. published the results of studies implemented in Argentina in 1993 combining administrative support, supplies availability, education and training, process surveillance and performance feedback, which produced a sustained improvement in HH compliance, (103) coinciding with a reduction in HAI rates.(108) Table 12 shows examples of intervention to improve HH in limited-resource countries. In 1993, the INICC started applying a HH multidimensional approach in Argentina and in 2002 in several limited-resource countries in Asia, Europe, the Middle East, and Latin America 19

28 (i.e., Argentina, Brazil, China, Colombia, Costa Rica, Cuba, Greece, El Salvador, India, Lebanon, Lithuania, Macedonia, Mexico, Pakistan, Panama, Peru, Philippines, Poland and Turkey). In 2002, the CDC published their HH guideline, including a recommendation to apply previously published strategies.( ) In 2005, the WHO launched a program also combining previously published data called Clean Care is Safer Care with the aim of promoting HH worldwide.(29, 153) In 2009, the WHO published its guidelines also including a combination of these previously published data, and introducing the five moments for HH in order to prevent cross transmission of microorganisms with hands.(30) WORLD HEALTH ORGANIZATION (WHO): CLEAN CARE IS SAFER CARE: GLOBAL PATIENT SAFETY CHALLENGE A hopeful sign related to HH is Clean Care Is Safer Care, the first global challenge of the WHO World Alliance for Patient Safety.(154) In October 2004, the World Alliance for Patient Safety was formed, focusing first on prevention of HAIs through a combination of initiatives that include mobilizing patients and patient safety organizations, generating teaching tools, directing and conducting research, developing a taxonomy of definitions and data management methods, and coordinating international efforts on future solutions. The intent is to engage all countries in infection prevention. Countries were invited to adopt this challenge for their own healthcare systems with the following main principles:(154) Formally assessing the scale and nature of HAIs within their healthcare system. Adopting an internationally recognized approach to surveillance of the problems so that current baseline incidence of HAI can be established and change can be monitored. Conducting an analysis of the root causes of the problem with particular emphasis on systems thinking. Developing solutions to improve safety and reduce risk by focusing on five action areas in particular: (1) HH, particularly use of alcohol hand rubs, (2) blood safety, (3) injection practices and immunization, (4) water, basic sanitation, and waste management, and (5) clinical procedures. Relying on evidence-based best practice in all aspects of addressing the challenge. 20

29 Chapter contained on Book Bennett and Brachman s Hospital Infection th Edition. Title of Chapter: Epidemiology and Control of Health Care Acquired Infections in Limited Resource Settings Author of this chapter: Victor D Rosenthal, INICC Founder and Chairman. Fully engaging patients and service users as well as HCWs in improvement and action plans. Ensuring the sustainability of all action beyond the initial two-year challenge period. Pittet and Donaldson (154) state the vision of the World Alliance for Patient Safety: to catalyse commitment by all players policy makers, frontline staff, patients and managers to make Clean care is safer care an everyday reality in all countries and everywhere healthcare is provided. INTERNATIONAL NOSOCOMIAL INFECTION CONTROL CONSORTIUM (INICC) SIX COMPONENTS MULTIDIMENSIONAL APPROACH TO IMPROVE HAND HYGIENE COMPLIANCE INICC has been implementing its multidimensional approach combining following six components: 1- administrative support, 2- supplies availability, 3- education, 4- reminders in the workplace, 5- process surveillance, and 6- performance feedback. Although the components are presented individually, they must be interpreted as interactive elements that are dependent on each other on a reciprocal basis, and not as separated elements. As will be noted below, one is implied on the other, and all of them must concur for any multidimensional approach to be effectively implemented. The components of the HH multidimensional approach started to be implemented at each of the INICC participating ICUs after documenting baseline compliance episodes during 2 months. RESULTS OF INICC MULTIDIMENSIONAL APPROACH TO IMPROVE HH COMPLIANCE In 1999, INICC started a prospective surveillance study in INICC member hospitals-- which is still ongoing--to determine the baseline HH compliance rate by HCWs before patient contact, analyze risk factors for poor adherence, and implement and evaluate the impact of the INICC multidimensional approach for HH which included the 6 above-mentioned items.(134) 21