Infection Control in Hospital Accreditation Paul Ananth Tambyah
Are Hospitals Dangerous??? Hospitals were originally set up for the sick and dying among the poor The wealthy had physicians go to their homes to provide care Hospitals were widely and correctly perceived as dangerous places Pittet et al http://www.hopisafe.ch
Many new technologies are introduced before protocols for safety and infection control are in place
The chain is as strong as its weakest link
Infection Control A Major Part of Accreditation
Reminders when JCI audits come round
The WHO Core Components http://www.who.int/csr/resources/publications/who_hse_epr_2009_1/zh/index.html
1. Infection Control Infrastructure: Ministry of Health section dedicated to Infection Control Each healthcare facility should have a designated Infection Control Officer A multidisciplinary infection control team should be constituted in each healthcare facility and should be recognized for their work There should be integration between the local infection control team, infection control officer and national and international agencies.
SHEA the Society for Healthcare Epidemiology in America
2. Local Infection Control Guidelines
APSIC has guidelines on Sterilization and Disinfection
Steam sterilisation
3. Trained healthcare workers: There should be access to training either locally or through international or regional agencies for infection prevention and control staff Healthcare worker protection needs to be a priority specifically addressing bloodborne pathogens and nosocomial respiratory infections including tuberculosis and respiratory viruses. A concerted effort should be undertaken to reduce injections and ensure that sharps are safely disposed.
The International Federation of Infection Control http://www.theific.org/basic_concepts/index.htm
CLABSI: Education makes a difference
An Improvised sharps box in East Asia
Hepatitis B Prevalence in Singapore Families of Hep B carriers (1980s): 38%(n=358) Multiple transfused patients (1984): 13% (70) Male prostitutes (1982): 14.9% (121) Dental surgeons (1985): 11.4% (114) NSmen (1984): 7.9% (1172) Female prostitutes (1982): 6.3% (239) HIV infected persons (1992): 8.5% (47) First time blood donors (1986): 3.9% (3342) Intellectually disabled children (1992): 2.7% (336) Goh KT. Ann Acad Med Sing 1997;26:671
4. Surveillance: There should be some kind of surveillance system in place for hospital acquired infections. At its most rudimentary, this can be surveillance for in hospital mortality or readmissions or returns to the operating room for infection. Surveillance should make use of what technology is available including mobile phone technology. Checklists should be implemented to reduce the incidence of surgical site infections.
There are international guidelines on surveillance of resistant bacteria
Special Article A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population Alex B. Haynes, M.D., M.P.H., Thomas G. Weiser, M.D., M.P.H., William R. Berry, M.D., M.P.H., Stuart R. Lipsitz, Sc.D., Abdel-Hadi S. Breizat, M.D., Ph.D., E. Patchen Dellinger, M.D., Teodoro Herbosa, M.D., Sudhir Joseph, M.S., Pascience L. Kibatala, M.D., Marie Carmela M. Lapitan, M.D., Alan F. Merry, M.B., Ch.B., F.A.N.Z.C.A., F.R.C.A., Krishna Moorthy, M.D., F.R.C.S., Richard K. Reznick, M.D., M.Ed., Bryce Taylor, M.D., Atul A. Gawande, M.D., M.P.H., for the Safe Surgery Saves Lives Study Group N Engl J Med Volume 360(5):491-499 January 29, 2009
Study Overview In eight hospitals throughout the world, implementation of a 19-item surgical safety checklist was associated with improved outcomes Use of the checklist may improve the safety of surgical procedures in hospitals in various economic circumstances
Haynes AB et al. N Engl J Med 2009;360:491-499 Elements of the Surgical Safety Checklist
Haynes AB et al. N Engl J Med 2009;360:491-499 Characteristics of Participating Hospitals
Outcomes before and after Checklist Implementation, According to Site Haynes AB et al. N Engl J Med 2009;360:491-499
Conclusion Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals
Device Associated Infection Prevention Closed urinary catheter drainage should be used with improvisation if necessary to ensure closed drainage. A system of reminders possibly nurse based should be used to reduce the utilization of devices including urinary catheters. Sedation protocols and education on aseptic technique are important for all facilities which mechanically ventilate patients. Oral rehydration should be encouraged as much as possible to reduce the use of vascular access devices including peripheral intravenous catheters. Bundles should be considered in attempts to reduce the incidence of central line associate bloodstream infection
International Nosocomial Control Consortium
Open vs Closed Systems Rosenthal & Maki AJIC 2004;32:135-141
5. Microbiology Laboratory All healthcare facilities should have access to a microbiology laboratory The laboratory should make use of software such as WHONET to generate local antibiograms This surveillance data should preferably be aggregated at a national level to monitor the emergence of novel and resistant pathogens External quality assurance whether national or international should be considered for all microbiology laboratories
International Lab Surveillance systems Big geographical differences in Asia Pacific
ESBL epidemiology High rates in SG, CN, SA
6. Environment: Healthcare facilities should ensure clean and safe water for clinical use Adequate ventilation should be provided for healthcare facilities using natural cross ventilation if appropriate Locally produced alcohol based hand rubs can be used effectively even in settings without running water.
A WHO Multimodal Implementation Strategy to improve hand hygiene An evidence System change based + approach Five core components Additional components can be incorporated Training and education + Measurement (observation and feedback) + Reminders in the workplace + Establishment of a safety climate
124 countries and territories which have committed to WHO hand hygiene campaign Source: http://www.who.int/gpsc/statements/en/index.html
7. Monitoring and Evaluation of Programs: Infection Prevention and Control Programs should be monitored on a regular basis both internally and externally.
International Accreditation has a focus on infection control
8. Links with public health and other services: Procedures have to be in place to ensure adequate linkages with ministries of health, agriculture and other appropriate agencies in preparation for pandemic or epidemic infections Adequate waste management procedures need to be in place including incineration of medical waste. Sterilisation and disinfection needs to be adequately monitored
International links are critical for Emerging Infectious Diseases http://www.ecdc.europa.eu/en/press/news/lists/news/ecdc_dispform. aspx?list=32e43ee8-e230-4424-a783-85742124029a&id=847
SARS showed the importance of global networks http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5212a1.htm
SARS controlled in China and globally
So is Influenza Airborne? Results of observational studies A A A Brankston et al Lancet Infectious Disease 2007;7:257-65
There was no difference!
SHEA and IDSA wrote to President Obama
Staff used N95s vs SARS
PAPRs were available
In Singapore Even bank robbers used N95 masks
It was Expensive
WHO guidelines may help resolve the issue
WHO guideline
Infection Control in a nutshell Everything I needed to know about infection control, I learned in kindergarten Julie Gerberding, former Director US CDC
Always clean your hands
Cover your mouth when you cough
Don t go to work when you are sick
Why do infection control?? It saves money It saves lives It is the right thing to do (not just when the auditors are around) Paul Ananth Tambyah