CNA(NZ) INC. - Infection Prevention and Control

Victoria Smith RN, Dip App Sci, BN, PGDip PH, MNS, CIC, FCNA(NZ)

Executive Summary

Healthcare associated infection has been documented as a significant problem for many years since Ignaz Semmelweis demonstrated in 1847 that the incidence of infection could be drastically reduced by enforcing handwashing amongst physicians (Wenzel 1997). In New Zealand, recent changes in the healthcare sector have resulted in a more effective framework for infection prevention and control in healthcare facilities. However, this brings with it a number of challenges including resourcing and capacity of the current workforce.

The extent of healthcare associated infection

International norms dictate that on average 5-10% of patients will acquire an infection whilst in hospital. Such infections predominantly include bloodstream infections, urinary tract infections, gastrointestinal infections, skin, soft tissue or surgical site infections and respiratory tract infections (Wenzel 1997). The only published estimates in New Zealand are based on data collected at Auckland District Health Board (ADHB) between 1996 and 1999 (Graves 2003). During that period, seven prevalence surveys were undertaken throughout Auckland, Green Lane and National Women's Hospitals. The pooled results showed a prevalence rate of 9.5% following the application of epidemiological techniques. This predicted a cumulative incidence of 6.33% (95% CI = 6.20% to 6.46%). Cost modelling using this data, predicted annual cost estimates for hospital acquired infection of up to $18.76 million for ADHB and as high as $136.61 million for all of NZ (Graves 2003).

Such studies only measure and estimate the in-hospital effects of infection acquisition, and do not reflect today's healthcare environment where most care is delivered in community settings involving a number of other healthcare providers. The costs related to infections acquired outside the traditional hospital setting as well as those infections manifest after discharge are seldom quantified. A recent study in the United Kingdom tracked 4,000 patients and reported an in-hospital infection rate of 7.8% (95% CI = 7.0 to 8.6%). Of these 4,000, 1,449 were followed up after discharge and infections were identified in a further 19% of these patients after leaving hospital. Those with an infection identified post-discharge on average had more contact with their general practitioner, district nurses and a doctor or nurse at the hospital (Plowman, 2001).

In non-inpatient settings, recent literature includes several situations where cross-infection has occurred including four people acquiring HIV following simple surgical procedures in an Australian doctor's office (Chant 1993), five patients infected with Hepatitis C after undergoing minor surgical procedures in Sydney (Chant 1994), and transmission of HIV to five patients by an infected Florida dentist (Clesielski et al. 1994). Investigations into these incidents all identified sub-optimal practices in relation to infection prevention and control.

Preventing hospital acquired infection

In the US between 1971 and 1976, an interventional cohort study was undertaken that compared hospitals with no, or inefficient, infection control programmes with well-organised, highly effective infection control programmes (Haley 1985). One of the key findings of the 'Study on the Efficacy of Nosocomial Infection Control' (SENIC) was that up to 32% of infections are preventable by "good infection control programmes". Good infection control programmes were defined as those with an appropriate infection control practitioner to bed ratio, intensive surveillance including feedback to staff, an extensive control programme including an infection control nurse with responsibility for data analysis and programme supervision, and a trained healthcare epidemiologist attached to the infection control programme. Hospitals without these components could expect 18% cumulative increases in infections.

A more recent systematic review evaluated thirty reports of multi-modal intervention studies and assessments of exogenous cross-infection, and reported that …'depending on the setting, study design, baseline infection rates and type of infection ... a great potential exists to decrease nosocomial infection rates.' It was suggested that a reduction would be seen in infections ranging between a minimum of 10% and a maximum of 70% exists (Harbartha 2003).

So what is an effective Infection Control Practitioner (ICP) to resourced bed ratio? The SENIC study suggested a ratio of 1 ICP to every 250 beds, however more recent data based on the healthcare environment of the 1990s indicates ratios of 1:175, 1:150, 1.5:200 and 1:100 as being more appropriate given current patient complexity and acuity (Hoffman, K., 1997; National Advisory Committee on SARS and Public Health, 2003, O'Boyle C., Jackson M., et al. 2002)

Framework for infection prevention and control in New Zealand

Organised infection control programmes have been operating in New Zealand public hospitals for approximately 25 years. However it has only been relatively recently that more significant moves have been made toward increasing resources and developing strong interdisciplinary teams that are well-educated and work collaboratively within and between hospitals.

In June 2003, the Office of the Controller and Auditor-General published a report of a performance audit that was undertaken under the authority of the Public Audit Act 2001 (Office of the Controller and Auditor-General, 2003). This report made 39 recommendations for improvement in infection control within DHBs, stating that hospital-acquired infection (HAI) in New Zealand hospitals is a serious problem that should be everyone's responsibility. It noted that the Standards New Zealand publication 'NZS8142:2000 Infection Control' provides a basis to establish effective infection control, that auditing of infection control practice should occur and that more visible and active commitment by managers is required. Infection control was described as an issue that should be a key component of risk and quality programmes, and that DHBs must have improved information on the risks of HAI and their management. The report concluded that it is important "that every reasonable action is taken to manage the risk of infection" (pg 8).

NZS8142:2000 Infection Control is one of four mandatory standards that all health care facilities are required to meet under the Health and Disability Services (Safety) Act 2001. Its aim is to 'facilitate consistently safe, quality health and disability service delivery by identifying principles designed to reduce the rate of infections…'. Along with its accompanying audit tool, it provides guidance to the sector as well as outlining mandatory practices and advised or recommended practices for hospitals and long-term care facilities.

Current issues and concerns

Skills
It is well documented that healthcare associated infections cause morbidity and mortality internationally, and this is also true in New Zealand. Reports regarding lessons learned during the SARS crisis showed that up to 70% of staff needed to be upskilled in basic infection control measures such as the wearing of gowns, gloves and masks. Thus, it appears that the knowledge and skills of the health workforce in relation to infection prevention are not optimal.

Facilities
In New Zealand, reviews of DHB facilities indicated that provision of negative pressure rooms was variable during this time. Primary care practices indicated concerns over risk within their facilities associated with poor access to personal protective attire.

Antibiotic Resistance
Increasing antibiotic resistance is a world wide problem, and New Zealand healthcare facilities are now seeing evidence of this through increasing numbers and outbreaks of multi-resistant Staphylococcus aureus (MRSA) and extended-spectrum beta-lactamase-producing organisms such as Enterobacteriaceae (ESBLs). NZS8142:2000 Infection Control contains a specific standard relating to appropriate antibiotic prescribing and the need for organisational policies and monitoring of prescribing. This is because of the link with overuse of antibiotics and the promulgation of multi-resistant organisms.

Emerging Infectious Diseases
Recently the media has reported outbreaks of new and emerging infectious diseases. In early 2003, SARS spread from China to 29 other countries, affecting almost 8,500 patients of which approximately 11% died and creating a huge impact internationally. More recently there has been the threat of avian influenza and the risk of viral mutation of human influenza strains and the potential pandemic that would be associated with this. The Ministry of Health's Clinical Services Directorate along with a sector advisory group has been developing a National Clinical Action Plan for managing new and emerging infectious diseases. This plan is being developed in parallel with the National Pandemic Plan.

Staffing
One of the challenges in implementing these and other plans in District Health Board (DHB) settings should an emerging infectious disease crisis occur is that there are insufficient numbers of infection control practitioners (ICPs) in hospitals. Using the international benchmarks cited above, DHBs are currently barely, if not under-resourced to cover in-patient infection control services. Thus coverage for primary care settings which are likely to have their own set of not insignificant issues is, at best, minimal. Capital and Coast DHB have recently put in place the first ICP to work with primary care providers but there are very few ICPs who work outside the hospital setting and who are funded to advise primary care.

So the capacity and capability of infection control resource throughout some parts of the health sector is of concern. This is a significant issue because infection control issues, particularly emerging infectious diseases such as SARS or avian influenza are likely to hit all parts of the health sector, not just DHB hospitals.

Preventative measures

Hand hygiene is the most important means of preventing the spread of infection. Hand hygiene encompasses handwashing with soap as well as the use of waterless, alcohol-based, hand sanitising products. International evidence and published guidelines show that alcohol-based hand gels are AS effective as handwashing. In addition, they are easier to use and the research shows that this promotes increased compliance (Pittet, 2000; Pittet, 2000; Girard, 2001).

Influenza vaccination is more important than ever this winter because of the risk of the usual seasonal mutation occurring and involving transfer of avian influenza genes. A decrease in the number of cases of influenza will decrease the likelihood of such mutations occurring. Nurses, particularly those working in primary care, have a major role to play in promoting and participating in the annual national influenza campaign.

Effective cleaning, disinfection and sterilisation are important in preventing cross-infection. There are joint Australian and New Zealand standards specific to office-based practice and to hospitals. Organisations must meet these standards and so should use them to review their practice and monitor themselves.

Surveillance is a key component of infection prevention and control programmes. Prevention programmes suffer from the age-old problem of "how do we know what we have prevented?" Surveillance and reporting of infections offers a solution to this problem and links with quality systems providing measurable outcomes (Perl, 1997).

Standard Precautions involve the use of barrier measures, including personal protective equipment (PPE) in all situations to prevent cross-infection. This includes the wearing of gloves, gowns and masks for contact with ALL body fluids and also the application of other measures to prevent cross-infection such as covering of cuts and scratches with occlusive dressings, effective cleaning up of body spills, sharps safety, containerisation of waste and protection during CPR. This concept has evolved from previous practices known as universal precautions and body substance isolation. It involves treating everyone with barrier precautions rather than singling out only known infections. It provides an effective basis for prevention of infection transmission to which more specific practices can be added once a communicable or other disease has been diagnosed.

A recent addition to standard precautions is 'cough etiquette'. This was recommended in December 2003 by the Centers for Disease Control and Prevention (CDC) in the USA as part of the global response to SARS. Implementation of cough etiquette/respiratory hygiene suggests that signs be placed at outpatient facility entrances instructing those with symptoms of respiratory infection to notify healthcare personnel of this fact and that they sit 1-metre away from others in waiting rooms. Where patients are symptomatic for respiratory infection, other measures to contain respiratory secretions are recommended including instruction to cover nose/mouth when sneezing, to use tissues to contain respiratory secretions and dispose of them in the nearest rubbish bin and to perform hand hygiene after having contact with respiratory secretions. The recommendation is that all healthcare facilities should provide facilities in waiting rooms for performing hand hygiene, tissues and rubbish bins for tissue disposal and surgical/procedure masks so that healthcare personnel can wear them routinely when examining patients with respiratory symptoms (Centers for Disease Control and Prevention (CDC), 2003).

The future

We know that trends overseas are moving away from controlling infections once they occur toward a preventative model (Gerberding, 2001). This idea fits well with the current population-based healthcare approach and the preventive nature of primary care in New Zealand.

There is more international recognition of the need for expansion of infection prevention and control efforts to non-hospital settings. This means moving the focus from controlling nosocomial infections to preventing healthcare-associated infections and ideally toward integrating primary care and other programmes with hospital-based infection prevention and control programmes such as surveillance (Jarvis, 2001). This is particularly important for the control of emerging infectious diseases.

Infection prevention and control is one field where there always has been multi-disciplinary collaboration on an international basis. Although this may have previously been a challenge in smaller New Zealand healthcare facilities (probably due to its historic place under nursing in organisational structures), overall it is integrated well within secondary and tertiary care. Nurses, physicians and allied health professionals need to continue to work collaboratively on preventative measures. This is particularly important for combating the spread of infections, both known infections and emerging pathogens. We now need to use the frameworks available in New Zealand as well as international evidence to move these infection prevention concepts from the hospital setting into primary care.

Questions to ponder having read this article:

How does your organisation, whether a DHB, PHO or other primary care provider, private hospital, rest home or other healthcare facility
o Manage and prevent infection? (Is there an organised infection prevention and control programme and is it linked to quality and risk programmes? Is it effectively resourced with infection control expertise available?)
o Respond to emerging infectious diseases?
o Maintain appropriate antibiotic prescribing?
o Identify the required capacity, knowledge, skills and facilities?
o Participate in surveillance programmes?

This paper has been adapted from a presentation given in March 2004 by Victoria Smith and Gillian Bohm to the Ministry of Health's Primary Health Nursing Sector Advisory Group.

References

Centers for Disease Control and Prevention (CDC) (2003). Fact Sheet Respiratory Hygiene/Cough Etiquette in Healthcare Settings. Atlanta, GA.

Chant, K., Kociuba K, Munro R, et al. (1994). "Investigation of possible patient-to-patient transmission of hepatitis C. Cited in Aust Fam Physician 1999;28 (Special Issue)." NSW Public Health Bulletin 5: 47-51.

Chant, K., Lowe D, Rubin G, et al. (1993). "Patient-to patient transmission of HIV in private surgical consulting rooms [letter]." Lancet 342: 1548-1549.

Clesielski et al (1994). Ann Intern Med 121(11): 886.

Gerberding, J. (2001). "Health-Care Quality Promotion through Infection Prevention: Beyond 2000

Julie Louise." Emerging Infectous DIseases: Centers for Disease Control and Prevention, Atlanta, Georgia, USA 7(2).

Girard, R. e. a. (2001). "Better compliance and better tolerance in elation to a well-conducted introduction to rub-in hand disinfection." Journal of Hospital Infection 47: 131-137.

Graves, N., Nicholls TM; Morris AJ, (2003). "Modeling the costs of hospital-acquired infections in New Zealand." Infect Control Hosp Epidemio 24(3): 214-223.

Graves, N. N., T., Wong, CG; Morris AJ, (2003). "The prevalence and estimates of the cumulative incidence of hospital-acquired infections among patients admitted to Auckland District Health Board Hospitals in New Zealand." Infect Control Hosp Epidemiol Jan;24(1):56-61 24(1): 56-61.

Haley, R. (1985). "The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals." American Journal of Epidemiology 121: 182-205.

Harbartha, S., Saxa, S., Gastmeier. P, (2003). "The preventable proportion of nosocomial infections: an overview of published reports." Journal of Hospital Infection 54: 258-266.

Hoffman K, Ed. (1997). The Modern Infection Control Practitioner. Prevention and Control of Nosocomial Infections. Wenzel, R (ed). Baltimore, Williams and Wilkins.

Jarvis, W. (2001). "Infection Control and Changing Health-Care Delivery Systems." Emerging Inf Diseases 7(2).

National Advisory Committee on SARS and Public Health (2003). Learning from SARS - Renewal of Public Health in Canada, Health Canada, Ottawa available on http://www.hc-sc.gc.ca/english/protection/warnings/sars/learning.html.

O'Boyle C., Jackson M., et al. (2002). "Staffing requirements for infection control programs in US health care facilities: Delphi project." American Journal of Infection Control. 30: 321-33.

Office of the Controller and Auditor-General (2003). Report of the Controller and Auditor-General Management of Hospital-Acquired Infection. Wellington, Office of the Controller and Auditor-General.

Perl, T. (1997). Surveillance, Reporting and the Use of Computers. Prevention and Control of Nosocomial Infections. R. Wenzel. Baltimore, Maryland, Williams and Wilkins.

Pittet, D. (2000). " Improving compliance with hand hygiene in hospitals." Infect Control Hosp Epidemiol Jan;24(1):56-61 21: 381-386.

Pittet, D., Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, et al. (2000). "Effectiveness of a hospital-wide programme to improve compliance with hand hygiene." Lancet 356: 1307-12.

Plowman, R., Graves N, Griffin MAS, Roberts JA, Swan AV, Cookson BC, Taylor L., (2001). "The rate and cost of hospital-acquired infections occurring in patients admitted to selected specialities of a district general hospital in England and the national burden imposed." Journal of Hospital Infection 47(3): 198-209.

Wenzel, R. (1997). Prevention and Control of Nosocomial Infections, 3rd Edition. Baltimore, Williams and Wilkins.

INFECTION PREVENTION & CONTROL

Victoria Smith RN, Dip App Sci, BN, PGDip PH, MNS, CIC, FCNA(NZ)