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As I had posted in the post JCI Standard MCI.20.1 – patient based data and aggregate data, in a process available to aggregate data to meet the needs of internal and external users (this link will open in a new tab of your current browser window), in this post I shall continue on infection prevention and control. This post is also a follow-up from the previous post on risk management in JCI Standard MCI.20.1, ME 1 (Part 1) – risk management, in “The organization has a process to aggregate data in response to identified user needs.” (this link will open in a new tab of your current browser window).
Infection prevention and control is one of a hospital’s four (4) performance improvement (PI) activities other than risk management, utility system management, and utilisation review PI activities a hospital is required to meet the Joint Commission International (JCI) Standard MCI.20.1, Measurable Element (ME) 1 which requires that a hospital as “The organization has a process to aggregate data in response to identified user needs.”
Although the details of infection prevention control are beyond the scope of this post and blog, I shall embark to highlight some aspects of infection prevention and control here. It is going to be a long post.
Health care–associated infections (HAIs) or also referred to as health care–acquired Infections, are infections acquired in the hospital or other health care facilities that were not present or incubating at the time of the patient’s admission. Hospital (or ‘nosocomial’) infection is infection acquired either by patients while they are in hospital, or by members of hospital staff. (eds. Adam & Christina 2009) define the term infection as “generally used to refer to the deposition and multiplication of bacteria and other micro-organisms in tissues or on surfaces of the body with an associated tissue reaction.”
At the time of the patient’s admission due to an illness – which impairs the body’s normal defense mechanisms, often the reason for hospital admission, the patient is in the state of risk for infection in which the patient is at increased risk for being invaded by pathogenic organisms because the patient has not been exposed to in the past what the hospital environment now provides the exposure to a variety of virulent organisms, therefore the patient has not developed any resistance to these organisms.
Health care personnel in hospitals who usually fail (eds. Adam & Christina 2009) to practice proper handwashing procedures or to change gloves between patient contacts, contribute to most HAIs been transmitted to hospitalised patients who are at risk from the most common HAI endemic infections in hospitals caused by multi-resistant tuberculosis, Clostridium difficile one of the major hospital infections in the elderly, vancomycin-resistant enterococci in some specialised units, and cross-infection with methicillin-resistant Staphylococcus aureus (MRSA) that affect the urinary tract, upper and lower respiratory tracts, gastrointestinal tract, conjunctiva, and skin.
HAIs have received increased attention due to their overwhelming consequences in terms of cost, morbidity, and mortality. One of the reasons for this increased attention is that these infections which are preventable through the adherence to numerous strict guidelines, legal requirements and other recommendations when caring for patients, is that they frequently occur in people whose health is already compromised by disease, age, or injury.
The data presented in the 1999 Institute of Medicine (IOM) study reported that an estimate of between 44,000 and 98,000 patients die as the result of preventable medical errors in hospitals each year and also reported that hospital-acquired infections, many of which can be prevented, take another 100,000 lives.
In the United States of America, payers have begun to refuse reimbursement for additional care resulting from treatment for an infection not present on admission with the underlying rationale that HAIs are preventable complications and denying reimbursement provides a strong incentive for quality improvement actions to avert them.
Then there are site-specific infection prevention to reduce (i) postoperative surgical wound infections through the use of appropriate surgical site preparation and also prophylactic antibiotic therapy, (ii) ventilator-associated pneumonia by for example minimizing the duration of intubation, (iii) central venous catheter infections for example with the use of sterile technique and full barrier precautions, (iv) urinary tract infection by avoiding unnecessary or prolonged use of indwelling bladder catheters, and (v) resistant organisms for example methicillin-resistant Staphylococcus aureus (MRSA) by employing (a) active surveillance procedures in which cultures are routinely obtained at scheduled intervals to promote earlier identification of resistant organisms, and (b) careful management of antibiotic use.
To address each type of HAI, many hospitals have adopted a series of practices called a “bundle” at a significant cost, failure to use all the measures prescribed in the “bundle”, for example in the approach to preventing central line-associated bloodstream infections (CLBSI) (this bundle includes the entire procedure for insertion, the daily cleaning protocols, and the protocols for use of the central line catheter) may adversely affect patient outcomes but adopting a “bundle” has been shown to decrease the incidence of the target infection, and thus been effective in improving quality of care which may then offset the significant cost.
Transmission of infection as an occcupational hazard in all hospital settings is a major concern when caring for infected patients made worse by the presence of resistant organisms which causes extra concern and makes treatment difficult.
Universal precautions are usually mandated for use with patients who pose the hidden danger when they have not been diagnosed as having an infection and for whom specific infection control measures have therefore not been prescribed. Universal precautions is a critical protective strategy with measures that include hand decontamination upon entering and leaving every patient encounter, isolation and the use of disposable gowns and gloves in addition to hand decontamination for patients with certain particularly dangerous types of infections. Provision of sharps containers wherever needles were used and the provision of a supply of gloves and protective eyewear for employee use are some other measures as part of universal precautions.
Blood-borne pathogens are not the only pathogens of concern in the healthcare environment. Body Substance Precautions are also used in all hospital settings to protect patients and staff members from infections that might be transmitted by any body substance, for example to protect staff members from the tuberculosis (TB) organism.
Confidentiality should be maintained at all times by Health Information Management (HIM) / Medical Records (MR) practitioners who may be needed to provide medical records of staff members exposed to HBV, HCV and HIV infection for review at the time of exposure of the source of their occupational exposure to the bloodborne pathogens including results of blood tests, admitting diagnosis and past medical history.
HIM / MR practitioners may be needed to work closely with an infection control officer at most hospitals which usually designate this officer who has the expertise to guide the staff in planning appropriate infection control procedures to protect staff members from blood-borne pathogens to prevent the spread of HIV, hepatitis B, and other such blood-borne pathogens.
HIM / MR practitioners may be involved in the development of policies and procedures is a key role for any infection control team. The central document is a collection of procedures (sometimes called an infection control policy or infection control manual).
As I have said in my previous posts, most hospitals today are involved in processes of quality improvement.
In the context of HAI, (eds. Adam & Christina 2009, p. 5) defines ‘surveillance which is a vital component of infection control as ‘the ongoing systematic collection and analysis of data about a disease (or organism) that can lead to action being taken to control or prevent the disease.’
As part of these processes, ongoing data are collected and analysed for problems or opportunities for improvement including using infection control and quality improvement data to improve care. An example of the use of infection control data reviewed from interviews in regard to care practices for patients with catheters in an intensive care unit (ICU) about the series of urinary tract infections for example by the same strain of Serratia as the infective agent that had been identified in all patients in that unit, showed that a deviation from the standard protocol for the unit with the use of one measuring container used by an infected patient cultured positive for the Serratia, and using it from patient to patient easily had transmitted the organism to another patient’s catheter, and the infectious agent could have been spread from patient to patient in this manner.
Quality of care aggregate data takes many forms, revealing such things as infection rates and unplanned returns to the operating room. Infection rates for example MRSA wound infections per 1000 bed days or per 1000 admissions are commonly computed rates like other rates for example average length of stay, based on discharge statistics data that are accumulated when patients are discharged. At the local level, (eds. Adam & Christina 2009) infection rates from surgical wound infections fed back to practising surgeons can demonstrate results in lowering infection rates.
Other forms quality of care aggregate data on HAIs is the reporting of infections.
A daily report generated by a laboratory-based system is able to give information based around ‘alert’ organisms that have the potential to cause outbreaks, for example the percentage of Staphylococcus aureus that are methicillin resistant and/or the percentage of wound swabs showing S. aureus.
Reporting is generated as recommended by (eds. Adam & Christina 2009) through (i) weekly reports by the Infection Control Nurse (ICN) and sent to the wards, departments and clinicians containing information on alert organisms and infectious patients including simple graphs that provide rapid feedback on current issues while they are still fresh, (ii) monthly reports sent to all members of the Infection Control Team (ICT) within two or three days of the new calendar month, (iii) quarterly reports that includes recommendations to management and education data on who attends the sessions, and (iv) a comprehensive annual report intended for the board members.
Local data must include ‘details’ of wards and consultants – to establish the ‘ownership’ of the data as well as the competitive element, needs to be analysed promptly and sent to the ward/clinician as daily and weekly reports.
All of the above are my observations, experiences and readings on infection prevention and control activities and processes in a hospital setting to aggregate data in response to identified user needs. They are by no means complete, in future posts I shall document on latest trends and developments in infection prevention and control activities.
In my next post on JCI Standard MCI.20.1, ME 1 I shall dwell on utilisation review PI activities a hospital is required to meet the JCI) Standard MCI.20.1, ME 1.
References:
Adam, PF & Christina, B (eds.) 2009, Ayliffe’s Control of Healthcare-Associated Infection A practical: handbook, 5th edn, Hodder Arnold, London, UK
Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, USA
Janice, RE, Celia, LH 2012, Nursing in todays world : trends, issues & management, 10th edn, Wolters Kluwer Health | Lippincott Williams & Wilkins, Philadelphia, PA, USA
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
