JCI-ASP Toolkit Module 1 (rev6) low res

Preventing Infections in theOperating Theater and Central Sterile Supply Department

MODULE #1

Global Challenges inthe Prevention of Health Care–Associated InfectionsBarbara M. Soule, RN, MPA, CIC, FSHEA

© 2015 by Joint Commission International / Joint Commission Resources 2

MODULE #1Global Challenges to Prevention of Health Care–Associated InfectionsTHIS JCI PROGRAM IS SPONSORED BY ASP.

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DISCLAIMERContributing Editor:Barbara M. Soule, RN, MPA, CIC, FSHEA

Authors:Barbara M. Soule, RN, MPA, CIC, FSHEARussell N. Olmsted, MPH, CICGeorge Allen, PhD, CIC, CNORSylvia Garcia-Houchins, RN, MBA, CICLinda R. Greene, RN, MPS, CIC

Content Editor and Project Manager: Mary KellyExecutive Director, Publications: Catherine Chopp Hinckley, PhD

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MODULE #1Contentsa. Overview and Learning Objectives

b. A Brief History of Health Care-Associated Infections

c. Effective and Participative Leadership

d. A Patient Safety Culture

e. Evidence-Based Practice

f. Measurement

g. Multidrug Resistant Organisms and Antimicrobial Stewardship

h. Summary

i. References


MODULE #1a. Overview and Learning Objectives

Health care–associated infections (HAIs) are a global public health issue that has existed for thousands of years. HAIs have resulted in harm to patients in most health care settings, including hospitals, long term care facilities, and ambulatory surgery, outpatient diagnostic, and treatment clinics/centers. The infections are a risk to patients and staff members in the health care environment.

HAIs cause significant morbidity and mortality and often result in increased medical costs for patients and families, loss of wages for families, and significant costs to health care systems. HAIs may also have negative effects on local or national economies. Although significant improvements have been made in preventing and controlling infections, disparate countries have implemented recommended practices unevenly because of dramatic differences in human and material resources, politics, and regulations.

This module presents an overview of HAIs: • A brief history of HAIs • The current global status of HAIs • The infection challenges common to most countries • The strategies to minimize or eliminate risk associated with these challenges

The module summarizes the critical role of leadership, evidence-based practices, patient safety, the environment, measurement, performance improvement, and emerging infections. Many of these issues are discussed more thoroughly in succeeding modules.

After reviewing this module, the reader will be able to:• Discuss a brief history of HAIs.• Describe the global status of HAIs.• Explain the endemic burden of HAIs in developing countries.• Discuss global challenges for HAIs.• State potential prevention strategies for global infection issues.

Attention to HAIs and infection prevention is increasing worldwide. Many countries have implemented systematic efforts to improve infection prevention and control (IPC) practices and outcomes. In emerging economies initiatives exist to reduce infections through better education and training of staff members, patients, and infection prevention specialists. These initiatives often include implementing evidence-based practices demonstrated to prevent infections and improve care. In developed economies with sophisticated health care infrastructures, the focus is to benchmark best practices, to meet or exceed them, and to create mandates for evidence-based IPC practices. Many countries have also increased infection prevention research to determine best practices and have expanded efforts to improve understanding of the human (behavioral) aspects of preventing HAIs.

Efforts are made, though not always successfully, to implement practices such as hand hygiene, appropriate use of protective measures with patients who have suspected or known communicable diseases, management of instruments and supplies, appropriate use of invasive devices, and improved surgical practices (or processes). Evidence-based practices have also found their way into the design of health care facilities.1 Although organizations are encouraged to set targets of zero practices that may lead to infections or to zero infections, we are far from achieving this goal.2 Implementation science is gaining support in the global community with strategies such as checklists that have been used to support, trigger, and remind health care workers to implement key steps in recommended practices to prevent infection.3 These efforts, such as with eliminating central line related infection, have had wide success, have been noted in policy-making bodies, and are being implemented by many health care organizations. Implementation science describes and promotes methods to integrate evidence-based practices in clinical areas. It is an area of knowledge relatively new to the field of IPC but is now available to support IPC practice.4 This methodology will be discussed later in this module.

In addition to implementation science, infection preventionists and health care epidemiologists have become more involved in learning and using performance improvement and patient safety methods to enhance infection prevention practices. These topics will be discussed later in this module and more fully in Module 2, Leadership, Module 6. Performance Improvement and throughout the toolkit.

Definition: Health Care-associated Infection (HAI)A health care-associated infection (HAI) is a localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that was not present on admission to the acute care facility.

- Centers for Disease Control and Prevention

LEARNING OBJECTIVES

INTRODUCTION


Medicine and public health have been concerned about transmission of infection for centuries. The idea of preventing HAIs is reflected in the well-known admonition to physicians to “first, do no harm,” which is the cornerstone of the Hippocratic oath.5 Infections that occur in association with health care provided in hospitals, long term care facilities, and outpatient clinics are particularly onerous, because the patient did not have an infection upon entering the hospital or other health care organization but acquired it while in the setting and receiving care. To fully understand the transmission of infection in hospitals, it is helpful to create the context in which HAIs occur. We can do this by reviewing the history, evolution, and role of the hospital.6

MODULE #1b. A Brief History of Health Care-Associated Infections

Early in history there were “places of healing” in the Roman and Greek empires (4000 BCE), and in India and Sri Lanka (200 BCE). These settings may have been a combination of places of healing, places to house the poor, or places of rest for the weak and dying. No thought was given to treatment or cure, only to support patients in their illnesses.

Hospitals arose in Europe in the Middle Ages mostly in monasteries, which often allocated space in their building(s) to infirmaries, houses for physicians, houses for bleeding, and bath houses. In the later Middle Ages, guilds and parishes began to care for their sick. Parish care gradually evolved into health services provided by lay citizens, and by the end of the fifteenth century, Europe had developed a large network of hospitals managed by local authorities. Mainly the poor and underserved used hospitals during this time; the upper classes received their care at home.7

The Hotel Dieu Hospital in Paris was founded in the seventh century (see Figure 1-1). For a period, it was the only hospital in the city, and it survived and expanded over hundreds of years. By the eighteenth century the hospital was large and crowded. It had about 1,000 beds, but never housed fewer than 2,000-3,000 patients.8 Estimates show that during French epidemics, the number of patients at Hotel Dieu Hospital topped 7,000, with as many as eight patients sharing one bed at a time and with beds that were sometimes occupied in shifts.8

At Hotel Dieu infection prevention techniques were mostly absent from care. For example, patients’ wounds were washed each day with a single sponge used from patient to patient. Thus almost all wounds became infected.9 Mortality from amputations was nearly 60%, in large part due to infection. Drinking water for patients came directly from the River Seine without benefit of processing. Puerperal fever (postpartum endometrial infection) was very common at this time, and in one epidemic in 1746, 19 of 20 women who became infected died.9 This may be attributed partly to the fact the maternity ward was in the hospital basement. Dirty water and garbage were deposited on the floor of the ward whenever the river rose, ensuring an unclean environment for

In the eighteenth century British hospitals seemed more aware of the role of cleanliness and sanitation in safe patient care. The hospitals were generally cleaner. For example, in 1771, patients who were admitted to one British infirmary received clean sheets upon admission and at least one other set of sheets every three weeks. Also, hospital policy stated that two patients were not to be placed in the same bed unless no other option existed.10

Most physicians did not know about or accept the germ theory of disease until after the pioneering work of Dr. Robert Koch (see Figure 1-2) and Dr. Louis Pasteur (see Figure 1-3). Koch (1843-1910), a microbiologist, first isolated tuberculosis, cholera, and anthrax organisms, and developed Koch’s Postulates of the germ theory.11 Pasteur (1822-1895), a French chemist and microbiologist who also recognized the germ theory, used it to create vaccines and other treatments.12 Afterward, some physicians understood that specific diseases could be transmitted among hospitalized patients.

Source: Wikimedia. Hotel Dieu. Accessed Oct 3, 2014.

Figure 1-1. Hotel Dieu Hospital in Paris

PLACES OF HEALING

CLEANLINESS AND SANITATION OF THE ENVIRONMENT

patients. From the circumstances at Hotel Dieu, it is apparent that hospitals were not the safest places for patients in the Middle Ages. Yet, the worse alternative for the homeless or poor was being ill on the city streets, with no care at all.


However, doctors were not aware of the route of transmission and often attributed the cause of disease to “bad air,” “effluvia,” or “miasmas.” Some hospitals did start using segregation (isolation) for patients who posed transmission risks. In the Middle Ages segregation was used for leprosy patients, who were placed in leprosariums, and in the fifteenth century for plague victims, who were put in lazarettos (quarantined settings). Fever hospitals were established in England in the early nineteenth century to segregate smallpox and fever cases.10 The value of isolation in preventing transmission was perhaps first clearly demonstrated in a study published in 1864. Another study compared a general hospital with a fever hospital. The investigator found that typhus spread easily in the general hospital. For approximately every four typhus patients admitted to the general hospital, there was nosocomial spread to one patient. In contrast, for every 40 patients with typhus admitted to the fever hospital, where isolation was practiced, there was also only one case of nosocomial spread, a tenfold difference in these two care settings. This difference indicated that isolation practices were effective in reducing spread of the infection.13


Source: Wikipedia. Robert Koch. Accessed Oct 3, 2014.

Figure 1-2. Dr. Robert Koch

Source: Wikipedia. Ignaz Semmelweis. Accessed Oct 3, 2014.

Figure 1-4. Ignaz Semmelweis, MD

Source: Wikipedia. Louis Pasteur. Accessed Oct 3, 2014.

Figure 1-3. Dr. Louis Pasteur

Source: Wikipedia. Joseph Lister. Accessed Oct 3, 2014.

Figure 1-5. Joseph Lister, MD

No discussion of the history of infection prevention and control in hospitals would be complete without mentioning Dr. Ignaz Semmelweis (see Figure 1-4) and his remarkable work in reducing puerperal fever among pregnant women delivering at Vienna General Hospital. Semmelweis is often considered “the savior of mothers.” His treatise, Etiology, Concept, and Prophylaxis of Childbed Fever, was published in 1861.14 The work was based on mortality outcomes associated with midwives who delivered babies versus doctors who delivered babies. This led to his insight that “something” was being transmitted from autopsy rooms, where the physicians had assisted in autopsies or handled cadaver tissue, to the uninfected women giving birth. Semmelweis insisted the doctors wash their hands in a solution of chlorinated lime when leaving the autopsy room or anatomy laboratory and before examining the women. This simple procedure reduced mortality in the physician ward from 18% to 2%, to match the ward in which only midwives delivered babies.15 Later Semmelweis began washing instruments as well, and mortality decreased to 1%. In 1843, Oliver Wendell Holmes published his essay on the “Contagious Nature of Puerperal Fever,” in which he identified puerperal sepsis as a contagious disease. He also recommended measures to reduce the spread of infection.16 The acknowledgment and acceptance of Semmelweis’s and Holmes’s work did not occur until two decades after Semmelweis’s death, when Koch and Pasteur produced evidence of the germ theory and British surgeon Joseph Lister (see Figure 1-5) of antisepsis. Then both Semmelweis and Holmes were credited for their excellent analysis and infection reduction.



Florence Nightingale’s (see Figure 1-6) enormous success in reducing infections and mortality in military personnel in the Crimean War (1854-1856) occurred because she was able to demonstrate to the military authorities that providing patients with safe food and water, and maintaining personal hygiene and clean environment in the wards could (and did) result in major reductions in deaths from HAIs.17 Nightingale felt strongly that there was a direct relationship between the sanitary conditions of wards and hospitals, and postoperative infections, erysipelas (group A streptococcal infection), pyemia (organisms in the blood–septicemia) and other complications, such as gangrene.17 In 1856, Nightingale met William Farr, the premier statistician in England, and eventually they worked together for more than 20 years because of their mutual interest and passion for data. Together they made significant strides in reducing HAIs by demonstrating through statistical analysis that the increased mortality in military personnel was significantly due to crowding and contagious diseases transmitted in the wards. Nightingale’s insistence on collecting infection data and analyzing it using basic statistical measures may be the first example of surveillance of HAIs by a nurse.7 patients. From the circumstances at Hotel Dieu, it is apparent that hospitals were not the safest places for patients in the Middle Ages. Yet, the worse alternative for the homeless or poor was being ill on the city streets, with no care at all.

It is likely that Joseph Lister, a pioneer of antiseptic surgery, read the work of Semmelweis and Holmes during his surgical career. Lister dramatically reduced HAIs in surgical patients. He thought microbes might be responsible for infections (such as wound suppuration) and that by killing organisms in wounds he could prevent surgical infections and death. He used carbolic acid on dressings to pack the wounds of patients with compound fractures. The prospect for recovery in these patients was generally grim. Additionally he soaked sutures and even his fingers in carbolic acid, and sprayed the operating theater with to kill germs in the air.18

He published his findings in 1867, and the evidence of decreased infections in his surgical population was so compelling that his techniques gained acceptance in the next decades. His surgical asepsis principles stand today in the operating theater.

By 1910, sterile instruments, gowns, and gloves and masks were standard in many large teaching hospitals. The original use of rubber gloves was to protect the hands of the surgical team from carbolic acid. However, the role of gloves in protecting patients from microorganisms on the hands of health care workers was recognized, and gloves became standard garb where available. Sterilizers were introduced, and they were fundamental to the preparation of sterile instruments and devices that protected most patients from surgical infections. In some clinics staff silence during surgery was required to limit bacterial contamination thought to be spread by talking. Gradually, some physicians began to keep records of infections and use active surveillance systems to track surgical infection trends.19

Each decade has brought changes in our knowledge about how organisms are transmitted within the health care setting. One of the first HAIs addressed in a 1929 study was catheter-related urinary infections by Cuthbert Dukes, MD.20 This study described the pattern of urinary infections in patients having rectal surgery who also had an indwelling urinary catheter. The researcher stressed that depending on the duration the catheter was indwelling in the bladder, there was certainty that infection would occur and that there was some predictability on how long it would take for the infection to develop. Dukes tested several urinary drainage systems and was able to find one that decreased infection by 66%. Dukes’s finding may have influenced the development of urinary drainage systems throughout the twentieth century.

DATA COLLECTION

ANTISEPSIS AND STERILIZATION

TWENTIETH CENTURY DEVELOPMENTS

Source: Wikipedia. Florence Nightingale. Accessed Oct 3, 2014.

Figure 1-6. Florence Nightingale, RN


As with other HAIs, as our understanding about their causes and mechanisms of transmission have increased, there have been improvements in reducing central-line associated bloodstream infection (CLABSI) and ventilator-associated pneumonia (VAP). Although CLABSI and VAP were once thought to be inevitable consequences of the care of critically ill patients, decreases in these infections have occurred through the use of careful aseptic and sterile techniques and reducing the length of time that the central line or ventilator is used for patient care. These device-associated infections are no longer considered inevitable for many patients. The shift in thinking is that nearly all of these infections are preventable. The implementation of “bundles,” a group of three to five evidence-based risk reduction practices, used simultaneously and consistently with central lines, urinary catheters and ventilators has driven dramatic declines in infections related to these devices.3,21 See Table 1-1, below, for an example of a “bundle” for central lines.

The advent of antibiotics brought about a major change in controlling and treating HAIs. Sulfonamides were used successfully after World War II to treat staphylococcal and streptococcal infection. When penicillin was discovered in 1929 by Alexander Fleming and developed into an antibiotic in 1941, it was viewed as a panacea for infection and generally lived up to this claim for many years. More recently the inappropriate use or abuse of antibiotics paired with the decline in effective antimicrobial drugs has created a worldwide public health problem that will be discussed later in this module.

Table 1-1. Key Elements of the IHI Central Line Insertion Bundle21


In the late 1950s and early 1960s, a pandemic of Staphylococcus aureus infections in American and European newborns led to changes in nursery practices. At the time family members of a woman in delivery were not allowed to be with the woman, and strict protocols (rules) said only hospital personnel could handle infants. All infants were housed in large multi-crib nurseries. Eventually scientists understood that the newborns were being exposed to S. aureus through contact with organisms on the hands of hospital nurses and doctors. Strict hand washing with antimicrobial soap was implemented in newborn nurseries. S. aureus infections in nurseries (and in surgical patients) in the 1950s and 1960s led to improved methods of newborn care, which included improved cleaning in the nursery, the initiation of cohort (grouped) nursing, and later “rooming-in” (having the baby stay in the room with the mother rather than in the nursery). Efforts were also made to decrease the babies’ length of stay in the nursery to less than three days to lower risk of colonization from other infants.22,23 Still, the S. aureus outbreak took years to control.

Subsequently, hospitals recognized the need for a sister/nurse in England or a nurse in the United States, and later physicians, to oversee infection prevention practices. This initiative evolved into new professional roles and a new discipline for the infection control practitioner (infection preventionist), and hospital or physician health care epidemiologist.23-25

Although most HAIs are endemic, periodic outbreaks have provided valuable information by raising awareness of specific risks and by contributing to the understanding of specific factors that increase risk of infection.26 New knowledge about causes of these outbreaks have been integrated into routine strategies for preventing and managing infections. Contamination of intravenous fluids and subsequent sepsis and mortality of neonates is an example of one such epidemic.27,28 More contemporary outbreaks are related to defective or inadequately cleaned equipment (and/or the environment), such as bronchoscopes29 or central line connector valves.30

In the United States, this led to process changes in cleaning, disinfecting, and sterilizing or producing equipment that have improved safety and reduced risks of infection. Similar outbreaks occur globally on a regular basis.

The understanding of HAIs and the epidemiology that has led to new knowledge continues to grow. Some developing countries with emerging economies are beginning to provide preventive, curative, or life enhancing procedures to large segments of their populations. These procedures extend life expectancy, but may also include an increase in chronic diseases of the elderly and expand the use of invasive procedures and technologies. Interestingly, these changes in health care outcomes may also increase the risk of HAIs.31

EVOLUTION OF THE ROLE OF THE INFECTION PREVENTIONIST

TWENTY-FIRST CENTURY EVENTS

• Hand hygiene • Maximal barrier precautions upon insertion • Chlorhexidine skin antisepsis • Optimal catheter site selection, with avoidance of the

femoral vein for central venous access in adult patients • Daily review of line necessity with prompt removal of

unnecessary lines



Information about the incidence of endemic HAIs in developing countries has been slow to be published. A 2010 article by Allegranzi, et al., discussed the burden of endemic HAIs in developing countries.32 In this systematic review and meta-analysis, the authors found that the prevalence rate of infections in low- and middle-resource settings averaged 15.5 infections per 100 patient days compared with a prevalence of 7.1 infections per 100 patients in Europe, and 4.5 infections per 100 patient days in the United States. Even more alarming was the incidence of infection rates in the ICUs of developing countries of 47.9 per 1,000 patient days compared with 13.6 infections per 1,000 patient days in the United States. Neonatal infections were found to be three to 20 times higher in the developing world,33 and the risk of surgical site infections (SSI) is also higher (for example, 5.6 per 100 surgical procedures in developing countries compared with 2.6, 2.9, and 1.6 infections per 100 surgical procedures in the United States, European countries, and Germany).32

In some developing countries, as many as 70% of injections administered are considered unnecessary and use unsafe injection practices (such as the reuse of disposable, one-time injection devices). This accounts for almost 250,000 new HIV infections per year. The 2008 European Centre for Disease Prevention and Control report estimates that HAIs are associated with 16 million extra hospital days and 37,000 attributable deaths annually.34-36 Clearly there are continuing challenges for HAIs worldwide.

Another concern relates to the costs of HAIs. It is hard to obtain cost data from various countries because average costs of HAIs will differ depending on the type of infection and prevalence in a hospital, the infection rate, and the cost of health care in the country.37 The methodology to calculate costs varies from physician-generated data to sophisticated economics methods that include consideration of direct and indirect hospital costs.38 This makes comparisons difficult if not impossible in most cases. Table 1-2, below, delineates the different factors for calculating costs of HAIs in hospitals.

Adapted from: Centers for Disease Control and Prevention (CDC). The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention, March 2009. Scott RD, II. Accessed Oct 3, 2014. http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf

Table 1-2. Factors for Calculating Costs of HAIs in Hospitals

Direct Costs in Hospitals

Indirect Costs in Hospitals

Intangible Costs

Lost Wages, Decreased Productivity, Family Burden (lost income, additional care costs), Increased Morbidity (illness) or Mortality (death), Decrease or Lost Leisure Time

Fixed CostsBuildings, Utilities, Equipment and Technology, Labor of Personnel

Variable CostsFood, Medications, Treatments and Procedures, Devices, Consultations and Additional Laboratory and Radiographic Support, Supplies

Psychological (anxiety, grief, disability, loss of job), Pain and Suffering, Alterations in Daily Activities and Social Functioning

CURRENT DATA

HAI COSTS


However, some cost data are available. Information from HAIs in the United States has been collected for many years, and the Centers for Disease Control and Prevention (CDC) regularly publishes costs based on hospital reports. A 2010 report from the CDC, The Direct Medical Costs of Infections, used two methods to calculate the annual direct medical costs for HAIs.38 The range of costs reported for HAIs annually was from US $28.4 to US $45 billion in 2007 dollars, depending on the technique used for calculations (see Table 1-3, below). As a corollary, HAI prevention costs were calculated as US $5.7 to US $31.5 billion, again depending on methodology. What is evident in these cost data comparisons is that prevention activities cost less than treating infections and would potentially save billions of dollars if implemented.

Costs of infections in the global community are hard to discern. For example, infection costs in New Zealand for medical and surgical patients were estimated at more than US $23 million for medical patients and US $38 million for surgical patients admitted to all hospitals there per year.39 In Switzerland, a study of the extra length of stay and costs attributed to health care-associated bloodstream infections in critically ill patients estimated that extra costs for the infection averaged US $40,000 for each person who survived.40 A study from Singapore evaluated the direct clinical and financial impact of health care-associated methicillin-resistant Staphylococcus aureus (MRSA) infections in hospitals there.41 Researchers found that MRSA infections were associated with higher hospital costs (US $18,129 for infected patients versus US $4,490 for non-infected patients). In an Iranian cardiac surgical unit, researchers found that excess direct medical costs for infected patients was double that of those without HAIs.42 The differences in these figures illustrate the challenge of identifying trends in costs of HAIs throughout the world.

Note: CPI – Consumer Price IndexAdapted from: Centers for Disease Control and Prevention (CDC). The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention, March 2009. Scott RD, II. Accessed Oct 3, 2014. http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf


Table 1-3. Average Attributable per Patient Costs of HAI by Selected Sites of Infection

Infection Site

SSI

CLABSI

VAP

CAUTI

CDI

Low Estimate of average attributable Costs ($ base year)

$10,44318

(2005)

$5,74319

(2003)

$11,89720

(1999)

$58921

(1998)

$5,04222

(2003)

Low estimate adjusted to 2007 $ using CPI-U

$11,087

$6,461

$14,806

$749

$5,682

High Estimate of average attributable Costs ($ base year)

$25,5463

(2002)

$22,9319(2002)

$25,07218

(2005)

$75818

(2002)

$7,17922

(2003)

High estimate adjusted to 2007

$ using CPI-U

$29,443

$25,849

$27,520

$832

$8,090



As described above, there is increasing global concern about HAIs as a patient-safety issue, especially as these adverse events are associated with additional morbidity, mortality, and excess costs.43 HAIs occur in patients in hospitals and other health care settings, such as long term care, primary health care, special clinics, and outpatient and surgical settings where patients receive diagnostic and therapeutic care. Therefore, a primary responsibility of all health care providers and support staff is to protect patients and staff members from HAIs.

Health care delivery in all countries carries with it similar infection risks, such as those associated with invasive devices and procedures, hand hygiene, and environmental cleanliness, although the degree of risk and the outcomes vary from one country to another.32 As years of life are increased through better care, patients who live longer may become immunocompromised and more susceptible to infections in their communities and in the health care setting. Many microorganisms are increasingly resistant to the available drugs with fewer new drugs in sight to treat the infections caused by these organisms. Technology is used more often in health care and brings with it both benefits and hazards.44,45 Complex care processes often involve invasive procedures that increase infection risk, and the care environment (acute or non-acute settings) can be a reservoir for infectious agents that can be transmitted to patients. In many countries resources for care are limited, which may hinder attempts to use best practices. Often patients remain in hospitals or long term care facilities for extended periods, which increases their risk of developing an HAI from exposures to microorganisms from their treatment, contact with health care personnel, other patients, or the hospital environment. Health care professionals are also at risk for infections from patients and the work environment. Many of these factors may be occurring at the same time, which complicates and compounds prevention efforts.

Each country, region, and organization has its own culture of patient care, quality and safety, as well as resources that influence how it views and addresses infection risk. Basic infection prevention strategies have common themes worldwide and unique characteristics depending on the circumstances of the country and the particular organization. The following discussion addresses some global infection prevention challenges and strategies to reduce HAI risks. Many risks will be further described in succeeding modules (see Sidebar 1-1, below).

GLOBAL STRATEGIES TO PREVENT HAIS

Sidebar 1-1. Global Infection Challenges and Strategies to Reduce Infection Risk in Health Care Organizations • Leadership: strong, visible, proactive • Infrastructure: physical structures and hospital design, policies and procedures, education, staff, resources, equipment, supplies • Culture of Patient Safety and Performance Improvement: no blame, zero tolerance; organizational learning; trained,

competent staff; transparent communication• Evidence-Based Practices and Interventions: for direct patient care and support services • Environment of Care: effective cleaning and disinfection of the patient care environment, proper management of

medical equipment, air and water supplies, and medical waste• Measurement: surveillance and cluster or outbreak investigation; effective, timely• MDROs and appropriate use of antimicrobial agents and antimicrobial stewardship programs• Emerging and reemerging diseases and epidemics


MODULE #1c. Effective and Participative LeadershipHealth care organizations and leaders in all countries must make IPC a priority. It is critical that leaders understand the potentially severe risks of illness or death to patients and employees from HAIs, as well as costs to the organization for caring for HAIs. Leaders have among their many tasks the responsibility to establish and maintain a culture of patient safety and with that the responsibility to provide the infrastructure and resources that support the best infection practices.46,47

A culture of safety and strong leadership starts with a mission and vision for the hospital or long term care facility. Creating the organization’s vision, mission, and core values is a critical component of a leader’s responsibility to guide the organization toward its strategic goals and help facilitate alignment between leaders and staff members to enhance patient care.46 The health care organization’s mission establishes the general direction of the organization, defining its fundamental purpose, and describing why it exists and what it will do to achieve its mission. The mission leads the organization to its current goals and objectives that must be described in clearly written policies and procedures to provide guidance for infection prevention practices among staff members, visitors, and others.

Vision statements should also be concise, as well as inspirational, clear, and memorable to be of the most value. The vision statement helps to describe and guide the organization toward the future. The vision communicates where and what the organization strives to be in a few years’ time and what the organization is working toward as its potential to achieve even better outcomes of care.

Many organizations also state their core values. These are values that guide the behavior of every employee in the organization. See Table 1-4, below, for examples of mission statements, vision statements, and core values, which are also discussed in Module 2.

Table 1-4. Examples of Mission Statements, Vision Statements, and Core Values

Leaders can support infection prevention by becoming knowledgeable in these areas:• the IPC program • the critical role it plays in patient safety • the ways to prevent or minimize HAIs

An important responsibility of organizational leaders is to make informed decisions about patient care and staff member safety relative to infection prevention. To make informed decisions, leaders must have valid and reliable data about infection risks, clinical outcomes, and financial consequences. Therefore, leaders should expect to receive risk assessments for infections and infection data that have been carefully collected, analyzed, and presented to assist them in supporting best practices decisions or making changes when necessary.

Remember This!The most effective mission statements describe the reason an organization or program exists and are used to help guide decisions about priorities, actions, and responsibilities.

Mission Statement Examples:• To contribute to the health and well-being of every patient by providing the best care through integrated clinical practice,

education and research. • To promote awareness about the importance of infection prevention and control measures of health care providers,

patient and visitors; to make infection prevention part of their daily practice; to prevent infections, ensure a safe working environment for employees and a safe care environment for patients.

Vision Statement Examples:

• To achieve the best infection prevention and control in the country.• Striving to be the world’s leader in positive patient experience, clinical outcomes, research, and education.

Organizational Core Values Examples:• Honesty, Trustworthy, Caring, Patient-Centered, Respectful, Service Focus


Sidebar 1-2. How Can IPC Personnel Gain Leadership Support for the IPC Program?47,51

• Communicate with leaders about infection prevention activities.• Provide leaders with analyzed surveillance data in an easy-to-understand format.• Provide regular reports of activities; focus on achievements, problems, and solutions.• Send minutes from the IPC committee to the leader(s) – or other committee that discusses infection prevention issues,

for example, OT, CSSD, Nursing.• Invite a leader to meet with the IPC team to discuss issues or to meet with another team with infection issues.• Encourage a leader to make environmental rounds with the IPC team.

MODULE #1c. Effective and Participative LeadershipClearly, it is the leaders’ responsibility to lead and support the adoption and implementation of a culture of safety in the organization. Whether the administrator, chief nursing officer, chief medical officer or others, the initiative must originate from this group. Then the leaders of departments and services, and staff can integrate the culture knowing their leaders will support them.

Leaders should attend IPC committee meetings if possible or designate a leader representative, and they may periodically participate in environmental rounds, discuss infection prevention at management meetings, and serve as role models by following IPC recommended practices, such as performing appropriate hand hygiene. It is important for leaders to provide the needed infrastructure and resources for the IPC program, such as hand hygiene supplies, rooms with negative pressure for isolating patients with airborne communicable disease, and staff education.47 The IPC program also needs resources to function effectively, such as an office, access to medical information, training, and preferably computers. Lack of these resources inhibits the implementation of best practices.48 Adequate numbers of well-trained infection prevention personnel49,50 and education and training for all appropriate clinical and support staff members, sufficient supplies, such as hand hygiene facilities (soap, water, towels or alcohol-based rubs, and environmental safety) are ultimately the leaders’ responsibility.

Leadership effectiveness for infection prevention is a two-way process. Infection prevention personnel must establish a relationship with their leaders and work within the culture of their organization(s) to emphasize the critical role of the infection prevention program in supporting and facilitating the group’s mission and goals. This type of interaction and communication is more likely to create the best relationship and maximize support for infection prevention. Sidebar 1-2, below, lists some activities that IPC personnel or staff members interested in infection prevention in any organization can undertake to obtain leadership cooperation and assistance for the IPC program and efforts.

Leadership will be discussed in greater detail in Module 2.

In developed, economically stable countries, most hospitals have essential supplies, adequate processes, and systems to identify and analyze HAIs to implement appropriate prevention measures. However, in many countries, the health care infrastructure is only nominal, and the absence of equipment, supplies, staff members, and clear policies are major barriers to preventing infections.52-54

Hospitals may even vary in resources within countries, with some hospitals fully equipped and others having barely adequate supplies. Scheckler, et al., developed nine recommendations for an infrastructure for infection prevention and control programs that can serve as a guide for organizations:47

1. Surveillance of nosocomial infections must be performed.2. Surveillance data must be analyzed appropriately and used to monitor and improve infection control and health care outcomes.3. Clinical performance and assessment indicators used to support external comparative measurements should meet the

criteria delineated by SHEA and APIC.4. Written infection prevention and control policies and procedures must be established, implemented, maintained, and

updated periodically.5. Policies and procedure should be monitored periodically for performance.6. Health care facilities should use infection control personnel to assist in maintaining compliance with relevant regulatory and

accreditation requirements.

INFRASTRUCTURE


MODULE #1c. Effective and Participative Leadership

7. Infection control personnel should have appropriate access to medical or other relevant records and to staff members who can provide information on the adequacy of the institution’s compliance with regard to regulations, standards, and guidelines.

8. The infection control program should collaborate with, and provide liaison to, appropriate local and state health departments for reporting of communicable disease and related conditions and to assist with control of infectious diseases.

9. The infection control program personnel should work collaboratively with the facility’s employee health program personnel.

A checklist is provided as Tool 1-1.

Health care facilities with a less developed infrastructure may lack adequate clean water and food for patients, as well as sinks for hand washing, soap or alcohol gel, or alcohol-based hand rub.55 Overcrowding, insufficient technology, and a shortage of trained staff members are frequently found in countries with limited resources. For example, in some countries or regions, hospitals may not have enough beds for patients and may place two to four babies in the same crib and more than one adult in a bed. This close proximity enhances the transmission of organisms and infections. Patients often share equipment that has not been cleaned, disinfected, or sterilized between uses. In some countries nursing care is supplemented and/or provided by the family with varying degrees of skill. Food, medical equipment, and medications are often provided by family and are not managed to avoid infection risk. When a country’s economy starts to improve, there may be better access to clean water, sterilizers, and other clinical aids. However, resources and supplies may continue to be variable for some time.

Countries with a substantially low level of health care resources will often lack adequate laboratory facilities to perform needed diagnostic tests for infections, including blood cultures or antibiotic susceptibility tests. Antibiotics may not be available to treat patients or may only be available in limited quantities. Many organizations may also lack adequate numbers of infection preventionists to oversee the IPC program.56

Organizations may not have the resources for disposable, single-use supplies and thus will, of necessity, reuse some items that should be discarded after use on one person (such as needles, syringes, and surgical gloves). These unsafe practices potentially expose patients to the blood or body fluids of previous patients with hepatitis B and C, and HIV.57 Some facilities do not have clearly written policies and procedures. This results in staff practicing without the knowledge of best methods or the standards of the health care organization. The absence of written policies and procedures can result in a lack of standardization of practices, a known risk for patient safety.

In summary, hospitals vary in resources by country and also within a country. Creating the most efficient and safest infrastructure, even in countries with limited resources, will help staff members function more effectively to reduce infection risk. Organizations can start by identifying infrastructure improvements that can be developed easily and with little cost, such as written policies and procedures, staff training and inexpensive supplies such as alcohol-based hand hygiene supplies made by the organizations.58 Accessible and free information on best practices, or practical tips are often available on the Internet. Other infrastructure supports will be determined by the individual organization and their resources. A checklist is provided to help organizations assess their infrastructure. See Tool 1-1. Specific infrastructure issues for the operating theater and the CSSD will be discussed in Modules 3, 4, and 5.


MODULE #1d. A Patient Safety Culture

It is well established that HAIs are one of the most frequent adverse outcomes associated with health care delivery and a significant patient safety event worldwide. Recognizing the HAI problem, the World Health Organization (WHO) established infection prevention as a patient safety priority.59,60 The WHO created The World Health Alliance, which initiated its first patient safety challenge in 2005: Clean Care is Safer Care (see Figure 1-7, to the right).61 This safety initiative focused on hand hygiene. Through this initiative, the WHO has successfully engaged more than 130 countries that have accepted the challenge of improving hand hygiene compliance, including Member States in Africa, the Americas, Eastern Mediterranean, Europe, South-East Asia, and the Western Pacific. “The combined efforts expected under the Challenge have the potential to save millions of lives, prevent morbidities and long-term disability for hundreds of millions of patients, and lead to major cost savings through the improvement of basic infection control measures in any healthcare setting, regardless of resources available or level of development.”59 In 2007, the WHO began work on their second patient safety challenge to reduce surgical site infections (SSIs). The Safe Surgery Saves Lives challenge has the potential to reduce SSIs around the world.62 One of the WHO SSI Prevention Guidelines is a surgical safety checklist to help reduce surgery related infections and death. The checklist is applicable to the global population of patients and is presented in Modules 2 and 3.63 This checklist approach is consistent with newer approaches to infection risk reduction strategies as discussed previously in this module.

The WHO believes strongly that infection prevention is critical to patient safety, and they currently support multiple programs to prevent infections. Many of these programs are described in an article by Allegranzi, et al,64 and are found in Table 1-5, below, and Tool 1-6

Program

Blood transfusion safety1

Main HAI prevention and control topic

Prevention of transfusion-transmissible infections (including HIV, hepatitis B, hepatitis C and syphilis, and bacterial contamination of blood and blood products)

Objectives specifically related to HAI prevention

and control

• To develop norms, standards, best practice guidelines, tools and materials relating to the entire blood transfusion process from donor to patient to ensure blood safety

• To support the establishment of sustainable national blood programs ensuring the provision of safe, quality blood and blood products to all patients requiring transfusion and their safe and appropriate use

Main guidelines/documents

• Blood transfusion safety: information sheet

• Prevention of health care-associated HIV infection: flyer

• Memory aid for blood safety • Memory aid for good policy

process for blood safety and availability

• Memory aid for national health authorities: developing a national blood system

• Universal access to safe blood transfusion

Table 1-5. WHO Programs Focused on Health Care-Associated Infection Prevention and Control

World Health Organization (WHO). World Alliance for Patient Safety – Global Patient Safety Challenge 2005-2006. Accessed Oct 3, 2014.

Figure 1-7. Clean Care is Safer Care



ProgramMain HAI prevention

and control topic


and control

• To build capacity in countries through structured training activities, voluntary unpaid blood donation, donor selection, donation testing, risk assessment and management, data and quality management, external quality assessment, blood cold chain, hemovigilance, and the clinical use of blood

• To support the implementation of quality system in all aspects of blood collection, processing, testing and clinical use, including setting up the system for surveillance, vigilance and monitoring

• To support the development of education and training programs and to incorporate transfusion medicine into medical and nursing school curricula

• To establish a global monitoring mechanism on safe blood and blood products and collect, analyze and disseminate reliable information on blood safety and availability

• To promote harmonization and collaboration of international efforts to ensure sufficient safe blood and blood products

• To promote research and development in the provision and appropriate use of safe blood and blood products


• Guidelines: maintaining a safe and adequate blood supply during pandemic influenza

• WHO resource materials on blood safety: CD-ROM

• The Melbourne declaration on 100% voluntary non-remunerated donation of blood and blood components

• Towards 100% voluntary blood donation: A global framework for action.

• Developing a voluntary blood donor program (DONOR): facilitator’s toolkit (6 modules): CD-ROM

• Blood donor selection: Recommendations on assessing suitability for blood donation

• Screening donated blood for transfusion-transmissible infections: Recommendations for blood transfusion services

• Memory aid for the blood cold chain• The blood cold chain: Guide to

the selection and procurement of equipment and accessories

• Manual on the management, maintenance, and use of blood cold chain equipment

• Memory aid for the clinical use of blood

• Memory aid for clinical transfusion process and patient safety

• Developing a national policy and guidelines on the clinical use of blood.

• Recommendations • The clinical use of blood:

information sheet for clinicians• The clinical use of blood: handbook• The clinical use of blood in general

medicine, obstetrics, pediatrics, surgery, and anesthesia, trauma, and burns: module

• The clinical use of blood: CD-ROM • Memory aid for quality systems for

blood safety• Quality management training

for blood transfusion services: facilitator’s toolkit (5 books, 15 modules, CD-ROM)

Blood transfusion safety1 (Continued)




and control topic


and control


• Distance learning in blood safety: flyer

• Establishing a distance learning program in blood safety: a guide for program coordinator.

• Safe blood and blood products: distance learning materials

• Safe blood and blood products: trainer’s guide

• Introductory module: guidelines and principles for safe blood transfusion practice• Module 1: Safe blood donation• Module 2: Screening for HIV and

other infectious agents• Module 3: Blood group serology

Clean Care is Safer Care2 HAI prevention control, in particular surveillance and prevention of the endemic burden of HAI, with special focus on hand hygiene

• To raise awareness on the burden of HAI worldwide and the importance of hand hygiene in health care

• To catalyze political and stakeholders’ commitment to reduce HAI

• To develop technical guidance and recommendations on hand hygiene and infection control measures and support their implementation in Member States

• To promote and sustain hand hygiene improvement at the point of care, through the SAVE LIVES: Clean Your Hands initiative and through a network of hand hygiene campaigning countries–the CleanHandsNet

• To undertake reviews and report updates related to the endemic burden of HAI and to promote HAI surveillance and data reporting

• To evaluate the impact of infection control interventions to reduce the HAI burden, with particular focus on settings with limited resources

• To coordinate the development of new approaches for the prevention of surgical site infections

• To integrate infection control and hand hygiene in the approach to preventing bloodstream infection

• Guidelines on hand hygiene in health care

• Guide to implementation of the WHO multimodal hand hygiene improvement strategy

• Hand Hygiene Implementation Toolkit (32 tools):

• Tools for system change• Tools for training and education• Tools for evaluation and

feedback• Tools as reminders in the

workplace• Tools for institutional safety

climate• Hand hygiene self-assessment

framework • “Hand Hygiene Moment 1–

Global Observation Survey”: summary report

• SAVE LIVES: Clean Your Hands promotional video

• Outline action plan and top 10 tips for country/area campaigns

• Using hand hygiene improvement tools to implement country/area campaigns

• Report on the endemic burden of health care-associated infection worldwide

• Health care-associated infections fact sheet

• Scientific publications in peer review journals




and control topic


and control


• To support development and strengthening of infection control capacity and knowledge, skills and behaviors improvement at regional, sub-regional and country level through the provision of tools and materials

• To develop and coordinate educational, training and research activities

• To advise WHO on infection control measures and priorities and their integration with patient safety strategies

Infection prevention and control in health care3

HAI prevention and control, in particular prevention, preparedness, and response to epidemics that can be associated with or amplified by health care

• To support infection prevention and control capacity building in Member States through technical assistance and development of guidance on core elements for national and local infection prevention and control programs.

• To provide support to help prevent spread of infectious diseases through development and dissemination of evidence-based infection control measures in health care settings

• To provide infection prevention and control tools for health care facility preparedness to respond to pandemics and epidemics

• To coordinate the Global Infection Prevention and Control Network1 (GIPC Network) to foster alignment of policies and enhance infection prevention and control practices worldwide

• To support Member States in responding to outbreaks through the WHO Global Outbreak Alert and Response Network (GOARN)

• To develop evidenced-based norms and standards for antimicrobial resistance containment strategies in health care settings

• To support infection control preparedness to cope with public health emergencies

• Prevention of hospital-acquired infections

• Practical guidelines for infection control in health care facilities

• Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health care. WHO interim guidelines and an accompanying set of implementation tools for community and hospital health care

• Interim infection control recommendations for care of patients with suspected or confirmed filovirus (Ebola, Marburg) hemorrhagic fever

• Core components for infection prevention and control programs and an accompanying set of implementation tools for national and local programs

• WHO policy on TB infection control in health care facilities, congregate settings, and households

• Natural ventilation for infection control in health care settings

• Advice on the use of masks in the community setting in Influenza A (H1N1) outbreaks

• Infection prevention and control during health care for confirmed, probable, or suspected cases of pandemic (H1N1) 2009 virus infection and influenza-like illnesses

Clean Care is Safer Care2

(Continued)


Injection safety4

Occupational health5

Prevention of blood-borne pathogens transmission through unsafe injection practices

Prevention of HAI among health care workers

• To promote the rational use of injections and safe practices for injections and related procedures, including phlebotomy, intravenous, and fingerpick procedures

• To produce policies on the prevention of needle stick injuries in health care workers and the use of personal protective equipment following accidental stick injuries

• To support the implementation of the recommendation for providing hepatitis B vaccine for all health care workers

• To improve access to safety engineered injection devices and sharps containers

• To promote safe sharps waste management

• To provide the secretariat for the “Safe Injection Global Network” (SIGN) aiming to achieve safe and appropriate use of injections worldwide

• To promote the protection of occupational health of health workers and the greening of the health sector (for example, less toxic disinfectants, natural ventilation)

• To support the hepatitis B immunization campaign for health workers (linked in regions to vaccination week and other vaccine-preventable diseases)

• To reduce the exposure to HIV and other sharps-related infections (hepatitis B and C) in health care workers associated with injections

• To review and report data on the global burden of disease from sharps injuries to health care workers

• First, do no harm: Introducing auto-disable syringes and ensuring injection safety in immunization systems of developing countries

• WHO best practices for injections and related procedures toolkit

• WHO guidelines on drawing blood: best practices in phlebotomy

• Revised injection safety assessment tool

• Communication strategy for the safe and appropriate use of injections

• The injection safety policy planner

• Guiding principles to ensure injection device security

• Guide to supervising injection providers

• SIGN 2010 meeting report

• Joint WHO-ILO-UNAIDS policy guidelines for improving health worker access to HIV and TB prevention, treatment, care, and support services.

• Occupational health: A manual for primary health care workers

• Role of the occupational health nurse in the workplace

• Protecting health care workers – preventing needlestick injuries tool kit

• Joint WHO/ILO guidelines on post-exposure prophylaxis (PEP) to prevent HIV infection



and control topic


and control



Safe Surgery Saves Lives6

Water, sanitation, hygiene, and health7

Reduction of complications due to surgery, including surgical site infections

Promotion of environmental health in health care settings, in particular safe health care waste management

• To improve the safety of surgical care around the world by ensuring adherence to proven standards of care in all countries

• To contribute to the prevention of surgical site infections through the use of the WHO surgical safety checklist

• To support the development and implementation of national policies, guidelines on safe practices, training, and promotion of effective messages in a context of healthy settings

• To develop technical guidance on environmental health standards in health care

• To develop technical guidance materials for assessing the quantities and types of waste produced in different facilities

• To develop national health care waste management guidelines

• To build capacity at national level to enhance the way health care waste management is dealt with in low-income countries

• WHO surgical safety checklist • Checklist implementation manual

• Safe health care waste management: policy paper

• WHO core principles for achieving safe and sustainable management of health care waste

• Management of solid health care waste at primary health care centers: a decision- making guide

• Essential environmental health standards in health care

• Natural ventilation for infection control in health care settings

• Mercury in health care: policy paper



and control topic


and control


1. World Health Organization (WHO). Blood Transfusion Safety. 2014. Accessed Oct 3, 2014.

http://www.who.int/bloodsafety/en/

2. World Health Organization (WHO). Clean Care is Safer Care. 2014. Accessed Oct 3, 2014.

http://www.who.int/gpsc/en/

3. World Health Organization (WHO). Infection Prevention and Control in Health Care. 2014. Accessed Oct 3, 2014.

http://www.who.int/csr/bioriskreduction/infection_control/en/index.html

4. World Health Organization (WHO). Summaries of Injection Safety Country Success Stories. 2014. Accessed Oct 3, 2014.

http://www.who.int/injection_safety/en/

5. World Health Organization (WHO). Health Workers. 2014. Accessed Oct 3, 2014.

http://www.who.int/occupational_health/topics/hcworkers/en/index.html

6. World Health Organization (WHO). Patient Safety. 2014. Accessed Oct 3, 2014.

http://www.who.int/patientsafety/safesurgery/en/index.html

7. World Health Organization (WHO). Water Supply, Sanitation and Hygiene Development. 2014. Accessed Oct 3, 2014.

http://www.who.int/water_sanitation_health/hygiene/en/

Source: Joint Commission International. Used with permission.


Adapted from: Behal R. In Youngberg BJ, Hatlie MJ, editors. The Patient Safety Handbook. London: Jones and Bartlett, 2004.

Adapted from: Pronovost P, Vohr E. Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out. New York: Hudson Street Press, 2010.

Source: Barbara M. Soule. Used with permission.


A strong patient safety culture in a health care organization, or a department or service of the organization, guides the interactions of caregivers to provide the best care, which helps to create a sense of health care as a helping profession. This then influences individual and group attitudes, customs, and behaviors. A patient safety culture exists when there is a focused effort by the entire staff to keep patients safe from harm. The culture affects the behavior of individuals and groups, which influences organizational performance leading to results. Figure 1-8 and Table 1-6 highlight the characteristics of a culture of safety.

Table 1-6. Safety Culture

In a safe culture, all staff members feel responsible and accountable for actions that lead to the safety of patients; not just preventing harm, but improving care to reduce harm to its lowest levels. Improving performance on a continual basis is critical to maintaining a safe patient environment. Performance improvement will be discussed in detail in Module 6; however, presented here is an example of positive improvement and change. Didier Pittet and his team from Switzerland demonstrated how to create a culture of patient safety for promoting a new method and system change for hand hygiene by using the interventions noted in Table 1-7, below.65

Table 1-7. Hospitalwide System Change for Improved Hand Hygiene65

Senior leaders, directors, and managers in the organization are responsible for establishing a patient safety culture as a priority by demonstrating leadership behaviors. This includes:

• Developing and presenting an organizational vision and mission • Setting the expectations for the safest care• Providing needed resources for care• Serving as role models for best practices • Supporting the desired and expected behaviors• Motivating staff members to use best practices in their daily work • Providing incentives and rewards for desired behaviors

Figure 1-8. Culture of Safety

Infection Processes and Outcomes

CultureIndividual and

Collective BehaviorOrganizational Performance

1. A culture where all workers (including front-line staff, physicians, and administrators) accept responsibility for the safety of themselves, their coworkers, patients, and visitors.

2. A culture that prioritizes safety above financial and operational goals.3. A culture that encourages and rewards the identification, communication and resolution of safety issues.4. A culture that provides for organizational learning from accidents.5. A culture that provides appropriate resources, structure, and accountability to maintain effective safety systems

• System change (from soap and water to alcohol-based hand rubs)• Education of health care workers (all staff members and all shifts)• Monitoring and feedback of performance (compliance)• Reminders in the work place (changing posters)• Administrative support (personnel for maintaining records) • Leadership and culture change (leadership commitment)



Without leadership commitment to these actions, it is hard to create and maintain a culture of patient safety. Table 1-8, below, contains key elements of a patient safety culture that can be applied in any country, region, health care setting, department, or service, with examples applicable to infection prevention. This same information is presented in Tool 1-2 for use in all clinical and support services. The culture of patient safety is discussed further in Modules 2-6.

Communication

Collaboration and Teamwork

Organizational Learning

No Blame-Just Culture

Evidence-Based Practices

Systems Thinking

Measurement and Data

Open, honest, sharing data, feedback, non-punitive reporting system for errors

Working together to maximize the talents and skills of all team members

Open minds to new information and new methods of providing care, or performing processes. Learning from errors to prevent them in the future.

Look at the system, encourage critical analysis of errors, avoid blaming individuals for system errorsLeaders must choose either blame and secrecy, or openness, forgiveness, and safety. Blame does not work

Adopting or adapting best practices and integrating into the work environment

Addressing problems or improvements by looking at all interconnected components, including people, processes, equipment, environmental issues, information

To identify gaps in best practices and quantify them; data collection and analysis

Sending surveillance reports, making rounds in the service or unit, analyzing errors and reporting them

Teams working on the clinical unit and in the OT to ensure that the patient is prepared correctly for surgery

Using new technology to ensure appropriate sterilization of instruments

Nonpunitive response to an infection that is not preventable Honest sharing of breaks in technique by staff in the OT that may have contributed to infection risk for patients; examining the OT systems that supported the technique errors, for example, not covering hair when operating; not following policy for PPE

Review of newly published guidelines from respected sources, for example, WHO, CDC, Ministries of Health, and reflecting guideline content in organizational or departmental policies and procedures

Inadequate space in the Sterile Processing areas to avoid contact between clean and dirty instruments. Investigating the environmental constraints, equipment flow, staff training, other parts of the system

Establishing performance indicators to monitor key processes, for example in Sterile Processing or the OT, Emergency, or other areas, and systematically collecting and analyzing data about these processes to determine improvement opportunities

Patient Safety Culture Definition Example for Infection Prevention

Table 1-8. Key Elements of Patient Safety Culture


Human Factors

Zero Tolerance

Identify points of convergence between the human behavior and work environment and technology, and modify the components to minimize or eliminate errors

Expect all staff members to use best practices when known

Identifying opportunities to support staff in best practices, for example, appropriate trays for immediate–use sterilization, alert systems when machines not working properly

When a new evidence-based policy is initiated, expect all staffers to comply with the policy, for example, not wearing surgical scrub wear out of the hospital; full preoperative scrub

Patient Safety Culture Definition Example for Infection Prevention



MODULE #1e. Evidence-Based Practice

To effectively minimize infections in patients, it is necessary to develop direct patient care practices and support service practices based on the most current evidence that demonstrates efficiency, efficacy, and safety. This topic is discussed below, and other sections of the toolkit describe in more detail these practices for the operating theater (OT) and the central sterile supply department (CSSD).

Evidence-based guidelines are created from valid scientific studies that examine specific practices to determine if they affect care outcomes. Many guidelines of evidence-based practices are available for use in clinical and support service practices. The guidelines may address direct care issues, such as prevention of device-associated infections and procedural risks, hand hygiene or practices related to the environment, such as cleaning of isolation rooms or isolation practices,66 disinfection and sterilization techniques used in services such as the OT,67 CSSD, and environmental services.68

Unfortunately, evidence-based practices are not always implemented in organizations or integrated into patient care or support service procedures. Lack of compliance with hand hygiene is a classic example.69,70 In spite of staff education about hand hygiene and information about the value of the practice and an organizational policy clearly supportive of adherence to hand hygiene, compliance may be less than optimal. This challenge applies to many guidelines. For all guidelines, lack of implementation may result from:

• The organization’s inability to access the most current information• Lack of resources to carry out and maintain the guideline• A deficiency in skill to implement and embed new information into daily work• Lack of procedures to sustain best practices• Barriers to implementation resulting from the culture and values of the organization and its leaders

Implementing evidence-based recommendations is an ongoing challenge for hospitals and a risk point for patients. Many guidelines exist that inform best practices infection prevention activities. A few are listed in Table 1-9, below.

Table 1-9. Evidence-Based Guideline Resources

• World Health Organization (http://www.who.int)• Centers for Disease Control and Prevention (http://www.cdc.gov)• Institute for Healthcare Improvement (http://www.IHI.org)• International Federation of Infection Control (http://www.theific.org)• Singapore Infection Control (http://www.icas.org.sg/gudeline.html)• National Guideline Clearinghouse (http://www.ngc.gov)• National Institute for Health and Care Excellence (NICE) UK (http://www.nice.org.uk)• Association of Perioperative Registered Nurses (AORN) (http://www.aorn.org/Books_and_Publications/Perioperative_

Standards_and_Recommended_Practices/Perioperative_Standards_and_Recommended_Practices.aspx)• Agency for Healthcare Research and Quality (AHRQ) (http://www.ahcpr.gov/clinic/epcix.htm)• Evidence-Based Practice Centers (http://www.ahrq.gov/clinic/epc)• National Resource for Infection Control (http://www.nric.org.uk)• Scottish Intercollegiate Guidelines Network (SIGN) (http://www.sign.ac.uk)• The-ASEAN-Guidelines-for-Disinfection-and-Sterilisation-of-Instruments-in-Health-Care-Facilities.pdf APSIC (http://

apsic.info/documents)• SHEA-Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals (http://www.

shea-online.org/Topics/CompendiumofStrategiestoPreventHAIs.aspx)• Association for Professionals in Infection Control and Epidemiology (APIC) Implementation Guides (http://www.apic.org/

Professional-Practice/Implementation-guides)• Hospital Infection Society India (http://hisindia.org)• Infection Prevention and Control Nurses New Zealand (http://www.infectioncontrol.co.nz/home)



Each facility must have a process in place to stay abreast of current science, the newest recommendations, and the obstacles to implementing evidence-based practice. One critical issue is identifying priorities so projects can be aligned with available resources and financial restraints. Once those factors are understood, the organization can more effectively integrate and sustain practices that will enhance patient safety and reduce infection risk.

Effective implementation of guidelines into routine work continues to be a major challenge. Even the best of new guidelines and evidence-based position papers are not readily adopted. What is clear from research is that simultaneous multiple implementation strategies are more likely to result in successful implementation than a single approach.71 In a synthesis of 44 systematic reviews and observations of professional behavior change, the following observations emerged (see Table 1-10, below).

Table 1-10. Observations of Methods to Create Professional Behavior Change

Designing and embedding evidence-based guidelines into daily work processes requires the involvement of a multidisciplinary team, including nurses, physicians, quality improvement and patient safety professionals, IPC professionals, and information technology.

Specialists from the departments or services involved, such as from the OT or CSSD service, should be included when the issue relates to their area. Senior leaders may also participate. The team can use various systematic methods to analyze and create improvement:

• Plan Do Study Act (PDSA) or Plan Do Check Act (PDCA)• The 4 Es: Engage, Educate, Execute, Evaluate• Define, Measure Analyze, Improve and Control (DMAIC)• Six Sigma • Lean Six Sigma• Robust Process Improvement

Other performance improvement methods can also employ general “change management” concepts to facilitate such changes. The methods for improving quality and performance are discussed in each module and presented in detail in Module 6. Examples of potential change projects in the OT and CSSD are listed in Table 1-11, below.

Table 1-11. Potential Performance Improvement Projects for the OT and CSSD72-75

Methods Less Likely to Succeed

Operating Theater Change Projects

Methods More Likely To Succeed

CSSD Change Projects

Passive dissemination of information—generally ineffective

Clinical Workflow During Surgery

Double Gloving for Surgical Procedures

Sharps Management in the OT

OT Design for Patient Safety

Timing of Room Turnover

Timing of Preoperative Antibiotic Administration

Methods for Minimally Invasive Procedures

Dissemination of educational materials and didactic educational presentations—usually ineffective

Audits, feedback, local consensus process, and use of local opinion leaders—variable results

Reminders, interactive educational sessions— generally effective

Efficient Flow of Instruments

Managing Endoscopy Equipment

Appropriate Cleaning of Instruments

Cleaning and Sterilization or High Level Disinfection of Anesthesia Instruments

Compliance with Personal Protective Equipment (PPE)

Process for Notification When Biological Monitor Fails

Process for Creutzfeldt-Jakob Disease Prion Contamination of Instruments

Interventions based on knowledge of barriers to implementation—more likely to succeed

Multifaceted interventions that focus on barriers to implementation—more likely to succeed

Adapted from: Gross PA. Implementing evidence-based recommendations for health care: a roundtable comparing European and American experiences. Jt Comm J Qual Improv. 2000 Sep;26(9):547-53. Used with permission.




Organizations benefit from a systematic approach to working through challenges for implementing evidence-based practices. Table 1-12, below, highlights challenges and potential Solutions for achieving evidence-based best practices. The table is also available as Tool 1-3.

Table 1-12. Checklist of Challenges and Potential Solutions for Achieving Evidence-Based Best Practices

The Challenge for Implementing Evidence-Based Procedures

Potential Solution(s) to the ChallengeAction(s) Taken to Achieve Success in

Overcoming the ChallengeOrganization Complete This Section

Absence of a Strategic Plan for the Department/Service

Lack of Support from Leadership

Lack of Adequate Staffing

Lack of Time to Attend to the Matter

Lack of Knowledge About the Topic

• Perform a Risk Assessment to determine risk points for unsafe care or need for improvement to evidence-based practice. (See Tool 1-7, Risk Assessment Primer.)

• Identify the best practices to be achieved.• Develop a list of priorities for the department.• Address the highest priority first, then others.

• Develop a compelling case for working toward best practice based on patient safety, cost, hospital mission, and objectives.

• Find a champion or mentor who is respected by leadership to work with you.

• Present the case to leaders.• State clearly what you need from leadership and

what you will provide, and the benefits to patients.

• Collaborate with and engage other department staff(s) to work on the issue.

• Align the work with organization mission, and leadership goals and objectives.

• Divide the work into easy to accomplish parts.• Share responsibilities with various health

care disciplines if possible.• Assign work to different staffs.• Develop a compelling business case for

additional staff. See Module 6.

• Divide work into small sections.• Develop project timelines and project due dates.• Establish realistic target goals and dates.

• Gather information including guidelines, recommendations, literature.

• Plan and present an educational program about the topic and the objective of change.

• Collaborate with the expert in the departments involved and the infection preventionist.


The Challenge for Implementing Evidence-Based Procedures

Potential Solution(s) to the ChallengeAction(s) Taken to Achieve Success in

Overcoming the ChallengeOrganization Complete This Section

Lack of Financial Clarity

Continual Change in Staff

• Work with the financial department; find a mentor in the department.

• Identify costs and resources needed to implement evidence-based practice.

• Identify low, intermediate and high priorities to accomplish goals.

• Develop a training program for all new staff to teach or reinforce best practices.

• Consider certification in practice before independent work.

• Establish a training budget. • Embed the best practice into work through

clear policy and expected behaviors.• Explore training assistance from vendors for

equipment, devices, and supplies.

Successfully implementing evidence-based preventive measures and embedding them into daily work processes requires understanding of the complex issues within an organization and may vary from one country or one facility to another.71,76,77 Figure 1-9, below, illustrates a model used in IPC for translating theory to practice, and Table 1-12, on the next page, lists actions that may be helpful to successfully translating best practices from theory to implementation and to embedding these practices into normal work routines. The effectiveness of implementation strategies to translate evidence-based guidance into practical work routines is challenging but critical to reducing infections and improving patient safety. Also see Tool 1-4.

Figure 1-9. A model used in IPC for translating theory to practice



Source: Saint S, Howell J, Krein SL. Implementation science: how to jump-start infection prevention. Infect Control Hosp Epidemiol. 2010 Nov;31 Suppl 1:S14-7. Used with permission.

Characteristics of the infection prevention practice

Adoption Decision ImplementationHealthcare-Associated

Infection Rate

Environmental context

Organizational Characteristics


Sidebar 1-3. Guidelines for Translating Best Practices from Theory to Practice1. Understand the culture of the organization and leaders with respect to change.2. Delineate the obstacles in the face of implementation.3. Form a multidisciplinary team to get input from users of the process.4. Describe the current state of the event and the desired state. 5. Use change management and performance improvement methods for the process. 6. Empower health care personnel to speak up.7. Start with a small change and move to a larger scale.8. Provide communication and feedback of data to health care personnel.9. Use checklists and reminders to reinforce desired behaviors.


Adapted from: Al-Tawfig JA, Memish ZA. Future issues in infection control. In Soule B, Memish Z, Malani P, editors: Best Practices in Infection Prevention and Control: An International Perspective, 2nd ed. Oak Brook, IL: Joint Commission International, 2012, 33. Used with permission.

Source: Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect Dis. 2006 Aug 16;6:130.

In health care settings worldwide, patients experience their care and caregivers and support staff perform their work, not in isolation, but within the environment of their organization. There is increasing evidence that the contaminated environment can be a factor in transmitting pathogens that can cause HAIs78 and that disinfection and sterilization processes may not prevent infections if not performed thoroughly and correctly.

The approach to reducing environmental risk for infections is similar in all countries and regions. Hospital staff must maintain a clean environment to minimize microorganisms that can be transferred and spread to patients or staff members. This is accomplished by sanitizing or cleaning to reduce microorganisms on surfaces, decontaminating or disinfecting to remove blood and body fluids and organisms, and disinfecting instruments. Each health care facility must establish and write its own policies for cleaning and disinfecting and ensure that environmental services staff performing these processes are well-trained, and that the chemical agents and the pH of the water or water temperature (for example, hot/superheated water) are being used correctly, are compatible, and are effective. Personnel who clean and disinfect equipment and the environment must wear appropriate personal protective equipment (PPE) for their safety.79

The great concern about the environment comes from the close and constant interaction between the inanimate environment and people. The environment serves as a reservoir that contains a large number of microorganisms that can often disperse efficiently, proliferate in moist environments and organic material, and even survive on dry surfaces. When cleaning, particularly of patient care rooms, is not thorough, organisms will remain on surfaces, and subsequent patients admitted to the room are at risk for acquiring infections.78 Microorganisms can change their metabolism to meet their environmental needs, making them more or less pathogenic to humans. Therefore, routine cleaning is necessary on an ongoing basis to keep the environment clean and free from dust and soil where organisms may reside.79

Figure 1-10, below, illustrates how organisms from the environment are transferred to the hands of health care workers and from there to patients.80

Figure 1-10. How organisms transfer in the care environment

ENVIRONMENT OF CARE

CLEANING AND DISINFECTING THE PHYSICAL ENVIRONMENT

Contaminated inanimate surface

Hands of healthcare worker

Susceptible Patientdirect transmission

Compliance in hand hygiene: - 50%


Source: Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect Dis. 2006 Aug 16;6:130. 2006 Aug 16;6:130.


Table 1-13, below, illustrates the amount of time various viruses can live on dry, inanimate surfaces. This information is useful for thinking about cleaning regimens and for teaching environmental services staff about cleaning and direct care providers about hand hygiene.80

Table 1-13. Persistence of Clinically Relevant Viruses on Dry Inanimate Surfaces

Type of virus Duration of Persistence (range) Source

Adenovirus

Astrovirus

Coronavirus

SARS associated virus

Coxsackie virus

Cytomegalovirus

Echovirus

HAV

HBV

HIV

Herpes simplex virus, type 1 and 2

Influenza virus

Norovirus and feline calici virus (FCV)

Papillomavirus 16

Papovavirus

Parvovirus

Poliovirus type 1

Poliovirus type 2

Pseudorabies virus

Respiratory syncytial virus

Rhinovirus

Rotavirus

Vacciniavirus

7 days – 3 months

7 – 90 days

3 hours

72 – 96 hours

> 2 weeks

8 hours

7 days

2 hours – 60 days

> 1 week

> 7 days

4.5 hours – 8 weeks

1 – 2 days

8 hours – 7 days

> 7 days

8 days

> 1 year

4 hours – < 8 days

1 day – 8 weeks

≥ 7 days

up to 6 hours

2 hours – 7 days

6 – 60 days

3 weeks – > 20 weeks

[32, 34, 38–41, 111]

[38]

[112, 113]

[114]

[34, 111]

[115]

[114]

[35, 38, 41]

[116]

[117–119]

[34, 111, 118, 120]

[39, 43, 121, 122]

[42, 45]

[123]

[118]

[118]

[35, 118]

[34, 38, 111]

[124]

[44]

[33, 125]

[36 – 38, 41]

[34, 126]



Infection risks in the environment may evolve from lack of adequate cleaning and disinfecting of the environment, particularly surfaces,81 and from the incorrect management of instruments and devices used for patient care. A 2008 multihospital study by Carling used a novel fluorescent targeting method to evaluate the thoroughness of cleaning. The results showed that from more than 20,000 surfaces tested, only 48% were cleaned. as the study began. The thoroughness of cleaning appeared to correlate with the expenditure for environmental service personnel. After interventions were implemented and performance feedback was provided to the environmental services staff, cleaning on environmental surfaces increased to 77%.82

In a related study Carling and his team evaluated cleaning in ICUs in 16 hospitals. Target surfaces were marked with a clear solution that would show up and would fluoresce when exposed to UV light if the surface was not well-cleaned. Interestingly high rates of cleaning (>80%) were found for toilet seats, sinks and tray tables. There was a low rate of cleaning (<30%) of bedpans, the toilet area hand hold, doorknobs, and light switches, all of which are frequently touched by caregivers and families. The methodology presented in these studies may help organizations improve environmental cleaning with little expense. 83

Another study of environmental contamination captured the percent of environmental cultures obtained that were positive for MRSA. This study found that the floor and patient bed linens were the most highly contaminated areas (but least likely to be involved in transmission of organisms to patients), and that the blood pressure cuff, bed side rails, and door handle showed lower contamination levels.84 Studies such as these can guide environmental cleaning practices.

The education of environmental services staff is essential for successful cleaning of the environment. These staff members need to know about the techniques they are to use, the agents, and how to measure or dilute and use them. They also need to know and take precautions for their own safety with PPE and careful management of waste that may be hazardous. Module 5 presents detailed information about a safe environment.

Sterilizing equipment such as surgical instruments, packs, and other supplies is a key infection prevention strategy in any health care organization and an important environment of care issue. Sterilization may be performed in the facility in a centralized or decentralized system, or by a contracted agency. The process for receiving, washing, sterilizing, packaging and storing instruments and other equipment should follow established standards, such as moving the instruments from dirty to clean without cross-contamination, having the appropriate washing and sterilizing equipment and technology, correct ventilation and air pressure, and storage areas that are restricted, have positive air pressure, and have a system to identify contaminated or outdated supplies. Tested guidelines are available, and these are discussed in greater detail in Modules 3, 4, and 5.

The management of medical waste is a challenge worldwide. Great quantities of waste are generated from the delivery of health care, and a significant part is considered medical infectious waste, which poses some risk to handlers and others. Below is a list of the major sources of health care waste:85

• Hospitals and other health care establishments • Laboratories and research centers • Mortuary and autopsy centers• Animal research and testing laboratories • Blood banks and collection services• Nursing homes for the elderly

STERILIZATION

MEDICAL WASTE



Various countries have performed detailed surveys of hospitals, clinical units within hospitals, laboratories, and other settings to quantify the types and amounts of waste and handling practices.86 -90 Some studies found that barriers to careful management of medical wastes included the following:

• Lack of guidelines• Lack of education and training for staff• Ineffective segregation at the source • Inappropriate collection methods• Unsafe storage • Poor control of waste disposal• Lack of PPE for staff • Financial and administrative issues

Other waste studies looked at different aspects of hospital wastes. One study identified the amount of multidrug resistance in bacteria from liquid wastes from a hospital in Nepal.91 A study in Iran looked at performance improvement using a quality management approach to try to reduce the amount of infectious waste that was generated.92,93 A qualitative study from Iran revealed that managerial weakness related to lack of education, organizational resources, and supervision were key factors.94 Various countries may define infectious waste differently, but in general it includes:

• Blood and body fluids from routine patient care activities, such as contaminated dressings, surgical drapes, and sponges• Any contaminated items that would release blood or other potentially infectious materials as a liquid if compressed, or items

caked with dried blood or other potentially hazardous materials that could release these materials during handling• Sharps such as lancets, needles, or glass contaminated with blood or body fluids, and phlebotomy equipment• Isolation waste from persons with highly infectious diseases, such as viral hemorrhagic fevers and other infectious materials• Pathological or microbiological specimens containing blood, or other potentially infectious materials

Waste management is also discussed in Module 5.

Injections are the most common health care procedure in the world, and many millions of injections are administered each year in developed, developing and transitional countries.95 Most needles and syringes end up as infectious waste, and they pose risks associated with waste disposal that can be very serious. More than 90% of injections are administered for therapy and the remaining 5-10% for prevention, such as immunizations. Unfortunately, most therapeutic injections in developing and transitional countries are unnecessary,95 and many injections are unsafe. The issue of reusing disposable, one-time use syringes and needles for injections is a problem in many countries, particularly certain African, Asian, and Central and Eastern European countries . The, the reuse places the patient or health care worker at risk for infection, disability or even death.85

The WHO estimated that in 2000, persons injected with contaminated syringes caused about 21 million hepatitis B virus (HBV) infections, two million hepatitis C virus infections, and 260,000 human immunodeficiency virus (HIV) infections worldwide.85 If the syringes had been disposed of in a safe manner, many of these infections would have been avoided.

INJECTION SAFETY



Each health care facility must have a clear policy on the safe handling of medical waste from the point of generation to final disposal, also termed “from cradle to grave.” The process must include the steps addressing how waste is handled and segregated at the bedside or in support departments, how it is contained, transported and stored within the facility, and how it is disposed of either in the facility with methods such as sterilization or incineration, or outside the facility in landfill. The WHO has developed an eight-step process outlining medical waste management that can be used as a tool to help facilities examine their current process to determine if improvement is needed. The process also provides many tools to assist organizations with waste management. See discussion and the tool in Module 5 and at http://www.who.int/mediacentre/factsheets/fs253/en/.

Everyone who handles sharps is at risk of being stuck with a contaminated needle or cut from a used scalpel. Specific procedures must be in place to prevent these injuries. As described in Modules 3 and 5, there are many creative ways to reduce risk to personnel. Waste management workers are particularly at risk for sharps injuries when safe disposal processes are not followed or when manual sorting is the process. Appropriate disposal of needles and syringes, and eliminating reuse are key to preventing these infections. The WHO has published Guiding Principles to Ensure Injection Device Safety97 and Best Practices for Injections and Related Procedures Toolkit as well as other helpful documents.98 Sharps management is also discussed in Modules 5 and 6.

WASTE MANAGEMENT

• No loose disposable injection equipment outside of packaging in the facility• No loose disposable phlebotomy equipment outside of packaging in the facility• No loose disposable intravenous equipment outside of packaging in the facility• No loose scalpels during surgical or other procedures• No evidence of re-sterilization of disposable injection equipment• No used sharps outside of safe containers specific for sharps• No multidose vials with needles left in the diaphragm• Running water and soap for cleansing hands before using sharps• Alcohol-based hand rub for cleansing hand before using sharps

Adapted from: World Health Organization (WHO). Revised Injection Safety Assessment Tool (Tool C – Revised). 2008. Accessed Oct 3, 2014. http://www.who.int/injection_safety/Injection_safety_final-web.pdf

See Table 1-14, below, for tips for safe management of sharps to prevent sharps injuries and infection risk. 96

Table 1-14. Tips for Safe Management of Sharps to Prevent Sharps Injuries and Infection Risk


• Incidence Surveillance: track all new cases of an infection during a defined period• Prevalence Surveillance: track all new and old cases (all existing cases) of an infection during a defined period• Control Charts: track infections over time in the context of controls or limits, for example 2 or 3 standard deviations from

the mean (average) to determine significant variation• Performance Indicator: a measure to monitor or evaluate the governance, management, clinical or support functions

affecting patient outcomes• Process Surveillance: measures a process or the steps in a process that lead to a specific outcome, (for example, using

aseptic technique when inserting an indwelling urinary catheter)• Outcome Surveillance: measures the result of a function or process, such as infection after surgery


MODULE #1f. MeasurementIn all countries and health care settings, measurement of processes of care and outcomes is necessary to determine if current practices are appropriate, to identify gaps in practice that need to be addressed, and to measure improvements or gains as they occur. In the past, IPC surveillance data have not been available in many countries. Limited resources and lack of infrastructure have been barriers to collecting infection information. However, in recent years, many countries have developed sophisticated surveillance systems and are now able to address HAIs based on their data.99-103

Perhaps some of the most remarkable progress in surveillance in countries with limited resources has been spearheaded by Victor Rosenthal, MD, who, through the International Nosocomial Infection Control Consortium (INICC)104 has worked with more than 100 countries to assist them in collecting, analyzing, and using surveillance data where none existed previously.105-108 This work has changed the abilities of these countries to design strategies to reduce HAIs and save lives.

Measurement helps staff and leaders manage the care delivered in their organization. To use measurement to help improve care, the data collected must be reliable and valid.109 A measurement or surveillance program should be established based on goals and objectives for the area, and staff members performing the measurements must select indicators and metrics to best achieve established goals.109 For example, if the goal is to reduce room turnover time in the OT, staff must first measure the current room turnover time (a process measure) and then identify the parts of the process that can be improved. The changes (improvements) should be monitored with follow-up data collection.

It is important to collect data by selecting a performance indicator such as an incidence or prevalence rate, or process or outcome measure, and by using statistical methods to calculate rates or control charts for analysis so the information can be easily analyzed and understood. Table 1-15, below, provides definitions of the above terms as used in epidemiology and infection prevention surveillance.

Table 1-15. Epidemiology and infection prevention surveillance terms


Sidebar 1-4. Attributes and Characteristics of a Performance Measure• Focuses on improvement in a health population• Is precisely defined and is specific• Is reliable and valid• Can be interpreted• Is risk-adjusted or stratified• Has defined data collection methods• Is under the control of the organization

• Establish goals and objectives for a monitoring or surveillance program• Select indicators to measure that will inform the goals and objectives.• Establish criteria for an event, such as an infection, hand hygiene, PPE in the OT, or cleaning dirty instruments. • Use consistent criteria to collect data; use benchmark data if available for comparison.• Use standard and consistent methods for monitoring or surveillance.• Determine when to maintain or to eliminate performance indicators so measurement activities are focused and useful,

and unneeded measurement data are not collected.• Stratify data whenever possible for more precise analysis, for example with SSIs and infections in the newborn population

or by components of a process.• Validate data and present in an understandable manner. • Share data with people and groups that need the information to inform their work.

MODULE #1f. Measurement

Example of a performance measure meeting the above requirements might be: • The average room turnaround time from completion of one surgical procedure to the next surgical procedure between the

hours of 7:00 A.M. (07:00) and 6:00 P.M. (18:00) during normal weekdays (Monday through Friday) in the inpatient surgical department

• Number of times per year the biological indicator for the sterilizer is POSITIVE after the appropriate method for the process and incubation period of the indicator for all sterilizer loads on all shifts and all days

• Rate of hospital-associated central-line associated infections in all ICU patients in the months of January through June 2014, based on established criteria for health care–associated CLABSI.

• Monthly rate of correct humidity and ventilation values in the CSSD or the OT

A measurement program should include the following steps outlined in the Table 1-16, below. This is also provided as Tool 1-5 in the tool section.

Table 1-16. Elements of a Measurement Program

Data that are collected must be analyzed and used to guide decisions about infection cluster or outbreak identification, and management and performance improvement to reduce infection risk for patients, staff members, families, visitors, and others. Outbreaks related to the operating theater and surgical services and the CSSD are described in Modules 3-5

Finally, it is important to note that simply collecting data and measuring direct care and support processes is not sufficient. The purpose of data collection is to use this information to change and to improve care.110

Adapted from: Soule BM, Nadzam DM. Performance Measures, Chapter 17:17-1 to 17-12. In APIC Text of Infection Prevention and Control and Epidemiology, 4th ed., Washington, D.C.: APIC, 2014.


The selection of performance indicators for either process or outcomes surveillance should be the result of discussion and careful thought.109 The attributes and characteristics of a performance measure are displayed in Sidebar 1-4, below. Analysis and display of the data and interpretation are shared with staff and leaders.


Note: The specific mortality outcome for each infection type is as follows: bloodstream infections and VAP = in-hospital mortality; SSI = 90-day postoperative mortality; all infections = 12-month mortality in those surviving the hospital discharge. MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-susceptible Staphylococcus aureus.

Source: Talbot TR. The Clinical Consequences of Antibiotic Resistance, Chapter 2. In The Cost of Antibiotic Resistance. What Every Healthcare Executive Should Know. Oak Brook, IL: Joint Commission Resources, 2010. Used with permission.

MODULE #1g. Multidrug Resistant Organisms and Antimicrobial StewardshipOf all the challenges faced by infection prevention professionals worldwide, the emergence and persistence of multidrug resistant organisms (MDROs) ranks near the top of the list. This issue is considered an impending crisis with dire predictions for future care of patients.111,112 Regardless of differences in countries or in the amount of antibiotics used, observers have seen an increase in the use of antimicrobials in most developed countries in the last 20 years.113

As discussed earlier, the revolution in antibiotic treatment was inaugurated by the discovery of penicillin by Alexander Fleming in 1928 and its use as an antibiotic in 1941. The subsequent explosion and industrial scale production of various antimicrobial agents used for therapy of infections marked one of the biggest turning points in IPC specifically and in medicine generally with significant decreases in infection-related mortality and morbidity. However, the widespread, and in many cases indiscriminate, use of antibiotics that followed and exists today, has raised new issues in IPC through the emergence of antimicrobial resistance and MDROs. The emergence of resistance and associated consequences have become a local and global public health issue that must be addressed.114-118

MDROs affect inpatients and outpatients, as well as healthy individuals in the community with no contact with the health care delivery system. While the incidence of infections among hospital patients caused by MDROs continues to rise, there are fewer new antibiotics available to treat these resistant microorganisms. The spread of MDROs is linked to two principle factors: 1) antibiotic overuse and misuse by prescribers, and 2) breakdown in IPC practices in hospitals that allow for transmission.

Patients with infections caused by MDROs may experience increased morbidity and mortality, and the cost to care for these patients increases exponentially for some infections.38 Figure 1-11, below, illustrates the difference in risk of mortality for patients with and without MRSA.

Figure 1-11. Mortality risks for patients with and without MRSA

In general, patients with MDROs can experience:119

• Two-fold increase risk of death• Increased risk and duration of ICU stay• Longer hospital stay• Delayed return to baseline health• Higher risk of adverse events• Increased cost of care

In a Canadian study, the additional costs of care for patients with vancomycin-resistant enterococci (VRE) alone was nearly US $18,000 with a cost increase of almost 62% compared with patients without VRE.120 A Brazilian study in one intensive care unit compared the costs of antimicrobial drugs used to treat patients infected with MDROs with those not infected. The study found that in the three-year test period, the overall cost of antimicrobial treatment was US $1,113,221, with treatment costs significantly higher for those infected with MDROs (p=0.010.)121

Countries throughout the globe have convened working groups to evaluate the issue of MDROs and to identify approaches to reducing the inappropriate use of antibiotics. Successful efforts are the result of collaboration among physicians, pharmacists, drug companies, and governments, among others. 122,123


Sidebar 1-5. Elements of an Effective MDRO Prevention Program• MDRO Risk Assessment Tool: Comprehensive evaluation of MDRO risks in the organization (Tool Found in the Risk

Assessment Primer)• MDRO and IPC Performance Assessment: Quantitative assessment of current prevention practices (Tool found in the

Risk Assesment Primer)• Antibiotic Stewardship: Assessment of prescribing practices and trends in resistance, and guidance on prescribing

antimicrobial agents. (An Antibiotic Stewardship Toolkit is available free from Joint Commission Resources at http://www.jcrinc.com/antimicrobial-stewardship-toolkit/.)

• Transmission Control: Deployment of basic and advanced practices to prevent dissemination• Education/Communication: Comprehensive approach to informing frontline staff and senior leadership about

importance of MDRO control

Sidebar 1-6. Key Steps CEOs Can Take to Reduce Cross-Transmission of MDROs in Their Facilities1. Make adherence to each core cross-transmission preventive activity-hand hygiene, isolation precautions, and

environmental hygiene-an institutional performance goal.2. Ensure that the facility has adopted clearly written policies for each of these core activities and that these policies are

reviewed on a regular basis.3. Create a process improvement team for each core activity and do the following:

• Recruit appropriate representation from clinical and administrative personnel (e.g., failing to include nursing representation on a team seeking to improve adherence with hand hygiene will likely result in project failure).

• Identify a process owner whose responsibility it is to ensure that the process improvement remains on target and is sustainable.

• Ensure appropriate level of resources.• Ensure that the program incorporates an ongoing performance assessment evaluation system to monitor project

success.4. Set concrete objectives that raise expectations (think about President Kennedy’s promise to put a man on the moon

before the end of the 1960s).5. Reinforce adherence with core activities:

• Encourage staff to reinforce desirable behaviors among themselves in a nonconfrontational manner.• Respond quickly to staff suggestions when barriers to the desired behavior are identified.• Reward staff and units that achieve or exceed performance measures.• Aggressively recruit and retain staff who exemplify a commitment to safety and quality.• Rapidly identify and address problem staff who willingly ignore remediation efforts.

MODULE #1g. Multidrug Resistant Organisms and Antimicrobial Stewardship

While all leaders and team members are important in preventing MDROs, the CEO has a special role in supporting certain behaviors and guidelines in the organization. See Sidebar 1-6, below.

Source: Weber S, Soule B. Antibiotic Resistance: Patients and Hospitals in Peril, Chapter 1. In The Cost of Antibiotic Resistance. What Every Healthcare Executive Should Know. Oak Brook, IL: Joint Commission Resources, 2010. Used with permission.

CEO, Chief Executive Officer; MDRO, multidrug-resistant organism.Source: Crnich C, Weber S, Soule B. Transmission Control to Prevent the Spread of MDROs in the Health Care Facility, Chapter 4:47. In The Cost of Antibiotic Resistance. What Every Healthcare Executive Should Know. Oak Brook, IL: Joint Commission Resources, 2010. Used with permission.

In the health care setting, several strategies combine to generate an effective MDRO prevention program (see Sidebar 1-5, below).


MODULE #1g. Multidrug Resistant Organisms and Antimicrobial StewardshipAnother very successful strategy to reduce antibiotic resistance is an effective antimicrobial stewardship program (ASP). Many studies over the years have shown that much antibiotic use is unnecessary. For example, in the United States, antibiotic use has been found to be unnecessary or inappropriate in up to 50% of cases.124 In developing countries, appropriate antimicrobial use is often hindered by lack of antibiotics, delivery disruptions, easily accessible antibiotics in the community, and lack of an antimicrobial stewardship program. ASPs proactively encourage the appropriate use of antibiotics and the reduction of unnecessary or inappropriate antibiotic administration, which can lead to resistance. ASPs have been shown to significantly reduce antibiotic use with concomitant reductions in resistant organisms and infections from MDROS.124 The ASP programs can also be very cost-effective, as antibiotics are one of the most common drugs used in acute care and are expensive.125-127 ASPs are generally co-directed by an infectious disease physician and a pharmacist trained or interested in infectious diseases, with a multidisciplinary team to oversee the program. The literature offers rationale and many approaches to ASPs.128-130

Outbreaks of MDROs occur with some frequency in health care facilities in most countries and can be hard to control. The case study below describes the process used in the Kingdom of Saudi Arabia to address these outbreaks.

Introduction and BackgroundSeveral infectious diseases outbreaks occur during the year in different health care facilities. These outbreaks are expected to cause morbidities and mortalities, and recognizing and managing such outbreaks can be challenging.

The General Directorate for Infection Prevention and Control (GDIPC) at Saudi Ministry of Health, MoH, established a countrywide outbreak management protocol and formed a technical support team to help institutions in investigating and managing outbreaks.

Methods, Actions and FindingsGDIPC has an established methodology of management of outbreaks. When an outbreak is detected, the health care facility’s infection control department forms an outbreak control team. The team’s roles include investigation, bringing the outbreak under control, and taking all possible measures to prevent similar outbreaks in the future.

In addition, the health care facility is required to report the outbreak to GDIPC through a Web-based notification form created in 2010 by GDIPC to enhance the notification process. Once sent, the notification is saved automatically in a database that can be accessed only by the outbreak support team and the GDIPC director.

The outbreak support team deals with all received outbreak notifications in a timely manner to help the health care facilities contain the outbreak early. The type of support may differ according to the size and seriousness of the outbreak.

For most received notifications, the impersonal support from GDIPC is usually sufficient to aid the facility. These types of support include consultation, advising of preliminary control measures, and facilitating availability of additional resources required for immediate use to investigate and control the outbreak without hindrance.

For notifications of large-size outbreaks or outbreaks of emerging infectious diseases, the GDIPC technical support team is delegated to the facility where the outbreak occurred to work directly with the local team to investigate and control the outbreak.

ResultsIn 2013, a total of 43 outbreak notifications were received. More than 90% of these notifications were for outbreaks on MDROs, and sizes of outbreaks ranged from one case to 37 cases. 34 of these outbreaks were contained effectively by the facility staff with remote assistance from GDIPC. With the other 9 outbreaks, the GDIPC outbreak technical support team visited the health care facilities to assist in investigating and containing the outbreaks.

The Web-based notification system has managed standardized reporting and collection of outbreak information. Beyond the immediate action taken to manage the outbreak, GDIPC uses the generated outbreak data from health care facilities to analyze the magnitude and character of outbreaks and to establish future control measures.

MONITORING, CONTROLLING AND PREVENTING OUTBREAKS OF MULTIDRUG RESISTANT ORGANISMS IN MINISTRY OF HEALTH (MOH) HOSPITALSCS 1-1



Infections and infectious diseases have existed for thousands of years, causing acute and chronic illnesses that have affected persons in the community and patients in health care settings. New infections and diseases continue to emerge, or old infections reemerge as microorganisms mutate or acquire resistance (for example, influenza, coronavirus), or as basic infection prevention strategies are abandoned that have been preventing the emergence of infections (for example, measures in public health to prevent tuberculosis). Emerging infections often start in the community but eventually may affect patients and staff members, and hospital functions. These infections require effective IPC strategies for minimizing transmission in the community, in acute or chronic inpatient settings, or in ambulatory clinics. Examples of such viral infections include pandemic influenza H1N1, the newer H7N9, SARs, Middle East Respiratory Syndrome (MERS), Coronavirus (CoV), MersCoV,131 Ebola virus,132,133 and bacterial infections from multidrug resistant bacteria, including methicillin-resistant Staphylococcus aureus (MRSA) and gram-negative organisms such as Klebsiella, Pseudomonas, Carbapenem Resistant Enterobacteriacaie (CRE) and Acinetobacter baumanni. The CDC has developed a robust Website for antimicrobial stewardship and published a toolkit for reducing CRE.134

Organizations must have appropriate IPC strategies and a plan in place to be prepared if a new emerging infection is identified or if an outbreak of an existing disease occurs. A risk assessment should be performed to determine if the organization dealing with an MDRO is managing it successfully or is ready for a new infectious disease. A sample risk assessment for MDROs is provided in the Risk Assessment Primer (Tool 1-7).

Plans for emerging pathogens and other emergencies should include policies that will help the organization respond rapidly, efficiently, and with standardized activities throughout the facility to reduce the potential for transmission of infection. Preparedness plans for IPC must have leadership support, infrastructure arrangements to potentially create temporary isolation facilities and to provide additional supplies of PPE based on the infectious organism. Methods to restrict access to exposed patients or staff members and the ability to ensure the continuation and additional burden of utilities, such as water and air pressure, and key functions such as, laboratory services, disinfection and sterilization, or surgery are critical. The preparedness plans may rely on infectious disease and epidemiology experts to determine how the infection is transmitted and how to best interfere with transmission.

Lesons Learned• Establishing a countrywide unified protocol to manage outbreaks, along with outbreak communication planning, is effective in

containing the outbreaks and allows for a better use of resources. • When the responsibility for investigating and controlling outbreaks is a shared concern between the health care facility and the

Ministry, rapid outbreak control can be achieved, with additional actions to prevent spread of the outbreak to other facilities or to society.

• A transition from paper-based reporting to Web-based reporting of outbreak data is a key determinant of success. Besides quickening notification time, online reporting improves the ability to describe and prevent outbreaks on a national level by focusing on deficiencies and risk factors associated with those outbreaks.

EMERGING AND REEMERGING INFECTIONS

INFECTIOUS DISEASE EMERGENCY OR PANDEMIC PREPAREDNESS


One proactive task is to perform a risk assessment to determine organizational readiness for an infectious disease emergency. This can be part of the overall IPC or the organization’s risk assessment and should be performed by a multidisciplinary team of involved, responsible persons.

The United States CDC published updated recommendations for management of persons with possible inhalation of anthrax. This is found at http://www.cdc.gov/anthrax/.135 Emergency plans should also establish effective communication for all concerned, including mechanisms to provide regular feedback to HCPs, health care administrators, and the authorities.

A paper from China described gains made from the country’s experience with SARs and how that has influenced a better response to H7N9 in terms of command and decision-making, organization and collaboration, and monitoring and early warning systems, as well as communication.136 Thailand had a similar experience with influenza A(H1N1) in 2009.137 At the organizational level, a plan published recently from APIC outlines in detail infection prevention planning and implementation for ambulatory care centers during disasters. This document contains many practical topics and suggestions that can also be used in the acute care setting. The Website contains other helpful publications for emergency planning. This is found at http://apic.org/Resource_/TinyMceFileManager/Emergency_Prep/2013_Ambulatory_Care_during_Disasters_FINAL.pdf.138

Advance preparation is necessary for emergencies because during a crisis, there may be insufficient time to educate staff about the disease and to design the appropriate actions to undertake to interrupt the spread of transmissible infections. Using a risk-based approach to prepare for epidemics or emerging infections will help with early identification of new infections. A risk assessment of the IPC program should be performed at least annually with one section of that assessment focused on potential evolving problems, including infection control/infectious disease emergencies. Performing a risk assessment for the hospital and for specific departments such as the OT or Sterile Processing will be helpful. See the Risk Assessment Primer with the Tools for guidance on performing an effective risk assessment.

The CDC and WHO work together on worldwide pandemics to issue prevention guidance as well as documents on treatment and other topics. One document is, Infection Control for Viral Haemorrhagic Fevers in the African Health Care Setting December 1998, is available at http://www.cdc.gov/vhf/abroad/vhf-manual.html139 and additional current guidance is forthcoming in response to the 2014 Ebola outbreak at http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html.140

Figure 1-12, below, is a checklist from the CDC of key areas for health care facilities to review to respond to MERS-CoV.141 The checklist in Sidebar 1-7 provides steps in the preparation for the Middle East respiratory syndrome coronavirus (MERS-CoV) as an example of how to prepare for this emerging viral infection or other similar infections.


Sidebar 1-7. Responding to MERs-CoVMiddle East Respiratory Syndrome (MERS) is a viral respiratory illness first reported in 2012 in Saudi Arabia. It is caused by a coronavirus called MERS-CoV. Most people who have been confirmed to have MERS-CoV infection develop severe acute respiratory illness. They may have fever, cough, and shortness of breath. About one third of those who develop the disease die. The epidemiology of this infection is still evolving. When more clearly defined, it will clarify the reservoir, the mode(s) of transmission, the best methods of isolation, and the PPE for those at greatest risk of infection and mortality.


Figure 1-12. Persistence of Clinically Relevant Viruses on Dry Inanimate Surfaces

Assigned to Completed

• Ensure facility IPC policies are consistent with the World Health Organization (WHO) or Centers for Disease Control and Prevention’s (CDC) MERS-CoV guidance documents.

• Review documents and compare with current policy.• Review procedures for rapidly implementing appropriate isolation and

infection practices for potential MERS-CoV patients. • Review policies and procedures for screening and work restrictions for

exposed or ill health care personnel (HCP), including ensuring that HCP have ready access, including via telephone, to medical consultation.

• Review procedures for laboratory submission of specimens for MERS-CoV testing. • Review plans for implementation of surge capacity procedures and crisis

standards of care.• Develop plans for visitor restriction if MERS-CoV is circulating in the community.• Ensure that specific persons have been designated within the facility who are

responsible for communication with public health officials and dissemination of information to other HCP at the facility.

• Confirm the local or state health department contact for reporting MERS-CoV cases and confirm reporting requirements.

• Assure ability to implement triage activities based on public health guidance, including at the facility and using remote (phone, Internet-based) methods where appropriate to minimize demand on the health care system.

• Ensure that negative-pressure airborne infection isolation rooms are functioning correctly and are appropriately monitored for airflow and exhaust handling.

• Ensure that frontline HCP have been medically cleared, fit-tested, and trained for respirator use.

• Provide education and refresher training in the next six weeks to HCP regarding MERS-CoV diagnosis, how to obtain specimen testing, appropriate PPE use, triage procedures, including patient placement, HCP sick leave policies, and how and to whom MERS-CoV cases should be reported, procedures to take following unprotected exposures (not wearing recommended PPE) to suspected MERS-CoV patients at the facility.

• Assess availability of PPE and other IPC supplies (hand hygiene supplies) that would be used for both HCP protection and source control for infected patients (facemask on the patient).

• Have contingency plans if the demand for PPE or other supplies exceeds supply.• Assess effectiveness of environmental cleaning procedures; provide

education/refresher training for cleaning staff.• Monitor the situation at CDC’s or WHO’s MERS Website.


Source: Centers for Disease Control and Prevention (CDC). Healthcare Facility Preparedness Checklist for MERS-CoV. Accessed Oct 3, 2014. http://www.cdc.gov/coronavirus/mers/downloads/checklist-facility-preparedness.pdf


This module began with a brief historical perspective of HAIs, leading up to the challenges that countries and the world face today in trying to minimize HAIs. Several global challenges to HAIs were presented along with proposed or suggested solutions. These challenges currently exist in most countries and daily affect the lives of patients and staff members. Other modules in the toolkit will expand on issues related to leadership, the OT, the CSSD and environments and performance improvement, and how each of these topics is important to understand to provide safer and higher quality care for patients and staff.

The globalization of infection transmission stems from the rapid mobility of the world’s population. Persons and populations move rapidly throughout the world and can carry infections with them and into the hospital or other health care settings. Infections can no longer be treated as if they are limited to a specific location or geography. They must be addressed as system issues and managed through local measures designed on the principles of transmission and disease control with the best evidence-based practices from around the world.

MODULE #1h. Summary


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