Scoping the Priorities for Quality in the Health and Disability Sector
Chapter 5
A National Programme for Infection Prevention and Control
Introduction
This chapter discusses the process and programme to be implemented in the NZ health and disability sector to improve infection prevention and control in District Health Boards (DHBs) over the next three years.The development and implementation of a national programme for infection prevention and control will focus on three initiatives: implementation of hand hygiene guidelines, reduction of catheter-related blood stream infections and surveillance of surgical site infections.
Definitions used in this chapter
/ SurveillanceThe continuous and systematic process of collection, analysis, interpretation and dissemination of descriptive information for monitoring health problems.[1]
Immunity
The resistance of a host to a specific agent, characterised by measurable and protective surface or humoral antibody and by cell-mediated immune responses.2
Infection
The successful transmission of a microorganism to a host with subsequent multiplication, colonisation and invasion.3
Healthcare acquired infections
Nosocomial infection
A localised or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) not present at the time of admission to the healthcare facility.4 Nosocomial infections are also referred to as hospital or healthcare acquired or associated infections.
Background
Introduction
/ Healthcare-acquired infections are documented to be a significant problem worldwide. These include bloodstream infections, gastrointestinal infections (e.g., the noro and rota viruses), urinary tract infections, surgical wound infections, respiratory tract infections (e.g., pneumonia) as well as skin and soft tissue infections. International studies show that on average, 5 to 10 percent of patients will acquire an infection whilst in hospital.Healthcare-associated infection (also referred to as nosocomial infection) presents many of the characteristics of a major patient safety problem. It has multiple causes, relating both to the systems and processes of care provision, as well as to behavioural practices.
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Scoping the Priorities for Quality in the Health and Disability Sector
Why is this priority important?
/ Reducing healthcare associated infections has been identified as a priority because of both the disease burden and the economic burden that these infections have created.The disease burden
At any one time, over 1.4 million people worldwide are suffering from infections acquired in hospital and up to 10% of patients admitted to modern hospitals in the developed world acquire one or more infections. The only published estimates in New Zealand are based on data collected at Auckland District Health Board (ADHB) between 1996 and 1999.[2] The pooled results from Auckland, Green Lane and National Women’s Hospitals showed an estimated prevalence rate of 9.5 per cent.
The economic burden
Healthcare associated infections in England are estimated to cost ₤1 billion a year.[3] In the United States, the estimate is between US$ 4.5- 5.7 billion per year.[4] The results from the NZ study predict an annual cost for hospital-acquired infection of up to $18.76 million to the ADHB and a national cost of $136.61 million.[5] Surgical site infections:
- account for about 14% of possible adverse events threatening patient safety in hospitals in developed countries.
- occur in at least 5% of the patients undergoing surgical procedures every year
- prolong hospital stay on average by 7.4 days, at an average cost of $1000 per day.
Why is this priority important?
(continued) / The importance of this issue in New Zealand has been further highlighted in the Controller and Auditor-General’s Report in 2003. The Controller and Auditor-General reported on the management of hospital-acquired infection in public hospitals in New Zealand and described and assessed systems for managing these infections in public hospitals.This report,Management of Hospital-Acquired Infection,comprehensively examined current infection control procedures in New Zealand public hospitals. There were several reasons given for the publication of this audit report:
- Hospital-acquired infections pose a serious risk to patients and hospital staff.
- A significant cost is associated with hospital-acquire infection.
- Hospital-acquired infections are avoidable.
- Certification requirements under the Health and Disability Services (Safety) Act 2001 require providers of health care services to meet the Infection Control Standard.
In May 2004, the Health Committee requested a briefing from the Office of the Attorney General (OAG) and conducted an inquiry into the issue of hospital-acquired infections. The Health Committee supported the OAG review and subsequently presented the Report on Inquiry into Hospital-Acquired Infection to the House. This report recommended to the Government that the Ministry of Health work to implement three key recommendations to improve infection control practice across New Zealand.
These were to:
- establish a national surveillance system for infections acquired in the health and disability system
- set and enforce nationwide standards that apply to the collection of data on hospital-acquired infection rates and hospital-acquired bloodstream infection rates
- ensure comparative data on all bloodstream infections and hospital-acquired infections are posted on the Ministry of Health website and are updated regularly.
Why is this priority important?
(continued)
/ On 29 July 2004, the Cabinet Committee approved the Government response to the Health Committee Report ‘Inquiry into Hospital-Acquired Infection’ (May, 2004). The Government tabled a response to the Health Committee on this report, in Parliament, on 4 August 2004. This response included a directive to the Ministry to submit a report by November 2004 outlining cost-effective options in furtherance of Recommendation 1. Both the Report of the Controller and Auditor-General and the response by the Health Committee called for the establishment of a New Zealand-wide infection surveillance programme. The report of the Office of the Controller and Auditor General however,primarily focuses on the hospital setting. The Health Committee and the Legislation Cabinet Committee recognise the needto extend the inquiry to include all levels of the health and disability system; primary, secondary and tertiary levels of care.One further point needs to be made. Failure to comply with hand hygiene is considered the leading cause of healthcare-associated infections, contributes to the spread of multi-resistant organisms and is recognised as a significant contributor to outbreaks of infection. “The potential benefit of successful hand hygiene promotion outweighs its costs, and widespread promotion should be should be supported”.[6] The excess use of hospital resources associated with only four or five serious healthcare-associated infections may equal the entire annual budget for hand hygiene products used in patient care areas.
An economic analysis of the United Kingdom’s “cleanyourhands” hand hygiene promotional campaign concluded that the programme would be cost-beneficial even if healthcare-associated infection rates were decreased by as little as 0.1%.[7]
Review of international action
Introduction
/ Over the past twenty years there has been a great deal of focus placed on the control of infections in international health systems. It would appear that the types of strategies used to address this issue vary for country to country. Some of these strategies are summarised below.Prepared by: CommunioPage 1 of 21Infection Prevention and Control
Scoping the Priorities for Quality in the Health and Disability Sector
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Scoping the Priorities for Quality in the Health and Disability Sector
World Alliance for Patient Safety
/ In October 2004, WHO launched the World Alliance for Patient Safety in response to a World Health Assembly Resolution (2002) urging WHO and Member States to pay the closest possible attention to the problem of patient safety. The Alliance raises awareness and political commitment to improve the safety of care and facilitates the development of patient safety policy and practice in all WHO Member States.Each year, the Alliance delivers a number of programmes covering systemic and technical aspects to improve patient safety around the world. “Clean Care is Safer Care” is the title of the current Global Patient Safety Challenge; the focus is on preventing infection associated with health care.
Hand hygiene remains the primary measure for reducing health care-associated infection and the spread of antimicrobial resistance. A wide range of hand hygiene programmes is underway around the world. For brief programme descriptions see AppendixTwo.To assist countries to reduce the burden of health care-associated infection WHO have produced “Guidelines on Hand Hygiene in Health Care” and recommend the implementation of these guidelines in all health systems and services.[8]
The hand hygiene promotion campaign at the University of Geneva Hospitals, Switzerland, is the first reported experience of a sustained improvement in compliance with hand hygiene, coinciding with a reduction of nosocomial infections and multi-resistant Staphylococcus aureus cross-transmission. The successful strategy included repeated monitoring of compliance and performance feedback, communication and education tools, constant reminders in the work environment, active participation and feedback at both individual and organisational levels, senior management support and involvement of sector leaders. The promotion of alcohol-based hand rub at the point of care largely contributed to enhanced compliance. Including both direct costs associated with the intervention and indirect costs associated with healthcare workers time, the promotion campaign was cost-effective. The total cost corresponded to less than 1% of the costs associated with healthcare-associated infections.
World Alliance for Patient Safety, cont.
/ A number of hand hygiene programmes have been conducted in international health systems. The Clinical Excellence Commission (NSW) has offered to provide to the New Zealand health and disability sector, all the resources that they have developed for the hand hygiene strategy in the NSW health system.Creating High Reliability in Healthcare organisations / Since the landmark reports from the Institute of Medicine (IOM) in 1999[9]and 2001[10] that documented that deficiencies in quality and safety of care, healthcare has turned to “high reliability organisations” e.g. aviation, who have achieved a high degree of safety or reliability despite operating in hazardous conditions. Reliability is often presented as a defect rate in units of ten and generally represents the number of defects per opportunity for that defect. In healthcare, an opportunity for a defect usually translates to a population of patients at risk of the medical error or adverse event. To begin to understand exactly what reliability means in healthcare and how we know if it is reliable, a study was undertaken at Johns Hopkins University by the Quality and Safety Research Groupto develop a model of reliability focusing on rate-based measures of safety in a specific clinical area. The model to improve reliability includes:
- Identifying interventions associated with an improved outcome in a specific patient
- Selecting interventions that have the biggest impact on outcomes and convert these into behaviours
- Developingmeasures to evaluate reliability and
- Measuring baseline performance
- Ensuring patients receive evidence-based interventions.
The project focused first on improving the safety culture in the ICU because of the belief that this change was necessary before teams could redesign care and improve reliability. At the start of the study 100 ICUs agreed to participate the results from 98 ICUs are presented in Table 1 overleaf.
Table 1: Catheter-Related Blood Stream Infection Rates per ICU-Month of Observation by Time Period*
Time Period* / ICU-Months of Observation (%) / Proportion with Zero CRBSI / p-value**
Pre-intervention baseline / 203 (23%) / 59% / Reference
Peri-intervention / 218 (25%) / 66% / 0.17
0 – 3 months post-intervention / 193 (22%) / 74% / 0.002
4 – 6 months post-intervention / 145 (16%) / 74% / 0.003
7 – 9 months post-intervention / 54 (6%) / 80% / 0.005
Unknown / 69 (8%) / 75% / 0.016
CRBSI = Catheter-Related Blood Stream Infection; ICU = intensive care unit
* Time period is measured in relation to implementation of the CRBSI intervention
** p-value for comparison with the proportion of ICU-months with zero CRBSI at pre-intervention baseline using two-sample test of proportion.
______
Creating High Reliability in Healthcare organisations, cont. / Dr Lucian Leape in his key note address at the Australasian Conference for Safety and Quality in Health Care in August 2006 reported the continuing improvements in 68 Michigan ICUs. Between March 04 – June 05 these ICUs had reported no catheter-related blood stream infections for more than six months.These results represent savings of:- 1578 lives
- 81,000 hospital days
- $165 M
National Surveillance Systems
/ Surveillance of infections is one of the most important functions of a hospital infection control programme. Conventional nosocomial infection surveillance has relied on ward rounds, reviews of medical charts and paper based reports of microbiologic results. Many countries have introduced national surveillance systems that consist of:- local action to collect and report infection data,
- local action to reduce infections
- national reporting of infection data
- nationally co-ordinated action to further reduce infections.
Infection identification in the United Kingdom is laboratory-based for bloodstream infections and ward-based for surgical site infections and urinary tract infections. The main difference between this system and others is that it utilises a 24-hour post-hospitalisation determination for infection rather than the standard 48 hours.
The New South Wales (NSW) Department of Health (DoH) has introduced the Infection Control Program Quality Monitoring system. In 1998, a surveillance project funded by the NSWDoH was piloted throughout 10 public hospitals. The surveillance system used NNIS definitions for the surveillance of hospital-acquired infections. NSW Health and the Australian Council on Healthcare Standards (ACHS) jointly developed a mandatory system and a methodology for collecting and reporting data. The pilot programme has since been mandated for over 200 hospitals throughout NSW. Reports are used to evaluate and improve infection control programs, practices and policies. The data are collected every six months and the aggregated data are reported on the NSW Health website.[12]
A review of national surveillance is summarised in Appendix Three.
Progress in the New Zealand Health and Disability Sector
Policy directives or strategies to date
/ Infection prevention and control programmes have been in existence in various forms within most New Zealand public hospitals for more than 20 years. A national surveillance system has already been established for monitoring bloodstream infections. However it is only within recent times that an appropriate framework has been established that allows for the effective functioning of such programmes. The legislative environment that has been established since 2000 emphasises patient safety, effectiveness and quality improvement, which are integral to infection prevention and control.In 2000, aNew Zealand standard (NZS 8142: 2000 Infection Control) was released to provide guidance on how to reduce the spread of infection within New Zealand healthcare facilities. This standard aims to facilitate consistently safe and high quality service delivery by identifying principles designed to reduce the rate of infection in the health and disability sector.
The Health and Disability Services (Safety) Act 2001 requires Designated Audit Agencies (DAAs) to audit healthcare facilities in order to measure compliance against the NZS 8142:2000 infection control standard. All New Zealand healthcare providers that are covered by this Act have been audited within the last two years. The findings from these audits demonstrate the considerable variability of infection prevention and control systems in DHB hospitals and importantly the extensive variability of surveillance of healthcare acquired surgical site infection and the lack of surveillance of procedure related healthcare acquired infections.
There are several factors that increase the risk of patients acquiring a bloodstream infection. These factors include the number of intravenous or intra-arterial lines (“drips”/intravenous catheters) patients have (the greater the number of lines, the higher the risk). Another factor is the status of a patient’s immune system
The Ministry of Health collects data on blood stream infections for Hospital Benchmark Information purposes from secondary and tertiary DHBs. Both tertiary and secondary DHBs provide services to the people in their districts, but tertiary DHBs are generally larger and provide specialist services to secondary DHBs.
Six DHBs are identified as having tertiary status for the Hospital Benchmark Information (Auckland, Counties Manukau, Waikato, Capital & Coast, Canterbury and Otago) being expected to report higher Hospital Acquired Bloodstream Infection rates. For Hospital Benchmark Information purposes, it may be appropriate to also classify MidCentral as a tertiary DHB because, as a cancer centre, it provides tertiary services.
Policy directives or strategies to date, cont.
/ The criteria for hospital acquired bloodstream infections used to calculate the rate for the Hospital Benchmark Information report are:- a blood test more than 48 hours after admission to hospital shows an infection
- there is no evidence the infection was present on admission (unless the patient had been in the same hospital recently)
- when blood tests show bacteria normally found on skin, two tests are required to confirm there is an infection (unless a clinician deems there is a bloodstream infection, in which case one test is enough).
These results demonstrate the potential for improvement from implementing a programme similar to the Michigan hospitals programme.
In 2002,guidance on microbiological surveillance of endoscopes and recommendations for cleaning and disinfection were developed and published.[13] This was in response to concerns about the potential transfer of bacterial or viral infection by endoscope and cases of transmission of infection between patients via a flexible hollow endoscope and the subsequent recall of patients. The implementation of this surveillance programme by DHBs has reduced the numbers of patients who require recall. This has resulted from the number of treatmentswith endoscopes that culture positive,falling from thousands in 2002 to single figures in 2005.
On 29-30 September 2006 the World Health Organization (WHO) held a meeting in Geneva for Commonwealth Fund countries to discuss the WHO’s Action on Patient Safety (High 5s) initiative. The Deputy Director-General, Clinical Services Directorate attended to represent Australia and New Zealand.
Policy directives or strategies to date, cont.
/ The WHO identified a number of patient safety issues, including those related to medication, infection and communication between different health providers as well as between health providers and patients. The five issues agreed on for further work were:- Handwashing, using recently published WHO guidelines
- Hand-off communication
- High concentration medications
- Medication reconciliation
- Wrong site / wrong procedure / wrong person surgery, including patient identification.
- Handwashing, using recently published WHO guidelines
- Hand-off communication
- High concentration medications
- Medication reconciliation.
The Ministry and DHBs will work together to determine which hospitals (if not all) and initiatives are most appropriate when WHO has confirmed the list of issues and how initiatives are to be monitored.The WHO is planning a press event in London in early December 2006 to announce the Action on Patient Safety (High 5s) initiative.
Implementation of a national surveillance programme in New Zealand has been seriously considered and examined by the Ministry since 1996. In the early 1990s, HAISS (the ‘hospital-acquired infection surveillance system’) was proposed and in the late 1990s a national surveillance programme with the acronym ‘RISK’ (reducing infection through surveillance and knowledge) was proposed as a joint venture between Alexander and Alexander, the Institute of Environmental Science and Research and Medlab South. Initial development of both systems involved computer software designed by the Institute of Environmental Science and Research. HAISS allowed for surveillance of non-traumatic surgical wounds throughout hospitals and for intensive care unit-based surveillance of pneumonias, bloodstream infections and urinary tract infections. However, both of these previous proposals were deemed cost-prohibitive at the time.
Policy directives or strategies to date, cont.
/ A recent survey of DHBs which was undertaken to identify activity that relates to the six priorities for quality has revealed that a number of DHBs are working on various aspects of infection prevention and control.Strategies that were identified through the survey include:
- Northland DHB: has developed infection control link nurses in each ward/department and a programme of monitoring of intravenous sites.
- Auckland DHB: measure blood stream infection rates six monthly in ICC
- Wairarapa DHB: has provided education sessions on the use of personal protective equipment to hospital services and some community providers
- Counties Manukau DHB: has implemented a Multi Resistance Taskforce; undertaken targeted surgical site surveillance; hand washing programmes and ongoing compliance to Infection Control Standards.
- Otago DHB :implementation of hand gels throughout the organization in association with a 'Keep your dirty hands off me" campaign.
The recommended programme scope