The Centre for Research in Critical Infection held a meeting recently at the University of Sydney, where the hazards of antibiotic resistance and barriers to infection control were key topics of discussion.
Professor Lyn Gilbert, an infectious diseases physician and clinical microbiologist, described how public reporting of hospital infections is helping to focus health services on the need for better infection control.
Patients deserve more action on hospital-related infections
Lyn Gilbert writes:
Too many hospital patients in Australia (among many countries) acquire an infection or become colonized with antibiotic resistant bacteria while in hospital.
The Council of Australian Governments (COAG) recently implemented measures designed to reduce their impact, based on the recommendations of the Australian Commission on Safety and Quality in Healthcare.
The aim of the National Hand Hygiene Initiative (NHHI), based on the WHO’s “5 Moments of Hand Hygiene” is to establish a national system to improve and measure healthcare workers’ compliance with hand hygiene and, ultimately, reduce infection. Rates of healthcare-associated Staphylococcus aureus bacteraemia (SAB) are, appropriately, the main indicator of compliance.
Two years into the program, results just published show an increase in hand hygiene compliance among staff of participating hospitals (covering 90% of public and 50% of private beds) but, so far, no significant fall in SAB rates. This is encouraging but there are still major challenges.
Hand hygiene campaigns nearly always achieve short-term improvement in compliance, but it is often not sustained; it remains to be seen whether the NHHI will be more successful.
Although overall compliance rates have improved since the NHHI began, they are still low in some hospitals, mainly those that joined the initiative recently, so are likely to improve.
In common with similar campaigns, compliance of doctors is lower than that of other hospital staff. It is not clear why this is so; it is unlikely that doctors are any less concerned with their patients’ welfare.
When asked, most doctors acknowledge the importance of hand hygiene and believe they comply, but they often demand more evidence of effectiveness when asked to change their ways.
There is plenty of evidence that hand hygiene can reduce transmission of infectious pathogens, but the effect is delayed and indirect rather than immediate and obvious.
The same applies to the effect of inappropriate prescribing of antibiotics on development of bacterial resistance, also a major problem in hospital practice and exacerbated by poor hand hygiene, which allows resistant bugs to spread to between patients.
Most doctors only see occasional patients with serious healthcare associated infections. It is often hard to convince them that it is a large, serious and, often, preventable problem that demands action.
Many doctors believe they are unavoidable “collateral damage”, in already seriously ill patients and more than offset by the life-saving miracles of modern medicine. But it is serious – some patients die, many more stay in hospital longer and suffer more than they otherwise would and the additional treatment costs the healthcare system far more than necessary.
It is only when somebody takes the trouble to count the cases and deaths, to identify what could have been done differently to prevent them and add up the costs, that it becomes obvious that this is neither trivial nor unavoidable.
The fact that rates of hospital-related infections vary enormously between countries with comparable health systems, and between hospitals with comparable case-loads, confirms that improvement is possible. Often, the studies that provide these data are short-term, unfunded projects, rather than properly planned prospective surveillance, which is the lynch pin of prevention.
Accurate surveillance data are powerful drivers of improvement. We can’t expect to fix a problem unless we know the size of it. Unless we can measure the effect of changes designed to reduce the problem, the changes won’t be sustained, especially if they are costly, inconvenient or difficult to implement.
This is why the publication of SAB rates at individual hospitals, on the MyHospitals website is welcome, despite limitations in the accuracy and comparability of the data. At this stage, there are significant differences between States and Territories in how data are collected, validated (if at all) and reported and in case definitions.
Nevertheless, they have drawn attention to the problem and their publication is a major stimulus to improving the quality of data and, more importantly, to reducing rates.
There is far more than hand hygiene compliance to reducing infection and antibiotic resistance, and much we still don’t know about how best to do it; more good research is needed.
Meanwhile, consistent, accurate hospital infection data are the best measure of the quality of infection prevention and control in our hospitals. Patients and taxpayers have a right to know and expect improvement.
• Lyn Gilbert is Director of the Centre for Infectious Diseases and Microbiology-Public Health at Westmead Hospital in Sydney, and Clinical Lead, Infection Prevention & Control Western Sydney Local Health Network
(References available on request)