Empowering consumers to prevent healthcare associated infections: is it more than just information and involvement

As healthcare providers it is often difficult for us to view or understand clinical issues from the perspectives of healthcare consumers, their family or friends. However, the recently released National Safety and Quality in Health Care Standards and in particular Standard 3 Preventing and Controlling Healthcare Associated Infections, mandate the provision of information to and involvement of consumers in infection prevention processes and decisions¹, writes Cathryn Murphy.
To provide appropriate infection prevention information and capitalise on consumer involvement we first need to better understand our consumers. What do they expect of an organisation in terms of infection prevention? How well do they understand the risks and consequences of healthcare associated infections (HAIs)? How skilled are they to recognise an infection prevention breach and how empowered and willing are they to question a non-compliant healthcare worker? The information provided here will help you appreciate consumer perspectives. A series of actions are recommended that your organisation may wish to consider in order to recruit the healthcare consumer as a valuable contributor to your infection prevention efforts.
What do consumers expect of an institution in terms of infection prevention?
Our understanding of consumer expectations regarding infection prevention aspects of care delivery and healthcare worker (HCW) behaviour is limited mainly to hand hygiene practice^{2, 3} and more recently some disease-specific measures.⁴ The research is scant and often contradictory, which may hinder our ability to influence consumer expectations and ensure they are reality-based.
Studies of Australian consumer attitudes to HAI prevention are few. The most recent³ indicates consumer expectations similar to those in other countries where national infection prevention programs are also underpinned by government policy and legislation. In 2013, in a comprehensive review of public and patient risk perceptions, Burnett’s findings were compelling. She reported that patients “generally perceived themselves to be at high risk of acquiring an infection… within a healthcare setting”. The public also recognise that HAIs are serious. They believe that HAIs are preventable and that hospitals are generally not doing enough to prevent them. They blame doctors and nurses for HAI transmission.^{2, 4} These findings are a call to action for all healthcare workers and administrators.
Other investigators who were seeking to better understand why some patients do not question obvious non-compliance with recommended infection prevention measures found the opposite. They reported that some patients assume, often incorrectly, that all HCW’s are working within the terms of infection prevention guidelines or that hospitals are doing the very best they possibly can in addressing systemic processes that reduce HAI risk.
How well do consumers understand the risks and consequences of HAIs?
HAI transmission is often complex and dependent on multiple patient and settingspecific factors as well as HCW behaviours.
Transmission modes differ according to pathogen, and prevention measures are generally a combination of standard and transmission-based measures. Historically, these concepts have been difficult even for HCWs to grasp and may partially explain the long history of HCW non-compliance with recommendations.^5-9
Given the complexity of HAIs is it reasonable for us to expect patients, their family or their friends to understand HAI prevention and to be able to accurately interpret publically reported HAI data as an indicator of their own HAI risk? Early reports from the US suggest not and instead show a general lack of public awareness of and ability to interpret HAI rates.¹⁰ Regardless, Australia is vigorously pursuing widespread public reporting of HAIs at national, state and sector levels.¹¹
How skilled are consumers to recognise an infection prevention breach?
Recognising infection control breaches is not always easy. It is obvious when HCWs are not wearing gloves or have not undertaken hand hygiene after touching an obviously contaminated site. However, identifying inadvertent use of an unsterile piece of equipment or recognising that a HCW is incorrectly or inappropriately wearing or not wearing a specific piece of personal protective equipment requires comprehensive knowledge. It also relies on an ability to apply principles. Both tasks are well beyond what we should expect of healthcare consumers.
Regardless, various novel programs nationally and internationally have recruited healthcare consumers as self-advocates for better infection prevention. Patients and carers observing infection prevention breaches have been encouraged to raise their concerns directly with the HCW(s) involved at the time of the breach and/ or provided with materials to assist those efforts. Materials have included information about how to recognise a breach, suggested language to use when verbally expressing concern or visual cues/signs to display to a HCW at the time of the breach.
Most patients surveyed report that they want to be involved in preventing HAIs yet less than half indicate they are actually comfortable with self-advocacy in the event of an infection prevention breach. In a study of patients who had observed hand hygiene breaches only five per cent had actually asked a HCW if they sanitized their hands before providing direct care to them.^{2, 3}
For a non-HCW to self-advocate they require knowledge, skill, permission and courage as well as assurance that by raising their concern, the quality of their care and subsequent interaction with any HCW’s will not be jeopardised. As your organisation continues to implement that National Standards we encourage you to explore additional, innovative ways in which you can better engage and involve patients, carers and their families to share our quest for better infection prevention. We recognise the inherent difficulties in that challenge and offer the following suggested checklist as motivation to assist you with it.
Does your organisation engage healthcare consumers by?

1. Encouraging and supporting their infection prevention feedback with absolute guarantee that there will be no negative impact on their care?


2. Providing written permission and tools to assist their feedback?


3. Displaying up-to-date, ward-specific infection data in an prominent place and in a format which is easily understood?


4. Encouraging patients to thank and compliment staff they observe adhering to required standards of infection control


5. Reassuring consumers by guaranteeing that regardless of HCW status, rank or profession they are each equally accountable for infection prevention compliance and equally subject to reprimand or remediation.

As Executive Director of Infection Control Plus Pty Ltd, Cathryn Murphy PhD provides independent consulting services to a range of clinical, public policy and commercial clients throughout the world. In more than 25 years working in Infection Control and Prevention Cath’s career has covered senior positions within the clinical, government, non-government and professional associations within Australia and internationally.
For more than twenty years Cath helped shape infection control domestically as an Executive member and then President of both her state and national Infection Control Associations. She was a foundation member of the Asia Pacific Society of infection Control (APSIC) and an invited member of the World Health Organisation’s Expert Technical Infection Control Group. Since 2004 she has been a senior partner in Infection Control Plus.
References
1. Australian Commission on Safety and Quality in Health Care. Safety and Quality Improvement Guide Standard 3: Preventing and Controlling Healthcare Assocaited INfections (october 2012). Sydney: ACSQHC; 2012.
2. McGuckin M, Govednik J. Patient empowerment and hand hygiene, 1997-2012. J Hosp Infect. Jul 2013;84(3):191-199.
3. Reid NM, Jason Moghaddas M, Loftus MM, et al. Can We Expect Patients to Question Health Care Workers’ Hand Hygiene Compliance? Infection Control and Hospital Epidemiology. 2012;33(5):531-532.
4. Burnett E, Johnston B, Kearney N, Corlett J, Macgillivray S. Understanding factors that impact on public and patient’s risk perceptions and responses toward Clostridium difficile and other health care-associated infections: A structured literature review. Am J Infect Control. Jun 2013;41(6):542-548.
5. Rubinson L, Wu AW, Haponik EE, Diette GB. Why is it that internists do not follow guidelines for preventing intravascular catheter infections? Infect Control Hosp Epidemiol. Jun 2005;26(6):525-533.
6. Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Perneger TV. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med. Jul 6 2004;141(1):1-8.
7. Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. Infection Control Program. Ann Intern Med. Jan 19 1999;130(2):126-130.
8. Larson E, Kretzer EK. Compliance with handwashing and barrier precautions. J Hosp Infect. Jun 1995;30 Suppl:88-106.
9. Madan AK, Rentz DE, Wahle MJ, Flint LM. Noncompliance of health care workers with universal precautions during trauma resuscitations. South Med J. Mar 2001;94(3):277-280.
10. Linkin DR, Fishman NO, Shea JA, Yang W, Cary MS, Lautenbach E. Public reporting of hospital-acquired infections is not associated with improved processes or outcomes. Infect Control Hosp Epidemiol. Aug 2013;34(8):844-846.
11. Mitchell BG, Gardner A, McGregor A. Healthcare-associated infections: getting the balance right in safety and quality v. public reporting. Aust Health Rev. Nov 2012;36(4):365-366.
This article was produced with assistance from Mitchell Lancaster, Communications Assistant, Infection Control Plus Pty Ltd.