Prima non nocere — new strategies are needed to eliminate preventable healthcare-associated infections

It is estimated that 5–10% of hospital inpatients develop healthcare-associated infections (HAI)¹, many of which are preventable.² Pathogens that cause HAIs are often resistant to antibiotics, prompting fears of the ‘end of the antibiotic era’.³

Significant differences in HAI/ABR rates, between apparently similar hospitals and units, suggest they are not inevitable collateral damage. Instead they reflect, among other things, differences in infection prevention and control (IPC)⁵ practices, organisational cultures,⁶ professional attitudes⁷ and workloads.⁸

In Australia and elsewhere, greater awareness of HAIs among healthcare administrators and clinicians, and reduction in some HAI rates, has resulted from, inter alia, mandatory public reporting, accreditation requirements and occasional, well-publicised infectious disease outbreaks or threats. However, day-to-day experience suggests that IPC remains a low priority for many busy clinicians and healthcare organisations with competing demands for limited resources. Among clinicians, doctors are the group least likely, overall, to prioritise and comply with IPC measures.^9,10 For example, audits of hand hygiene compliance generally show 15–20% differences between doctors and nurses.¹¹

In a focus group study¹² among hospital staff, non-medical participants rated doctors’ hand hygiene practices as the worst. Doctors generally followed the example of senior colleagues, overestimated their compliance and were concerned that performing hand hygiene before patient contact would be negatively perceived by patients.¹³ There are wide variations in doctors’ compliance within hospitals, between specialties⁹ and between different levels of seniority and education.¹⁴ Senior doctors’ attitudes and behaviours are the major influence on those of junior doctors and other hospital staff.¹⁵

Numerous interventions can, at least in the short-term, improve IPC compliance and/or reduce HAI rates,^7,16 but most studies have failed to address how they do so¹⁵ or account for the complexity and contexts of IPC activities or barriers to sustainable improvements. Organisational factors associated with successful adoption of new IPC practices include structure (leadership, resources); culture (shared mission, values); politics (interprofessional relationships); and emotion (commitment to a shared vision).¹⁷

Many senior doctors are sceptical that failure to observe IPC practices causes harm; perhaps understandably, since its effects are usually invisible, cumulative and delayed. Well-designed HAI surveillance, with timely feedback of results to clinicians, can lower rates.^18,19 It is not clear how it does so, but specificity (for patient and doctor) and timeliness of feedback are important, suggesting that it promotes clinician awareness and accountability.

Further attempts to improve doctors’ IPC practices must address medical practice models and beliefs, to which they are apparently antithetical. IPC practice involves habitual, rule-based behaviours, with no immediate reward or consequences of omission. Doctors often complain — sometimes with good reason — that IPC policies are unnecessarily rigid and cumbersome and efforts to enforce them are intrusive. By contrast, the medical practice model typically involves solving specific clinical problems and emphasises professional autonomy and personal achievement.

Many doctors see serious HAIs as unpredictable, rare events which they are powerless to prevent, and often attribute them to patient comorbidities or ‘system failure’. They are often unaware of less serious but more common and, for patients, distressing HAIs.

Resolving these issues will require more consistent organisational commitment, senior clinical leadership and innovative strategies to increase awareness, interest and participation in IPC of whole-of-hospital communities.

References

1. World Health Organisation. Report on the burden of endemic health care-associated infection worldwide. WHO, Geneva, Switzerland, 2011.
2. Umscheid CA, Mitchell MD, Joshi JA, et al. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol. 2011; 32: 101-14.
3. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2013: US Department of Health and Human Services, 2013.
4. McGowan JE. Antimicrobial stewardship--the state of the art in 2011: focus on outcome and methods. Infect Control Hosp Epidemiol. 2012; 33: 331-7.
5. Scheithauer S, Lemmen SW. How can compliance with hand hygiene be improved in specialized areas of a university hospital? J Hosp Infect. 2013; 83 Suppl 1: S17-22.
6. Gardam M, Reason P, Rykert L. Healthcare culture and the challenge of preventing healthcare-associated infections. Healthcare Qual. 2010; 13 Spec No: 116-20.
7. Edwards R, Charani E, Sevdalis M et al. Optimisation of infection prevention and control in acute health care by use of behaviour change. Lancet Infect Dis. 2012; 12: 318-29.
8. Daud-Gallotti RM, Cost SF, Guimarães T, et al. Nursing workload as a risk factor for healthcare associated infections in ICU: a prospective study. PLOS ONE. 2012; 7: 52342.
9. Pittet D, Simon A, Hugonnet S, et al. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med. 2004; 141: 1-8.
10. Erasmus V, Daha TJ, Brug H, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol. 2010; 31: 283-94.
11. Hand Hygiene Australia. National Data Period Three, 2014.
12. Jang J-H, Wu S, Kurzner D, et al. Focus group study of hand hygiene practice among healthcare workers in a teaching hospital in Toronto, Canada. Infect Control Hosp Epidemiol. 2010; 31: 144-50.
13. Jang JH, Wu S, Kurzner D, et al. Physicians and hand hygiene practice: a focus group study. J Hosp Infect. 2010; 76: 87-9.
14. Duggan JM, Hensley S, Khuder S, Papadimos TJ, Jacobs L. Inverse correlation between level of professional education and rate of handwashing compliance in a teaching hospital. Infect Control Hosp Epidemiol. 2008; 29: 534-8.
15. Erasmus V, Brouwer W, van Beeck EF, et al. A qualitative exploration of reasons for poor hand hygiene among hospital workers: lack of positive role models and of convincing evidence that hand hygiene prevents cross-infection. Infect Control Hosp Epidemiol. 2009; 30: 415-9.
16. Huis A, Holleman G, van Achterberg T et al. A systematic review of hand hygiene improvement strategies: a behavioural approach. Implement Sci. 2012; 7: 92.
17. Krein SL, Damschroeder LJ, Kowalski CP et al. The influence of organizational context on quality improvement and patient safety efforts in infection prevention: a multi-center qualitative study. Soc Sci Med. 2010; 71: 1692-701.
18.  Kok J, O’Sullivan MV, Gilbert GL. Feedback to clinicians on preventable factors can reduce hospital onset Staphylococcus aureus bacteraemia rates. J Hosp Infect. 2011; 79: 108-14.
19. Sykes PK, Brodribb RK, McLaws ML, McGregor A. When continuous surgical site infection surveillance is interrupted: the Royal Hobart Hospital experience. Am J Infect Control. 2005; 33: 422-7.

*Lyn Gilbert is an infectious diseases physician and clinical microbiologist whose current research interests include the ethics of hospital infection prevention and control, antimicrobial resistance and emerging infectious disease preparedness and response. She is a Professor in Infectious Diseases at Sydney Medical School, Senior Researcher, Marie Bashir Institute for Infectious Diseases & Biosecurity & Centre for Value Ethics and the Law in Medicine (VELiM), University of Sydney and Consultant Emeritus, Western Sydney Local Health District.