The Role of Australian Consumers in Infection Prevention and Control

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Healthcare acquired infections (HCAI) contribute an additional strain on healthcare systems by increasing patients’ morbidity and mortality. It has been previously suggested that 7 out of every 100 patients admitted to hospital will be affected by a HCAI [1]. This means that each year there are around 200,000 cases and an estimated two million bed days lost in Australian hospitals [2].

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Over the last ten years there have been some great initiatives introduced into hospitals to try and reduce the rate of infections. Initiatives have been aimed at encouraging healthcare workers (HCWs) to wash their hands and get vaccinated, and at strengthening surveillance activities and improving environmental cleaning. The problem is that there continues to be a pervasive lack of compliance to evidence-based infection control guidelines to prevent HCAI [3]. The reasons for low compliance with infection control strategies in the healthcare setting are multi-factorial and can include a lack of awareness about infection control issues; ineffective communication and dissemination of guidelines; time constraints; workload pressures; disagreement over the composition of infection control guidelines; high risk patients; overcrowding; understaffing; and outbreaks [3, 4].
Ten years ago the World Health Organisation (WHO) decided to approach the HCAI problem from another angle. They suggested that hospital patients could advocate for safer healthcare settings and play a more active role in the prevention of HCAI. It has been suggested that patients and their families provide a unique perspective on the system and in doing so can help identify risks and solutions for reducing harm. Involving patients in their healthcare has been used to promote medication adherence, improve patient safety after surgery, and foster open communication with hospital HCWs [5]. Strategies to involve patients in clinical safety generally fall into five categories: inviting patients to provide feedback, directly involving patients in improvement strategies, encouraging patients to share information, getting patients to intervene directly and working with patients so that they are better able to manage their treatment regime safely [6].
The idea of involving or empowering patients to take a role has been around since the 1970s in healthcare, but it has only recently been expanded to the field of patient safety [7]. The term empowerment can have different meanings and interpretations, but in healthcare, it generally refers to the process that allows an individual or a community to gain the knowledge, attitudes and skills needed to make choices and participate in their care [8]. This marks a shift from a more passive to a more active engagement of patients, families and communities in both their own health and in the delivery of health services. Perhaps not surprising there have been several criticisms directed at this approach. There is concern, for example, that this shift of emphasis is actually about transferring some responsibility to patients for their care in order to reduce healthcare costs. The possibility also remains that an over-reliance on patients to care for themselves could also inadvertently lull HCWs into a false sense of safety. For other clinical staff, relinquishing ‘control’ to patients threatens their professional identity [9]. Underpinning each of these criticisms is a central concern that relying on patients to check on the care they receive from health professionals is neither an effective nor an appropriate strategy for promoting patient safety. However, the counterargument is that a paternalistic approach centred on the notion of professional infallibility is no longer relevant in a consumerist 21st century. Patients are now actively using the Internet both individually and as part of support groups, to gather and assess information about their conditions and their care. Consumer engagement strategies are not relying on patients to check on the delivery of their healthcare to ensure their safety; rather they actively involve patients in their own care, as a part of a range of efforts are made to improve both the quality and the safety of their care [9].
In regards to empowering patients around the HCAI issue, one previous stream of activity has been an empowerment program aimed at assisting both patients and their healthcare providers to remember to ask and perform hand hygiene (HH). Patient empowerment is an integral part of the WHO HH multimodal strategy. In 2009, the “Save Lives: Clean Your Hands” campaign, an extension of the 2005 “Clean Care is Safer Care” WHO Patient Safety Challenge, was launched to stimulate international efforts in promoting HH compliance among HCWs in an endeavour to reduce HCAI [10, 11]. In the United Kingdom, the National Patient Safety Agency initiated the “Cleanyourhands” campaign, aimed at best practices in HH compliance among HCWs, with an emphasis on performing HH “at the right time and in the right place” [12]. A central message of this campaign was “It’s OK to ask,” encouraging patients to ask HCWs whether they had performed HH before providing patient care [13].

Why don’t patients feel comfortable to ask their healthcare staff to wash their hands before touching them?

While studies generally report high levels of ‘willingness to participate’ in programs, rates of actual engagement with staff around HH are significantly lower. So why don’t patients feel comfortable to ask their healthcare staff to wash their hands before touching them? We recently undertook a program of research to explore the attitudes and readiness of hospital patients from Sydney, Australia towards the use of patient empowerment as a strategy to reduce HCAI [14, 15].
We undertook in-depth interviews with a sample of patients from the surgical department of a large public hospital and found that while patients generally agreed with the sentiment that they had a role to play in the prevention of infections, most felt that their role was limited to maintaining their own personal hygiene. They did not mention interacting with staff members. When asked whether they would be comfortable to engage with staff members, many voiced concerns about upsetting or annoying the staff member. Other participants were concerned that by speaking out it would be perceived as a criticism of the staff members work. Of concern, was that some patients believed that there would be negative consequences on the quality and delivery of their healthcare if they spoke out about infection control or asked a HCW to wash their hands [15]. Amongst the patients we interviewed, we found that there were low levels of health literacy about HCAIs and very little provision of information.
The second stage of our study was to develop a patient empowerment tool aimed at increasing awareness and engagement of patients in preventing HCAI [14]. We undertook a pilot study to examine the receptiveness of hospital patients toward the new empowerment tool which involved following up a group of surgical patients and comparing the attitudes of patients exposed to the patient empowerment concepts to a control group. At the baseline, just over half of the participants were highly willing to assist with infection control strategies. Participants were significantly more likely to be willing to ask a doctor or nurse a factual question then a challenging question. At the time of discharge, 23 of the 60 patients reported that they had discussed a health concern with a staff member; however, only three participants asked a staff member to wash their hands. Participants reported that they found the material interesting and informative and a good starting point, with one participant suggested the material “opened your eyes”. However, they also felt that there needed to be information on: what symptoms to look out for, on the myths about HCAI, and about the rate of infections in hospitals.
While there has been a shift in the rigid structures of healthcare of yesteryear towards a space that recognises that patients have an important role to play, healthcare authority is still very strong and the concept of ‘confronting’ hospital staff goes against what some people believe is normal and accepted. Patients will continue to be unwilling or unable to engage with staff or adopt behaviours to promote infection control, unless they are empowered and encourage to by their health providers. Somehow we need to start passing on the message that hospital staff would actually appreciate and welcome a friendly reminder about hand hygiene.
In attempt to get this message across, some hospitals have previously used posters, pamphlets, bedside reminders and other visual aids. However, there has not been a comprehensive evaluation of these mechanisms and one cannot currently conclude which approach (or combination of approaches) works most effectively. It has been suggested that communication cues need to be developed for staff members to assist them with answering questions about HCAI and about infection control and to aim them with engaging with patients around HH. However, staff must also be encouraged to take the initiative to tell patients about HCAI/infection control and to continue to provide cues throughout the patients stay at the hospital. Staff need to be convinced about the potential gains from an ‘empowered patient’ i.e. that if they are more aware, taking responsibility, contributing to infection prevention, being an advocate to family members and visitors etc. Given that staff members are very accepting of the concept of patient centred care, emphasis should be placed on how patient empowerment builds on from that concept.
For patients, the ultimate value of an infection control program is measured by lower rates of infection, higher rates of survival, avoidance of or decreases in morbidity, shorter periods of illness or hospital confinements and more rapid return to good health. Reductions in readmissions, extended hospital stays and costs are just some of the benefits to the hospital system that will result from a reduction in healthcare associated infections.
The trend to include patients in safety initiatives is growing. Although the role of the patient in HH as a means to prevent infection has been recommended by others, patient engagement remains an underused method of preventing HCAI. Evidence suggests that patient participation does yield positive results, and that most patients are willing and able to not only participate in their own hand hygiene but also to engage with hospital staff and encourage them to comply with it. However, more work is needed to acknowledge and address the unequal power relationship between patient and health workers, the resulting vulnerability of patients and their natural fear of raising concerns about infection control in case it affects their care.
 

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Dr Holly Seale

Dr Holly Seale is a Senior Lecturer at the School of Public Health and Community Medicine, University of New South Wales, Australia. As an infectious disease public health researcher, she is particularly interested in the perceptions and behaviours of different groups of health professionals regarding infectious diseases, particularly vaccine-preventable diseases (VPDs) and disease prevention strategies, such as immunisation. She has experience in microbiology, virology, public health and epidemiology.

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References

1. Inweregbu K, Dave J, Pittard A: Nosocomial infections. Continuing Education in Anaesthesia, Critical Care & Pain 2005, 5(1):14-17.

2. Cruickshank M, Ferguson J: Reducing Harm to patients from Health care Associated Infection: the Role of Surveillance. In.: Australian Commission for Safety and Quality in Health Care; 2008: 3.

3. Gurses AP, Seidl KL, Vaidya V, Bochicchio G, Harris AD, Hebden J, Xiao Y: Systems ambiguity and guideline compliance: a qualitative study of how intensive care units follow evidence-based guidelines to reduce healthcare-associated infections. Qual Saf Health Care 2008, 17(5):351-359.

4. Pittet D, Mourouga P, Perneger TV: Compliance with handwashing in a teaching hospital. Infection Control Program. Ann Intern Med 1999, 130(2):126-130.

5. Longtin Y, Sax H, Leape LL, Sheridan SE, Donaldson L, Pittet D: Patient participation: current knowledge and applicability to patient safety. Mayo Clinic proceedings, 85(1):53-62.

6. King A, Daniels J, Lim J, Cochrane DD, Taylor A, Ansermino JM: Time to listen: a review of methods to solicit patient reports of adverse events. Qual Saf Health Care 2010, 19:148-157.

7. Steele DJ, Blackwell B, Gutmann MC, Jackson TC: Beyond advocacy: A review of the active patient concept. Patient Education and Counseling 1987, 10(1):3-23.

8. Lau DH: Patient empowerment--a patient-centred approach to improve care. Hong Kong Medical Journal, 8(5):372-374.

9. Longtin Y, Sax H, Leape LL, Sheridan SE, Donaldson L, Pittet D: Patient Participation: Current Knowledge and Applicability to Patient Safety. Mayo Clinic Proceedings 2010, 85(1):53-62.

10. Pittet D, Allegranzi B, Storr J, Donaldson L: ‘Clean Care is Safer Care’: the Global Patient Safety Challenge 2005 2006 Int. ernational Journal of Infectious Diseases 2006, 10(6):419-424.

11. Storr JA, Engineer C, Allan V: Save Lives: Clean Your Hands: a WHO patient safety initiative for 2009. World Hospitals & Health Services, 45(1):23-25.

12. Cleanyourhands campaign [http://www.npsa.nhs.uk cleanyourhands/. ]

13. Pittet D, Panesar SS, Wilson K, Longtin Y, Morris T, Allan V, Storr J, Cleary K, Donaldson L: Involving the patient to ask about hospital hand hygiene: a National Patient Safety Agency feasibility study. Journal of Hospital Infection, 77(4):299-303.

14. Seale H, Chughtai AA, Kaur R, Crowe P, Phillipson L, Novytska Y, Travaglia J: Ask, speak up, and be proactive: Empowering patient infection control to prevent health care-acquired infections. American journal of infection control 2015, 43(5):447-453.

15. Seale H, Travaglia J, Chughtai AA, Phillipson L, Novytska Y, Kaur R: ‘I don’t want to cause any trouble’: the attitudes of hospital patients towards patient empowerment strategies to reduce healthcare-acquired infections. Journal of Infection Prevention 2015, 16(4):167-173.