Research Report on Hospital-acquired Infections and the Dominance of Hand Hygiene in This Sector

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Introduction

Hospitals are the trusted entities for people when they are affected by serious disease conditions. However, it is an irony that hospital itself creates several complications and puts the needy in a greater dilemma. Hospital-acquired infections are one of the most common complications affecting hospital patients, in which most of them make raises the morbidity and mortality rate among patients. They include surgical site infections, urinary tract infections, pneumonia, Bloodstream infections, central line, and peripheral line-related bloodstream infections, multi-resistant organisms, Infections associated with prosthetics and implantable devices, and gastrointestinal infections. They often raise the hospital re-admission rate and thereby increase the cost of delivery of care considerably. (ACSQHC 2018) The Australian Commission on safety and quality in health care has established a standard (standard 3), which is “preventing and controlling healthcare-associated infections” aims to minimize the chances of getting preventable infections and managing them appropriately using evidence-based strategies once they have occurred. Within the sub-criteria provided, I believe “ACHIEVING MAXIMUM HAND HYGIENE COMPLIANCE” is the best possible measure to use as a tool to prevent hospital-acquired infections. Poor hand hygiene is one of the major reasons to spread of antibiotic-resistant organisms and thereby a primary cause of hospital-acquired infections. (Queensland health 2019). Thus, I believe it is worth conducting research on hospital-acquired infections and the dominance of hand hygiene in this sector. This report tries to analyse various factors related to issue, comparing the existing situation with practicable improvement opportunities and trying to find possible recommendations for a healthy health care system.

Stakeholders I need

Provision of care with the support from stakeholders benefits the health system significantly to access maximum hand hygiene compliance in preventing health care infections. Stakeholders can be both internal and external in minimising hospital acquired infections, however, strong commitment by all key stake holders s essential to achieve maximum hand hygiene compliance as there are multiple factors contribute poor hang hygiene practices. They include lack of knowledge, poor hand hygiene techniques, understaffing or overcrowding, poor access to hand washing facilities, skin conditions, and lack of institutional commitment. In achieving hand hygiene compliance, the key stakeholders’ incudes but are not limited to

1)Patients- they are extremely important stakeholders as the care provides directly affects their overall health outcome and length of stay 2) Nurses are Inevitable part of team in preventing infections 3)Physicians 4) health care leaders-Removing barriers, supply hand hygiene products to clinical areas, ensure the provision of hang hygiene posters and other educational materials. 5)Board, executives, infection control departments, auditors-Setting up of goals and expected outcomes, Auditing and other quality measurement initiatives, identify areas to improve. (Hand hygiene today 2006)

The others stakeholders can be unit techs, medical assistants, respiratory therapists, social workers, dietitians, physical therapists, pharmacists, and environmental technicians, microbiologists, administrative staff as they have frequent interactions with patients and a slight change in the hand hygiene practices can change the workflow of all of them.( Amy H et al 2018) Stakeholders Involved in the selection and installation of hand hygiene products are also relevant to ensure maximum output. Housekeeping also plays a vital role in preventing hand hygiene practices by timely refilling of hand hygiene products, dispose and manage leftover stock and garbage disposal. (Amirov C et al 2017). The more experts involved, the better will be the outcome. Each of them will be an expert in their profession. (Van Limburg M et al. “Managing stakeholders needs” and “quality communication with stakeholders” are essential while coordinating care with them. (OSSIE toolkit 2010)

Pest influence

It is worth analysing the issue based on “PEST”; political, economic, social and technological pressures on these nosocomial infections. While considering political pressures on hospital-acquired infections, funding from the government is a vital component. There would be a colossal demand for funding with the outburst of infections in a hospital facility and the unavailability of these funds would create serious laps in the quality and safety of patient care from the particular organization. (Dalzell S 2019) However, there is a recent initiative from commonwealth government Australia, which is withholding the payment to hospitals where patients have avoidable complications; aims to improve the quality of care and to reduce the cost of delivery of care. The hospital will be funded on an activity-based system, means receive money for the service they deliver. (Dickinson H 2017). However, hand hygiene is considered the most successful and cost-effective strategy which can be adopted.

The below-mentioned data enlightens how governments are benefitted adopting hand hygiene as a preventive strategy for hospital-acquired SAB infections. (Graves N et al 2016)

Economic pressures on hospital-acquired infections are another crucial concern require much attention. It is evident from the researches that people especially those who are non-citizens and with no insurance support ending up with greater financial burdens from out of pocket payments for the additional diagnostic tests, treatments, number of days in the hospital, and post-discharge complications due to these nosocomial infections. (Y. Mo et al 2019)

The below graphical representation clearly represents the increase in the cost of care as a result of hospital-acquired infections in Australia (pricing framework for Australian public hospital services).o

A Hand hygiene program conducted by the University of North Carolina hospital in the USA reveals the relevant data showcase the significance of hand hygiene to ease health care infections. (Sickbert-Bennet e et al 2016).

Comparing these two studies clearly defines the significance of hand hygiene in reducing the economic burden created by healthcare-associated infections.

Studies have also identified some social challenges due to these infections and hospital stays. Even though some people demand, strengthening their family bond due to frequent visits during the hospital stay, it is also apparent that there are disharmonies among family members due to the hospital bills, responsibilities of family members during hospitalization. Patients are also in need of multi-disciplinary approach which includes services from social workers, psychologists, emotional and financial support to enable complete recovery from post-traumatic stress as a result of extended hospital stay. (Y. Mo et al 2019). Following proper hand hygiene practices can ease the prevalence of healthcare infections and in turn, reduces the length of hospital stay.

While taking technological pressures into consideration, unsuitable isolation design, poor facility ventilation, ineffective triaging, and shortage of equipment are few of the technical errors in hospitals, especially in developing countries. (Rajakurna s 2017)

In developed countries, technological advancements play a major role to ease healthcare-associated infections. However, technological innovations such as hospital-owned tablets and iPad would act as a potential source of bacteria and would intensify the risk of patients. (Black R 2017)

Gap measurement in the healthcare organization and micro meso macro levels of analysis to resolve the issue

The major causes of health care infections include older age, poor immunity, medical conditions such as diabetes and other chronic illnesses, prolonged hospital stay, surgical and invasive procedures, inadequate hand hygiene practices, non-intact skin, Poor personal and environmental hygiene. Three levels of analysis such as micro (individuals), meso (groups within the hospital), macro (the organization as a whole) to identify the prevalent trigger in the particular organization and to resolve the issue.

Like hospitals all over the world, my health care organization is also exposed to the risk of hospital-acquired infections to a certain extend.

However, the preventive measures and strategic plan to control them show greater positive feedback to keep them under control. The policy to prevent healthcare-associated infections includes requirements for patients, staff, and visitors from acquiring preventable hospital-acquired infections, effectively managing infections if they occur using evidence-based strategies and limiting antimicrobial resistance as apart of anti-microbial stewardship. Our organisation follows seven principles;1) Governance 2) Risk and safety (Risk assessment bases on the type of procedure, health status, Clinical contacts, etc.) 3) Safe care( safe working environment through standard and transmission-based precautions, hand hygiene, aseptic technique, appropriate use of clinical devices, environmental hygiene, workforce immunisation programme4) Communication(patient-centered care, privacy, and confidentiality)5) Anti-Microbial stewardship6) Education and Training(patient and family education, staff training) 7) Compliance(Legislative compliance-public health act 2005, industry standards).

In regard to minimize these infections, my facility takes every possible initiative. Our health care facility ensures all three levels (micro, meso, macro of analysis to ensure minimizing the risk of hospital-acquired infections. Individual staff member’s infection control competencies including hand hygiene competency are assessed by unit managers (micro-level). Compliance with infection prevention and control and antimicrobial stewardship will be monitored by audits and surveillance programs by infection prevention and control committee (Meso level). Internal and external benchmarking will be performed to identify the areas of performance to be improved in the surveillance and audits (macro-level). “Environmental cleaning policy” also plays a crucial role in mitigating these infections.

However, our facility considers “HAND HYGIENE” as a simple and most effective measure to prevent hospital-acquired infections. It can be performed using either soap and water or with alcohol-based

hand rub using the proper technique (steps and duration). It is also vital to follow five moments of hand hygiene, especially in a hospital setting. The selection of the handwashing agent demand greater significance according to the situation. Patients and family members should be encouraged to participate in hand hygiene to improve the expected outcome. (ACSQHC 2020).

The below data provides a clear-cut picture of hand hygiene compliance in our hospital.

It is identified in the data that, there are missed moments especially in “before touching patients” and “after touching the patient’s surroundings”. Also, it is indispensable to note that the compliance rate is less than 85% among some health care workers such as food services, administrative staff, personal care staff and interestingly medical practitioners as well. The areas of improvement are identified which lead to the above-mentioned errors. They include improper placement of antimicrobial gel and lack of literacy regarding the 5 moments.

The process owners and stakeholders should incorporate their work to deal with the identified errors. Our organization has increased the frequency of auditing which showcased “Hawthorne effect “among our health care workers. Education and training, selection and proper installation of hand hygiene products in participation with stakeholders enabled vast improvements in hand hygiene practices. Our facility has relaunched the hand hygiene program called “Clean hands are safe hands” which covers three major areas. 1)Ongoing auditing of hand hygiene compliance (Macro and meso) 2) Auditing bare hands and arms (bare below the elbow) 3) Speaking with good judgment (Reminding people to practice hand hygiene). (Micro level).

Opportunities to improve

Concentrating more on certain areas such as opting antimicrobial hand gel as a preferred choice unless hands are visibly dirty as it has proven that alcohol-based hand rub has the broadest anti-microbial spectrum, better skin tolerability and shorter time for effective decontamination. Wearing gloves is not always protect the healthcare workers from infection, thus, hand washing should be performed at any time when indicated and after the glove’s removal. (Hand hygiene Australia). Direct observation of hand hygiene practices is a golden standard, however, controversies exist that it is a time- and resource-consuming method. Even though electronic monitoring of hand hygiene gains popularity today, researches are still in need to accept electronic monitoring as a standard due to the issues related to cost and situational awareness. (Murthy R 2018 et al). Patient participation is a potentially successful component in this area, whereas socio-cultural limitations and negative reactions of health workers would be the hindrance for effective co-operation from consumers (Alzyood M 2018 et al). Even though education and training play a vital role in improving hand hygiene practices, behavioural modification of health care workers is another key to experience quality health practices (M Pyrek 2018).

I would also like to introduce WHO’s multimodal strategic plan to improve hand hygiene compliance as it seeks immense dominance in this sector, which we can be adopted to attain successful hand hygiene compliance and thereby preventing healthcare-associated infections. Australian health system depends this strategic plan to establish improvement steps in hand hygiene compliance. Studies have proven that the key elements in this strategy would greatly suit the health system (macro-level) to achieve unprecedented outcomes in hand hygiene compliance. The five key elements include

1) System change

It includes two main areas a) Alcohol-based hand rub should be placed in all areas of point of care (example: wards, other clinical areas) or provided to staff as pocket bottles. b) Ensure access to safe and continuous water supply (one sink for every ten beds and disposable towels)

2) Training and education

Ensure all staff in the clinical setting follow the proper techniques and “five moments of hand hygiene” through training and education. It is essential to establish short, medium and long-term updating programs to ensure the quality and safety

3) Evaluation and feedback

Monitor hygiene practices and infrastructure in the frequent intervals, constructive feedback should be provided to the staff based on their knowledge and performance.

4) Reminders in the workplace

Prompting and indicating the importance of hand hygiene is vital in a clinical setting via positioning the posters. “How to” and “5 moments of hand hygiene” are in the first line in this area.

5) Institutional safety climate

Create an environment and perceptions which promotes patient safety, while guaranteeing hand hygiene improvement as a higher priority at all levels

To implement this strategy in place WHO has provided stepwise approach, they comprise

Step1: facility preparedness – readiness for action
Step2: baseline evaluation – establishing knowledge of the current situation
Step3: implementation – introducing the improvement activities
Step 4: follow-up evaluation – evaluating the implementation impact
Step 5: ongoing planning and review cycle – developing a plan for the next 5 years (minimum)

To summarise, the below infographic image the overall expectation of this multimodal strategic plan. The organization (Macro level) plays a major role in the application of this model: however, collaboration with the other two levels such as health care leaders (Meso level) and individual staff members (Micro level) is inevitable to reap maximum expected outcome.

Overall hand-hygiene compliance in pilot sites worldwide before and after implementation of WHO’s improvement strategy by category of health professional (A) and hand-hygiene indication (B)

Anticipated benefits and potential difficulties of implementing who’s multimodel strategy

Multiple pieces of research and studies ha proven the existing and anticipated benefits of WHO’s multimodal strategy for hand hygiene compliance. Australia’s health system has adapted this strategy and modified it for the Australian environment. WHO insists on the relevance of including a range of complementary strategies instead of a single strategy to cover structural, institutional and organizational factors. Even though hospitals worldwide have accepted these initiatives, proactive steps should be taken for quality implementation by limiting flaws and errors.

When considering the barriers of implementing these strategies, there are potential consequences with a different system, resources, and cultural backgrounds. Risk of resistance to change, scarcity of continuous resources for sustainability, cultural and religious barriers for adoption, scale-up, and maintenance. (Allegranzi B 2013). It is also noticed, implementation of isolated elements such as a change in the infrastructure and distribution of educational posters does not guarantee the successful hand hygiene compliance whereas, strong commitment and involvement of management with security actions, constructive feedback with active and permanent methodologies for education are essential to ascertain sustainability in the implemented strategy (Valim M D 2019et al).

All the other aspects mentioned above for the “opportunities to improve” should also be monitored and implemented appropriately for the effectiveness of strategic plans in hospitals.

Recommendations

In our current scenario of COVID 19, we all have acknowledged the pertinence of maintaining hand hygiene in our day to day life and we should be more sensible when it comes to hospital ambiance. In ACSQHC standard 3, there are several other criteria along with hand hygiene that should be considered while aiming to prevent healthcare-associated infections. Effective hand hygiene practices work hand in hand with all other infection control measures such as antimicrobial stewardship, aseptic techniques, invasive medical devices, clean environment and so on. Healthcare organizations should develop necessary initiatives to review a list of accepted strategies and apply them to the clinical practice of an individual health worker as well as institutional supportive measures to encompass overall hospital-acquired infection efforts.

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