HOSPITAL=20 INFECTION CONTROL

F.=20 D. Dastur , Ajita Mehta, Camilla Rodrigues, Hinduja National=20 Hospital,Mumbai

The=20 health care scene is changing in India. =20 Today two thirds of the population seek medical care in the = private=20 sector. Corporate hospitals are increasing in number as are those built = with NRI=20 funds. Medical tourism is = being=20 vigorously pursued in some areas. =20 At the same time foreign insurance companies and Third Party=20 Administrators (TPA=92s) are entering the arena. In future it is likely = that=20 hospitals will only receive reimbursement for DRGs¹ = (diagnosis=20 related groups eg. Pneumonia, hernia etc.) and not be payed for disease=20 complications such as hospital acquired infections. This will provide strong = motivation for=20 hospital administrators to promote infection control programmes which = are=20 already mandatory abroad for hospitals seeking = accreditation².=20

Do=20 Infection Control Programmes work ?

In=20 the 1970=92s in the United States the Centres for Disease Control and = Prevention=20 (CDC) began a nationwide =93Study of the efficacy of nosocomial = infection control=20 =96 the SENIC project=94. The project involved 638 hospitals nationwide. = After a=20 decade the study established that the broad overall activity of = infection=20 control programmes predicted infection rates³. The most = important=20 predictors in decreasing order of importance were intensity of = surveillance,=20 intensity of control measures, an infection control practitioner / = sister for=20 every 250 beds, presence of a trained infectious disease specialist on = the staff=20 and provision of SSI (surgical site infection) rates to surgeons in = order to=20 influence their behaviour. =20 Hospitals having such programmes demonstrated a 33% reduction in = hospital=20 infections compared to hospitals without any programme⁴. One = hospital=20 having an effective programme calculated yearly cost saving in excess of = 2=20 million dollars. Thus substantial gains are to be expected for both = doctors and=20 administrators by supporting infection control=20 programmes⁵.

The=20 Infection Control Committee

Prevention=20 of hospital infections is essentially a big policing operation. First one has to gather people = to=20 perform this function, namely the infection control = committee⁶. The core committee consists of = a=20 physician, a microbiologist and a surgeon, with representatives from = operation=20 theatres, CSSD and ICUs. Inputs are also required at times from others = in=20 housekeeping, laundry, = food=20 services and engineering, who work as a team to maintain the hygiene and = cleanliness of any institution. For committee members the job of = infection=20 control isadded on to their other commitments, so that a personworking = full time=20 is required to coordinate activities, - this is usually the infection = control=20 sister⁷. = Finally the=20 committee requires its recommendations to be implemented and so must = have access=20 to administrative heads of the institution.

Functions=20 of the Committee

The=20 committee performs three = principal=20 functions. The first is = to gather=20 data. Each institution = needs to=20 know the microflora of its high risk areas such as operating theatres, = adult and=20 neonatal ICUs, dialysis units and oncology services. A good microbiology = laboratory is essential to isolate organisms, to plot antibiotic = resistance=20 patterns and to indicate to clinicians trends and changes in hospital=20 flora⁸. The = laboratory=20 is also best suited to identify outbreaks (3 or more cases of infection = with the=20 same organism and antibiogram) and to alert clinicians=20 accordingly.

The=20 second function is to = carry out=20 surveillance⁹. Whole =20 hospital surveillance is impractical and largely meaningless. = Most=20 hospitals target surveillance at infections that (1) are associated with = a high=20 level of morbidity (eg ICU related infections and ventilator pneumonia); = (2) are=20 costly such as post cardiac surgery wound infections; (3) are difficult = to treat=20 such as infections due to antibiotic resistant bacteria; (4) are = potentially=20 preventable such as vascular access related = infections¹⁰. Having established the = baseline rates of=20 infection for any procedure, surveillance is able to detect sudden = increases in=20 these rates so that remedial steps can immediately be taken. The method thus detects = breakdowns in=20 aseptic practices or sudden outbreaks of infection¹¹. = Surveillance is=20 a powerful tool in infection control but is time consuming and = expensive. Spot=20 surveillance is sometimes a quicker and cheaper approach; for example = how many=20 people in an ICU examine patients without first washing hands or using = an=20 alcohol rub. Solution^{12, 13}.

The=20 third function of the committee is to enforce good infection control = practices.=20 For this certain concepts must be ingrained¹⁴. Nosocomial pathogens have = reservoirs and=20 are transmitted by predictable routes to susceptible hosts. Thus = hospital tap=20 water in India may be contaminated with E coli or Legionella and cause=20 infections. Operating theatre air must be kept pathogen free with the = aid of 15=20 air changes per hour and the use of bacterial filters. Sometimes members = of the=20 operating team are chronic shedders of staphylococci either from the = nose or=20 perineum, who because of their proximity to the surgical site can = initiate wound=20 infection. In the wards and ICUs cross infection is a bigger threat. = Transfer of=20 organisms on the hands of health care workers from one patient to = another makes=20 hand washing the single most important infection control = practice¹⁵.=20 At other times improperly diluted disinfectant solutions can harbour = pseudomonas=20 organisms and cause outbreaks of infection.

Hospital=20 infections are increased by invasive devices and there must be a = conscious=20 effort to remove these at the earliest opportunity. Bacteraemias, pneumonias, = urinary tract=20 infections line infections and =20 surgical site infections are the major causes of morbidity and=20 mortality. In USA 2 = million=20 patients suffer from hospital infections each year of whom 88,000 die. = The=20 estimated cost is 4.5 billion dollars¹⁶. In India this cost is more = than what the=20 Government spends on total health care. =20 Any hospital can be expected to record a 5-10 per cent incidence = of=20 hospital acquired infections even with an active infection control = programme=20 because of today=92s aggressive approach to sick = patients.

Hospital=20 Infection Control =96 the broader view

=93The=20 first requirement of a hospital is that it should do the sick no harm=94 = was=20 Florence Nightingale=92s dictum. Today this has been extended to = incorporate the=20 health and safety of hospital employees. Their needs have been = highlighted by=20 the HIV and SARS epidemics. The former gave rise to the concept of = Universal=20 Precautions (now Standard =20 Precautions) for all diseases that are infectious through blood = or body=20 fluids¹⁷. The = latter=20 which affected a disproprotionately large number of health care workers = demanded=20 strict isolation of victims in negative air pressure rooms, strict = respiratory=20 precautions for attendant health workers, and quarantine for any = contact health care worker developing = a=20 fever¹⁸. That = level of=20 discipline has yet to be achieved in India.

Hospital=20 waste disposal is also a growing issue¹⁹. In Mumbai out of = 6000=20 tonnes of waste generated daily, only 40 tonnes comes from hospitals. = But the=20 problem is that hospitals are not clearly segregating waste into = infectious and=20 non infectious and are therefore contaminating the entire quantum of = solid=20 waste. The real risk of = infection=20 comes from =91sharps=92 which transmit HIV, Hepatitis B and C = viruses²⁰=20 Waste should be handled as little as possible but there is the social = problem of=20 rag pickers who remove syringes, needles and the like and recycle these = items=20 without sterilization. = Hospitals=20 that incinerate waste containing plastics made from organochlorines, = release=20 toxic dioxin and furan gases into the environment. Both matters are of concern = for public=20 health.

The=20 reuse of expensive =91disposable=92 items merits consideration in a = resource poor=20 country like India. = Cardiological=20 societies for instance have made guidelines for the reuse of cardiac = catheters=20 after thorough cleaning and sterilization in order to benefit poor=20 patients²¹. = The=20 infection risk appears to be minimal if reuse is limited to three=20 occasions.

This=20 brief account outlines the multifaceted nature of Hospital Infection=20 Control. Moreover the = reader will=20 appreciate that infection control is a never ending struggle as medicine = becomes=20 more invasive and the proportion of ageing and immunocompromised = patients in our=20 population continues to increase.

References

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2. =20 Haley=20 RW, White JW, Culver DH et al. = The=20 financial incentive for hospitals to prevent nosocomial infections under = the=20 prospective payment system : an empirical determination from a = nationally=20 representative sample. = JAMA 1987;=20 257 : 1611 =96 14.

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