Ask the Experts: Healthcare-associated infections – surveillance, prevention and control

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Healthcare-associated infections pose a serious risk to patients, staff and visitors in addition to incurring significant costs and causing serious morbidity to those they infect. In this article we talk to two experts about issues surrounding healthcare-associated infections and infection prevention and control including the role of surveillance, the involvement of patients and the importance of behavior change.

We take a closer look at these questions and more with thoughts from Philip Russo, Associate Professor and Director of the Cabrini Monash University Department of Nursing Research (Monash University, Victoria, Australia, on Twitter as @PLR_aus) and Marylouise McLaws Professor of Epidemiology, Healthcare-associated Infection and Infection Control and a Member of the Academic Board at the University of New South Wales (Sydney, Australia).

The challenges facing healthcare-associated infections

Why do you consider healthcare-associated infections an area of unmet need?

Marylouise McLaws: To give an example, here in Australia, the last count of patient numbers with Staphylococcus aureus bloodstream infections was in triple figures, around 1500. We have many memorial days for when individuals die such as a nasty accident in Australia in 1977, when a train at high speed collided into the side of a bridge and on January 18 every year we pay our respects. However, we don’t consider the burden of bloodstream infections as serious enough to have a memorial day to mourn up to a quarter of patients with a healthcare associated bacteraemia who die.  Patients suffer and die each year from healthcare-associated infections but because they die or suffer silently, it is not acknowledged. Even if approximately 90% of patients who enter hospital leave without an infection, 10% who are adversely affected is not an acceptable level. To those 10 people out of every 100 who acquired an infection, the infection may not resolve, they may be severely incapacitated. I think that until each individual healthcare worker understands that it is their behavior that can severely impact, we won’t get to zero, or close.

What challenges are facing the field of healthcare-associated infections ?

Marylouise McLaws: The challenge for infection prevention and control now and into the future hasn’t changed, it’s all about organizational culture and the behavior of the individual healthcare worker. Until we see changes in the mentality of the individual healthcare worker, we will still see HCAIs. The challenge with hospital infections is compounded with patient movement between wards within the hospital– we don’t routinely perform typing and whole-genome sequencing to track where these infections have come from so, it’s very difficult to say to a team that they caused it.

We keep congratulating ourselves as the numbers of infections go down, but it’s premature. I believe that the challenge is changing culture. One of the big cultural issues is when we introduce a new prevention programs, and healthcare worker thinks, ‘We don’t do things like this at this hospital.’ I’ll give you the example of a project I was leading into automation in hand hygiene compliance. We ran the automation for 18 months and we also documented results from human auditing – I asked the healthcare workers at the morning handover to say to each other, ‘I give you permission to remind me to hand hygiene as I’m entering the patient’s room’. Now when we evaluated this, the worst ward, with a really low level of compliance, said to me, ’Well, we don’t talk like that around here. This is not what we do.’ Their leader had agreed to this, we had practiced it for several weeks and why shouldn’t we want to remind people about something as important as hand hygiene? So, it’s acceptable if we stop a surgeon from a serious adverse event by saying, ‘hang on, you’re just about to remove the wrong leg’ that’s okay, but reminding each other about hand hygiene isn’t?

The challenge I see is that we need to change the mindset of the nurse and doctor so that they don’t come to work to practice as an individual. Their practice should be open to criticism and practice improvement should be a group effort. So, I think the big challenge is to get the healthcare worker to realize they no longer practice individually in hospitals, they are answerable to peer review from their colleagues. Care provision should not be two parallel operations, with nurses doing their thing and the physicians doing theirs, it has to be a whole change of mentality for integrated care that integrates infection prevention.

Healthcare-associated infections are not seen as the same level of severity as a patient needing a MET call, returning to theater or having a fall on the ward because it’s very hard to pin down who has caused it – the infection is thought of as being somebody else’s fault.

The environment and emerging technologies

How important is the role of the hospital environment and equipment in healthcare-associated infections?

Philip Russo: I think the role of the hospital environment and equipment has always been important, but it has probably been somewhat neglected over the past 5–10 years. It is now starting to become obvious that it plays really a crucial role because we have data that demonstrates microorganisms can survive in hospital for long periods of time – up to several months. So, whilst they are present in the environment, unless there is appropriate cleaning being undertaken, then there is a risk of transmission.

There has recently been a lot of attention on surfaces that we call ‘high-touch surfaces’ or ‘frequently touched surfaces’, for example, bed rails, nurse bells, doorknobs, light switches etc. as these can act as reservoirs and present the largest risk of contamination as everybody is touching them.

Moreover, what we also know is that if a patient gets admitted into a room that was previously occupied by a patient who had a multi-drug resistant organism then that new patient is at an increased risk of subsequent colonization and infection with that organism; there have been a number of studies demonstrating this. These findings suggest that the environment is an important part of the hospital transmission but also that we need to focus more on cleaning, and that we need to do some more research into what the ideal cleaning model for a hospital setting is.

So, I think we are at a place now where we appreciate the environment has a really important part to play, and that has come to light largely because of multi-drug resistant organisms that are being spread but also due to our ability to detect transmission. As a result, we are starting to focus on studies that are looking at better cleaning models.

Can new or emerging technologies help to detect, prevent or target healthcare-associated infections?

Philip Russo: I was involved in a recent review of the Australian infection control guidelines, a document that provides recommendations and guidelines for infection prevention in all healthcare facilities, everything from hospitals to family doctor offices. Often some of the recommendations are very broad and general, but one of the areas that we reviewed was the use of new solutions that have come into light.

Specifically thinking about new cleaning technologies, technologies such as hydrogen peroxide vapor disinfection and ultraviolet light disinfection have seen quite a bit of research demonstrating their efficiency, and clearly some hospitals were also already using some of this technology. Part of what the guidelines review did was to commission a systematic review on the existing evidence for those technologies in reducing the acquisition of healthcare-associated infections (and these are available on this website). Generally speaking, we found that whilst there some studies that do demonstrate that effect, we were unable to come up with a strong recommendation that those technologies should be used and really at this stage there is not enough data. The studies that have been undertaken are perhaps not of the highest quality and have reasonable amount of bias in them, so we were unable to look at that data and come up with a strong recommendation.

So, I think certainly this is an area where there could be an explosion of activity in the next few years, and it is certainly attracting a lot of industry interest. Further studies will continue to happen, and I would expect that at some stage that these technologies will be demonstrated to be very effective in reducing the healthcare-associated infections.

Leadership, behavior change and patient engagement

How important is leadership for the control and prevention of healthcare-associated infections?

Philip Russo: I think leadership is crucial because a lot of infection prevention interventions require behavior change and a change of practice. Often it is a practice that has been done routinely for a number of years and so when you are trying to change practices to improve infection prevention you often get the response: ‘This is the way that we have always done it.’

So, when you are designing interventions it is important that you get leaders on board – this could be champions from clinical staff or champions from the executive staff who will push that cause. A common example here in Australia is that you often see the Chief Executive Officer leading the campaign for the annual influenza vaccination program, they are often pictured getting their injection. At a very simple level that can work, I think that strong leadership is crucial for behavior change.

We have also seen the influence of leaders in hand hygiene programs both in Australia and internationally, if you don’t get the support of the leaders in the hospital then it is very difficult to run those programs successfully. Finally, there are a number of infection prevention bundles – where a number of interventions that put together prevent infections, for example, surgical site infection bundles or central line-associated bloodstream infection bundles. So, these are several smaller activities that you undertake as a team but they often require a change in historical practices, and again you call on leadership to demonstrate and support those causes.

Marylouise McLaws: I think that leadership is absolutely pivotal to infection control. However, I believe that you can’t introduce leadership without understanding the culture. A leadership program in one cultural setting may not work for another –there is not a one size fits all approach. We all come from a different social background. Having worked and observed in many different countries I understand the need to be respectful of the appropriate leadership style. For example, in Australia, very formal, dictatorial leadership won’t work well at all, but it might work very well where that style is the social norm.

I don’t think physicians or the nursing profession are taught leadership. Medical training focuses on clinical practice, and do not teach leadership, and this needs to change. I think that leadership is the only solution to changing poor infection prevention related behavior. I think we need to supplement those who have already gone through medical and nursing schools with leadership training and start to include leadership for the next generation of nursing and medical students.

However, not everybody’s going to be a leader – it’s okay to be a follower! We always talk about the importance of good leadership, but good followership is also important. I think we need to teach doctors and nurses we expect them to be good followers of guidelines and policies, but they don’t comply as often as they should, and I think patients are often lucky that they don’t get more infections. I think followership needs to be developed, it’s about following protocols and also following the leaders.

How important is communication between hospital departments for infection control intervention?

Philip Russo: I think what we need to remember is that there is never one single intervention that is going to prevent all healthcare-associated infections, so for example, it is no good having great hand hygiene in your hospital if your hospital is dirty and it is no good giving antibiotics on time before a surgical procedure if sterile instruments are not used.

Often its a whole range of activities and interventions that decreases the risks of infection, so that means there are different people involved, different healthcare worker groups, different departments that are engaged in preventing infection. That’s probably common internationally –infection prevention is everybody’s business – so that needs to be facilitated by good communication both between staff and between departments within the same hospital.

Do you think patient and public engagement is important in taking infection prevention control strategies forward?

Philip Russo: Yes, I do. In Australia, we have this term ‘the pub test’; it is often used in relation to politics, so for example, if a politician is found to have given their family a job in their office you go to the pub and ask the people there if they think that is an acceptable behavior or not – it is supposed to represent the ‘common man’.

I think we can also apply that philosophy to infection prevention in hospitals because as clinicians, researchers and hospital executives it is often easy to lose touch with what is not acceptable for the average consumer. What is acceptable to the clinician or the hospital executive might not actually be acceptable to the public, and what we see as priorities may be completely different to what the public sees as priorities, so I think it is really important to engage patients and the public.

Most hospital boards in Australia would have a consumer as a board member, although I am not sure if it is common to have them as members of the infection control committee. There is also a big momentum to involve consumers with research, which is what I’m involved in, not only in the planning of research but also in determination of the outcomes. I am also an advocate of transparency in public reporting. I think that we should be very open and transparent in performance data from our hospitals.

So, in the context of Australia, which is quite different to many other countries, we don’t have a national surveillance program, and we currently don’t have any meaningful public reporting of healthcare-associated infections– certainly this is being discussed and it will happen in the future and I think this will be an excellent way to engage with public.

Marylouise McLaws: I think that ethically, morally, our patients have a right to have the risks and benefits of certain practices and procedures discussed with them. But are we moving the responsibility of being a good practitioner onto vulnerable patients and their families? For example, hand hygiene, if a patient, or their families asks a healthcare worker, ‘Have you practiced hand hygiene?’ that places that patients and their family in a very difficult position with their healthcare worker because most nurses and doctors aren’t ready yet to be told, to be questioned. Currently questioning a simple thing, like ‘Why should I take this tablet?’ can often set up a difficult relationship, and asking about something like hand hygiene can really put a wedge in a trusting relationship. So, the ethics of placing the onus of infection prevention onto a patient and their family can be problematic.

I think the challenge is for healthcare workers to be taught to accept a patient and their family’s request for knowledge and accept being questioned. That’s not going to necessarily happen readily in this current cohort of doctors and nurses, the challenge is for the next generation to be taught that this is part clinical practice; ‘I’m your doctor, I will share your treatment decisions and this also includes you questioning me’. And again, this change comes back to behavior and leadership.

Surveillance, antimicrobial resistance and final thoughts

Do you think increasing antimicrobial resistance globally is presenting additional challenges?

 Marylouise McLaws: Absolutely. In Australia I haven’t seen a poster in a public place yet that asks if we really need that antibiotics for a cold this winter? I don’t think the public help and the prescribers are not diligently following the guidelines. In a survey of public hospitals released in 2014 reported around 40% of patients in public hospitals were prescribed at least one antibiotic of which a quarter were considered to be noncompliant with guidelines and a quarter were inappropriate. I think the extra challenge is that prescribers are not taking the rise in resistance seriously because writing a prescription is not like performing a surgical procedure, it’s writing a drug that they’ve been prescribing for years and they can’t see the looming catastrophe. Prescribers need to consider that writing a prescription is like performing a surgical procedure – it’s serious and it needs preparation and consideration. The challenge is to get prescribers to understand that they are about to perform a very important and potentially life-threatening event every time they pick up the pen or enter their request online.

Finally, how important is surveillance for the prevention of healthcare-associated infections?

Philip Russo: It is crucial. We often say that surveillance is the cornerstone of infection control and the reality is that the entire value of an infection prevention program in any hospital is totally dependent on the quality of surveillance. Quite simply, if you don’t know who is getting infected – where and how many cases – then you cannot possibly plan interventions that are going to have any effect.

Surveillance programs need to be purposeful and goal-directed – this is an issue when it comes to areas that mandate surveillance on certain activities, which might not be in alignment with the hospital’s priorities at the time, so I think surveillance programs needs to be flexible, they need to be able to adjust to various demands over time and they need to be constantly reviewed.

The other area I think is evolving quite rapidly in surveillance is that traditionally it has been very time consuming, it’s required a lot of footwork from infection prevention staff to try and identify those patients who have acquired an infection. However, the advent of electronic medical records and the development of automated surveillance programs has meant that those resources have been able to be reduced. There has also been some recent research on the development of algorithms that can look at databases and some of these have proven to be equally accurate in identifying patients with infections as the traditional gold standard of staff identifying these. So, I think there is a lot of potential there, and there is the possibility this is going to explode is with the use of artificial intelligence.

The ideal situation would be that, because of the huge datasets we are now able to look at, we can predict those patients who are more likely to get an infection when they walk into the hospital – and through artificial intelligence, machine learning etc. I think that is a real possibility in the future. Surveillance is crucial, but I think we also need to change our mindset about how it has been done in the past and be a little more innovative in looking forward.

Marylouise McLaws: The challenges for surveillance are around using it for prevention. We focus on surveying outcomes but I don’t believe we focus on rapid feedback of the information. Moreover, we’ve now understood the bundling processes, which has been a wonderful awakening that it does take multiple things to prevent infection because there are so many complex and small issues that may not have reached an evidence-based level, but professionals agree may likely cause infection or be somehow associated.

I think this has been a very good strategy but one of the problems is we focus on outcome surveillance instead of process surveillance of the elements of bundles. As an ex-WHO advisor for countries developing surveillance I asked them to focus on process surveillance. The challenge was these countries want to ‘have what the high-resource countries are having’, which is outcome surveillance. It wasn’t until the SARS outbreak that there was a realization that we should get the process right first without the fancy outcomes analysis. After all, it doesn’t matter how accurate you are at measuring outcomes you still need to go back and work out the cause.

Process surveillance is important even in high-resource countries where the numbers of healthcare-associated infections are often small. The question is, why are we still having problems? I think it’s because we still need to survey each process in the bundles. I think the challenge is to accept that we need to go back to process surveillance. We certainly do that for sterilization, we check it’s reached the right temperature and pressure time, and I think that we need to do this for infection control, instead of thinking, ‘We’ve only had a few CABG infections, so we’re doing great.’ This also ties into the challenge about culture and behavior of complying with processes.

Is there anything else you wanted to add, anything you particularly wanted to highlight?

Marylouise McLaws: Leadership and behavior of every healthcare worker – these are the key challenges for infection prevention.

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