Infection Control

Resurgence or Reaction?

The existence of hospital infections and the techniques for prevention have been clearly described for many years.1 Even before SARS affected the world, infection control was already an established field. Even then, there were several international reference journals already and a host of professional societies across the globe established in the field. However, appropriate attention was never given to the problem. Few hospitals would be willing to admit that they are wanting in their infection control systems, but whenever an audit is done, deficiencies are detected. The audit by the UK's National Audit Office, for example, found that nearly 90 per cent of the hospitals in UK2 did not meet the one infection control nurse (ICN) for every 250 beds ratio recommended by international guidelines.

After the SARS outbreak, infection control is finally receiving the priority it deserves. We must ensure, however, that this is not simply a knee jerk reaction. The Joint Commission of the United States pointed this out when they introduced their new infection control standards, which should go into effect in 2005.4 Hospitals were advised not to take a quick-fix approach to the problem of reducing infections, but rather it must be a long-term commitment not simply the 'problem of the month'.

Perhaps one reason for the lack of focus for infection control is that there is nothing 'spectacular' in its preventive techniques. Many of the preventive measures recommended seem so mundane. It is now known that most nosocomial infections that are preventable are due to patient-care practices, of which hand washing is the best known.5 However, to implement these practices is never easy and often have to encroach on the daily workflow of frontline staff. When there are no severe infections, like SARS, affecting the hospital, the constant call for compliance to these practices can be even construed as an irritation by frontline staff. This was well illustrated by the experience of Semmelweis, recognised as the father of hospital infection prevention. In 1860, he clearly showed that poor hand hygiene was related to the high infection and mortality rate in his labour ward. He insisted on proper hand hygiene for all medical staff, but the resulting controversy was so fierce that he had to finally leave the hospital.

The SARS epidemic has helped the hospital community to realise the importance of hospital infection control. A unique feature of SARS is that hospital staff are also affected while, in the past, most hospital-acquired infections mainly affected the patients. Other than SARS, the usual hospital infection pathogens are often organisms that are already colonising the patient. These include, for example, Staphylococcus aureus found on the skin or E coli in the gut, and when the usual defenses of the patients are compromised, an infection results. This occurs when a surgical wound is contaminated or the gut is perforated. However, the hospital staff would not be affected, because they are usually in good health during the course of rendering care to the patient. It is a different scenario for SARS because both staff and patients have no immunity to this new virus and, when contamination occurs, both became infected.

The essential ingredient of a good infection control programme has been defined by vigorous research dating back to the 1970s. The classic 'Study in the Efficacy of Nosocomial Infection Control' (SENIC),5 conducted by the Centers of Disease Control in Atlanta established these parameters by careful analysis of data deriving from more then 6000 hospitals in the USA. Guidelines and international communiquŽ have also been written on these essential ingredients of successful infection control.3 It would be worthwhile to review these ingredients as hospitals seek to build infection control systems that would be effective in the long term.

Ongoing Surveillance

Surveillance is one of the anchor stone of the hospital infection control programme. We must know the types and nature of infections before effective control could be implemented. The SARS epidemic has drawn immense attention to cluster detection in the hospital. However, in a five-year study, Wenzel et al reported that only 10 per cent of hospital infections presented as clusters and only 4 per cent were subsequently found to be definite epidemics.7 The vast majority of hospital-acquired infections in fact belong to four big systems, namely the urinary tract, respiratory tract, surgical wounds and bacteremias. The surveillance programme must cover these systems adequately. The surveillance programme should also be ongoing and active rather then being passively reported up to the hospital by frontline staff. The results should be benchmarked with other hospitals and reported back to the appropriate groups. It has been demonstrated that, in the case of surgeon-specific wound infection, reporting back to the surgeon involved is effective in reducing the surgical wound infection rates in the hospital.

Appropriate Staff Infrastructure

As pointed out by the Joint Commission, the prevention of hospital infections: 'isn't just putting handwashes all over the organisation. You need to put the right people there.'4," The SENIC study showed that the effective control of nosocomial infections is related to having one full time ICN for every 250 beds in the hospital. Many national bodies, including the UK's,2 now also recognise this ratio as critically important. Many experts have stated that this ratio ought to be even lower for acute hospitals.9 Another finding of the SENIC study was that if a medical doctor was deployed to supervise the ICNs, the programme was more effective.5 This is done in most countries. In the USA the hospital epidemiologist is the designated supervisor,10 while in the UK, it is the infection control officer (ICO). The supervising doctor and the ICNs form the infection control team that is responsible for implementing the infection control programme in the hospital.

Appropriate Training and Education

It is essential that special training be provided for all ICNs.5 There is a body of knowledge that must be mastered by all practicing ICNs. After acquiring such knowledge, practical experience is needed to ensure competence in the field. In the USA, a special certification programme is in place to facilitate such training. As for the doctor supervising the team, although no formal training is stipulated, it is felt that: 'the increasing sophistication of the published literature argues that this is essential.'3 Infection control personnel are expected to keep themselves current in this rapidly progressing field by continuing education. Finally, the infection control team is responsible for providing education for all healthcare workers in the hospital. This could take up as much as 45 per cent of the work of the ICNs.11 The infection control doctor should also actively teach. Research had shown that when both the ICO and the ICNs teaches in the programme, the results are superior.

Intervention Programmes

Control programmes must entail the formulating and implementation of infection control guidelines and policies in the hospital. It is now recognized that these must be evidence based and supported by the scientific literature. There are many 'rituals' that are shown to be ineffective like the soaking of equipments in disinfectants or the cleaning of the floor with these chemicals. All clusters of infections must obviously be investigated and the appropriate response taken. It is often not appreciated that such investigation must be done rapidly, as the hospital is a collection of susceptible patients to many potential pathogens and the appropriate control measures should be implemented within 48 hours. The infection control team must collaborate with the facility's employee health programme to ensure that appropriate mechanisms are in place to evaluate and manage infectious diseases occurring among the staff. Immunisation must also be provided for all staff and it is the responsibility of the infection control team to ensure that this is provided and the records are appropriately kept for future reference.

Support Mechanisms

Support of the laboratory is critical in the work of infection control. Microbiology data from the data should be reviewed daily by the infection control team to identify potential clusters and other trends. The investigation of outbreaks would also require adequate laboratory support and it would be convenient if the office of the ICNs is located near the microbiology laboratory in the hospital. Adequate office space should be made available to the infection control team and without doubt, computers and the appropriate access to the hospital information system must be made available.

The above five points represent merely the bare essentials of a good infection control programme. Other activities should be initiated when needed. For example, staff consultation and active programmes of antibiotics audit and control are undertaken by many infection control teams. However, as pointed out by the Joint Commission, an effective programme can only be realised if there is organisation-wide involvement and commitment. It can never be implemented by the infection control team alone.

This new interest in infection control could indeed be the catalyst to spark off a new golden age for the field. However, if not conducted with commitment and care, it could simply be a reaction and not a resurgence.

References

1. LaForce, FM. 'The Control of Infections in Hospitals 1750-1950' in Prevention and Control of Nosocomial Infections 3rd edition, Editor Wenzel, RP. pp 1-17, 1997, Williams & Wilkins, Baltimore.
2. The Management and Control of Hospital Acquired Infection in Acute NHS Trusts in England National Audit Office. 2000, The UK National Audit Press, London.
3. Scheckler, WE; Brimhall, D; Buck, AS; et al. 'Requirements for Infrastructure and Essential Activities of Infection Control and Epidemiology in Hospitals: A Consensus Panel Report' Infect Control & Hosp Epidemiol 1998;19;114-124
4. 'JCAHO revises IC standards, add new patient safety goal for 2004' Briefings on Infection Control pp1,2 January 2004.
5. Haley, RW; Culver, DH; White, J; et al. 'The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals' Am J Epidemiol 1985;121:182-205
6. Nuland, SB. 'The enigma of Semmelweis - an interpretation' J Hist Med 1979:159-189.
7. Wenzel, RP; Thompson, RL; Landry, SM; et al. Hospital-acquired infections in intensive care unit patients: an overview with emphasis on epidemics. Infection Control 1983;4:371-375
8. Pritchett, CJ; Seto, WH. 'The surgeon-specific wound infection rate - a worthwhile strategy for Asian hospitals' Asian J of Surgery 1990:13:121-124.
9. O'Boyle, C; Jackson, M; Henly, S. 'Staffing requirements for Infection Control programs in US health care facilities' Am J Infect Cont 2002; 30,6, 321-333
10. Haley, RW. 'The hospital epidemiologist in US hospitals, 1976-1977: a description of the head of the infection surveillance and control program' Infection Control Hosp Epidemiol 1980;1:21-32
11. Castle, M; Ajemian, E. The Infection Control Programme in Hospital Infection Control 2nd Edition pp26-36, 1987, John Wily and Sons, Denver
12. Seto, WH. 'Staff Compliance with Infection Control. Practices: application of the behavioural sciences' Journal of Hospital Infection 1995: 30 (supp.) 107-115.