The BMA this past summer published a useful position paper on approaches to reduce HAI’s.
They noted a 2005 Cochrane Review that showed restrictive interventions to improve antimicrobial prescribing (eg. formulary restrictions, authorization from infectious disease consultants, selective reporting of lab susceptibilities, etc.) are much more effective than “persuasive” interventions (like education, opinion leaders, audit and feedback, etc.). Strategies incorporated into structural changes (eg. CPOE) may have good potential to improve prescribing practices.
They provide sample guidelines from some UK healthcare trusts. These include practical (yet often neglected in the US) considerations such as always requiring the indication for the antimicrobial be clearly documented, record a stop date or review date, use narrow-spectrum drugs where appropriate, re-evaluate any necessary broad-spectrum coverage for de-escalating to narrow-spectrum coverage wihin 48 hours, and moving to oral therapy as soon as appropriate.
Of course they discuss hand hygiene and the many barriers to compliance (understaffing, poor design of facilities, confusing or impractical guidelines, insufficient commitment and enforcement by infection control personnel). They note that single interventions to improve hand hygience compliance are seldom successful so multifaceted approaches are necessary. They do acknowledge for hand hygiene the importance senior staff and physicians serving as role models but they stress structural changes such as easy access to alcohol-based hand rubs at points of care and improved design of those (eg. use of elbow-operated or no-touch taps). And the also talk about behavioral techniques and social marketing techniques in hand hygiene campaigns.
Though they acknowledge that educational efforts may help reduce indwelling device and catheter related infections, they stress high impact interventions such as use of care bundles like the IHI VAP prevention bundle. However, they stress the importance of ensuring that each element of the care bundle be well-defined and based on strong evidence. They also stress the importance of good sterile technique for insertion and ongoing management of such devices (including such things as ready access to sterile supplies).
Perhaps the biggest difference for recommendations in the UK compared to the US is related to dress codes. They stress a “bare below the elbows” dress code in which short sleeves are required and no wristwatches or jewellery are allowed. Neckties and traditional “white coats” are also discouraged and items like pens or scissors should not be kept in outside pockets. Many trusts also include provisions for changing uniforms before leaving facilities. However, they admit that the evidence base for these strict dress codes is soft and there remains a need to balance risk of microbial transmission against the need to maintain an appearance of professionalism.
Cleaning and environmental hygiene are discussed. They note that traditional cleaning protocols had always focused on things like floors and toilets and paid less attention to “near-patient high-touch” sites (eg. bed rails, bedside lockers, infusion pumps, door handles, switches, etc.). That focus needs to be reversed. (Hey! We just heard that this month in the Wall Street Journal! See our November 2009 What’s New in the Patient Safety World column “Ten Ways to Prevent Healthcare-Associated Infections”). They also point out that “deep cleaning” (eg. intense cleaning with a detergent followed by a steam cleaner) has not been shown to be effective.
They note there is a relationship between both bed occupancy and bed turnover (Wow! You mean there is a silver lining to the downturn in occupancy all our hospitals have seen during the economic downturn!). They note that a facility with a 90% occupancy rate could expect a 10.3% higher MRSA rate than one with an occupancy rate below 85%. Longer turnover intervals are negatively correlated with MRSA rates and may be even more important than the occupancy rates. High occupancy rates increase the proximity of patients to each other, make it more difficult to clean thoroughly when one occupant in a room remains after the other is discharged or transferred, and probably increase the movement of patients from one room to another. These have been factors in the trend toward single room designs for new hospitals (see our June 2009 What’s New in the Patient Safety World column “Are Single Hospital Rooms Controversial?”).
They have a good discussion of screening and isolation, noting that screening is only applicable where colonization is associated with an increased risk of transmission, where an effective rapid screening tool is available, and where the microorganism can be successfully eliminated following identification. They conclude that the evidence shows MRSA screening can be effective in certain hi-risk populations (eg. patients transferred from SNF’s, patients previously infected, etc.) or in hi-risk units (eg. ICU’s) but note that the evidence for universal screening is not yet strong. There are also downsides to isolation (see our March 25, 2008 Patient Safety Tip of the Week “More on MRSA” and also a recent editorial by Millar in the BMJ).
They also discuss the impact of performance targets that may compete with good infection control measures (eg. admission rates, wait times, LOS, financial, etc.) - obviously more ETTO’s (see our September 15, 2009 Patient Safety Tip of the Week “ETTO’s: Efficiency-Thoroughness Trade-Offs”).
Sections on the importance of management and leadership, teamworking, culture of safety, clinical governance, systems for tracking and providing audit/feedback, and staffing issues in prevention and control of hospital infection are also included.
They conclude with a section on issues for future research
British Medical Association.Tackling healthcare associated infections through effective policy action. 08 June 2009
Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G, Holmes A, Ramsay C, Taylor E, Wilcox M, Wiffen PJ. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD003543. DOI: 10.1002/14651858.CD003543.pub2 (first published online: October 19. 2005)
Millar M. Should we screen low risk patients for meticillin resistant Staphylococcus aureus? BMJ 2009;339:b4035 (Published 8 October 2009)