The World Alliance for Patient Safety had selected healthcare associated infection (HAI) as the topic for its first ‘Global Patient Safety Challenge’. These infections are a major patient safety concern. They affect hundreds of millions of people worldwide every year. Infections take their toll in terms of avoidable patient deaths and disability. They also waste scarce healthcare resources. No country can claim to have solved the problem completely. Some of these HAIs also impact healthcare workers, compromising their safety and thereby putting a huge burden on these scarce resources.
HAI is growing as a problem. Patients are becoming more susceptible to infections because of more serious underlying illnesses. Poor compliance with hand hygiene by healthcare staff, lack of access to safe water, unclean instruments and environmental surfaces all contribute to the problem. The environment of patient care is also important. Factors such as understaffing, high levels of bed occupancy and increased transfer of patients, all create new risks of infection.
WHO reports that at any time over 1.4 million people worldwide are suffering from infections acquired in hospital. Between five and 10 per cent of patients admitted to modern hospitals in the developed world acquire one or more HAIs. In the US, one out of every 136 hospital patients becomes seriously ill as a result of acquiring an infection in hospital; this is equivalent to two million cases and about 80,000 deaths a year. In England, more than 100,000 cases of healthcare associated infection lead to over 5000 deaths directly attributed to infection each year. In Mexico, an estimated 450,000 cases of healthcare associated infection cause 32 deaths per 100,000 inhabitants each year. Healthcare associated infections in England are estimated to cost £1 billion a year. In the US, the estimate is between $4.5 billion and $5.7 billion per year. In Mexico, the annual cost approaches $1.5 billion.
There is no uniform data on HAIs in India, as a result of which the incidence and prevalence is not known. There is not yet a surveillance programme that has been institutionalised across healthcare setups, and as a result the information on HAIs is limited. However WHO reports that the risk of healthcare associated infection in developing countries is two to 20 times higher than in developed countries. In some developing countries, the proportion of patients affected by a HAI can exceed 25 per cent.
The most common sites of HAIs are the urinary tract, lung, surgical site and blood. There are also certain risk factors that underlie the occurrence of these HAIs.
- Urinary tract infections may be caused by catheterisation and invasive procedures while it has certain risk factors like advanced age, severe underlying disease, urinary stones, pregnancy and diabetes.
- Lung infections may be caused by ventilators (ventilator associated pneumonia—VAP) and aspiration procedures. Predisposing factors like prolonged hospital stay, malnutrition, old age, immunodeficiency, surgery etc. are associated with development of lung infections.
- Surgical site infections (SSI) may be caused by inadequate and wrong antibiotics following surgery, improper skin preparation before surgery, prolonged surgery, inappropriate wound care etc. Diabetes, immunodeficiency, inadequately trained staff and poor supervision on adherence of infection control processes could be the precursor for such SSIs.
- Blood stream infections (BSI) are usually caused by improper vascular access. Critical care patients, immunodeficient patients and patients with underlying disease can have higher BSIs. It is therefore critical to ensure that proper preparation of the vascular access site is made with appropriate cleansing agents. Moreover scientifically proven long lasting cannula materials made of Vialon or PTFE should be used, so that there is no need for repeated cannulation, which usually happens when materials of lower quality are used. Training of healthcare workers in understanding BSIs and supervision of the healthcare workers is critical to reduce BSIs. Some of the WHO statistics are worrying. In intensive care, healthcare associated infection affects about 30 per cent of patients and the attributable mortality may reach 44 per cent. In Brazil and Indonesia, more than half of the babies housed in neonatal units are affected by HAI, with a fatality rate between 12 per cent and 52 per cent. The infection rate associated with vascular devices among neonates is three to 20 times higher in developing than in developed countries. The greatest risk of nosocomial transmission of hepatitis B virus takes place from patients to healthcare workers. Despite these statistics, hepatitis B vaccine is not made available to immunise healthcare workers in the majority of developing countries.
The magnitude of HAIs prevalent in India is still unknown because of the paucity of data. However, India has the knowledge and resources to dramatically reduce the impact of HAIs. What is needed is commitment and action at all levels, to ensure that every patient’s right to safe care is achieved.
India has committed to reduce risks of HAIs, by joining hands to fight the spread of healthcare associated infections. The Ministry of Health and Family Welfare, Government of India has signed the Global Patient Safety Challenge and pledged to acknowledge India’s commitment to address this problem. A programme called NIPS (National Initiative for Patient Safety) was launched by the Department of Hospital Administration, All India Institute of Medical Sciences (AIIMS), WHO, INCLEN Trust and Becton Dickinson India (as knowledge partner) in 2009 to address the important issues on patient safety, especially HAIs. This educational programme carried out over two years has reached more than 80 medical and teaching colleges on aspects of addressing Infection Control. Another programme called “Safe-I” has been rolled out by National Accreditation Board for Hospitals and Healthcare Providers (NABH) with Becton Dickinson (as knowledge partner) has been rolled out across two states of Punjab and Kerala. This programme is being considered as the stepping stone towards complete accreditation of NABH. Most hospitals across India do not possess time, and managerial bandwidth to carry out an important task like accreditation, since it requires time and effort to improve infection control processes. “Safe-I” seeks to address these issue that hospitals and healthcare institutes face in terms of paucity of resources. Dedicated infection control specialists are provided to help hospitals achieve the primary step of setting up and infection control programme; one that is robust and has aspects of quality parameters based on processes, protocols and outcomes. Efforts are being made to set up data repositories which would put a proper perspective on efforts required to make Indian healthcare comparable with the best available anywhere across the globe. The opportunity for further action has never been greater, nor its need more urgent.
(Adapted from the WHO)