control ing nosocomial infections

8/3/2019 Control Ing Nosocomial Infections

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15 CONFERENCIA DE LA ORGANIZACION ASIA PACIFICO DE CALIDADXXXVII CONGRESO NACIONAL DE CONTROL DE CALIDAD

28 Convencin Nacional de Crculos de Calidad1er Foro Asia Pacfico de Trabajo en Equipo

18o Foro Internacional de IMECCA sobre la ISO 900011o Foro Internacional de IMECCA sobre la ISO 14000

3erForo Internacional de IMECCA sobre la OHSAS 18000Cd. de Mxico, octubre 7 al 10 del 2009.

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Controlling Nosocomial Infections The Dr L H Hiranandani Hospital Experience

Uday Tewary*with inputs from

V M P Thomas**, Suvin Shetty***, Sheena Binu****

*AGM Pharmacy, **General Manager Operations & Projects,***Consultant Pathologist, ****Infection Control Nurse

Dr L H Hiranandani Hospital, India

Abstract:

Dr L H Hiranandani hospital manages a vibrant and effective infection control

program. The hospital infection control committee (HICC) has a multidisciplinary

constitution. The surveillance of nosocomial infections is the foundation for

organizing and maintaining an infection control programme. Hence, the infection

control data collected and analysed include surgical site infections, catheter-related

bloodstream infections, urinary tract infections and ventilator-associated infections.

The analysis involves comparing the data with the national and international

benchmarks. The isolated microorganisms in the clinical specimens and their

antibiogram are discussed to assess the trends and prevalence of antibiotic

resistance and emergence of multidrug resistant bug. The measures taken after

analysis help in taking corrective actions to reduce the average length of stay of

patients and associated morbidity and mortality.

The infection control programme has helped to preempt any outbreaks in the high

dependency areas of the hospital. It has also reduced the overall stay of the patient

in hospital as evinced by a decreasing Average Length of Stay (ALOS), there by

decreasing cost of treatment to the patient and a faster turnover for the hospital a

win win situation for all.


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Controlling Nosocomial Infections The Dr L H Hiranandani Hospital Experience

Uday Tewary*with inputs from

V M P Thomas**, Suvin Shetty***, Sheena Binu****

*AGM Pharmacy, **General Manager Operations & Projects,***Consultant Pathologist, ****Infection Control Nurse

Dr L H Hiranandani Hospital, India

Summary

Dr L H Hiranandani hospital has a vibrant hospital infection control committee, which has

effectively implemented the hospital infection control programme. The surveillance of

nosocomial infection is the foundation for organizing and maintaining an infection

control programme. Hence, the infection control data collected and analysed include

catheter-related bloodstream infections (CRBSI), catheter associated urinary tract

infections (UTI) and ventilator-associated pneumonia (VAP)

The analysis involves comparing the data with the national and international

benchmarks. The isolated microorganisms in the clinical specimens and their

antibiogram are discussed to assess the trends and prevalence of antibiotic

resistance and emergence of multidrug resistant bug. The measures taken after

analysis help in taking corrective actions to reduce the average length of stay of

patients and associated morbidity and mortality.

Introduction

A nosocomial infection also called hospital acquired infection can be defined as: Aninfection acquired in hospital by a patient who was admitted for a reason other thanthat infection (1).

A more complete definition would beAn infection occurring in a patient in a hospital orother health care facility in whom the infection was not present or incubating at thetime of admission. This includes infections acquired in the hospital but appearing afterdischarge, and also occupational infections among staff of the facility (2).


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The term healthcare associated infection is now widely used instead of the traditionalnosocomial infections and is defined by the CDC as a localized or systemic conditionresulting from an adverse reaction to the presence of an infectious agent(s) or itstoxin(s). There must be no evidence that the infection was present or incubating at thetime of admission to the acute care setting.

Hospital acquired infections are a world wide phenomenon. Patient care is provided insettings ranging from small health care providers with only basic facilities to sophisticatedhighly equipped clinics and large university hospital with state of the art technology. Despiteprogress in public health and hospital care, infections continue to develop in hospitalizedpatients and also in hospital staff. Factors promoting infection among hospitalized patientsinclude decreased immunity among patients; the increasing variety of medical proceduresand invasive techniques creating potential routes of infection; and the transmission of drug-resistant bacteria among crowded hospital populations, where poor infection control practicesmay facilitate transmission.

Nosocomial infections occur worldwide and affect both developed and poor countries.Infections acquired in health care settings are among the major causes of death andincreased morbidity among hospitalized patients. There is a significant burden both for thepatient and public health. A prevalence survey conducted under the auspices of WHO in 55hospitals of 14 countries representing 4 WHO Regions (Europe, Eastern Mediterranean,South-East Asia and Western Pacific) showed an average of 8.7% of hospital patients hadnosocomial infections. At any time, over 1.4 million people worldwide suffer from infectiouscomplications acquired in hospital (3). The highest frequencies of nosocomial infections werereported from hospitals in the Eastern Mediterranean and South-East Asia Regions (11.8 and10.0% respectively), with a prevalence of 7.7 and 9.0% respectively in the European andWestern Pacific Regions (4). The most frequent nosocomial infections are infections of

surgical wounds, urinary tract infections and lower respiratory tract infections. The WHOstudies, and others, have also shown that the highest prevalence of nosocomial infectionsoccurs in intensive care units and in acute surgical and orthopaedic wards. Infection rates arehigher among patients with increased susceptibility because of old age, underlying disease,or chemotherapy.


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The various factors influencing the development of nosocomial infections include:a. Microbial agent factors

i. Resistance to antimicrobial agentsii. Intrinsic virulenceiii. Amount (inoculum) of infective material

b. Patient susceptibility factors like

i. Ageii. Immune statusiii. Underlying diseaseiv. Diagnostic and therapeutic interventions

c. Environmental factors likei. Crowded conditions within the hospitalii. Frequent transfers of patients from one unit to anotheriii. Concentration of patients highly susceptible to infection in one area

Dr L H Hiranandani Hospital is a 130 bed multi specialty tertiary care hospital located at thesuburb of Powai in Mumbai. Spread over 210,000 square feet it has an unmatched bed to

space ratio of 1:1600. The hospital is only five years old but within this short period of time ithas made a name for itself in the healthcare scenario of the country. It is an ISO: 9000certified organization and the first in Mumbai and Western India to be accredited by theNational Accreditation Board for Hospitals and healthcare providers (NABH), the winner of theRamkrishna Bajaj National Quality Award (Indian award using the Malcolm Baldrige model) in2008 and the only Indian hospital to win an award at the International Asia Pacific QualityOrganization. In the subsequent paragraphs we would deal with the various strategiesimplemented by the hospital to have a firm control over healthcare associated infectionrates.

Hospital Infection Control Programme at Dr L H Hiranandani Hospital

Environmental factors: The design considerations itself took cognizance of therequirements of minimizing hospital infections and thus reducing the morbidity and mortality.The various factors which has been considered include

1. Building: The building has a bed to space ratio of 1:1600 thus providingadequate spatial segregation of patients, thereby eliminating the factor ofovercrowding.

2. Zoning of hospital into various areas based on the risk of acquiring infections.These include: Low-risk areas: e.g. administrative sections and physiotherapy


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Moderate-risk areas: e.g. regular patient units, High-risk-areas: e.g. isolationunit, intensive care units and very-high-risk areas: e.g. operating rooms.

3. Traffic flow: adequate consideration has been taken to the flow of patients, staffand materials so as to prevent crisscrossing to the extent possible. In areas likethe critical care and the operating rooms the flow of clean and dirty traffic issegregated. Material like food and biomedical waste is segregated in protected

containers so that there is no contamination, even when the material is sent tothe biomedical waste disposal area. Not only is there spatial segregation, buttemporal segregation is also ensured by moving biomedical waste at laid downtime.

4. Material: the choice of construction material has been made based on therequirement of each area. Thus the operating rooms and intensive care areashave vinyl flooring with polyurethane paint on the walls for ease of cleaning.Special attention has been given to the coving of corners and the cold solderingof joints.

5. Ventilation: The hospital follows the American Society of Heating Refrigerationand Air conditioning Engineers (ASHRAE) standards. Thus each operating roomhas a separate air handling unit (AHU) with three stage filtration including highefficiency particulate air (HEPA) filters with sufficient air changes and laminar airflow, the critical care areas like the intensive care, intensive cardiac care andthe neonatal intensive care units also have separate airhandling units. There are designated areas with positive air pressure forimmunologically compromised patients and in the operating rooms. Isolationareas for infective cases are at a negative pressure.

6. Potable water is supplied by the Mumbai Municipal Corporation. Even this wateris tested periodically for chlorine content, chemical analysis and for bacterialcontamination. Raw water used in dialysis department is tested every day forpH, total dissolved solids and Chlorine.

7. Food: Food borne infection is prevented by meticulous attention to the sourcing,storage, preparation and distribution of food. The food is cooked in house.Multiple levels of checks are in place. The kitchen has been designed so as toseparate the clean and dirty area. Periodic medical examination of cooks andfood handlers are also carried out. Daily check of personnel hygiene of thesestaff is carried out. Protective clothing is used in the kitchen and by the foodhandlers.


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8. Waste: Waste is segregated at the point of generation into different colourcoded containers / bins as laid down by the Gazette of India notification onBiomedical WasteManagement. Sharps are destroyed and collected at source and disposed ofinto earmarked containers made of high density plastic.

The following standard precautions are used while treating all patients

1. Washing of hands promptly after contact with infective material

2. Use of no touch technique wherever possible

3. Wearing gloves when in contact with blood, body fluids, secretions, excretions,mucous membranes and contaminated items

4. Washing hands immediately after removing gloves

5. Handling all sharps with extreme care

6. Cleaning up spills of infective material promptly

7. Ensuring that patient-care equipment, supplies and linen contaminated withinfective material is either discarded, or disinfected or sterilized between eachpatient use

8. Ensuring appropriate waste handling

9. Proper handling of soiled linen

10. Use of hand sanitizers before and after contact with a patient.

CSSD: The Central Sterile Supply Department (CSSD) carries out the procurement,packing, cleaning, sterilization and supply of all sterile equipment and stores. Laiddown procedures are there for ensuring proper sterilization including running of testsamples with each load as well as tests for bacterial cultures from different areas. Theclean and non clean areas are strictly segregated.


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Surveillance: Microbiological surveillance for bacterial growth of the high risk areas isdone in the following manner:

1. OTs Fortnightly

2. NICU - Monthly

3. ICU - Monthly

4. Labour room - Monthly

5. Dialysis - Monthly

6. CSSD Fortnightly

Figure 1 Surveillance Results OT & CSSD Swab Culture Jan 08 till date

Average per monthYear OT CSSD

Tested Positive Tested Positive

2008 13 1.3 2 0.08

2009

(upto April) 13 0.4 2 0

Whenever a surveillance culture shows growth the area is washed down, the operating room /CSSD is cleaned thoroughly, and a repeat surveillance is done. The operating room is madeoperational only after the next swab culture is shown to be sterile.


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I. URINARY CATHETER ASSOCIATED URINARY TRACT INFECTION:

The hospital carries out a surveillance of all patients on Urinary catheter for the developmentof UTI. The hospital follows the CDC guidelines for defining UTI (6). Thus

1. Patient has at least 1 of the following signs or symptoms with no other recognized cause:

fever (>=38

0

C), urgency, frequency, dysuria, or suprapubic tenderness

and

patient has a positive urine culture, that is, >=105 microorganisms per cc of urine with nomore than 2 species of microorganisms.

2. Patient has at least 2 of the following signs or symptoms with no other recognized cause:fever (>=380C), urgency, frequency, dysuria, or suprapubic tenderness

and

at least 1 of the following

a. positive dipstick for leukocyte esterase and/ or nitrate

b. pyuria (urine specimen with >=10 white blood cell [WBC]/mm3 or >=3 WBC/highpower field of unspun urine)

c. organisms seen on Grams stain of unspun urine

d. at least 2 urine cultures with repeated isolation of the same uro-pathogen (gramnegative bacteria or Staphylococcus saprophyticus) with >=102 colonies/mL in non-voided specimens

e. >=105 colonies/mL of a single uropathogen (gram-negative bacteria or Ssaprophyticus) in a patient being treated with an effective antimicrobial agent for aurinary tract infection

f. physician diagnosis of a urinary tract infection

g. physician institutes appropriate therapy for a urinary tract infection.


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3. Patient =38OC rectal), hypothermia (=105 microorganisms per cc of urine with no morethan two species of microorganisms.

4. Patient ==380C), hypothermia (=10 WBC/mm3

or >=3 WBC/high-power field ofunspun urine)

c. organisms seen on Grams stain of unspun urine

d. at least 2 urine cultures with repeated isolation of the same uropathogen (gram

negative bacteria or S saprophyticus) with >=102

colonies/mL in nonvoided specimens

e. >=105 colonies/mL of a single uropathogen (gram-negative bacteria or Ssaprophyticus) in a patient being treated with an effective antimicrobial agent for aurinary tract infection

f. physician diagnosis of a urinary tract infection

g. physician institutes appropriate therapy for a urinary tract infection.


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Figure 2 Incidence rate of catheter associated UTI

Average per month

YYEEAARR AADDMMIISSSSIIOONNSS IINNHHOOSSPPIITTAALL

PPAATTIIEENNTTSS OONNCCAATTHHEETTEERR

CCAATTHHEETTEERRDDAAYYSS

NNOO..OOFF UUTTII UTI PER 1000CATHETER

DAYS22000077 555522 111199 335511 33..55 10.16

22000088 557777 111166 337733 11..88 4.97

22000099((UUppttoo AApprriill))

550066 111188 334422 22..00 5.74

The above rates are comparable to the International Nosocomial Infection ControlConsortium (INICC) report data summary which gives a rate of 6 per 1000 catheterdays for hospital acquired UTI. (7)

Figure 3 Incidence rate of catheter associated UTI compared with INICC Rate

UTI per 1000 Catheter Days

0.002.00

4.006.00

8.0010.0012.0014.00

Nov 07Jan 08Mar 08May 08 Jul 08Sep 08Nov 08Jan 09Mar 09

Months

Rate

UTI cases per 1000 Catheter daysINICC Rate


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II. CENTRAL LINE ASSOCIATED BLOOD STREAM INFECTION:

Similarly the hospital carries out a surveillance of all central line patients admitted. Again CDCguidelines are followed to define the cases.

Figure 4 Incidence rate of CRBSI

Average per month

YYEEAARR AADDMMIISSSSIIOONNSS IINNHHOOSSPPIITTAALL

NNOO..OOFFCCEENNTTRRAALL

LLIINNEESS

CCEENNTTRRAALL LLIINNEEDDAAYYSS

NNOO.. OOFFCCRRBBSSIICCAASSEESS

CRBSI casesper 1000 Central

line days

22000077 555522 2255 145 00..55 3.46

22000088 557777 2288 174 00..55 2.70

22000099 ((UUppttooAApprriill))

550066 2233 119988 00 0

The above rates are comparable to the International Nosocomial Infection ControlConsortium (INICC) report data summary which gives a rate of 9 per 1000 line days forcentral line infection rates. (7)


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Figure 4 Incidence rate of CRBSI compared to NNICrates

III. VENTILATOR ASSOCIATED PNEUMONIA (VAP):

The hospital also tracks the incidence of ventilator associated pneumonia. VAP cases aredefined as per the CDC guidelines. The incidence rates are comparable to internationalstandards.

Figure 5 Incidence rate of VAP

Average per month

YYEEAARR AADDMMIISSSSIIOONNSS IINNIICCUU

NNOO.. OOFFVVEENNTTIILLAATTEEDD

PPAATTIIEENNTTSS

VVEENNTTIILLAATTOORRDDaayyss

NNOO..OOFFVVAAPP

VAP cases per1000 Ventilator

days

22000077 110033 1122 5500 33..00 46

22000088 111144 1100 5500 00..55 7

22000099 ((UUppttooAApprriill))

110044 99 4411 00 0

The above rates are comparable to the International Nosocomial Infection Control Consortium(INICC) report data summary which gives a rate of 20 per 1000 ventilator days for ventilatorassociated pneumonia rates (7).

CRBSI Rates comparison with INICC

0.00

5.00

10.00

15.00

20.00

Nov 07Jan 08Mar 08May 08 Jul 08Sep 08Nov 08Jan 09Mar 09

Month

Rate

CRBSI cases per 1000 Central line days INICC Rate


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Figure 6 Incidence rate of VAP compared to INICC rates

Surveillance of multidrug resistant organisms: The hospital carries out a surveillance ofmulti drug resistant organisms from the cultures found positive. The data for the years 2008 &2009 have been shown in the Figure 7 below.

Figure 7 Multidrug resistant organisms

MDRO LHHH data(2008 2009)

Comparator

ESBL E coli & Klebsiella spp 26.3% 20.6%

MBL Pseudomonas spp 19.8% 21.1%

MRSA (clinical specimens) 32% 59.6%

Vanco-resistant Enterococci 10% 28.5%

* NNIS System Report, ICUs data; 2004

VAP Comparison with INICC Rates

0.0010.0020.0030.0040.0050.0060.0070.00

Nov 07 Jan 08 Mar 08 May 08 Jul 08 Sep 08 Nov 08 Jan 09 Mar 09

Month

Rate

VAP cases per 1000 Ventilator days INICC Rate


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The above figures indicate that MRSA is still not the scourge it is in the west. The hospitalcarries out active surveillance for MRSA cases by subjecting all patients transferred in fromother hospitals, patients coming from abroad and clinically suspect cases to MRSA screeningtest. In addition staff exposed to MRSA patients and randomly those involved in patient careare also randomly surveyed to detect asymptomatic carriers. Those found positive are treated

with suitable antibiotics and followed up till they are negative.

Antibiotic policy: Based on the sensitivity pattern, the hospital has a laid down antibioticpolicy for various clinical conditions. All treating doctors are expected to adhere to theantibiotic policy. The antibiotic policy is revised regularly based on the antibiotic sensitivitypattern and feedback received from clinicians. Discussions are also held on antibiotic usageand streamlining as also the possibility of taking a decision on Antibiotic holiday in case ofover usage of any antibiotic.

Average length of Stay (ALOS): Right from inception the hospital has been process driven.The various SOPs were formulated while the hospital was still under construction. Thesewere modified over a period of time to improve operational efficiency. The hospital has beentracking its average length of stay from the very beginning. Currently the average length ofstay in the hospital is 2.75 which is outstanding by any standards for a multispecialty tertiarycare hospital of this size. A low ALOS is due to multiple factors. An important factor being a

low rate of complications; this in turn could be due to the low nosocomial infection rate. Thefollowing figure tries to correlate the ALOS to the nosocomial infections (catheter related UTI,CRBSI and VAP rates). The correlation is not too evident as the infection rates are availablesince 2007 only. At this stage the ALOS was 3.19. Further reduction in the ALOS would bevery difficult for a hospital of our size. The figure below tries to graphically correlate the ALOSto the hospital infection rates. VAP has been correlated to rate per 100 as the rate perthousand goes out of scale of the graph.


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Figure 8 Comparison of ALOS & infection rates (INF)

ALOS & INF RATES

0.0

2.0

4.0

6.0

8.0

10.0

12.0

2004 2005 2006 2007 2008 2009

YEARS

RATES

ALOS UTI CRBSI VAP

The Hospital Infection Control Committee (HICC): All this would not have been possiblewithout the yeoman efforts of the hospital infection control committee and especially that ofthe infection control nurse. The committee is headed by the Senior Consultant in Pathology,the senior Intensivist, the Infection Control Nurse (ICN), the in charge of the CSSD, the seniorSurgeon, the senior Physician,. In addition the quarterly meetings of the committee areattended by the CEO and other management staff. The committee has not only set policiesand procedures at all levels, but has also ensured that it is implemented. There is a verystrong stress right from the induction level, when all staff is sensitized to the requirements of

infection control. The infection control nurse carries out rounds, where it is ensured that thepolicies are being implemented. The nursing team has been motivated to not only adhere tothese procedures but to also ensure that it is followed by others especially the doctors. Thishas resulted in a paradigm shift in the ownership of the various processes in the hospital. Thestress laid on hand hygiene has paid rich dividends, in decreasing incidence of all forms ofinfections. The insistence on proper disposal of sharps has drastically reduced the incidenceof needle stick injuries. The surveillance of swabs in the OT and the CSSD have reduced theincidence of nosocomial infection. In a short period of time, despite the hospital occupancybeing high we have been able to achieve decreasing trends in the infection rates. The HICChas now started monitoring surgical site infections also. These are still early days formeaningful trends to set in.


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Conclusions

Dr L H Hiranandani Hospital has an effective Nosocomial Infection Control Programme. TheHospital Infection Control Committee is the monitoring and the implementing body and hasstrong institutional support across the board. The infection control programme is based onfollowing practical guidelines as enunciated by the WHO and the CDC and includes buildingdesign parameters, surveillance and adherence to laid down policies and procedures withregards to antibiotic usage, biomedical waste management and control and treatment of

multidrug resistant organism. There is strong emphasis on simple methods like hand hygiene.The hospital actively tracks catheter associated UTI, central line related blood streaminfections and ventilator associated pneumonias. These are comparable and surpassinternational data from the INNIC. One of the factors responsible for a low ALOS is the lowincidence of complications, the major cause of which is nosocomial infection. A correlationhas been made between the nosocomial infections rates and the average length of stay.

References

1. Ducel G et al. Guide pratique pour la lutte contre linfection hospitalire. WHO/BAC/79.1.

2. Benenson AS. Control of communicable diseases manual, 16th edition. Washington,American Public Health Association, 1995.

3. Tikhomirov E. WHO Programme for the Control of Hospital Infections. Chemiotherapia,1987, 3:148 151.

4. Mayon-White RT et al. An international survey of the prevalence of hospital-acquiredinfection. J Hosp Infect, 1988, 11 (Supplement A):4348.

5. Ducel G et al. Prevention of Hospital Acquired Infections A practical guide (2ndedition)WHO/CDS/CSR/EPH/2002.12

6. Teresa C. Horan, et al CDC/NHSN surveillance definition of health careassociatedinfection and criteria for specific types of infections in the acute care setting. Am. J. Infect.Control. 2008;36:309-32

7. Victor D. Rosenthal, Dennis G. Maki, Ajita Mehta, et al. International Nosocomial InfectionControl Consortium (INICC) Report, Data Summary for 2002- 2007, American Journal ofInfection Control- In Press, 2008

control ing nosocomial infections

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