[box type=”shadow” align=”aligncenter” ]In the last quarter of 2017, Clean India Journal interacted with some of the Government hospitals and small healthcare centres. Speaking to infection control nurses, microbiologists and infection control in-charges on the challenges faced by them in following rules, understanding and implementing processes came to fore. Clean India Journal discussed the challenges with Dr Dhruv Mamtora, MBBS, MD, DHA, Consultant Microbiologist and Infection control officer, S. L. Raheja, A Fortis associate, Hospital, Mumbai and Dr Sweta Shah, Consultant, Microbiology & Infection Prevention, Kokilaben Dhirubhai Ambani Hospital & Medical Research Institute. Here’s a sneak peek into their views on the major concerns facing healthcare facilities and the people visiting them.[/box]
The incidence of Hospital Acquired Infections (HAIs) or nosocomial infections which is largely due to pathogens that were existing or incubating at the time the patient’s admission to the healthcare facility. It takes over 48 hours or more following admission to get infected. However, it may not become clinically evident until after discharge. Hence, maintaining follow-up records of patients who get HAI post-discharge is a big challenge, especially in a highly populated country like India.
Given this scenario, Dr Mamtora and Dr Shah, explain the need , processand implementation of infection control in the following Q&A:
Are WHO guidelines applicable in India?
WHO guidelines are instructions about health interventions, whether clinical, public health or policy guidance. WHO have set many guidelines for cleanliness and hygiene in the healthcare facilities for infection control all over the world. But are the Indian hospitals following the protocol?
- Water – quality, quantity, facilities and access to water,
- Excreta disposal
- Waste water disposal
- Healthcare waste disposal
- Cleaning and laundry
- Food storage and preparation
- Building design, construction and management
- Control of vector borne diseases
- Information and hygiene promotion
Each of the above requirements can be fulfilled if there is strong commitment and willingness for same. Many places including hospitals don’t get water in India so as there are hospital premises which get flooded in monsoon season. Our environmental conditions are variable across the country, so we must adopt such that what suits best for that locality.
Cleanliness in hospitals differs from area to area. High risk areas like OT, ICU, transplant unit, procedure labs, blood bank, laboratory, Dialysis and CSSD departments require deep cleaning or more thorough cleaning than other areas. Special training is required for staff if they are designated in these areas and if possible, the workforce for cleaning in these areas need to be designated and should not be rotated. If there is a replacement contract worker in case of staff absenteeism then he/she might not as well know what type of cleaning is done in that specialized area of hospital and since it is only for a day, he might not be trained for that duty. Empowering housekeeping managers is important in such scenarios.
One of the critical areas to maintain hygiene is the food preparation space, where controlling of vectors during the monsoon season is a challenge.
Information and hygiene promotion methods have been shared through the media but healthcare centres have failed to implement and provide training for improving skill or even improvising through proper equipment for cleanliness.
Does it ensure that infection prevention is taken care of completely?
Dr Dhruv Mamtora
Dr Mamtora: Partly it covers majority of t hings but still there are many day to day practices like microbiological surveillance, surgical safety and other clinical related practices e.g. safe injection and infusion practices, hand hygiene, biomedical waste management, prevention of device associated infections and isolation precautions which are ongoing activities on day to day which needs to be supervised by an expert. Also, if we see infection prevention and control, there is shortage of trained manpower. At many places traditional age-old practices are followed which are outdated and there is complete lack of awareness or too much of negligence with respect to infection control practices as it is a costly exercise and not a primary objective.
Dr Shah: It will be utopianto claim that any guidelines can completely eliminate all infections. WHO provides guidelines as a base upon which the program needs to be built.Even if the program does not take care of all infections, it will definitely reduce number of infections, associated morbidity,mortality and cost of treatment by a great extent.
Why is infection spreading in hospitals in spite of preventionand precautions?
Dr Sweta Shah
Dr Mamtora: There are three primary things which are responsible for infection. It will depend upon agent, host and environment (triad of epidemiology). Agents these days are stronger than what used to be before. We are on verge of postantibiotic era as there are only few high-end antibiotics which are still effective and drug resistant bacteria which are resistant to almost all classes of antibiotics causing infections.
Our actions are slow and negligible to curb this manmade disaster. Also, there can be potential resistance to disinfectants which are commonly used. Appropriate disinfectants are either used in high dilution or cheaper poor-quality substitutes are used which are less effective or not effective at all.
If we talk about the host, there are immune-compromised patients who are vulnerable to infections. There are transplant patients; there are patients on long term steroid therapy, extremes of age who are most susceptible to infection, diabetes and cancer patients. India is diabetes capital of world with largest number of diabetes who are highly susceptible to infection.
Dr Shah: Prevention and precautions can certainly help reducing infections and there is no doubt about it. In fact, prevention practices are the reason why surgeons can perform very complex surgeries like transplant, intensivists can bring back a patient from multi-organ failure and babies less than 500g birth weight can survive. Infection prevention practices are proven scientifically in various studies and hence is accepted by WHO. However, in India, we do have a long way to for implementation of prevention measures in all the health care facilities.
Infection can spread from one patient to another; from environment of hospital like table, trolley or stethoscope to the patient, from health care personnel to the patient and also from patient to health care personnel. This is due to lack of hand hygiene, incomplete adherence to standard (universal) aseptic precautions, incomplete vaccination, inadequate isolation when indicated and breach in infection prevention and control practices.
What are the methodologies used and what is lacking?
even though huge is in the form of one-time investment.
In India, we don’t give importance to having proper designated person for infection control. Often, skilled workers face harassment in the hospitals. Either medical microbiologists or senior clinicians or infection control nurses are given the responsibility. Since there are always double or multiple responsibilities, expert advice itself is compromised. Sometimes meetings related to infection control are not effective to implement standard guidelines due to delay in budget approval or staff resistance. When hand hygiene needs to be implemented on priority basis, in many places, there is no hand-washing facility or there is water shortage.
Another challenge is there are different guidelines from different associations and the executive summaries may be at times contradictory because these are evidence-based guidelines, so extrapolation of guidelines should be suitable for given settings and they have to be thoughtfully implemented. As we all know majority of these guidelines come from western countries which is developed, and privileged world and we are still developing world.
Recently NABH accreditation has started collecting data on quality parameters from hospitals but still majority of hospitals are not participating for accreditation programs as it is purely voluntary participation. The scenario is changing since NABH has developed Pre-Accreditation Entry Level Certification for CGHS schemes. However, journey is long, but it cannot be predicted due to low. If there is more participation from hospitals and especially from the government sector, which has large bed strength hospitals including ICU beds, then the data will be more representative of population data and actual rates of hospital acquired infections can be known.
There is also lack of standardization of processes. Every institute follows different practices and protocols.
Sometimes they may be overdoing which leads to unnecessary wasteful expenditures. Sometimes it may happen that organizations are insisted upon certain practices to be followed which are though subjective but are implemented. If we look at the challenges, there are manifold. It needs appropriate staffing, appropriate resources, proper planning of what is best suited in given scenario and willingness for implementation.
Dr Shah: Healthcare is a human driven system. Universal implementation of guidelines requires behavioural changes at all the levels i.e. administration, doctors, nurses, technicians, other support staff, relatives and patient themselves. In fact, pharmaceutical and other health care accessory manufacturing companies also play a role in prevention. A significant emphasis is not yet given to prevention during training period of health care personnel like doctors and nurses. It is necessary to consider prevention strategies as important as treatment of the patient. There is a huge lacuna in this holistic approach. Automation in health care is far away unlike many other industries. A huge role hence can be played by government too.
Spread of infection is a result of: Negligence of hospital officials, lack of knowledge, lack of hygiene practices or infection control is expensive…
Dr Mamtora: Spread of infection can never be pin pointed to anything or rather it is a combination of multiple factors. It is primarily related to patient’s medical conditions which are sometimes morbid and even fatal or devastating. Infection can also be related to infectious agents that are drug resistant bugs, antiviral resistant viruses, antifungal resistant fungus, drug resistant parasitic diseases or vectors which are additionally becoming resistant to insecticides. There are some of zoonotic diseases which can be transmitted from animals.
There are also certain diseases which are emerging like SARS, Viral haemorrhagic fevers and recently zika virus. We must note the detailed medical history of patients including travel and occupation which are sometimes difficult to obtain in critical conditions. There are certain infections which were restricted to geographic areas but due to travelling are now seen in new geographic areas.
The epidemiology of infectious diseases itself is changing. With rampant drug resistance, within no time we will land up in post antibiotic era and then only thing which will be available will be infection control practices which are simple yet effective and with bare minimum cost involved. We always speak about prevention which is better than cure. But in majority of cases, we don’t practice preventive medicine because medical field is totally overburdened due to lack of adequate facilities and manpower issues. With increased consumerism and litigation, doctors are forced to practice defensive medicine. Quality of overall education in our country is degrading with evolving time, which is really a major issue, but not given due attention.
Infection control is expensive but at same time it saves on costs resulting from poor quality. There is cost involved in infrastructure for isolation rooms as per international standards. HVAC, water and sanitation practices. There are other expenditures like cost of training manpower, cost of equipment and their maintenance, cost of quality services, cost of disinfection and sterilization practices, cost of qualified staff and above all cost of maintaining all these things in place for sustaining services. Many a time, in organizations, aesthetics is given more importance over infection control which should be other way.
Dr Shah:
a) Negligence of hospital officials
- Administrative controls in infection prevention are crucial. If adequate hand hygiene products like soap, alcoholic hand rub and gloves are not available, even if a health care personnel is trained and willing; cannot implement hand hygiene.
- Also, vaccination for all health care personnel should be made mandatory e.g. Hepatitis B and Tetanus vaccine by officials.
- The infection control data is not being captured uniformly in our country. There is no national requirement for the same. It is a voluntary exercise. Thus, sometimes it is captured in parts and many a times is not captured at all.
- If one cannot measure the problem, one cannot reduce it
- It is important to have surveillance mechanism
- Many laboratories across India are not equipped to test antimicrobial susceptibilities and resistance. Microbiologists are not available for interpretation of the results and its application in many areas. This has an adverse impact on infection prevention and control
b) Lack of knowledge
- It is crucial to incorporate infection prevention during graduation training and post-graduation training period of all the personnel who will join health care and related field.
- The patients and relatives need to be trained in their language regarding acquiring and transmission of infection. Personal hygiene of patients and relatives in the hospital many a times is a challenge. Some myths are carried by Indian patients like not to bathe if one has fever. Hand wash by relatives and patient is infrequent too.
- There needs to be a continuous training program on infection control for in service health care personnel which has been found to be useful across the globe.
- Patient education program for certain critical group of patients e.g. patients undergoing dialysis or chemotherapy for cancer are required.
- These are simple measures and do not require huge funds. They require willingness.
- Few NGOs or patient groups are working towards infection control. A strong liaison between community and hospital for infection control is yet to be formed.
c) Lack of hygiene practices
- Hospital acquired infections (or nosocomial infection) is an outcome of lack of hand hygiene practices.
- This problem varies from various types of health care sectors. The implementation is patchy in our country.
- There are some areas where practices are much better than the other especially in metro cities. The better practices are mostly due to awareness rather than availability.
- The reasons are of different types which unfortunately include all: unavailability, unawareness, unwillingness or indifferent attitude.
- Involvement of administration and doctors is essential. The program gets implemented in much better way when it is a multidisciplinary team managing the show.
- However, there is a golden line on the dark cloud. We are definitely moving ahead and changing for betterment
d) Infection control is expensive
- We need to agree that nothing is more expensive than the life. And we need to understand that infection is expensive not prevention of infection.
- Cost of vaccine is not more than the cost of treatment of the disease.
- WHO provides most costeffective guidelines which can be implemented in resource poor countries like ours.
- Infection prevention and control needs to be considered as integral part of treatment since giving a new hospital acquired infection(HAI) to a patient is costlier. It requires more expensive therapy, high end antibiotics and can lead to longer stay in hospital and can lead to death of the patient who could have been treated for the primary disease.
- Consider a patient has come for a simple surgery like hernia and breach in surgical infection prevention practice leading to intra-abdominal infection for which another surgery may be needed, and long-term therapy may be needed. The cost cannot be less than using sterile material and using aseptic precautions.
- Hospital acquired Infections (HAI) contribute to antibiotic resistance in significant proportion. We need to remember that as far as antibiotics are concerned India is in a very grim situation.
- Awareness, training, behavioural changes and willingness are most important stepping stone for infection control and definitely do not require huge resources.
Yash Sama