Essential Resources for Effective Infection Prevention and Control Programs: A Matter of Patient Safety - A Discussion Paper

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5.0 Importance of Infection Prevention and Control Programs

5.1 Evolution of Infection Prevention and Control Programs

The problem of HAIs appeared as soon as sick people started being cared for in hospitals.⁽¹⁸²⁾ The introduction of infection control (IC) programs to monitor such infections did not occur until the mid-1950s, in response to a pandemic of hospital staphylococcal infections.^(182-184) Initial IC programs were usually staffed by registered nurses, whose main function was to gather data through hospital-wide environmental surveillance and outbreak monitoring.⁽¹⁸⁵⁾ During the 1960s, with the rise of infectious diseases as a clinical specialty⁽¹⁸⁴⁾ and support from the fields of epidemiology and microbiology,⁽¹⁸⁵⁾ IC programs became increasingly outcome oriented. Thus, the seeds for evidence-based best practices were sown and the initial foundation for a scientific basis for infection prevention formally developed.

Infection prevention in the 1970s addressed new issues about disinfection and sterilization as well as new risks for hospital-acquired infections associated with the increasing use of invasive medical devices (e.g., peritoneal dialysis catheters, central lines for total parenteral nutrition).⁽¹⁸⁵⁾ At about the same time, the risk of transmission of infections (e.g., tuberculosis, hepatitis B) between health care workers and patients and occupational health issues also became infection control considerations.⁽¹⁸⁵⁾ The Association of Practitioners in Infection Control was established in Toronto, Canada, in 1972 and the Canadian Hospital Infection Control Association, now with over 1,000 members, was formed in 1976. L’Association des Infirmières en Prévention des Infections in Québec, founded in 1978, currently has over 150 members. These professional organizations work to provide support and training to ICPs across Canada.

The introduction of accreditation requirements for a comprehensive IC program and designation of an ICP to manage the program were important milestones in the development of infection control during the 1970s.^(182-184) The most significant development for infection control during that decade, however, was the US Centers for Disease Control and Prevention’s ten-year study on the efficacy of nosocomial infection control (SENIC) project.^(182;185) Health care delivery had been consuming a steadily increasing percentage of the gross domestic product and there was a concern that the resulting pressures on hospitals to reduce costs would prompt the elimination of preventive programs of unproven value.⁽¹⁸³⁾ The SENIC report, published in 1985, provided evidence that organized IC programs are not only effective, they are also cost-effective.⁽¹⁰⁾ Thus, the value of a formal IPCP was well established more than two decades ago.⁽¹⁰⁾

In 1980, the Bureau of Infection Control was instituted at Health Canada’s Laboratory Centre for Disease Control, with a mandate to produce national infection control guidelines to serve as a basis for the provinces and territories in developing local practices. In 1985 the Canadian Hospital Infection Control Association was renamed the Community and Hospital Infection Control Association-Canada to acknowledge the role of infection prevention and control in facilities (i.e., acute care, long term/extended care) as well as community (i.e., ambulatory care, home care) settings. Throughout the 1980s, infection control resources were continually stretched by the appearance of acquired immune deficiency syndrome (AIDS)^(182;185) and AROs.⁽¹⁸⁵⁾

By the 1990s patient care beyond the traditional health care settings and the focus on knowledge management, together with complex moral and legal considerations, made decision making regarding infection prevention and control issues increasingly challenging^(95;183) while resources were stagnant or decreasing.^(9;95;186) A plethora of guidelines to control and promote the rational use of antimicrobials^(2;46;187) has not curtailed the plague of antimicrobial resistance.^(140;142) In addition, while appropriate hand hygiene reduces the risk of infection⁽¹⁸⁸⁾ and antibiotic resistance,⁽¹⁸⁹⁾ ensuring optimal handwashing practice remains problematic in hospitals.⁽¹⁸⁹⁾
Toward the end of the decade, experts called for IPCPs to take on new leadership roles within health care organizations^{(140;186;190-192)} to achieve the goal of these programs, minimizing infections related to the delivery of health care.

The new millennium has seen infection prevention and control teams contributing to pandemic influenza planning, responding to the SARS outbreak in Toronto,⁽¹⁷³⁾ revisiting practices to prevent the transmission of respiratory infections in light of the SARS experience,⁽¹⁹³⁾ and responding to the outbreaks of severe C. difficile infections.^(14;162)Critical issues facing an IPCP today include demonstrating its value,^(9;185;194) and considering the cost-effectiveness of its policies and procedures^(21;47;49) within a complex and economically challenged system.

5.2 Infection prevention and control programs and patient safety

The prevention of HAIs will result in increased safety of patients within the Canadian health care system.^(1;7;28-30) Health care associated infections are the most common adverse event affecting hospitalized patients.⁽⁸⁾ Surgical site infections are the second single largest category of adverse events as reported by the Harvard Medical Practice Study.⁽¹⁹⁵⁾ It is reported that more than 30% of HAIs can be prevented with effective IPCPs.⁽¹⁰⁾

Effective IPCPs reduce the financial and human burden of HAIs^{(4;6;9-11;177;196)} and are an integral component of an overall patient safety strategy.The Canadian Safer Healthcare Now! and the American 100,000 Lives campaigns recognize the efficacy of IPCPs. The purpose of both these initiatives is to reduce the incidence of preventable morbidity and mortality associated with the delivery of health care. Three of the original six strategies for the Safer Healthcare Now! campaign are aimed at preventing HAIs: central line infections, surgical site infections and ventilator-associated pneumonia.⁽¹⁹⁷⁾

Infection control’s integral role in patient safety is also recognized by the Canadian Council on Health Services Accreditation,⁽¹⁹⁸⁾ whose patient safety goal is to reduce the risk of HAIs and their impact across the continuum of care/service. Health care organizations are required to do the following:

• adhere to federally and/or provincially-developed infection control guidelines
• deliver education and training for staff, other providers and volunteers on handwashing/hygiene
• monitor infection rates and share this information throughout the organization
• examine, and where indicated, improve the processes for sterilization of medical equipment

The evidence to support the efficacy of IPCPs is unequivocal and organizations like the Canadian Council on Health Services Accreditation are relying on these programs to improve our patient safety record; however, these programs are only effective when they have adequate resources.⁽³⁵⁾

5.3 Evidence of efficacy of infection prevention and control programs

Infection Prevention and Control Programs need to have benefits that outweigh their costs.⁽¹⁹⁹⁾ IPCPs are considered one of the most cost-effective activities in health care because they can reduce costs and improve the quality of health care simultaneously.^{(9;11;35;38;47;171;191;196)} Infection Prevention and Control Programs have been credited with significant cost savings including the following:

• a reduction in hospital health care costs⁽⁶²⁾ and lengths of stay
• a reduction in incidence and costs of surgical site infections^(200;201) including post- Cesarean section⁽²⁰²⁾and post-cardiac surgery⁽²⁰³⁾
• a 19%–22% decrease in antibiotic expense without negative impact on patient outcomes⁽²⁰⁴⁾
• a process improvement project that achieved increased accountability and improved compliance with isolation
• precautions to control the transmission of MRSA that resulted in a sustained 30% decrease in its incidence over two years even though the number of days at risk increased, with a cost avoidance of more than $2 million⁽²⁰⁵⁾

Different types of cost analyses are reported in the literature.⁽⁴⁹⁾ For example, in 1995 Wenzel⁽³⁸⁾ compared the cost utility ratio (adjusted cost/quality of life years saved) and found that IPCPs save between $1,786 and $7,143 compared with $5,100 for bypass surgery for left main disease (of the coronary artery). Other studies used a cost-benefit analysis to measure the feasibility of infection prevention and control measures. Based on data from the SENIC project, a 1:5 cost-benefit ratio for IPCPs was reported.⁽¹⁶⁾ This measure comes from dividing the money spent on the program by the value of the benefit derived from that program. The expenditures of an IPCP for a 250-bed hospital were estimated at US$60,000⁽¹⁶⁾ in 1985 and had risen to $200,000 by 1995.⁽³⁸⁾

The efficacy of IPCPs is demonstrated by these different cost analyses. A cost-benefit analysis performed to determine the net benefit and costs associated with the use of gowns in preventing the transmission of VRE found that while gown use adds costs, the benefits of preventing VREtransmission outweighed the costs.⁽²⁰⁶⁾ A ten-year survey in the Netherlands demonstrated that funding the implementation of a strict infection prevention policy resulted in epidemiological and financial benefits.⁽⁵⁵⁾

There are further studies and reports supporting the efficacy of IPCPs in all health care settings. Several examples are listed below for each setting.

5.3.1 Acute care setting

• The reduction of the surgical site infection rates following the introduction of surveillance programs^{(200;207-210)} with a system of reporting infection rates back to surgeons in a timely fashion⁽¹⁰⁾ led to the endorsement of this practice by the American College of Surgeons⁽²¹¹⁾ and the Centers for Disease Prevention and Control.⁽²¹²⁾
• A study of post-discharge surveillance for surgical site infection reported a reduction in the infection rate from 16% to 3% over a three-year period.⁽²¹³⁾
• The reduction by ≥10% of surgical site infections in all patients and all HAIs in intensive care unit patients between 1990 and 2000 indicated the durability of IPCPs.⁽¹⁹⁶⁾
• There was a 10-year decline of more than 30% in rates of HAI (with the largest reduction in blood stream infections occurring in hospitalized patients). The Centers for Disease Control and Prevention, Atlanta, credited participating facilities for recognizing the critical importance of an appropriate level of qualified ICPs who contributed to the steady and significant rates of decline.⁽¹⁹⁶⁾
• A policy change in the screening of patients previously infected with C. difficile prior to readmission resulted in savings of $48,500 annually and contained the C. difficileinfection rate below the threshold.⁽²¹⁴⁾
• An enhanced infection control policy significantly reduced the endemic rate of C. difficile in acute elderly patients, helped maintain a lower incidence of MRSA, and resulted in eliminating prolonged ward closures.⁽²¹⁵⁾
• Infection prevention and control interventions for neutropenic patients resulted in a significant decrease in health care associated invasive aspergillosis (an invasive infection associated with high mortality and morbidity) during hospital construction.⁽²¹⁶⁾
• A multi-disciplinary group led by the IPCP implemented hospital-wide infection prevention practices, resulting in a reduction and stabilization of ventilator associated pneumonia rates.⁽²¹⁷⁾
• The implementation of a comprehensive IPCP resulted in a prompt and significant reduction in the rates of cardiac device–associated infections,⁽²¹⁸⁾ potentially saving the institution the enormous cost of health care expenses treating these infections.
• When published infection prevention and control guidelines for tuberculosis control were fully implemented, transmission of multi-drug-resistant Mycobacterium tuberculosis among HIV patients^(219;220) and to health care workers⁽²²⁰⁾ ended.
• In an oncology setting,⁽⁷²⁾ enhanced infection prevention and control strategies significantly reduced both the VRE colonization and bloodstream infection rates.
• Boyce⁽¹⁵⁷⁾ demonstrated that MRSA control programs that include active surveillance cultures combined with barrier precautions were successful in reducing MRSA rates.⁽¹⁵⁷⁾ Others have also found such strategies to be cost-effective.^(52-56)
• Introduction of an enhanced integrated IC Program that included a molecular epidemiology program lowered actual health care costs by $4,368,100 over two years, and reduced nosocomial rates by more than 10% (6.49 per 1,000 days to 5.79 per 1,000 days).⁽⁶²⁾
• To control the spread of MRSA, admission screening and preventative isolation were found to be cost-effective in 14 intensive care units in France as determined during a six-month study.⁽⁵⁶⁾
• A ten-year review of a strict policy that consisted of screening and isolating MRSA colonized or infected patients in a Dutch University hospital determined the policy to be cost-effective compared with the projected increased incidence of MRSA and subsequent related expenditures.⁽⁵⁵⁾
• An enhanced infection prevention and control policy resulted in a significant reduction of C. difficile infection and MRSA colonization in elderly patients, preventing ward closures and thereby netting an estimated extra five beds per day during the winter months.⁽²¹⁵⁾

5.3.2 Long-term care setting

• Influenza A is the most costly infection in long-term care settings in terms of morbidity and mortality.⁽²²¹⁾ Although antiviral prophylaxis is effective in the control of an influenza outbreak,^(221-225) vaccination of both residents and staff against the influenza virus is a more effective infection control strategy.^(226;227) It has been demonstrated that increased vaccination rates are associated with the presence of an ICP⁽²²²⁾ in the facility.
• An interventional study⁽²²⁸⁾ showed that infection containment practices were effective in reducing the residents’ MRSA colonization rate from 52% to 2% and their infection rate to 1.4% with a net savings of $429,500. The savings were calculated on 93 infections prevented at $5,000/acute care admission.

5.3.3 Ambulatory care setting

• Outbreak prevention and containment is a function of an IPCP. An investigation⁽²²⁹⁾ of epidemic keratoconjunctivitis in an ambulatory clinic revealed that all the infections were linked with four physicians and 61% of the infections were linked with one particular physician. Lack of routine handwashing and inappropriate disinfection of instruments between patients were identified as the sources for HAI in this physician’s practice. These factors were brought to the physician’s attention and there was an immediate elimination of the infection. Within a year, there was a second outbreak of epidemic keratoconjunctivitis that was once again traced to this one physician. The outbreak was controlled as soon as infection prevention and control practices were applied consistently. The surveillance component of the IPCP identified and described the problem and the infection prevention and control practices eradicated this HAI.
• With the addition of postoperative surveillance to a program of direct observational surveillance and reporting of surgeon-specific surgical site infection rates, an outpatient clinic study demonstrated a reduced infection rate from 16% to 3% in three years.⁽²¹³⁾
• The presence of a dedicated ICP in an ambulatory setting with 62 associated clinics was reported to be instrumental in improving infection control practices.⁽²³⁰⁾

5.3.4 Home care setting

• Four home care agencies participated in an infection survey reporting that their surveillance methods could be implemented by other agencies, thus creating infection control benchmarking between home health agencies.⁽⁸⁷⁾
• An important function of the IPCP is to determine the level of safety, in terms of infection control, for the provision of care. In a study of blood stream infections,⁽²³¹⁾ the maintenance of a central line for paediatric patients receiving total parenteral nutrition in the home care setting compared with the hospital setting proved more efficacious in reducing both costs and health care associated infection rates.
• Infection Prevention and Control Programs also evaluate the safety of products. For example, needleless intravascular access systems have been introduced to reduce the risk of needlestick injuries among health care providers. These devices seem like the product of choice for home care, especially with family members often providing some or all of the care. However, a case-control/cohort study⁽²³²⁾ demonstrated that needleless infusion systems used for total parenteral nutrition were associated with an increased risk of blood stream infection. A similar device was identified through an infection prevention and control investigation to be responsible for an outbreak of bloodstream infections in patients receiving home intravenous infusion therapy.⁽⁸⁶⁾

6.0 Resources for Effective Infection Prevention and Control Programs

Requirements for optimal infrastructure and essential activities of effective IPCPs have been published for hospital⁽⁶⁾ and out-of-hospital settings.⁽⁴⁾

The integrated nature of IPCPs must be considered when making decisions regarding their funding. For example, introducing computer programs to enhance data collection capabilities for surveillance while cutting back on laboratory funding will not improve the program. The data conversion process is complex and involves technical and professional laboratory staff to prepare and interpret the samples, office staff to produce the reports, an epidemiologist to analyze and interpret the reports, an infectious disease physician or medical microbiologist for appropriate clinical practice, and an adequate number of appropriately trained ICPs to communicate with and instruct the front line staff in infection prevention and control measures. IPCP personnel should include dedicated trained ICP(s), an infection prevention and control physician and/ or hospital epidemiologist, technical and clerical support staff, as well as access to professionals with a background in microbiology, biostatistics, informatics, health care management and adult education.^{(105;233;234)} The following recommendations outline resources that are required to develop and maintain effective IPCPs across the health care continuum.

6.1 Recommendations

The following recommendations support the IPCP goal of reducing HAIs to the lowest possible level and incorporating the essential components of an IPCP, namely surveillance, case management, outbreak management and preparedness, education, policy and procedures, audit and feedback, construction planning and auditing, and reporting outcomes.

1. Infection Prevention and Control Programs should be staffed appropriately to meet the goals of the Program.

A Canadian expert panel developed a model to identify the human resources required to support an effective IPCP. The model recommends, as a minimum, three full time equivalent ICPs per 500 beds in acute care hospitals and one full time equivalent ICP per 150–250 beds in long-term care facilities.⁽²³⁵⁾ This same recommendation was provided to the National Advisory Committee on SARS and Public Health by the Community and Hospital Infection Control Association Canada, 2003. The province of Quebec mandated one ICP per 133 beds in acute care and recommended a ratio of one ICP per 100 beds in acute care settings with specialized programs, e.g., transplants, burns, etc. as seen in tertiary-quaternary care centres.⁽²³⁶⁾ Staffing requirements of IPCPs have been reviewed in the United States as well. The results of the Delphi project⁽⁹⁴⁾ recommended a ratio of 0.8–1.0 ICPs for every 100 occupied acute care beds. The authors noted that recommendations for infection prevention and control staffing and resources should not be made on the basis of bed size or patient census alone; IPCP staff requirements must take into account the intricacies of the health care facility or program, the different types of settings within the program, the complexity of the patient population and the needs of the community and or facility.

The IPCP should be positioned within the organizational structure of the facility or agency so that the ICP has direct access to decision makers and the ability to implement critical infection control measures in a timely fashion. As recent experience with SARS has demonstrated, IPCP staffing must incorporate a reasonable surge capacity.

 

Table 5. Minimum Ratio of Infection Control Practitioners to Number of Beds

Standard/Group	Acute Care	Specialty Acute	LTC
Alliance/CHICA(235;237)	3:500		1:150-250
Quebec(236)	1:133	1:100
Delphi(94)	0.8 to 1.0:100

In addition to the appropriate number of staff, ICPs must have basic training in infection prevention and control from a recognized course such as those available at the University of Calgary; Queen’s University, Kingston; the University of British Columbia; and Centennial College, Toronto. A professional who has worked as an ICP for two years may qualify to write the certification examination in infection control offered by the Certification Board in Infection Control. Obtaining this certification within five years of entering the infection control profession is part of the ICP’s professional standards.⁽²³⁸⁾

2. Infection Prevention and Control Programs should have access to expert resources including an infectious disease physician and/or a medical microbiologist. These consultants should be reimbursed for their time and expertise.

Over two decades ago, the SENIC study identified a trained infection control physician as an essential component of an effective IPCP^(10;11).

3. To support the surveillance activities and to identify and manage outbreaks, Infection Prevention and Control Programs should have readily available access to microbiology and virology laboratory diagnostic services. This includes access to qualified reference laboratories that can provide timely molecular typing.

As well as helping to determine treatment options, the microbiology laboratory is pivotal in the detection, investigation and control of outbreaks of infection.⁽²³⁹⁾ High volume laboratories can serve a reference function by tracking AROs and other events in both individual patients and in populations within different health care facilities or settings.⁽²⁴⁰⁾ Examples are the molecular/genetic fingerprinting of MRSA,^(241;242) and C. difficile isolates.

4. An effective Infection Prevention and Control Program should collaborate and consult with internal (e.g., patient safety, quality assurance, reprocessing, occupational health) and external (e.g., other facilities and local, provincial/territorial and national health agencies) partners to ensure appropriate communication and sharing of information.

Collaboration and consultation between infection prevention and control and other health care disciplines or settings is a responsibility of IPCPs. Examples include, but are not limited to, working with occupational health to prevent the transmission of infectious diseases to staff who may in turn transmit to patients, health care workers or visitors⁽²⁴³⁾or with the reprocessing department to ensure standards are maintained for the cleaning, disinfection and sterilization of patient care equipment.^(244-247)

5. Health care organizations should ensure that surveillance of both infection prevention and control processes and outcomes related to health care associated infections is performed; analyzed appropriately; provided to front line staff, clinical leadership, and administrators; and used to monitor and improve related patient outcomes.

Surveillance is an essential component of any effective IPCP.⁽¹⁷⁸⁾ The effectiveness of reducing the number of nosocomial infections by providing feedback of surveillance data to key stakeholders is well documented.⁽¹⁷⁷⁾ A region-widedatabase is needed to identify and track health care associated infection trends such as C. difficile diarrhea, MRSA, and infections such as SARS among all health care settings, as patients move between health care facilities and health care settings. This type of surveillance, however, requires effective IPCPs that cooperate and communicate among the various settings and facilities to ensure there are standardized data collection, analysis, and interpretation methods so that the reported rates and estimated costs of HAIs are reliable.

Surveillance should not be solely limited to an outcome. Identifying processes that influence the outcome and perhaps require improvement is one of the lessons learned from industrial applications. Process surveillance is required to link the final outcome with related processes.^(178;248) An example within infection prevention and control would be to recognize the relationship of a process (timing of antibiotic prophylaxis) with the result (prevention of surgical site infection) as the timing directly influences surgical site infection rates.^(201;249)

6. Infection Prevention and Control Programs should conduct ongoing educational programs for health care providers (including volunteers, family members and students) to reinforce current standards of infection prevention and control practices, emphasizing the importance of hand hygiene.

Infection prevention and control programs should provide basic and continuing education to health care providers regarding principles of infection prevention and control^(250;251) to help prevent the transmission of emerging infectious diseases such as SARS⁽²⁵²⁾ and the re-emergence of infections such as C. difficile.⁽¹⁴⁾ These programs should include comprehensive risk reduction strategies necessary to minimize the risk of HAIs to patients, staff and visitors.^(92;253) Education is an important tool in ensuring that health care personnel and visitors comply with IPCP policies. The importance of this compliance can be demonstrated by recognizing the failure to use basic infection control techniques such as appropriate hand washing^(254;255) as the major factor for  cross transmission in hospitals, including the dissemination of AROs.^(13;140;256) Educational programs should be evaluated regularly and include auditing compliance of infection prevention and control measures with timely feedback for optimal improvement.

7. Infection Prevention and Control Programs should have access to current infection control literature, textbooks, journals, standards and/or guidelines, in addition to Internet access.

Members of the IPCP require appropriate knowledge-based information to keep current with infection prevention and control literature, standards, and guidelines.

8. Infection Prevention and Control Programs should have adequate office space and secretarial, data entry and computer support.

Secretarial support providing computer data entry; typing of minutes, documents and reports; answering telephones; and arranging meetings is essential for the IPCP.⁽⁶⁾

9. Health care organizations should ensure that there is adequate nurse staffing with the appropriate skills to apply infection prevention and control measures when providing patient care. Other health care providers in all settings where health care is delivered (e.g. respiratory therapists, physiotherapists) should also have the skills to apply infection prevention and control measures when providing patient care.

The evidence^{(13;26;104;130-133;135;137-139;257-260)} is consistent that deteriorating nursing care associated with understaffing results in negative patient outcomes and contributes to the risk of HAIs. This emphasizes the need not only for effective IPCPs, but also for adequate numbers of health care providers with the proper skill sets.

10. Health care organizations should ensure that there is adequate housekeeping staff with the appropriate training to provide a clean and safe environment for patient care.

A 2004 study⁽²⁶¹⁾ demonstrated that high levels of cleaning played an important role in controlling a 14-month outbreak of Acinetobacter baumannii in an intensive care unit. The authors noted that failure to follow strict cleaning protocols resulted from problems recruiting, retaining and training cleaning staff and appeared to exacerbate the outbreak. The patient’s right to be cared for in a clean, safe environment is irrefutable.^(262;263) An integrated cleaning and monitoring program as well as basic training and regular updates for housekeeping staff are crucial  components of an effective IPCP.^(264;265) A new role of “clinical housekeeper” is emerging in the fight against HAIs.⁽²⁶⁶⁾ This worker’s main responsibility is to prevent the spread of infection through the cleaning of clinical equipment and the health care environment.⁽²⁶⁶⁾

7.0 Conclusion

Infection prevention and control programs are of demonstrated value in improving the quality and safety of health care and in reducing its costs. Effective IPCPs minimize the risk of infection in all health care settings and are important to the health and safety of Canadians and to the global community. However, in order for the IPCP to implement, monitor, and evaluate all the infection prevention and control interventions recommended, appropriate resources are required. The ultimate goal of the IPCP is to reduce HAIs to the lowest possible level. The resources must support this goal.

Infection prevention and control is a public health issue of great concern. Decision makers need to recognize the essential components of Canadian health care settings and thereby devote adequate resources to this end. It is a matter of protecting the health and safety of Canadians.

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