Healthcare-associated infections: a worldwide epidemic

By Anne MacLaurin

Healthcare-associated infections (HAIs), or infections acquired in healthcare settings, are the most frequent adverse event in healthcare delivery worldwide.

Every year, 220,000 Canadian patients – approximately one in nine – will develop an infection during their hospital stay, and an estimated 8,000 of those patients will lose their lives (Zoutman et al., 2003).

Complicating the problem is that many HAIs are caused by antimicrobial-resistant organisms (AROs). Without harmonized and immediate action, the world is facing a post-antibiotic era in which common infections could once again be deadly (WHO, 2015). AROs could lead to infections that are difficult, if not impossible, to treat. Action needs to happen on multiple levels to prevent the emergence of antimicrobial resistance, and special care must be taken to protect the most vulnerable populations.

Patients are placed at risk of acquiring an infection each time they enter the healthcare system with an open wound or a suppressed immune system, when they require surgery or have an invasive device inserted, and from a myriad of other ways that are seemingly innocuous to the unaware. To better understand the magnitude of the problem, take the case of one senior who ping-ponged throughout the healthcare system and later died from a HAI:

Herbert Strasser, a very active 72-year-old, collapsed at his home in Belleville, Ontario on the morning of August 3^rd. One minute he was standing at the door drinking coffee, and the next minute he was literally a paraplegic lying on the floor. He was rushed to the local hospital and then on to Kingston General Hospital (KGH).

Strasser was diagnosed with a disc decompression, requiring urgent surgery. He spent 10 days recovering before being transferred to a rehabilitation center. He was there five days before being sent back to KGH for symptoms of a urinary tract infection. He stayed overnight in the ER, and was then transferred back to the rehab center.

Once back at the rehab centre, Strasser continued to deteriorate and after several days was sent back to KGH where it was determined he was septic from an abscess that had developed at the surgical site on his back. He received antibiotics, an incision and drainage and was reassured that a very close eye would be kept on this infection. Over the next several days he lost his appetite, developed a severe thrush in his mouth and suffered episodes of chills and shakiness.

Strasser desperately wanted to be transferred back home to be closer to his family. The doctors agreed he was stable and “there was nothing being done at Kingston couldn’t be done at Belleville.” He was transferred late one evening without pertinent transfer records; they were to follow. A physician-to-physician report did not occur and within 24 hours Strasser became quite ill with various issues. Prior to transfer a very important antibiotic for the spinal abscess was accidently discontinued.

Within six hours of being transferred as a “stable” patient, Strasser tested positive for C. difficile. He was severely dehydrated, the thrush in his mouth persisted to the point where eating and drinking had become painful. Strasser was transferred to the ICU, where tragically he died on September 19^th.

Post mortem it was determined that the spinal abscess had not resolved, it had in fact crept up from the base of his spine to his neck and the infection was literally disintegrating his neck. The C. difficile was so severe his colon was macerated and the thrush in his mouth had extended all the way down his throat.

Several healthcare improvements have since been made. At KGH, protocols were initiated to identify patients at high risk for C. difficile; transfers are limited on weekends and off hours; and physicians give doctor-to-doctor reports. The Belleville hospital made positive changes to medication reconciliation as well as communication between physicians. The rehab facility also made changes to address communication and nursing staff issues.

Reducing HAIs

Currently, there is not a consistent approach across provinces/territories or even within some provinces for how infections are defined, measured, or reported. The Canadian Patient Safety Institute is supporting a number of pan-Canadian initiatives to implement standardized surveillance definitions and leading a public awareness campaign – STOP! Clean Your Hands Day – aimed at helping to change behaviours around cleaning your hands to help prevent infection.

Under the leadership of Infection Prevention and Control Canada (IPAC Canada), in collaboration with the Association of Medical Microbiology and Infectious Diseases Canada (AMMI Canada) and the Canadian Patient Safety Institute, standardized surveillance definitions for HAIs in acute care and long term care have been identified. The nationwide adoption and application of these definitions will impact how infections are defined, measured and reported and ultimately reduce infections. Senior leaders are called upon to endorse, promote and use these case definitions within their jurisdiction, facility and/or network.

In addition, the Public Health Agency of Canada, the Canadian Nosocomial Infection Surveillance Program, the Canadian Institute for Health Information, AMMI Canada, IPAC Canada and the Canadian Patient Safety Institute are working in collaboration to identify potential strategies for national surveillance of HAIs.  Good surveillance data and information is essential for improvement. The group seeks support to facilitate the collection, analysis and reporting of HAI surveillance data across Canada. Ultimately, this data will serve to reduce infections, like the HAI that ended Strasser’s life.

As front line health-care workers, there is something you can do right now to help prevent the spread of HAIs. Proper hand washing serves as the foundation to prevent HAIs: in Canada, the Canadian Patient Safety Institute promotes STOP! Clean Your Hands Day each year to foster engagement and participation. Improving the implementation of evidence-based practice in order to make patient care delivery safer depends on behaviour change (Michie et al, 2011), and events like these help provide the tools and resources to encourage that behaviour change. STOP! Clean Your Hands Day highlights the dangers in not cleaning your hands, not only in healthcare, but also in our communities. If we are going to defeat HAIs, we should report them, honour the memory of those they affect, and face the problem with clean hands.

STOP! Clean Your Hands Day

Cleaning your hands is one of the best ways to stop the spread of infection. In a Canadian Hand Hygiene audit the national compliance rate for hand hygiene was 78.3 per cent (CPSI, 2014). Current data estimates that compliance rates by province range from 48 to 90 per cent.

Each year, thousands of healthcare providers in sites across Canada join the fight against the spread of infection by participating in STOP! Clean Your Hands Day – led by the Canadian Patient Safety Institute, in conjunction with the WHO’s SAVE LIVES: Clean Your Hands campaign. The day is celebrated annually on the fifth day of the fifth month, representing five fingers on each hand.

The WHO slogan for May, 5, 2019 is “Clean care for all – it’s in your hands”. Calls to action have been created, targeted to each of these audiences:

• Health workers: “Champion clean care – it’s in your hands”
• Infection Prevention and Control leaders: “Monitor infection prevention and control standards – take action and improve practices”
• Health facility leaders: “Is your facility up to WHO infection control and hand hygiene standards?”
• Patient advocacy groups: “Ask for clean care – it’s your right”

Planning is now underway to celebrate STOP! Clean Your Hands Day across the country on Monday, May 6, 2019. Visit www.handhygiene.ca to learn how you can participate.

Anne MacLaurin is a Senior Program Manager with the Canadian Patient Safety Institute, leading the infection prevention and control national strategy.