Variation in hospital cleaning

Hospital cleanliness has a number of implications for patients and staff in addition to simply preventing the spread of infection. Aside from infection, for patients and their families, a tidy and sanitary ward greatly improves comfort and provides assurance of the quality of their treatment. For staff, a hygienic environment means a more appealing workplace.

Throw in numerous studies demostrating and articulating links between the environment and infection [1-5], it’s easy to see why effective cleaning is of utmost importance when it comes to maintaining safe and quality hospital care. In light of this, it is difficult to believe that we have no uniformity across Australian hospitals when it comes to cleaning practices, staff training, products used or even standards by which to evaluate whether a hospital environment is clean and safe.

Variation in hospital cleaning practice and process in Australian hospitals: a structured mapping exercise [6] is the first paper to identify the variations in cleaning practices present among Australian hospitals. It describes in detail a range of discrepancies found in cleaning processes used across the country, in a study of 11 private and public Capturehospitals.

This paper is the latest from The ‘Researching Effective Approaches to Cleaning in Hospitals’ (REACH). The REACH study uses a bundle of standardized interventions in an attempt to combat healthcare-associated infections, with a view of gathering evidence that could be used to inform better and more standardized cleaning methods in the future.

The variation in cleaning practice and processs highlighted in this paper, demonstrates  the need for nationally recognised standards in hospital cleaning and outlines the challenges associated with the current system – or lack thereof.

 

References

  1. Dancer SJ. The role of environmental cleaning in the control of hospital-acquired infection. J. Hosp. Infect. 2009;73:378-385
  2. Mitchell BG, Dancer SJ, Anderson M, Dehn E. Risk of organism acquisition from prior room occupants: a systematic review and meta-analysis. J. Hosp. Infect. 2015;91:211-217.
  3. Hayden, M. K., Bonten, M. J., Blom, D. W., Lyle, E. A., van de Vijver, D. A., & Weinstein, R. A. (2006). Reduction in acquisition of vancomycin-resistant enterococcus after enforcement of routine environmental cleaning measures. Clinical Infectious Diseases, 42(11), 1552-1560.
  4. Donskey CJ. Does improving surface cleaning and disinfection reduce
    health care-associated infections? Am J Infect Control. 2013;41(5):S12–9.
    http://dx.doi.org/10.1016/j.ajic.2012.12.010.
  5. Barker J, Vipond IB, Bloomfield SF. Effects of cleaning and
    disinfection in reducing the spread of Norovirus contamination via
    environmental surfaces. J Hosp Infect 2004; 58(1): 42–9. doi:10.1016/
    j.jhin.2004.04.021
  6. Mitchell, B. G., Farrington, A., Allen, M., Gardner, A., Hall, L., Barnett, A. G., . . . Graves, N. Variation in hospital cleaning practice and process in Australian hospitals: A structured mapping exercise. Infection, Disease & Health. doi:10.1016/j.idh.2017.08.001

 

 

 

The burden of HAIs in Australia

Today, we published an article in Infection, Disease and Health estimating the number of HAIs occuring in Australia each year. [1]

To do this, we undertook a systematic review of the peer reviewed literature between 2010 and 2016. We identified 24 articles that reported the incidence of HAIs in Australian hospitals.

Overall, data from these multi centred studies suggested 83,000 HAIs per year in Australia. UTIs are were the most common, followed by C.difficile, SSIs, respiratory infections and Staphylococcus aureus bacteraemia. HAI burden.png

Of course, these numbers are a very  large underestimate given the lack of or incomplete data on common infections. It is also limited to data published in the peer reviewed literature.

Incidence data on infections such as pneumonia, gastroenterological and bloodstream infections (other than SAB) were not identified, thus potentially
missing up to 50% of infections. That being the case, the

PPS blog incidence of HAIs in Australia may be closer to 165,000 per year.

Don’t believe me? Have a look at the results of point prevelance studies in Europe (right). Respiratory tract infections, bloodstream infections and others account for a large proportion of HAIs.  Of course, Australia has not had a PPS undertaken in 30 years, so we don’t really know. However, for readers of this blog, you will know that will soon change.

A figure of 200,000 HAIs per year in Australia is commonly cited, however, this figure was derived from one study undertaken several years ago (a sign of what was available at the time). Our study, may, in part, demonstrate the increasing number of publications on HAIs in Australia. We are certainly not suggesting a reduction in HAIs and any such claim based on the findings of our study should be immediately dismissed.

There are some other equally important findings from our study:

  • There needs to be a determination and action by state and national government bodies to achieve consensus on national HAI definitions
  • We need national approaches to HAI surveillance and transparent regular reporting. Australia is so far behind other countries in this regard [2] [3]
  • In the absence of action by government, we call on those undertaking HAI surveillance (especially incidence) to report your data in the peer reviewed literature

We also found there is little information about healthcare associated respiratory infections, such as pneumonia. Maybe it is in the too hard basket (nice blog by Martin Keirnan which says it all). Well, I think we should do something about healthcare associated pneumonia – at the very least, understand the incidence and risk factors a little better. I am working on it…..

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Footnote: Some of the research I have been involved with has been supported by donations from the public. For that, I am very grateful. Should you or your company wish to make a tax deductible donation, you can do so here.

References

  1. Mitchell, BG., Shaban, R., MacBeth, D., Wood, CJ., Russo, PL (2017). The burden of healthcare-associated infection in Australian hospitals: A systematic review of the literature. Infection Disease and Health. https://doi.org/10.1016/j.idh.2017.07.001
  2. Russo, P. L., Cheng, A. C., Richards, M., Graves, N., & Hall, L. (2015). Healthcare-associated infections in Australia: time for national surveillance. Australian Health Review, 39(1), 37-43.
  3. Russo PL, Cheng AC, Mitchell BM, & L, H. (2017). Healthcare associated infections in Australia – Tackling the “known unknowns”! Australian Health Review, (published online 7 March 2017), http://dx.doi.org/10.1071/AH16223

 

Australian HAI Point Prevalence Study is Coming

Followers of this blog will know how passionate Phil Russo and Brett Mitchell are about the need for national surveillance and a point prevalence study (PPS). Map Aus2We are very pleased to let you know that a HAI PPS is coming, by way of a research project.

For more information, please see www.ipcca.com.au/pps

 

 

#SHEA2017 & Behaviour Change (bundle?)

change_ahead

Clearly the current toolkit for the ICP extends well beyond knowledge of infection prevention and control. Amongst others throw in a dose of psychology, implementation science and behaviour change.

Matthew Kreuter is a leading national public health expert in the field of health communications at Washington University in St Louis, and at the SHEA Spring Conference presented a plenary titled May the Forces be with You: Understanding How to Change Behaviour. Krueter packed in a lot of useful information in his presentation. Much of what he said I believe really underlined the importance of a comprehensive implementation strategy.

There is no substitute for taking time to understand the people you are dealing with and the environment they work in. One of the biggest challenges in behaviour change and infection prevention is we don’t always see the consequences of our action (the missed hand hygiene > unclean hand > contaminated environment > patient colonisation > breach of first line defences > infection), and not every bad action will necessarily result in an adverse outcome. Furthermore, HCW’s may suffer from a curse of “smartness”,  i.e. “I know my patients best” which can lead to rejection of guidelines.

Some of the key messages I took away from this talk include:

  • The easiest behaviours to change are the simple ones that have clear and immediate benefits “to me”
  • When planning behaviour change, focus on identifying meaningful benefits and personalise the consequences. The consequences need to be relevant
  • Utilise authentic stories of the consequences. Sadly we have no end of patients who have suffered as a result of a HAI, consider involving them and their stories
  • Other factors that work include credible messengers (peers, champions) performance feedback and aspirational identity

Kreuter concluded by listing 4 factors that work MORE:

  1. Policies
  2. Environment
  3. Organisational Culture
  4. Engineering and Design, or
  5. a combination of these

note he didn’t use the term “Bundle”!

 

Phil

#SHEA2017 Spring Conference and the International Ambassador Program

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Some of the SHEA IAP’s at the Arch in St Louis, Mo

I was recently honoured to be a member of the Society for Healthcare Epidemiology of America (SHEA) International Ambassador Program (IAP) at the SHEA Spring Conference in St Louis, Missouri.

If you don’t know about the SHEA IAP, I strongly encourage you to find out more about it here. It provided me the opportunity to meet 17 other ambassadors from across the globe, attend a special pre-conference program that included a visit to Barnes-Jewish Hospital, (saw my first ever fully automated microbiology lab) attend the SHEA Foundation dinner (where we were privileged to be present for a special dedication to Denis Maki), and of course attend the SHEA Spring Conference.

SHEA combine a full conference with a Training Certificate Course in Healthcare Epidemiology which is available to conference delegates. This was quite handy as I was able to junto into a few Epi sessions to brush up on a few skills.

There were many learnings and observations from my time in St. Louis, and I will get my thoughts in order and post them on this blog over the next week or so.

Phil

Declaration: The SHEA IAP is also supported financially by 3M, and I’d like to express my gratitude to both SHEA and 3M for their support.

 

Would you like some antibiotics?

This is part two of my blog from Cambodia. The first part is here What can $6m buy you

I have spend some time at Angkor Hospital for Children and have been amazed. Amazed at the challenges faced and amazed at the quality of infection control given the limited resources. The IC program consists of continous prospective surveillance of all HAIs, hand hygiene, feedback of infection data, environmental cleaning (twice a day), cleaning audits, training, good governance and the list goes on.  Hand hygiene compliance is above 80%, but not all moments have been introduced yet (1000+ moments a month observed). IMG_2308

The fact that a hospital here can undertake continous surveillance of all HAIs is quite amazing. They asked if I could benchmark them against some Australian hospitals/what the rates are in Australia. And there we ended back to where this blog always seems to – a lack of co-ordinated, meaningful HAI surveillance at the national level in Australia.  But enought of that, see Phil’s blog for the pub test.

Not all is of course perfect, but given the resources, I think it is quite extrordinary. Another difficultly (apart from ovecrowding, lack of resources, limited clean water etc etc) is a some local work suggesting 60+% of patients coming into the hospital are colonised with a MRGN, mainly resistant in some form. That got us talking a lot about strategies and future work, but I also have myself an challenge….

This test invovled me trotting up to a local pharmacy. It went like this “My wife has a cut on her arm, it is inflammed/red”. That is pretty much it. The response:

  • Pharmacy 1 – topical cream that consistent of gentamicin, erythromycin and clotrimazole, all combined in one convenient tube. I asked about oral amoxicillin and was told “antibiotics you swallow are only for infections on the inside, the don’t work anywere else”.
  • Pharmacy 2 – Ciprofloxacin was handed to me.

Dishartened, I changed my tack. I went to another pharmacy and said “My wife has a cough and fever”. They asked if it was a dry cough. I said no, productive sputum. I was handed paracetamol. Yeah! There is hope.

This blog, I hope, illustrates the challenges  in infection control (&AMR) in a resource deprived country. We need to support our colleagues in our region, in any way we can. OneHealth is a global issue.

(By the way, I did not purchase any of the antibiotics, so as not to contribute to the issue).

 

 

 

 

 

The Pub Test

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For many Australians there is a long held tradition of going to the pub at the end of the day/week to discuss life’s big questions (a practice not native to Australia I’m sure). Sadly, the pubs I frequented in my youth are now apartments (because we need more of those!) and like the live music they used to support, they are gradually disappearing from our urban landscape.

Anyhow, arising from the communal attempt to discuss worldly issues, comes the term “the pub test”.  Briefly, the pub test seeks to evaluate the views of “ordinary Australians” on certain issues. In my home state of Victoria, the recent application of the pub test has resulted in the downfall of several senior politicians who were accused of rorting their privileges by making extravagant travel claims. Though arguably they may not have breached any rules (stretching them perhaps). The media applied the pub test and the punters down at the pub believed the politician’s behaviour was unacceptable. In an impressive display of the power of the popular vote, these politicians have been stood down.

Now I’m not convinced of the rigour of the pub test, not the least I suspect the results may be influenced by the pubs location and the time of night you visited, but nevertheless it got me thinking, what if we applied the pub test to the state of infection prevention in Australia?

I wonder if these statements, reflecting some of our local infection prevention issues, would pass the pub test?

  • Some people get an infection as a result of their healthcare, but we’re not really sure how many Australians this happens to.
  • If you are infected with a ‘superbug’ in some hospitals, sometimes the staff that look after you will be wearing gowns, gloves and masks, and sometimes they wont.
  • If you are placed in a room that was previously occupied by a patient with a ‘superbug’ you are probably at a higher risk of being infected with that ‘superbug’ than if you are placed in another room.
  • Not all hospitals use the same criteria to identify an infection.
  • If you ask a hospital CEO which of the surgeons in their hospital has the highest infection rate, they probably wont tell you.

(I can think of many other examples to put to the pub test, and I invite you to share yours).

What would be the reaction of the ‘ordinary Australian’ to these statements? Would the power of the popular vote on these issues catch the eye of those in authority?

 

Declarations: I occasionally go to a pub – Phil