Management of Hospital-acquired Infection.

Infection control is an essential element of good clinical practice and is vital for patient safety. The purpose of our performance audit was to describe and assess systems for managing hospital-acquired infection in public hospitals.

Overall Conclusions

Hospital-acquired infections are recognised nationally and internationally as a serious problem. In common with other parts of the world, they are an important concern in New Zealand’s public hospitals.

Here, and in other developed countries, it is estimated that about 10% of patients admitted to hospital will acquire an infection as a result of their hospital stay. The costs of dealing with hospital-acquired infections in this country’s public hospitals are estimated to be more than $137 million a year.

A fair proportion of hospital-acquired infections can be avoided through effective infection control practices. Everyone working in a hospital should take responsibility for infection control. Making sure they do take responsibility – and that every reasonable action is taken to manage the risk of infection – is challenging.

The legislative framework and the Infection Control Standard1 (the Standard) provide a solid basis for hospital services2 to establish effective arrangements for infection control. Hospital services are making progress towards meeting the Standard. Some dimensions of infection control are working particularly well – such as collaboration between infection control and laboratory staff. Others require more attention – for example, auditing of infection control practice, which provides a vital source of assurance about compliance by hospital staff.

In some hospital services, there needs to be more visible and active commitment by managers and clinical and other staff to the importance of infection control. Infection control needs to be a key component of hospitals’ risk management and quality assurance arrangements. District Health Boards (DHBs)3 must have the information they need to be accountable to their communities for providing safe health care services – and that should include information on the risks of hospital-acquired infection and how the risks are being managed.

Action is also required by the Ministry of Health (the Ministry) to improve national arrangements – for example, to establish comprehensive surveillance4 of hospital-acquired infection that would provide a national picture of the incidence and causes of such infections.

The Framework for Infection Control

The Health and Disability Services (Safety) Act 2001 aims to promote the safe provision of health and disability services by establishing national standards-based certification. The Ministry engaged Standards New Zealand5 to prepare the Standard that sets out the basic principles and systems forming the foundation of effective infection control.

The Standard is proving to be a valuable resource for hospitals – although few were applying the accompanying infection control audit tool. The Ministry has been promoting voluntary accreditation of health care services, which will help hospitals to prepare for certification.

In addition, the Ministry’s infectious disease strategy6 sets useful goals – outlining strategies to reduce the incidence of infectious diseases, and specifying action plans to improve the prevention and control of hospital-acquired infection.

Only a comprehensive national surveillance programme will provide the Minister of Health, patients, and the general public, with information about rates and types of hospital–acquired infection that is necessary for reasonable assurance about the safety and quality of public health care. The Ministry has made a commitment to establish a national surveillance programme for hospital-acquired infection, but has yet to set a timetable.

District Health Board Governance

DHBs are responsible for ensuring that publicly funded health care services are safe – which includes safeguarding patients, staff, and others (as far as possible) from the risks of infection.

Infection control is about managing risk, by using information on what the risks are and how they are being managed. Most hospital managers were receiving regular reports on rates and cases of hospital-acquired infection, but:

  • Not all hospital services provided such reports to quality assurance and risk managers – reflecting the absence of a co-ordinated approach, and poor integration of infection control activities with quality assurance and risk management.
  • The Boards of DHBs were not receiving regular information on hospital-acquired infection rates or infection control systems. Without such information, Boards are not in a position to provide assurance to their communities about the safety of their hospital services.
  • Few DHB plans made reference to infection control, and DHB reporting to the public on hospital-acquired infection was limited and not always reliable and consistent.

These observations suggest that more attention needs to be given to infection control as a key part of risk management and high-quality health care.

Infection Control in DHB Hospitals

How Infection Control Is Organised and Managed

Infection control programmes were generally comprehensive and were monitored regularly. However, fewer than half of the programmes specified how their infection control team contributed to setting standards in clinical and support services, or identified planned audits of the services. This suggests that some hospitals may be giving insufficient attention to the infection control implications of clinical or other hospital practices.

Infection control responsibilities were appropriately allocated to a range of clinical staff and managers. Infection control teams were well established, and were normally made up of hospital nursing and medical staff with appropriate training and skills in infection control.

A range of factors suggested that some hospital services might not have applied the appropriate level of resources to infection control. Those factors included:

  • the wide variety of tasks undertaken by infection control staff in different hospitals and in the community;
  • widely varying ratios of infection control staff to occupied beds;
  • the relatively little time spent in some hospital services on auditing compliance with infection control procedures; and
  • high costs associated with managing outbreaks.

Infection control staff are doing clerical work which is not a good use of their skills and experience. Providing clerical support would free up more time for the infection control teams.

Relationships Between Infection Control and the Rest of the Hospital Service

Infection control is a hospital-wide activity. The infection control committee should provide a key interdisciplinary forum for considering infection control matters throughout the hospital, bringing together the interests of different clinical and non-clinical groups. In most DHB hospital services, membership of the infection control committee reflected the range of infection control interests in the hospital service. Some committees needed to be strengthened by adding representation from two important groups – hospital pharmacies and occupational health services.

In some hospital services, attendance at infection control commitee meetings was sporadic. Absence of some members resulted in meetings not having the benefit of all relevant views, and valuable knowledge and experience may not be shared. Irregular attendance may also reflect a lack of proper commitment to, and support for, infection control.

"… An important but unquantifiable effect of infection control activities is a general increase in awareness of good clinical practice that minimises risk of hospital-acquired infections …"

Communication is an important function of an infection control committee. Few committees reported on their year’s activities. Those reports we saw were informative, and provided useful summaries of plans and performance to a wide audience throughout the hospital.

Infection control teams had effective relationships with laboratory staff, enjoying good access and constructive collaboration on infection control matters.

Establishing a network of infection control representatives can be a useful way of raising awareness, sharing knowledge, promoting best practice, and helping with surveillance and early detection of outbreaks. Two-thirds of hospital services had infection control representatives in ward areas. A number of obstacles must be overcome to make best use of these staff – in particular, a lack of recognition, limited training, and inadequate resourcing. Clearly defining the role of the infection control representative is an essential first step.

Changes to the hospital environment – such as purchase of new equipment, building re-design, and the introduction of new services or contractors – can add new risks of spreading infection. Infection control staff can provide useful advice about the practical impacts of proposed changes, drawing on their wide experience of how the hospital works. Even so, they were often not consulted when such changes took place. This is a missed opportunity and increases the risk that important infection control matters may be overlooked.

Setting Infection Control Policies, Educating People to Follow the Policies, and Making Sure They Do

Infection control teams and other hospital staff had ready access to documented, up-to-date infection control policies and procedures – both for day-to-day reference and guidance, and to use as a benchmark for auditing against good practice. However, few sets of policies were comprehensive. Important omissions included policies relating to staff vaccination, the management of beds, and aspects of clinical practice.

Drawing up and maintaining infection control policies is time-consuming, and many aspects of good practice are applicable to all hospital services. There is scope for DHBs to collaborate more on policies.

Training in good practice and familiarity with policies helps promote a culture of good infection control throughout the hospital. Nurses received training in infection control when starting work in a hospital, but training was given less often to senior doctors and support services staff, creating the potential for lack of awareness. Moreover, without regular refresher training, commitment may wane over time and standards of good practice may slip.

Almost two-thirds of hospital services were assessing the effectiveness of training through follow-up audits. However, some infection control teams were not auditing enough to ensure that policies were being followed – representing a serious gap in quality assurance that must be addressed.

The teams were commonly carrying out audits of hospital hygiene, but some audits covered limited areas of the hospital environment, reducing the level of assurance provided. We noted instances where hygiene audits had led directly to substantial improvements. In some hospital services, the audit results needed to be distributed more widely to ensure that lessons were communicated to all relevant parts of the hospital service.

Infection control teams were not always involved in audits of related clinical practices – such as audits of isolation units and wound care. As a result, these audits may not have sufficient regard for the infection control aspects of such clinical practices.

While most hospital services had policies on appropriate use of antibiotics, more than half of infection control teams and hospital pharmacies were not working together to ensure compliance. Few infection control teams had access to the pharmacy data necessary to establish relationships between infections and antibiotic prescribing. This limited collaboration and access to information reduced the opportunities for effective communication throughout the hospital about prudent antibiotic usage.

Screening and Surveillance to Identify Hospital-acquired Infection

Screening patients and staff plays an important part in preventing and controlling infectious disease in a hospital. All but one hospital service routinely screened certain groups of patients, and 16 routinely screened staff to identify any who might be colonised7 or infected.

Surveillance is an essential component of preventing and controlling infection in hospitals. All hospital services undertook some form of surveillance, but many used different definitions – making it difficult to set benchmarks, interpret data nationally or for groups of hospitals, or draw meaningful comparisons. Most infection control teams had satisfactory access to information systems for surveillance purposes, and regularly examined surveillance data – mainly laboratory reports and electronic patient records. But data collection and collation needed to be improved.

For effective surveillance, all relevant information and risk factors should be monitored. In most hospital services, surveillance programmes needed to be more comprehensive – only one programme in the six DHBs with tertiary8services covered all of the important risk factors.

Surveillance results provide valuable information about hospital practices that could put patients or staff at risk of infection but, in some hospital services, clinical staff were not receiving results that could help them eliminate unsafe practices and target possible causes of infection.

Most hospital-acquired infections become apparent only after a patient has been discharged. The most serious of these cases may require the patient to be re-admitted. However, most hospital services had no reliable information on re-admissions of patients with a hospital-acquired infection.

Most hospitals were carrying out periodic surveillance to establish the extent to which infections appeared after a patient’s discharge from hospital. Enhancing post-discharge surveillance would give hospitals a more accurate picture of their rates of hospital-acquired infection.

Few hospital services were carrying out a risk assessment to establish whether their arrangements for isolating infectious or at-risk patients were adequate. Some respondents expressed the view that arrangements in their hospitals for isolating patients were unsatisfactory, and had concerns about the availability of beds and the quality of facilities.

Managing Outbreaks of Hospital-acquired Infection

Nearly all hospitals had documented arrangements or plans to deal with infection outbreaks, endorsed by the infection control committee. Reports on reviews of how well outbreaks were handled can contain important lessons for the management of future outbreaks. Some hospital services would benefit from making such reports more widely available to all staff responsible for taking action on the issues raised.

1: Standards New Zealand: NZS 8142:2000 Infection Control. Organisations obliged to comply with the Health and Disability Services (Safety) Act 2001 will be required to demonstrate compliance with this Standard (for existing licensed providers by 1 October 2004).

2: The term hospital services refers to that part of the DHB delivering services in a hospital setting within the DHB.

3: There are 21 DHBs, which are responsible for ensuring the provision of health care services to their communities (see Figure 1 on page 33).

4: Surveillance involves the collection and interpretation of data on infections, and reporting the results so that clinical staff and managers can take action, if appropriate.

5: Standards New Zealand is the trading arm of the Standards Council, a Crown entity operating under the Standards Act 1988.

6: An Integrated Approach to Infectious Disease: Priorities for Action 2002-2003 is one of a number of supporting strategies designed to give effect to The New Zealand Health Strategy; Ministry of Health, Wellington, December 2000; ISBN 0-478-23993-9 (Book), ISBN 0-478-23994-7 (Internet)

7: In a colonised person, the organism is present in the person’s body but has not caused an infection in that person.

8: We use the term tertiary to refer to those DHB hospitals providing very specialised care and performing the most complex procedures. These services are predominantly delivered by the DHBs based in major cities.

page top