The Journal of National Accreditation Board for Hospitals & Healthcare Providers

ORIGINAL ARTICLE
Year
: 2014  |  Volume : 1  |  Issue : 2  |  Page : 44--51

Healthcare associated infections: A menace-role of management at a multi-super-specialty hospital in North West Region of Delhi


Kiran Chawla, Arun Madan, Rakesh K Chawla, Aditya K Chawla 
 Department of Quality and Medical Operations, Jaipur Golden Hospital, Saroj Hospital and Heart Institute, Rohini, New Delhi, India

Correspondence Address:
Dr. Kiran Chawla
Singhania University, Pacheri Bari, Rajasthan
India

Abstract

Background: Healthcare-associated infections (HAIs) are usually related to a procedure or treatment used to diagnose or treat the patient俟Q製 initial illness or injury. Aim: To find and compare the incidence of HAI in different Intensive Care Units (ICU俟Q製) of Hospital A. To show a correlation, between HAI with mortality, morbidity and average length of stay (ALOS). Materials and Methods: The study was carried out at three ICU俟Q製 of Hospital A in North-West Delhi-Surgical Intensive Care Unit (SICU), Respiratory Intensive Care Unit (RICU) and Medical Intensive Care Unit (MICU). All patients admitted were followed from admission to 2 days after discharge from the ICU during a period of January 2010-December 2011-December-2012. The total sample amounted to 35,582 patient device days-13,051 for 2010 and 11,659 for 2011 and 10,872 for 2012. Continuous training was there from 2011 onwards for bundle approach and hand hygiene monitoring. Results: The rate of ventilator-associated pneumonia (VAP) from 55.93 per 1000 device days to 7.91 per 1000 device days from 2010 to 2012, catheter-associated urinary tract infection (CAUTI) decreased from 6.33 per 1000 device days to 1.43 per 1000 device days but catheter-related bloodstream infection (CRBSI) increased from 8.46 per 1000 device days to 21.80 per 1000 device days. There is a significant correlation between mortality and HAI P value 0.03 with no significant correlation between morbidity and HAI P value 0.74 also no significant correlation in ALOS and HAI P value 0.17. Conclusion: The trend in VAP and CAUTI in 3 ICU俟Q製 from 2010 to 2012 shows a decreasing trend, the trend of CRBSI in 3 ICU俟Q製 from 2010 to 2012, which shows a decreasing trend in MICU with no trend in SICU and RICU. There is a significant correlation between mortality and HAI with no significant correlation between morbidity and HAI also no significant correlation in ALOS and HAI.



How to cite this article:
Chawla K, Madan A, Chawla RK, Chawla AK. Healthcare associated infections: A menace-role of management at a multi-super-specialty hospital in North West Region of Delhi.J Nat Accred Board Hosp Healthcare Providers 2014;1:44-51


How to cite this URL:
Chawla K, Madan A, Chawla RK, Chawla AK. Healthcare associated infections: A menace-role of management at a multi-super-specialty hospital in North West Region of Delhi. J Nat Accred Board Hosp Healthcare Providers [serial online] 2014 [cited 2019 Jun 24 ];1:44-51
Available from: http://www.nabh.ind.in/text.asp?2014/1/2/44/151301


Full Text

 Introduction



Healthcare-associated infection

An infection that is acquired by or originates in a patient while in hospital or other health care facility and refers to a new disorder associated with being in a hospital, unrelated to the patient's primary condition for which he or she is admitted. [1] Healthcare-associated infection (HAI) had its humble beginning as late as the eighteenth century. Early nineteenth century saw segregation of fever hospitals from general hospitals. Ignaaz Semmelweiss (1861) pioneered the concept of asepsis. A dramatic reduction in infection rates was brought by the simple technique of hand washing with chlorinated lime. [2] By the end of the nineteenth century, use of surgical gloves was introduced in USA. In the early part of 20 th -century cubicle and barrier, nursing was introduced. The first infection control nurse was appointed in the UK in early 1970's. [3] In the mid-20 th century established method of infection control, were laid down - clean air for operating theaters, aseptic procedures for wound dressing, isolation procedures, establishment of antibiotic policies, Hospital Infection Committees. [4] About 5-10% of patients admitted to acute care hospitals and long-term care facilities in the United States develop a hospital-acquired, or nosocomial infection, with an annual total of more than one million people. HAIs are usually related to a procedure or treatment used to diagnose or treat the patient's initial illness or injury. The Centers for Disease Control (CDC) of the US Department of Health and Human Services has shown that about 36% of these infections are preventable through the adherence to strict guidelines by health care workers when caring for patients.

Description of the research work

Aim

To find and compare the incidence of HAI in different Intensive Care Units (ICU's) of Hospital A so as to format the quality improvement program. To show a correlation between HAI with mortality, morbidity and average length of stay (ALOS).

Methodology: Research problem

Total Incidence of HAI in ICU's of Hospital A.Incidence of HAI in ICU's.Device Related Infections in ICU's of Hospital A.Ventilator-associated pneumonias (VAPs).Catheter-associated Urinary tract Infections (CAUTIs).Catheter-related bloodstream infections (CRBSIs).Causative organisms.Comparing with data as per other organizations.Continuous Quality Improvement.

The study was carried out at three ICU's of Hospital A in North-West Delhi-Surgical Intensive Care Unit (SICU), Respiratory Intensive Care Unit (RICU) and Medical Intensive Care Unit (MICU). All patients admitted were followed from admission to 2 days after discharge from the ICU during a period of January 2010-December 2011-December-2012. The total sample amounted to 35,582 patient device days-13,051 for 2010 and 11,659 for 2011 and 10,872 for 2012.

Patients admitted were followed up daily for the development of device-related nosocomial infections - VAPs, CAUTIs and CRBSIs. The CDC and Prevention Case definitions were followed.

 Materials and Methods



For VAP we took Endotracheal (ET) Secretions, ET tip, broncho-alveolar-lavage for culture sensitivity from patients on a ventilator or with tracheostomy on ventilator. For CAUTI sample was collected in a sterile way from the middle part of the tube in a zigzag manner along with catheter tips. For CRBSI blood from the peripheral vein along with a catheter tip if changed was sent for culture. The cultures were taken on 3 rd day (48-72 h) of admission provided same organism is not there at or before admission. The comparison of the incidence of Hospital Infection Rates among different ICU's where different protocols of PPE are being followed, as per the observational data for hand hygiene compliance and observational data following the aseptic measures during the invasive procedures in different ICU's after the procedure is done.

 Limitations



The limitations of this study are:

The patients sometimes do not have baseline cultures that are to be sent on day 1 of admission.The tips of catheters are sometimes not sent for cultures while changing the catheters.The sterile methods are not adopted while collecting the samples sometimes.

 Results and Observations



Observations

When we compared VAP between MICU, SICU and RICU respectively for the 3 years it shows that there is a significant difference in the three ICU's in 3 years, that is, 2010, 2011 and 2012. The trend in VAP in 3 ICU's from 2010 to 2012 shows a decreasing trend. Once we observe CAUTI for the 3 years it shows that there is a significant difference in the three ICU's and the trend of CAUTI in three ICU's from 2010 to 2012 shows a decreasing trend. The trend in 3 ICU's from 2010 to 2012 for CRBSI shows a decreasing trend in MICU with no trend in SICU and RICU. In 2012, all ICU's have improved. There was a significant decrease in mortality in 3 ICU's in 2011 and in 2012. There is a significant correlation between mortality and HAI with no significant correlation between morbidity and HAI also no significant correlation in ALOS and HAI. The data for causative organisms is given as shown in the tables and figures.

[Table 1] shows that there is a significant difference in the three ICU's (P value 0.047) in 2010 and post-hoc comparison shows this significant difference lies between MICU and SICU (P value 0.038) with no significant difference in MICU versus RICU (P value 0.073) and SICU versus RICU (P value 0.817).{Table 1}

In 2011 also there is a significant difference in the three ICU's (P value 0.032) and post-hoc comparison this significant difference lies between MICU and SICU (P value 0.011) with no significant difference in MICU vs. RICU (P value 0.562) and SICU vs. RICU (P value 0.067).

In 2012, all ICU's have improved, and there is no significant difference among any of the ICU (P value 0.229).

Once we observe for the 3 years it shows that there is a significant difference in the three ICU's (P value 0.012) and post-hoc this significant difference lies between MICU and SICU (P value 0.003) with no significant difference in MICU versus RICU (P value 0.050) and SICU versus RICU (P value 0.363).

This Graph 1 shows the trend in VAP in 3 ICU's from 2010 to 2012 which shows a decreasing trend. [SUPPORTING:1]

[Table 2] shows that there is a significant difference in the three ICU's (P value 0.005) in 2010 and post-hoc comparison this significant difference lies between MICU and SICU (P value 0.031) and MICU versus RICU (P value 0.004) and with no significant difference in SICU versus RICU (P value 0.062). In 2011 also there is a significant difference in the three ICU's (P value 0.027) and post-hoc comparison this significant difference lies between MICU and SICU (P value 0.011) with no significant difference in MICU versus RICU (P value 0.295) and also significant difference lies between SICU versus RICU (P value 0.042). In 2012 also there is a significant difference in the three ICU's (P value 0.038) and post-hoc comparison this significant difference lies between MICU and SICU (P value 0.033) with no significant difference in MICU versus RICU (P value 0.894) and also significant difference lies between SICU versus RICU (P value 0.015). Once we observe for the 3 years it shows that there is a significant difference in the three ICU's (P value 0.010) and post-hoc this significant difference lies between MICU and SICU (P value 0.001) with no significant difference in MICU vs. RICU (P value 0.108) and SICU versus RICU (P value 0.316).{Table 2}

This Graph 2 shows the trend of CAUTI in 3 ICU's from 2010 to 2012 which shows a decreasing trend. [SUPPORTING:2]

[Table 3] shows that there is a significant difference in the three ICU's (P value 0.010) in 2010 and post-hoc comparison this significant difference lies between MICU and SICU (P value 0.019) and MICU versus RICU (P value 0.018) and with no significant difference in SICU versus RICU (P value 0.952). In 2011, there was no significant difference among any of the ICU (P value 0.818). In 2012 also there is a significant difference in the three ICU's (P value 0.045) and post-hoc comparison this significant difference lies between MICU and RICU (P value 0.025) with no significant difference in MICU versus SICU (P value 0.547) and SICU versus RICU (P value 0.097). In 2012, all ICU's have improved, and there is no significant difference among any of the ICU (P value 0.229). Once we observe for the 3 years it shows that there is no significant difference among any of the ICU (P value 0.645).{Table 3}

This Graph 3 shows the trend in three ICU's from 2010 to 2012 which shows a decreasing trend in MICU with no trend in SICU and RICU. [SUPPORTING:3]

This [Table 4] shows that there is a significant difference in morbidity in three ICU's in 2011 P value 0.001 and in 2012 P value 0.040. On post-hoc comparison, there is a significant difference in MICU versus SICU in 2011 P value 0.001 and MICU versus RICU P value 0.003 with no significant difference in SICU versus RICU P value 0.355. In 2012 there is significant difference in MICU versus SICU in 2011 P value 0.033 with no significant difference in MICU versus RICU P value 0.106 and SICU versus RICU P value 0.259.{Table 4}

This [Table 5] shows that there is a significant difference in mortality in three ICU's in 2011 P value 0.002 and in 2012 P value 0.035. On post-hoc comparison, there is a significant difference in MICU versus SICU in 2011 P value 0.002 and SICU versus RICU P value 0.003 with no significant difference in MICU versus SICU P value 0.644. In 2012, there was significant difference in MICU versus SICU in 2011 P value 0.002 and SICU versus RICU P value 0.003 with no significant difference in MICU versus SICU P value 0.644.{Table 5}

This [Table 6] shows that there is no significant difference in all ICU's in 2011 and 2012, and they all are comparable.{Table 6}

This [Table 7] shows there is a significant correlation between mortality and HAI P value 0.032 with no significant correlation between morbidity and HAI P value 0.739 also no significant correlation in ALOS and HAI P value 0.168.{Table 7}

 Discussion



We conducted this study in Hospital A with retrospective data of 2010 and prospective data of 2011 and 2012. The study was carried out at three ICU's of Hospital A in North-West Delhi-SICU, RICU and MICU. All patients admitted were followed from admission to 2 days after discharge from the ICU during a period of January 2010-December 2011-December-2012. The total sample amounted to 35,582 patient device days-13051 for 2010 and 11659 for 2011 and 10,872 for 2012. After starting with the bundle approach in June 2011 and monitoring of Hand Hygiene significant differences were observed in different ICU's. Firstly only PPE difference was there among the three ICU's then continuous training was there from 2011 onwards for bundle approach and hand hygiene monitoring. There was a decrease of 2.26 per 1000 device days in HAI in hospital A in 2011 from 2010 and 10.93 per 1000 device days from 2011 to 2012. The rate of HAI decreased to 10.38 per 1000 device days with continuous training and monitoring for bundle approach and hand hygiene compliance along with protocols followed during invasive procedures from 2010 to 2012.Whereas, rate of HAI as per above study in Hinduja Hospital was 9.06 per 1000 device days [5] and as per the study conducted in Brazil by applying the definitions of the US CDC and Prevention National Nosocomial Infections Surveillance System (CDC-NNIS) it was 29.8 per 1000 device days. [6] The rate of VAP decreased in 2012-7.91 (48.02 per 1000 device days decrease) from 2010 which was 55.93 per 1000 device days., CAUTI decreased from 6.33 per 1000 device days to 1.43 per 1000 device days (4.9 per 1000 device days decrease), but CRBSI increased from 8.46 per 1000 device days to 21.80 per 1000 device days (as it was a prospective data in which we started sending the tip of CVP Catheter culture every time when it was removed and awareness increased). The DAI as per study conducted in Brazil were VAP-20.9 per 1000 device days, CAUTI was 9.60 per 1000 device days and CRBSI was 9.1 per 1000 device days and as per PD Hinduja Hospital Study (INICC approach) VAP was 10.46 per 1000 device days, CAUTI was 1.41 per 1000 device days and CRBSI was 7.92 per 1000 device days. When compared with the data of mortality, morbidity (stay >14 days) and ALOS. There is significant correlation between mortality and HAI with no significant correlation between morbidity and HAI also no significant correlation in ALOS and HAI. It has been observed in different studies that increased length of stay increases the risk of HAI, but increase in length of stay can be due to co-morbidities, delays in progression of treatment, delays in shifting out from ICU's and if strict compliance is there of hand hygiene and VAP bundles that risk of HAI also can be reduced. Hence, further studies are required, to differentiate and find out the different causes for increased length of stay compared with HAI along with following infection control protocols. The correlation is based upon 2011-2012 data as we could not get this data retrospectively. This data we could only get from 2011 onwards. This data showed that if proper training is given and followed significant differences can be made in ICU's. There was significant difference as per observational data in three ICU's where different protocols for PPE were followed. SICU followed strict protocols for shoe covers and for all invasive procedures strict hand hygiene, mask, cap and gloves were used in SICU which was also followed in RICU but lapses were in hand hygiene compliance, as per observational data of hand hygiene monitoring and observational data following the aseptic measures during the invasive procedures in different ICU's after the procedure is done. In MICU it was not followed properly with no proper hand hygiene protocols. Continuous training and bundle approach brought significant difference. For VAP there was significant difference among three ICU's and on post-hoc it was in MICU and SICU although no significant difference in MICU and RICU or RICU and SICU. Similarly for CAUTI there was significant difference among three ICU's and on post-hoc it was in MICU and SICU although no significant difference in MICU and RICU or RICU and SICU. For CRBSI there was no significant difference in any of the ICU's and it was found that all PPE is followed in central line insertion as you have enough time to prepare for this procedure. Causative organisms for VAP [[Table 8] and Graph 4] were in the order of Acinetobacter spp., Pseudomonas aeruginosa and then Klebsiella pneumoniae. Causative organisms for CAUTI [[Table 9] and Graph 5] are candida spp., Escherichia coli and K. pneumoniae and in cases of CRBSI [[Table 10] and Graph 6] the organisms are Acinetobacter, Staphylococcus aureus, K. pneumoniae and P. aeruginosa. [SUPPORTING:4] [SUPPORTING:5] [SUPPORTING:6]{Table 8}{Table 9}{Table 10}

Prevention and evaluation

An effective surveillance system must identify priorities for preventive interventions and improvement in quality of care. By providing quality indicators, surveillance enables the infection control program, in collaboration with patient care units, to improve practice, and to define and monitor new prevention policies. The final aim of surveillance is to decrease nosocomial infections and reduce costs. Audit has to be carried out intermittently in a particular manner and this a process of detection of deficiencies and correcting and then finally checking if the changes made have really changed the healthcare delivery to patients. [7],[8],[9],[10],[11]

Importance of the research work

This work is important as now awareness among patients is increasing and also as per law in some countries the financial liability of HAI lies with the hospitals itself. As is rightly said prevention is better than cure, if we prevent HAI financially the burden is going to be less than when we are already fighting with the infection. Furthermore, the mortality rate is going to be lesser than if we can't prevent infections as they are positively correlated.

References

1Girard R, Perraud M, Pruss A, Savey A, Tikhomirov E, Thuriaux M, et0 al. In: Ducci G, Fabry J, Nicolle L, editors. Prevention of Hospital - Acquired Infections - A Practical Guide. 2 nd ed. WHO; 2002. p. 47-54.
2Muralidhar V, Muralidhar S. In Introduction to HAI-Hospital Acquired Infections, Power Strategies for Clinical Practice. 1 st ed. Anshan Ltd; 2006.
3Wenzel, Richard P, Edmond M, Pittet D, Devaster JM, Brewer T, et al. In: a Guide to Infection Control in the Hospital. An Official Publication of the International Society for Infectious Diseases. BC Decker Inc.; 1998. p. 1-4.
4Speller DC, Humphrey H. Hospital acquired infection. In: Collier L, Balows A, Sussman M, editors. Topley & Wilson's Microbiology and Microbial Infections. 9 th ed., Vol. 3. Arnold Publishers; 1998. p. 187-230.
5Mehta A, Rosenthal VD, Mehta Y, Chakravarthy M, Todi SK, Sen N, et al. Device-associated nosocomial infection rates in intensive care units of seven Indian cities. Findings of the International Nosocomial Infection Control Consortium (INICC). J Hosp Infect 2007;67:168-74.
6Salomao R, Rosenthal VD, Grimberg G, Nouer S, Blecher S, Buchner-Ferreira S, et al. Device-associated infection rates in intensive care units of Brazilian hospitals: Findings of the International Nosocomial Infection Control Consortium. Rev Panam Salud Publica 2008;24:195-202.
7Berwick DM, Enthoven A, Bunker JP Quality management in the NHS: The doctor's role - I. BMJ 1992;30 4:235-9.
8Bell D, Layton AJ, Gabbay J. Use of a guideline based questionnaire to audit hospital care of acute asthma. BMJ 1991;302:1440-3.
9Crombie IE, Davies HT, Abraham SC, Florey CdV. Methods of audit. In: The Audit Handbook. Improving Healthcare through Clinical Audit. Chichester, England: John Wiley & Sons; 1993. p. 101-25.
10Shaw CD Aspects of audit 1. The background. Br Med J 1980;280:1256-8.
11Gulliford MC, Petruckevitch A, Burney PG. Hospital case notes and medical audit: Evaluation of non-response. BMJ 1991;302:1128-9.