Infection Prevention and Control (IP&C)

Learning objectives Outline the history of infection prevention and control. Describe the goals of infection prevention and control programs. Discuss how an IP&C program can make a positive impact in any healthcare organization. December 1, 2013

Time involved 35 minutes December 1, 2013

What is IP&C? The discipline concerned with preventing nosocomial or healthcare-associated infections a sub-discipline of epidemiology Similar to public health activities, mainly practiced within a health-care delivery system Focuses on evidence-based practices and procedures that can prevent or reduce the risk of transmission of microorganisms to health care providers, clients/patients/residents and visitors December 1, 2013 It is an essential part of the infrastructure of health care, especially patient safety programs. Prevention and control of healthcare-associated infections is an important focus at the local, national and international level. Infection prevention and control is an issue of health and safety; a necessary component of safe, high quality patient care and it is essential for the well being of patients and staff.

Why is IP&C Important? Infections are a leading cause of morbidity and mortality in healthcare settings Infections can cause pain, suffering and often, permanent scarring Infections cause prolonged hospital stays which has an impact on costs December 1, 2013 Before advancements in infection prevention and control, only conditions that brought patients near death warranted the risk of surgical intervention. If patients survived the operation, infection was nearly inevitable and death occurred by overwhelming sepsis. In the late 19th century, with the development of the germ theory by Louis Pasteur and its subsequent application to surgical sterility by Joseph Lister, surgeons were able to operate with a substantially reduced risk of infection. Infection is a major cause of human suffering. Even relatively minor infections can become more serious, leading to major infection and can, in some cases, lead to patient death. In addition to patient suffering, infection causes distress to family and friends. In addition, the acquisition of occupationally-acquired infections may pose a risk to health care providers. In order to protect patients and staff and to reduce the costs of healthcare-associated infections, it is necessary to prevent infections before they occur. Recent studies suggest that at least 55% of HAIs could be prevented through infection prevention and control strategies. [Umscheid CA, et al. Estimating the Proportion of Healthcare-Associated Infections That Are Reasonably Preventable and the Related Mortality and Costs. Infect Control Hosp Epidemiol 2011;32(2):101-114]

History Pre 1800: Early efforts at wound prophylaxis 1800-1940: Nightingale, Semmelweis, Lister, Pasteur 1940-1960: Antibiotic era, S. aureus outbreaks in nurseries 1950-1970: Surveillance begins, documentation of need for infection control programs, infection control committees develop 1980: HIV issues, resistant bacteria, SENIC study and NNIS in USA 1990: Blood-borne pathogens 2000: Pandemics, patient safety December 1, 2013 During the 1950s, epidemic penicillin-resistant Staphylococcus aureus infections, especially in hospital nurseries, captured the public's attention and highlighted the importance of techniques to prevent hospital-acquired infections, now referred to as healthcare-associated infections (HAIs; i.e., nosocomial infections). In the USA, landmark studies in the 1970s triggered the rapid evolution of IP&C in the clinical setting. Ongoing surveillance of HAIs was initiated and stimulated further when IP&C and surveillance activities were mandated by the Joint Commission for the Accreditation of Healthcare Organizations. In 1980, the Study on the Efficacy of Nosocomial Infection Control (SENIC) demonstrated that surveillance for HAIs and IP&C practices that included trained professionals were effective in reducing HAIs. The USA Centers for Disease Control began the National Nosocomial Infections Surveillance System (NNIS) to provide a mechanism for reporting HAIs. As a result, an important role developed for hospital epidemiologists and infection control practitioners. A first national study of the prevalence of HAIs in the United Kingdom was conducted in 1980. Belgium performed a prevalence study in 1984. At the end of the 1990s, most countries in Western Europe had guidelines for the prevention of HAIs. In Germany, a national reference center for nosocomial infections (NI) was created in the early 1990s (Nationales Referenzzentrum für Krankenhaushygiene in Berlin and Freiburg). In 1992, the Comité Technique National de l’Infection Nosocomiale divided France into five large geographical areas for the coordination of IP&C activities. The Nosocomial Infection National Surveillance Scheme (NINSS) was established by the UK Public Health Laboratory Service to develop surveillance of HAI in the health service in early 2000s. In 2009 the European Commission published a "Council Recommendation on Patient Safety, including the prevention and control of Health-Care Associated Infections" where HAI risk and ways to control it are specifically noted.

Florence Nightingale The first infection prevention and control champion Research into hospital sanitary problems made her a firm believer in pure air, pure water, efficient drainage, cleanliness, and light Nightingale’s firm belief in preventive medicine led to an established standard of formalized cleanliness and sanitation in hospitals and the military December 1, 2013 Florence Nightingale (1820‐1907) is considered the first infection control (IC) nurse. Her work with the epidemiologist William Farr in England was one of the first examples in history demonstrating the effectiveness of close collaboration between IC nurses and hospital epidemiologists. She once stated, “It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm.” She observed that open windows interfered with the ventilation of hospital wards and allowed air from the wards to pass into the corridors. Nightingale believed that respiratory secretions were potentially dangerous, especially among the sick and that the sick should be isolated.

Ignaz Semmelweis - 1 Demonstrated that routine hand washing could prevent the spread of puerperal fever Noted that maternity patients were dying at such an alarming rate that they begged to be sent home from the hospital to deliver with a midwife Semmelweis’ analysis revealed that medical students, responsible for deliveries in Division I, often performed autopsies before assisting in deliveries, while midwives, who worked in Division II, did not December 1, 2013 A Hungarian obstetrician in Vienna. Ignaz Semmelweis is credited with first discovering that health care providers could transmit disease, as he described the mode of transmission of puerperal sepsis. The death rate was five times higher for mothers who delivered in the hospital than for mothers who delivered at home. He also witnessed a pathologist die of sepsis after sustaining a scalpel wound while performing an autopsy on a patient with puerperal sepsis. He noted that the pathologist's clinical illness mimicked that of women with puerperal sepsis and identified that not only a scalpel but also physicians' hands contaminated after an autopsy could transmit contaminated material or microorganisms to mothers in labour. He introduced chlorinated lime hand washing into the clinic staffed by obstetricians and medical students, with drastic improvements in rates of maternal mortality. He was ignored and ridiculed by colleagues. When Koch's postulates were published in 1890, the germ theory of disease and Semmelweis' theory of transmission from patient to patient were considered plausible. More information can be found at http://www.infectioncontrolservices.co.uk/semmelweis.htm

Ignaz Semmelweis - 2 Theorized that disinfecting hands could prevent transmission of infection from a diseased cadaver to a pregnant patient Required medical students to wash their hands with chlorinated lime before assisting in deliveries Resulted in a dramatic outcome - deaths on the maternity ward fell fivefold December 1, 2013 A Hungarian obstetrician in Vienna. Ignaz Semmelweis is credited with first discovering that health care providers could transmit disease, as he described the mode of transmission of puerperal sepsis. The death rate was five times higher for mothers who delivered in the hospital than for mothers who delivered at home. He also witnessed a pathologist die of sepsis after sustaining a scalpel wound while performing an autopsy on a patient with puerperal sepsis. He noted that the pathologist's clinical illness mimicked that of women with puerperal sepsis and identified that not only a scalpel but also physicians' hands contaminated after an autopsy could transmit contaminated material or microorganisms to mothers in labour. He introduced chlorinated lime hand washing into the clinic staffed by obstetricians and medical students, with drastic improvements in rates of maternal mortality. He was ignored and ridiculed by colleagues. When Koch's postulates were published in 1890, the germ theory of disease and Semmelweis' theory of transmission from patient to patient were considered plausible. More information can be found at http://www.infectioncontrolservices.co.uk/semmelweis.htm

Joseph Lister - 1 Troubled by high mortality rates from post-surgical sepsis First to see the connection between Pasteur's discoveries of the fermentation process and the suppuration of wounds December 1, 2013 A professor of surgery at Glasgow, Scotland. Lister is credited with the beginnings of sterilization in the operating theatre. Before surgery, he sprayed the operating rooms with carbolic acid, because he thought that the infections were caused by dust particles in the air. He was largely ignored by medical colleagues.

Joseph Lister - 2 In 1867 he published his paper on antisepsis, stating that "all the local inflammatory mischief and general febrile disturbance which follow severe injuries are due to the irritating and poisoning influence of decomposing blood or sloughs." He began applying carbolic acid to compound fracture wounds The wounds healed, amputation averted, and the mortality rate plummeted from 45% to 15% December 1, 2013 A professor of surgery at Glasgow, Scotland. Lister is credited with the beginnings of sterilization in the operating theatre. Before surgery, he sprayed the operating rooms with carbolic acid, because he thought that the infections were caused by dust particles in the air. He was largely ignored by medical colleagues.

Infection Prevention and Control Programs The earliest formal programs were in the 1950s Began as an effort to address issues like staphylococcal epidemics The first Infection Control Nurses were appointed at this time; they often had a background in bacteriology Surveillance of hospital infections was instituted and policies and procedures developed Early infection control programs focused on environmental cleanliness Antimicrobial resistant pathogens became a concern in the 1970s December 1, 2013 During the past twenty years or so there have been major advances in the field of IP&C. The focus has moved to identifying risks and prevention techniques for various types of HAIs, including pneumonia, bloodstream, urinary tract, and surgical site infections. HAIs are being caused by pathogens with greater resistance to antimicrobials. There is a major focus on preventing spread of these microbes through antimicrobial stewardship and proven infection prevention and control practices.

Healthcare-Associated Infections (HAI) - 1 HAIs include urinary tract infections, pneumonia, bloodstream infections and surgical site infections The WHO states urinary tract infection is the most frequent HAI in high-income countries; surgical site infections in settings with limited resources* December 1, 2013 Healthcare-associated infections (HAI) are infections caused by a wide variety of common and unusual bacteria, fungi, and viruses during the course of receiving medical care. Of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one health care-associated infection. EU from 2007: Each year in the European Union (EU), approximately 4 million patients acquire an HAI and approximately 37,000 of them die as the direct result of the infection. EU data are at http://www.ecdc.europa.eu/en/publications/Publications/120215_SUR_HAI_2007.pdf England: It is estimated about 1 in 10 patients acquire an HAI whilst they are in hospital. HAIs cost the NHS in excess of £1billion per annum and causes 5,000 deaths per year. USA from 2002: The estimated number of HAIs in hospitals was approximately 1.7 million: 33,269 HAIs among newborns in high-risk nurseries, 19,059 among newborns in well-baby nurseries, 417,946 among adults and children in ICUs, and 1,266,851 among adults and children outside of ICUs. The estimated deaths associated with HAIs were 98,987: of these, 35,967 were for pneumonia, 30,665 for bloodstream infections, 13,088 for urinary tract infections, 8,205 for surgical site infections, and 11,062 for infections of other sites. USA data are at http://www.cdc.gov/nhsn/PDFs/dataStat/NHSN-Report-2011-Data-Summary.pdf Australia data are at http://www0.health.nsw.gov.au/hospitals/hai/ Canada: it is estimated that 220,000 incidents of HAI occur each year in Canada, resulting in more than 8,000 deaths. Developing country’s data are at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61458-4/abstract WHO information is at http://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf * Statistics in low resource countries are often non-standardized or incomplete

Healthcare-Associated Infections (HAI) 30% of patients in intensive care units (ICU) are affected by at least one HAI in high-income countries In low- and middle-income countries the frequency of ICU-acquired infection is at least 23 fold higher* Newborns are at higher risk of acquiring HAI in developing countries, with infection rates three to 20 times higher than in high-income countries* December 1, 2013 Healthcare-associated infections (HAI) are infections caused by a wide variety of common and unusual bacteria, fungi, and viruses during the course of receiving medical care. Of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one health care-associated infection. EU from 2007: Each year in the European Union (EU), approximately 4 million patients acquire an HAI and approximately 37,000 of them die as the direct result of the infection. EU data are at http://www.ecdc.europa.eu/en/publications/Publications/120215_SUR_HAI_2007.pdf England: It is estimated about 1 in 10 patients acquire an HAI whilst they are in hospital. HAIs cost the NHS in excess of £1billion per annum and causes 5,000 deaths per year. USA from 2002: The estimated number of HAIs in hospitals was approximately 1.7 million: 33,269 HAIs among newborns in high-risk nurseries, 19,059 among newborns in well-baby nurseries, 417,946 among adults and children in ICUs, and 1,266,851 among adults and children outside of ICUs. The estimated deaths associated with HAIs were 98,987: of these, 35,967 were for pneumonia, 30,665 for bloodstream infections, 13,088 for urinary tract infections, 8,205 for surgical site infections, and 11,062 for infections of other sites. USA data are at http://www.cdc.gov/nhsn/PDFs/dataStat/NHSN-Report-2011-Data-Summary.pdf Australia data are at http://www0.health.nsw.gov.au/hospitals/hai/ Canada: it is estimated that 220,000 incidents of HAI occur each year in Canada, resulting in more than 8,000 deaths. Developing country’s data are at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61458-4/abstract WHO information is at http://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf * Statistics in low resource countries are often non-standardized or incomplete

Goals of IP&C To prevent the spread of infections from patient-to-patient patients to health care providers health care providers to patients health care providers to health care providers and to visitors and others in the health care environment CONSEQUENTLY To protect patients from HAIs, resulting in improved survival rates reduced morbidity associated with infections shorter length of hospital stay a quicker return to good health December 1, 2013 These goals are relevant to care activities across the spectrum of health care settings including acute care, complex continuing care, rehabilitation hospitals, long-term care homes, ambulatory and community settings and home health care programs.

Functions of IP&C To obtain and manage critical data and information To implement evidence-based practice, standards and guidelines through setting-specific policies and procedures To intervene directly to prevent infections To provide effective occupational health programs To educate and train healthcare workers, patients, and non-medical caregivers To provide communication of infection-related issues and relevant practices to leaders and staff to facilitate improvements To evaluate the program and improve it as necessary December 1, 2013 The fundamental functions are applicable to all settings where health care is being provided. Regardless of the structure or hierarchy of the healthcare system, major responsibilities include surveillance, continuous quality improvement, consultation, committee involvement, outbreak and isolation management, regulatory compliance, and education & awareness. Policies and procedures are typically written, approved by some group (e.g., an infection control committee) and shared with pertinent staff. These policies may include: Cleaning/disinfection/sterilisation Waste management Antibiotic use Hand hygiene Device management Isolation/precautions Occupational health Construction/renovation Food/water/air safety Visitation

Practice of IP&C Today Surveillance Outbreak investigations Prevention through practices/guidelines hand hygiene, use of barriers, isolation/precautions, construction/renovation, sterilisation/disinfection, antibiotic resistance, blood-borne pathogens, food/water/air safety, cleaning Antibiotic use Education Occupational health Audits December 1, 2013 Infection prevention and control programs have been shown to be both clinically effective and cost-effective, providing important cost savings in terms of fewer HAIs, reduced length of hospital stay, less antimicrobial resistance, and decreased costs of treatment for infections. These activities are generally for all programs – the practices for each function will vary depending on the facility, patient population, and issues identified by the program.

References Cardo D, et al. Moving toward elimination of healthcare-associated infections: A call to action. Am J Infect Control 2010: 1-5. http://www.apic.org/Resource_/TinyMceFileManager/Position_Statements/AJIC_Elimin.pdf Friedman C, et al. Requirements for infrastructure and essential activities of infection control and epidemiology in out-of-hospital settings: A Consensus Panel report. Am J Infect Control 1999; 20:695-705. Haley RW, et al. Efficacy of Nosocomlal Infection Control (SENIC Project): Summary of study. Am J Epidemiol 1980; 111: 472-485. Scheckler WE, et al. Requirements for infrastructure and essential activities of infection control and epidemiology in hospitals: a consensus panel report. Am J Infect Control 1998;26:47-60. December 1, 2013

Web Resources World Health Organization - http://www.who.int/csr/bioriskreduction/infection_control/en/index.html Centers for Disease Control and Prevention - http://www.cdc.gov/hai/ National Institute for Health and Clinical Excellence - http://guidance.nice.org.uk/CG139 IFIC - http://www.theific.org/ International Nosocomial Infection Control Consortium - http://www.inicc.org/english/index.php National Health and Medical Research Council - http://www.nhmrc.gov.au/node/30290 December 1, 2013

Quiz Infection prevention and control programs have been proven to be effective. T/F? IP&C is important in health care because of its: Focus on patient health and safety Focus on healthcare worker safety Focus on decreasing costs All of the above IP&C programs are relevant to all healthcare settings. T/F? December 1, 2013 True D 3. True

International Federation of Infection Control IFIC’s mission is to facilitate international networking in order to improve the prevention and control of healthcare associated infections worldwide. It is an umbrella organisation of societies and associations of healthcare professionals in infection control and related fields across the globe . The goal of IFIC is to minimise the risk of infection within healthcare settings through development of a network of infection control organisations for communication, consensus building, education and sharing expertise. For more information go to http://theific.org/ December 1, 2013