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Hand hygiene is the most important prevention strategy to reduce the risk of HCAIs, and it's also the easiest one to follow. However, healthcare worker compliance with this strategy is generally low, according to a December 2009 review from the Journal of Hospital Infection (1). More recent research shows similar results. For instance, a study from 2019 evaluated hand hygiene compliance among healthcare providers in Northwest Ethiopia and found it was poor (2).
The April 2021 issue of JAMA Internal Medicine published a study that revealed that compliance to hand hygiene is low in the US, averaging 50% across nationwide hospitals. However, during the COVID-19 pandemic, the compliance with hand hygiene practices in hospitals increased and peaked at 92.8% in March 2020 (3).
Proper hand hygiene prevents the spread of pathogens and other microorganisms, including bacteria resistant to antibiotics. The World Health Organization (WHO) outlines five moments where healthcare workers should clean their hands. These are (4):
Simple hand washing exhibits a positive effect in preventing transmission of pathogens, whereas the use of antiseptic soaps, i.e. those containing chlorhexidine, can reduce bacterial count on hands when used adequately.
Reasons for poor compliance to hand hygiene in healthcare settings are numerous, with understaffing being among the biggest culprits. For example, in ICU, understaffing can pave the way to the spread of MRSA through reduced attention to basic measures to control or prevent infections, such as hand hygiene. Additionally, time demands play a role in the lack of hand hygiene compliance. In many cases, the time necessary to complete patient care duties tends to compete with the time required for hand hygiene, particularly in ICU and other technically intense environments.
Proper hand hygiene is more cost-effective than the costs of the treatment of HCAI. For that reason, it is crucial to ensure all the personnel in the healthcare setting adhere to proper hand hygiene practices, especially those working with patients in ICU. However, it’s not just about instructing healthcare workers to wash their hands properly and in a timely manner. Handwashing promotion is also necessary, and it's also vital to select and introduce methods that improve the process and monitor adherence. For example, in environments where time demand is an obstacle, waterless alcohol-based hand rubs can be of huge help.
One of the most significant principles in the prevention of HCAIs is environmental hygiene or cleanliness. After all, the environment surrounding a patient contains bacteria. These bacteria come from infected wounds as well as healthy and intact skin. It’s perfectly normal for skin to shed dead skin cells, which is why patient gowns, bedside furniture, and bed linens become contaminated easily.
Bacteria can also contaminate surfaces in the patient care setting, including nursing uniforms, blood pressure cuffs, and others. As a result, cross-contamination with patients may occur. For example, microorganisms can reach healthcare workers’ gloves when they touch a surface near a colonized patient, even if they don’t touch the patient at all.
A growing body of evidence confirms that keeping the healthcare environment clean keeps patients safe by decreasing the colonization of various bacteria (5).
Taking care of environmental cleanliness to prevent HCAI also implies considering the likelihood of hand contamination and also adhering to proper hand hygiene. Staff in healthcare settings needs to ensure their bare hands are clean before they touch general-use and clean surfaces, which can reduce the risk of contamination. Additionally, all surfaces should be properly disinfected.
The main objective of environmental cleanliness is to decrease both direct and indirect transmission routes. That way, it becomes easier to protect patients from HCAIs and improve treatment outcomes.
Cases when patients have diseases with Clostridium difficile and known colonization with antibiotic-resistant microorganisms need special attention. Besides standard precautions, they also require contact precautions in order to decrease the transmission to others. For instance, nurses need to make sure the medical equipment is clean before each patient. Environmental services staff need to ensure the patient room is entirely clean.
To avoid cross-contamination in the healthcare environment, it is necessary to educate patients and their families about the importance of hand hygiene, too. At the same time, it is important to use EPA-registered chemical germicides for cleaning and disinfection of equipment. Housekeeping staff needs to comply with cleaning and disinfection procedures, especially when it comes to high-touch surfaces such as doorknobs, bedrails, charts, and others.To minimize the risk of cross-contamination, disposable patient care items are helpful. Also, hypochlorous acid based products for disinfection of surfaces are necessary when the Clostridium difficile infection is documented.
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In other words, preventing HCAIs requires clean and disinfected environments as much as possible. Adhering to cleaning and disinfecting practices can help reduce the risk of contamination and protect patients from these infections.
When it comes to HCAI prevention strategies, they go beyond hygiene and a clean environment. Hospital leadership and teamwork also play an important role here, although it’s largely overlooked. Every staff member in the hospital has the responsibility to reduce the risk of HCAIs within the roles they have.
Hospital leaders such as directors, administrators, and individual practitioners represent and nourish specific values in their workplace. The values drive behaviors, i.e. describe the types of behaviors that are encouraged or frowned upon. At the same time, behaviors contribute to the performance of the healthcare organization. Hospital culture is defined by collective behaviors.
Why is this so important? It matters because safe and reliable care depends on strong leadership and effective teamwork to propose new solutions and execute them properly. Nursing leaders in hospitals collaborate with administrators and other coworkers. The quality of this collaboration determines the effectiveness of communication and the development or application of new technologies and solutions.
Hospital leadership needs to focus on evidence-based practices and engage necessary resources to implement changes that would help prevent HCAIs.
In other words, hospitals need strong leaders that establish prolific and effective relationships with other staff members, so they work together on maintaining best practices for the prevention of healthcare-acquired infections. A multifactorial approach coupled with a high level of commitment is necessary to reduce the risk of contamination.
What we can conclude here is that the prevention of HCAI requires every staff member to adhere to the protocol and works well with others to implement current and develop new solutions and strategies.
Early detection plays an important role in preventing or controlling healthcare-acquired infections. For instance, screening preoperative patients for MRSA could reduce the number of postoperative infections. In other words, active surveillance cultures for high-risk patients and placing those patients under contact precautions can control or even eliminate bacteria that trigger HCAI.
While this may seem simple, implementing active surveillance cultures isn’t that simple and easy because it also raises ethical questions regarding confidentiality, conflict of interest, and other issues such as isolating patients when they don’t need to be (6). That said, isolating at-risk patients or those with pathogenic microorganisms could prevent infections from spreading.
Screening and cohorting patients serve as a practical prevention strategy, but it is necessary to work on details that resolve ethical issues that arise.
Public health surveillance can contribute to the prevention of HCAI. This type of surveillance includes ongoing systematic collection, analysis, and interpretation of data about an event in healthcare. Healthcare professionals use this data for public health purposes to decrease mortality and morbidity and to improve patient health and outcomes.
Surveillance information regarding HCAI serves to evaluate the status of infections, transmission, and incidence rates. The information helps healthcare professionals improve their performances, reduce the risk of infections, and prevent potential complications that could arise from HCAIs.
Yet another benefit of surveillance is that it can speed up the time at which HCAI is recognized. The more hospitals participate in surveillance, the better the quality of data healthcare professionals can use to recognize and reduce the risk of infections in their clinical environments.
Healthcare workers use personal protective equipment (PPE) to protect mucus membranes and skin from pathogens. Proper use of PPE is vital for infection control practices, which is why healthcare workers can benefit from education on the use of this equipment. Through proper use of PPE, healthcare workers have maximum protection. However, masks, gloves, or other pieces of equipment don’t provide a 100% protection level. For that reason, improper use could pave the way to contamination.
Besides the education of healthcare workers, it is necessary for hospitals to get PPE that meets all the latest standards and regulations.
The term antibiotic stewardship refers to an effort to measure and improve how clinicians prescribe, and patients use antibiotics. McGowan and Gerding coined the term antibiotic stewardship back in 1996. They emphasized that clinicians need to consider antibiotics as a one-time resource. The main goal of antibiotic stewardship is to improve patient outcomes while reducing resistance to antibiotics. These measures also reduce unnecessary costs.
By focusing on antibiotic stewardship, healthcare professionals can control the dosage and duration of antibiotic treatment and avoid common pitfalls that usually happen in this area. This practice reduces the incidence of some microbes and thereby helps prevent HCAIs.
Even though healthcare workers have a high educational level, their adherence to infection control precautions is quite poor. In other words, some healthcare professionals do not adhere to evidence-based practices (7). Lack of adherence prevents healthcare workers from providing the best level of care that would reduce the risk of infection and improve patient outcomes. Everything starts with leadership. The institution, i.e. hospital, needs to keep up with the latest developments and implement practices that can boost the effectiveness of strategies to prevent HCAI.
While HCAIs are common worldwide, there's a lot that healthcare professionals can do to prevent them. The most crucial prevention strategies are hand hygiene and adherence to evidence-based practices and protocols. Every healthcare staff member needs to collaborate with others to work on a common goal – to reduce the risk of contamination and infection.
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(1) https://pubmed.ncbi.nlm.nih.gov/19720430/
(2) https://aricjournal.biomedcentral.com/articles/10.1186/s13756-019-0634-z#Sec18
(3) https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2779293
(4) https://www.who.int/campaigns/world-hand-hygiene-day
(5) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8857881/
(6) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7532064/
(7) https://www.ncbi.nlm.nih.gov/books/NBK2683/
(8) https://www.cdc.gov/hai/data/index.html
(9) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6245375/
(10) https://www.cdc.gov/hai/data/portal/progress-report.html
(11) https://www.ecdc.europa.eu/en/publications-data/infographic-healthcare-associated-infections-threat-patient-safety-europe