How to Prevent Healthcare-Associated Infections: 7 Best Practices

Healthcare-associated infections (HAIs) are common and can lead to increased morbidity, mortality, hospital stays, and costs. The frequency of different HAIs varies between countries and according to economic conditions. The risk of acquiring HAI is up to 20 times higher in low-income and middle-income countries (LMICs).  

A study conducted in India found that the rates of bloodstream infections (BSI) were between 5.3 to 7.3 per 1000 patient days, while the central line-associated bloodstream infection (CLABSI) rates were between 8.3 to 12.1 per 1000 central line days. In ICU, the pooled urinary tract infection (UTI) and catheter-associated urinary tract infection (CAUTI) rates varied between 1.7-2.8 per 1000 patient days and 8.3-12.1 per 1000 catheter days, respectively.

Other HAIs are ventilator-associated pneumonia and surgical site infections. Therefore, it is prudent to work on following basic practices to prevent and minimise these HAIs.

Designing of healthcare facilities must be done to ensure the availability of infrastructure: 

• With appropriate heating, ventilation, and air-conditioning (HVAC) systems with fresh air intake and recirculating of air as required according to the treatment area. According to NABH 2018 guidelines for Air conditioning in operation theatre (OT), operating rooms should have a minimum of 20 air changes per hour. Additionally, it is recommended to maintain an air face velocity of 25-35 FPM (feet per minute) for air conditioning in the OT.

• To avoid surgical site infections. Surgeries must be performed in properly designed operating rooms that meet specific requirements. These include a minimum positive pressure of 2.5 pascals, as well as specific temperature and humidity control.

• With high-efficiency particulate air (HEPA) filters installed in critical areas, including operating rooms, intensive care units, and bone marrow transplant units. Air quality at the grille level is crucial for operation theatres. Superspecialty OTs require Class 100/ISO Class 5 air quality at rest, while general OTs require a Class 1000/ISO Class 6 at rest.

• To safely isolate and manage patients with highly transmissible diseases in an effective negative pressure facility. The need was evident during the recent Covid-19 pandemic.

• With the ability to quickly transform areas into critical care units or wards to handle pandemics like Covid-19. One idea is to add small conduits to the walls of ICUs or patient wards for infected individuals so that ventilator tubes, intravenous lines, and monitor cables can be safely passed outside to nursing stations. Such modifications help in infection control.

In any setting where health care is delivered, standard precautions are the key to the prevention of healthcare-associated infections and infection control. These are the minimum infection prevention practices to be used in all patient care, regardless of the patient’s suspected or confirmed infection status.

Standard precautions include:

• Performance of Hand Hygiene

• Use of personal protective equipment (PPE) whenever possible exposure to infectious material is suspected

• Following respiratory hygiene/cough etiquette principles

• Appropriate patient placement as per patient disease e.g., in an isolation room whenever required

• Appropriate handling, cleaning and disinfection of patient care equipment and instruments/devices

• Appropriate cleaning and disinfection of the environment

• Careful Handling of textiles and laundry

• Following safe injection practices

• Ensuring healthcare worker safety including proper handling of needles and sharps

In addition to standard precautions, transmission-based precautions are used for infection control and prevention of infection transmission for patients who are infected with certain infectious organisms. There are three types of such precautions

• Contact precautions

• Droplet precautions

• Airborne precautions

​​Antimicrobials are drugs which are used to treat infections caused by bacteria, viruses, fungi, and parasites. While these can be life-saving in many situations, their overuse or misuse can lead to the development of antibiotic-resistant bacteria.

All healthcare facilities must have an antimicrobial stewardship program, which must include the surveillance and monitoring of antimicrobial resistance patterns.

 Preventing the spread of antimicrobial-resistant organisms and promoting the  appropriate use of antimicrobial agents is essential to reducing the incidence and impact of healthcare-associated infections.

 Globally, 15% of patients develop an infection during a hospital stay, with the proportion much greater in low-income countries. Unsafe water and poor sanitation can contribute to these healthcare-associated infections.

 Healthcare facilities should implement measures to ensure the safe and quality water used in patient care to mitigate the risk of healthcare-associated infections associated with waterborne pathogens.  

Due diligence must be given to infection control by implementing the following measures:

• Effective water management program.

• Ensure that water entering a healthcare facility meets all applicable quality standards.

• The hot and cold water piping systems in the hospital building are designed and maintained in a manner to minimise the growth and spread of waterborne infectious organisms in both the supply and waste sides.

• Exposure to infection risks from water sources is minimised.

• Designing and maintenance of sinks, drains and plumbing

 As per recent evidence, multidrug-resistant organisms (MDROs) contaminate sinks and other drains, such as toilets or hoppers, in healthcare facilities. Whenever there are water splashes from the drain, there is a risk of patients getting exposed to these organisms. There are chances of splashes when water flow hits the contaminated drain cover or when a toilet seat is flushed. The following measures can reduce the risk of such events:

• Daily cleaning and disinfection of surfaces near the drain, including the sink basin, faucet, faucet handles, and surrounding countertop.

• No patient care or personal items should be kept on counters next to sinks.

• Discharging of faucets should not be directly above the drain to prevent splashing.

• Sinks in patient care areas should be with adequate depth and the maximum water flow as regulated to prevent splashing.

• Install and utilise hopper and toilet covers.

• Do not discard patient waste down sinks. Minimise discarding liquid nutritional supplements or other beverages down sinks or toilets.

All healthcare organisations must ensure that the hospital food service provides nutritious and safe food to patients and employees. Following four fundamental steps in the kitchen must be ensured:

• Clean: Washing hands, and surfaces frequently and washing of fruits and vegetables.

• Separate: work in a manner that no cross-contamination is done. Raw meat, chicken and other poultry, seafood and eggs are to be kept separately from ready-to-eat food to prevent the spread of germs.

• Cook to the right temperature.

• Chill: Prompt refrigeration is done. It is essential to keep the fridge temperature at or below 4.4ºC (40ºF) and the freezer temperature at or below -17.8ºC (0ºF). Perishable food (meat, seafood, dairy, cut fruit, some vegetables, and cooked leftovers) should be refrigerated within 2 hours. Food should be refrigerated within one hour, if the food is exposed to temperatures above 32.2ºC (90 °F). 

Hospitalised patients are susceptible to infectious diseases, especially elderly and immunocompromised hosts. The outbreaks may result from a breakdown in only one step of food safety control measures. Hence, it is important to have control measures in place.        

 HACCP (Hazard Analysis and Critical Control Point) is a system for reducing the risk of safety hazards in food. To provide safe food in hospitals, adherence to HACCP is critical. 

In addition, the maintenance of personal hygiene among food handlers is also important. Hospitals require food handlers to undergo regular health check-ups, including tests like chest X-rays, CBC, and stool examination, as well as vaccination for the Hepatitis A virus, as per the infection control team’s policy.

Infection prevention and control risk assessment in any healthcare facility needs to be conducted regularly. It’s important to know the key parts of infection prevention and control according to WHO and use their recommended tools at your healthcare facility. The tool has eight core components with a total score of 800. The framework results are to be reviewed, and an action plan needs to be developed.

Conclusion

 Healthcare-associated infections can lead to increased morbidity, mortality, hospital stays, and costs. Implementing evidence-based, best infection prevention and control practices will lead to a substantial reduction in HAIs and an improvement in overall healthcare quality.

It is recommended for healthcare settings to have a robust infrastructure and engineering control at the time of facility design, expansion or renovation. Besides standard and transmission-based precautions, the role of appropriate antibiotic usage, and safe food and water supply is mandatory. Regular infection prevention and control assessment, review of results and implementation of appropriate interventions are required to achieve a safer environment for the patients, visitors and hospital staff.