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.

Digitalisation in healthcare for patient safety has become a major factor in achieving high patient safety for medical organisations and professionals in recent years.

What does digitalisation in healthcare mean?

How does it differ from digitisation?

What is the way digitalisation can be utilised to improve patient safety?

What are the challenges faced by various healthcare organisations in implementing digitalisation?

Besides improvement in patient safety, what are the other advantages of digitalisation for the patients and healthcare providers?

These are some of the questions which arise in one’s mind, more so in the Indian scenario where the healthcare digitalisation is relatively newer.

Digitisation is conversion of an information from physical format to digital version for example scanning a doctor’s prescription written on paper and saving it as a pdf format. Whereas digitalisation is utilising technology to enhance various processes in an organisation, for example, writing prescription directly in electronic format. The digital transformation encompasses not just the digitalisation process but also the organisational change that accompanies it.

In this article, I will answer the following questions for everyone’s better understanding of utility of digitalisation for improving patient safety:

• How can digitalisation improve patient safety?
• What are the challenges in implementing digitalisation in healthcare?
• Besides patient safety, what are the other advantages of digitalisation?

Over the past two decades digitalisation in the healthcare industry has spread its tentacles to fascinate us all. Let us investigate ways or areas where digitalisation can be utilised in any healthcare system:

Most of the time EMR and EHR are being used interchangeably. But we need to understand the real difference between EMR and EHR. Electronic medical record is the digital version of a patient’s paper record like medical history, diagnosis, treatment entered electronically by any healthcare practitioner. EMR is not directly accessible to other practitioners within the organisation or outside the organisation or to patient himself. Whereas electronic health records (EHRs) are designed to encompass all features of electronic medical records (EMRs) generated in a healthcare organisation and go beyond the organisation which primarily collects the patient’s data. The information in EHRs can be shared with various specialists, other healthcare providers e.g., laboratories, other healthcare organisations and the patients themselves for a better coordinated and safer patient care. Information about a patient’s past and ongoing treatment, any allergies are easily accessible and prevent inadvertent errors. The patients themselves can track their own records at any point of time such as investigations done a year back or findings of any surgical procedures.

Most of the hospitals in India are using EMR as a form of digitalisation and very few have moved or are moving towards EHR. Although even EMR offers patient safety especially so in reducing medication errors because of legible prescriptions.

The Ministry of Health and Family Welfare, Government of India, had notified EHR standards for India in 2013 and revised it in 2016 with an objective to introduce a uniform standard-based system for creation and maintenance of electronic health records by the healthcare providers. National Digital Health Blueprint (2019) is one of the policies which the Government of India has formulated as a framework for implementation of digital health record systems all over India. Implementation of all such standards and policies will strengthen our healthcare system in terms of safer patient care.

Radio frequency identification (RFID) and barcode technology make accurate and reliable information readily available at the point of care and helps in preventing medical errors. All patient care activities right from admission and during the patient’s stay, can be tracked, e.g., specimen collection, monitoring medications, infusions etc. It is immensely helpful in preventing identification errors like wrong patient and wrong medication, wrong patient and wrong blood samples and so forth.

With RFID technology medical staff can pinpoint the location of any patient in the hospital to ensure their safety. Patient tracking is especially relevant in neonatal units, paediatric departments, mental health facilities, or for tracking geriatric patients.

Although telemedicine has been around for several decades with slower acceptance, we all have seen the spurt in its utilisation during Covid 19 pandemic. Nothing could have been safer in view of the need of social distancing. Being a clinician, my own apprehensions of doctors not physically examining the patient was gone during pandemic days. Online consultations provided a means of safer, cost effective and timely treatment methodology.

Even though the pandemic has slowed down, telemedicine is an option which is now being chosen by many because of its multiple benefits. Telemedicine provides options for safer treatment choices as the patients can have multiple specialists or a team of specialists’ opinion from different regions of a country or outside his or her own country. It also provides better patient and family engagement.

Most of the hospitals have been using paper formats for reporting of incidents which occur in any healthcare organisation. We all are aware of drawbacks associated with reporting incidents in paper format. Transparency issues, non-availability and non-accessibility of the format at all times, at every place and by all healthcare workers including clinicians, delay in circulation of the paper for root cause analysis and corrective and preventive actions by all concerned authorities are some of the drawbacks. To overcome these drawbacks, many of the private healthcare organisations now have digital mobile and desktop-based applications for reporting of healthcare incidents and errors. Even clinicians among their busy schedule can immediately report the incidents which they encounter, through their mobile apps. Photos as evidence can be uploaded in real time.

The software has the automated integration for information to concerned stakeholders with a provision for documentation of corrective and preventive actions. Data is analysed, trends seen, discussion done in various meetings and with management for improvement in systems and processes for a safer healthcare environment. In my own experience I have found these tools to be very user friendly and efficient in reduction in incidents like medication errors, patient falls etc.

Every healthcare organisation is implementing various quality accreditation standards in order to make the facility safer for the patients. Auditing plays a significant role in continuous quality improvement. Instead of a traditional method of auditing and documenting observations on paper, organisations are using digital auditing system software which have inbuilt standard and objective elements against which audit can be performed.

Auditing tools have the facility to automatically assign the scheduled audits to concerned auditors at defined interval. Observations are documented, pictures can be uploaded, action plans are made by the auditor and assigned to concerned stakeholders. An automated mail gets generated as an information for action taking and to any administrative personnel if required. Closure report is uploaded which again automatically sends the report to the auditor for acceptance or rejection with his or her comments. Data is analysed and comprehensive reports are downloaded for further discussion and system improvement.

I have used the digital audit tools with all the above features. The stakeholders are surprised and very happy to receive the automated reports on their email for action taking, analysis and further corrective and preventive actions in the system.

The business intelligence (BI) tools use medical software to safely and electronically gather, standardise, and manage patient information to improve patient care and decision-making. The healthcare providers can access comprehensive data, visualise trends and make faster decisions to provide timely care and hence improve patient safety.
Use of BI tools e.g., Tableau in my practice led to easier management of the data flow and actionable information. Multiple data trends could be clearly visualised and utilised for improving systems and processes for higher patient safety.

Multiple challenges like financial issues, manpower non-conversant with technology, low doctor patient ratio etc exist which prevent wider adoption of EMR and EHR in India. Lack of Integration and sufficient data for care continuity, patients’ lack of technical skills, expensive technology, privacy concerns, lack of insurer coverage of telehealth services, low or no reimbursement are some of the barriers to telemedicine. Financial constraints remain the main reason for non-implementation of technology like RFID, barcode system, business intelligence tools. Whereas cost and training issues are the main barrier to digital incident reporting and audit systems.

Digitalisation leads to a transparent, quicker and more organised system without any data loss, it’s less time and manpower consuming. Patient and healthcare organisations are benefitted in cost reduction. According to a pilot survey done by Soham Sinha, Srishti Majumdar and Arpita Mukherjee from June-October (2019) in 15 hospitals in India (private and government based) multiple perceived benefits of EHR adoption were reported. Survey participants pointed out that digitalisation can make healthcare more affordable, accessible, and equitable. It can contribute to economic growth, reduce reliance on imported medical devices, and allow for a more patient centric approach.

Digitalisation is the need of the hour as a key for high patient safety. It allows for a more patient centric approach and healthcare organisations can utilise the technology in multiple systems and processes to make patient care safer, affordable and easily accessible. The challenges faced in implementing digitalisation can be overcome by judicious planning and integrated approach with various stakeholders. Moreover, a broader vision for contribution towards the improvement of the healthcare system at the national level needs to be kept.

As healthcare delivery becomes increasingly complex, it is of paramount importance to be aware of healthcare essentials for the healthcare system to be patient centric and safer in every aspect including the healthcare staff and organisational safety. Besides the involvement of healthcare staff, the role of the patient and its family, the community cannot be dismissed. In my whole clinical career of over 25 years as an anaesthesiologist along with over 20 years of working on patient safety as my passion, learnings urge me to share the tips for a robust  and safer healthcare system.

Introducing essential safety protocols for healthcare professionals – learn 7 effective tips to ensure patient safety in a healthcare system.

Designing any healthcare facility needs to have a collaborative participative approach at a very initial stage of building plan by inclusion of experienced critical care and operation theatre consultants, infection  control officer and quality consultants. Nitty gritty of day to day working, advantages and disadvantages of a departmental structure can be best understood by the end users. Users inputs  result in best patient and staff friendly infrastructure especially with respect to infection control, facility risk hazards prevention e.g. fall and other injuries.

 I have seen ICU’s being designed by some of the  best designers with oxygen, compressed air and vacuum outlet points installed right at the back of the head end of the patient’s bed. This form of designing is not safer for the patient because of risk of tubing disconnection and also not convenient for the ICU staff while he or she is working from the head end of patient’s bed. Another common example is non-existence of clean and separate medication preparation area for nurses in various wards. All of such challenges can be addressed with early planning and involvement of right mix of team at the time of construction and renovation.

 A judicious mix of adequate number and skilled manpower as per the specialities, vision and mission of the organisation  need to be recruited along with cost optimization. When I say appropriate, positive attitude of the hired staff is the most important characteristic, be it in a leader or in subordinate staff. All systems and processes for a safer environment can only be implemented with a positive approach team. Skills can be learned and improved but attitude is difficult to change.

Besides procuring all the required utility and medical devices and equipment for the functioning of a department, budgeting for smaller equipment is equally important. For example, biological indicator culture machine in laboratory which gives result within 2-3 hrs or POCT (Point of control test) for Trop I in cardiac centres/in Emergency Rooms/ICUs. I have seen in multiple centres procurement of such equipment take backstage because initially these were not budgeted, hence compromising infection control measures and timely decisions in cardiac care respectively.

Implementation of safer healthcare practices in every department  mandates the documentation of various policies, procedures, guidelines and protocols. In my career of quality journey and passion for patient safety, I have ensured that users write their documents as per required quality standards. This has always resulted in better and sustainable implementation. 

No patient enjoys infection, be it healthcare associated or outside healthcare facility. Hand hygiene; antibiotic stewardship programs; disinfection and sterilisation protocols for equipment, devices and facility; safe injection practices; biomedical waste disposals are prominent areas which need efficient implementation for facility to be safer. The key is involvement of clinicians, nurses, critical care and OT incharges, CSSD, housekeeping staff by infection control officers and infection control nurses in hospital infection control meetings and audit processes. Moreover the patient and family education plays a significant role in reduction of hospital associated infection (HAI) and other infection. 

Medication errors; wrong site, wrong side and wrong patient surgeries and/or procedures; patient falls; hospital acquired pressure ulcers (HAPU); Thrombophlebitis; surgical site infection (SSI); central-line associated bloodstream infection (CLABSI); catheter-associated urinary tract infection (CAUTI); ventilator-associated events (VAE); non-ventilator-associated hospital acquired pneumonia are some of the errors and incidents encountered in healthcare facilities. Reduction strategies include, but not limited to, careful planning of preventive steps, root cause analysis, corrective and further preventive actions in case of occurrence. Multiple times it  has been seen that actions are taken without the involvement of  concerned stakeholders especially clinicians. It is recommended to have an effective incident committee with clinicians also as the members. In my own experience we were able to reduce the incidents by around 60% because of regular monthly conduction of incident committee along with clinicians and other concerned stakeholders.

Various research  articles indicate that ineffective communication among health care professionals is one of the leading causes of patient harm and medical errors. Usage of SBAR (Situation, Background, Assessment and Recommendation) tool, multidisciplinary rounds with comprehensive actionable care plan, escalation matrix where nurses escalate change in patient condition to physicians in timely manner, written shift handovers, written handovers during shifting of patients for diagnostic or therapeutic procedure are some of effective healthcare communication ways. In my experience healthcare communication workshops for physicians and staff have been instrumental for improving patient safety.

Patient and family education (PFE) makes the healthcare facility safer in various aspects and the education should commence right from the area to which the  patient comes in his or her first visit to healthcare facility e.g in OPD the fall prevention education can be imparted with display of posters and verbal education during  nursing assessment.  Brochure /pamphlets with brief education on prevention of HAI, Hand hygiene, vaccination, common food drug interaction, rights and responsibilities of patients with verbal reinforcement by healthcare professionals at various point of contact supplements all the efforts for patient safety by any healthcare facility.

Patient safety in any healthcare facility depends upon its infrastructure designing, careful manpower and equipment planning; various policies, procedures and protocols; a robust infection control program; healthcare incidents and errors reduction strategies; effective communication and participation of patient and family in their own care by effective education.