Healthcare Associated Infections (HAI)

Service: Risk Management
Subject: Care
Setting: Infection
Type: Risk Reference Sheets

Healthcare associated infections (HAIs), also known as nosocomial infections, are a significant, yet often preventable, patient safety issue. The World Health Organization defines HAIs as “infections occurring in a patient that are acquired during the process of delivery of health care in a hospital or other healthcare facility, which were not present or incubating at the time of admission” (2010).  Multiple factors such as advanced age, underlying immunosuppression, complex treatment modalities, duration of procedures, length of stay, and the increasing prevalence of antibiotic-resistant organisms increase the risk of HAIs. American studies suggest the continued increase of HAI during the second year of the COVID-19 pandemic. For example, significantly higher incidence was reported related to central line-associated infections (CLIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated pneumonias (VAPs, Clostridium difficile infection (CDI), and Methicillin-resistant Staphylococcus aureus (MRSA) Bloodstream infections (BSIs) in 2021 compared to 2019 (Lastinger, et al., 2023).

In 2015, client death or serious harm arising from the use of improperly sterilized instruments or equipment provided by the health care facility was recognized as a Canadian “never event” (defined as “patient safety incidents that result in serious patient harm or death that are preventable using organizational checks and balances” (Health Quality Ontario and Canadian Patient Safety Institute, 2015).

HIROC legal claims experience demonstrates that breach of Infection Prevention and control (IPAC) practices cause HAIs.  The multifaceted IPAC programs and compliance with IPAC routine practices and additional precautions are key factors in managing this risk, i.e. evidence-based environmental services, diligent surveillance practices, and safe medical device reprocessing practices.

Expected Outcomes

Ensure compliance with the federal and provincial guidelines for IPAC program scope, structure, monitoring and reporting of KPIs.

Develop a resilient process for prevention, early detection and prompt interventions for HAI transmission, increased incidence, outbreaks, epidemics, and pandemics.

Conduct regular training, education, and tabletop exercises.

Definitions and Acronyms

Additional Precautions - required when a client is infected with a microorganism for which transmission cannot be prevented with the use of Routine Practices alone.

ARO – Antibiotic-resistant Organisms.

BSI – Bloodstream Infections.

CAUTI – Catheter-associated Urinary Tract Infections.

CDI – Clostridium Difficile Infection.

CLIS – Central Line-associated Infections 

Client – Includes all persons who receive healthcare and related services, including patients, residents and persons in care.

Disease and Condition Table – Alphabetical listing of common and technical names or conditions and the microorganisms that cause the disease; each entry includes a transmission-based precaution.

HAI – Healthcare-Associated Infections; infectious diseases typically acquired in healthcare facilities and care settings.

HVAC – Heating, Ventilation, and Air Conditioning.

IPAC – Infection Prevention and Control.

KPI – Key Performance Indicators.

Lookback Review – Process that involves the identification, tracing, notification/disclosure and ongoing care/monitoring of a select group of clients potentially impacted by a safety event, alert, recall, or advisory.

MAC – Medical Advisory Committee.

MRSA – Methicillin-Resistant Staphylococcus Aureus.

PPE – Personal Protective Equipment.

VAP – Ventilator-Associated Pneumonia.

Common Claims Themes and Contributing Factors

Organization
  • Inadequate management of an outbreak.
  • Facility design issues, such as:
    • Contaminated and disinfected endoscope and gynecological equipment bins stored in close proximity to each other.
    • Insufficient or poorly placed hand washing sinks and hand sanitizer dispensers.
    • Inadequate housekeeping staffing levels and cleaning measures (e.g., wrong type and/or improper selection and application of surface and equipment disinfecting products).
  • Lack of IPAC coordination, expertise, and medical oversight.
  • Lack of IPAC process, training, and overall preparedness for outbreak prevention, detection, and management.
  • Inadequate stock of personal protective equipment.
Knowledge and Judgement
  • Lack of monitoring of IPAC measures and interventions.
  • Insufficient compliance with IPAC policies, procedures, and guidelines.
  • Failure to identify, screen, and initiate appropriate Additional Precautions for patients/residents/clients who present with communicable diseases or who are colonized with significant AROs.
  • Delayed performance of ordered screening or testing.
  • Lack of timely communication and documentation of patient symptomology (e.g. signs and symptoms of BSI, CUTI, VAP, or sepsis/septic shock).
  • Improper donning and doffing of PPE.
Documentation and Communication
  • Conflicting definitions for “outbreak” within the IPAC team and externally.
  • Delayed action and/or communication with ordering practitioners, healthcare team and IPAC team, and/or external stakeholders regarding:
    • Significant positive or screening results;
    • The presence and/or severity of a confirmed or suspected outbreak
  • Poorly conducted lookbacks and patient notifications (disclosure) following an exposure or HAI; particularly a large-scale notification/disclosure.

Mitigation Strategies

 

Reliable Care Processes

 

Strategies for Acute, In-Patient Additions and Mental Health, Residential and Long-Term Care Settings

  • Implement targeted and current evidence-based strategies to prevent, identify, and manage healthcare-associated infections.
  • Adopt current evidence-based organism-specific client screening, surveillance, initiation of Additional Precaution, and cohorting (where indicated) protocol/manual/disease and condition table.
  • Where cohorting and Additional Precautions (where indicated) may not be possible (e.g., limited space or infrastructure), develop and formalize collaborative relationships with local facilities, hospitals and public health to develop a plan to transfer the patients where indicated (Public Health, 2020).
  • Develop, implement, and monitor evidence-based antibiotic stewardship program.
  • Implement an interdisciplinary best practice IPAC oversight committee that reports to the Board of Directors through the MAC and/or senior leadership team.

Strategies for Community and Clinical Office Practice Settings 

  • Implement formal strategies to facilitate compliance with current evidence-based IPAC practices and legislation (where in place) (Public Health Ontario, 2024) (Association of Ontario Midwives, n.d.) (College of Physicians and Surgeons of Alberta, 2024) (Surrey/North Delta Division of Family Practice, 2019)

 

Incident/Management Response

  • Implement formal strategies to ensure the organization’s current evidence-based multi-client, outbreak and pandemic preparedness and response plan:
    • Is integrated with the organization’s emergency preparedness and response plan for other events that pose risk to human health (e.g., extreme weather, cyber-attacks, mass casualty disasters);
    • Aligns with the organization’s multi-client lookback review, notification (internal and external) and disclosure processes (HIROC, 2015) (Incident Analysis Collaborating Parties, 2012);
    • Includes scheduled and periodic tabletop exercises, skill drills and/or simulations to support and enhance the organization’s preparedness and response plans, procedures, and systems.

Facility and Space Design

  • Implement formal strategies to ensure IPAC best practices and concepts are incorporated into the planning, renovation, demolition and construction of facilities, rooms, and surfaces (IPAC Canada, 2016) (CSA Group, 2018) (International Health Facility Guidelines Part D - Infection Control, 2022) (HRET, ASHE, Association for Professionals in Infection Control and Epidemiology, Society of Hospital Medicine and University of Michigan, n.d.) (AgnewPeckham Health Care & Facility Planners, 2021).

Environmental Cleaning and Ventilation Systems

  • Implement current, standardized and evidence-based environmental cleaning practices and protocols for use in all clinical care and public areas (Public Health Ontario, 2020) (Centre for Disease Control, 2022) (Ayukekbong, 2021).
  • Implement/participate in a formal inspection, service, and maintenance program for all ventilation systems (Ayukekbong, 2021).
  • Where an HVAC system is in place, implement strategies to ensure the HVAC system complies with applicable regulations related to the facility’s type (CSA Group, 2023).

Equipment and Supplies

  • Implement formal strategies to ensure sufficient and easily accessible:
    • Inventory of personal protective equipment and supplies;
    • Point-of-care sharps containers;
    • Dedicated hand washing sinks and hand sanitizer dispensers (CSA Group, 2018).
  • Implement formal strategies to validate that medical device reprocessing practices – across the organization’s sites (e.g. acute, long-term care, pediatrics), programs (e.g., endoscopy and day surgery) and settings (e.g., clinical office-based practice and EMS/ambulance services) comply with current evidence-based medical device reprocessing practices (Infection Prevention and Control Canada, 2019)  (Center for Disease Control, 2023) (Alberta Health Services, n.d.) (IPAC Canada, 2018) (IPAC Canada, 2022) (Association of Ontario Midwives, n.d.) (College of Physicians and Surgeons of Alberta, 2024) (Surrey/North Delta Division of Family Practice, 2019).
  • Ensure the organization’s reprocessing program and guidelines address (but are not limited to):
    • Reprocessing of single-use devices (including, where this practice is permitted in limited situations, as well as where this practice is prohibited);
    • Documentation and retention of sterilization logs for office and desktop autoclaves;
    • Flash steam sterilization where this is utilized;
    • Requirements and considerations when outsourcing medical device reprocessing;
    • The organization’s infection control breach and outbreak investigation protocol/process.  (Association of Ontario Midwives, n.d.) (Infection Prevention and Control Canada, 2019) (Centers for Disease Control and Prevention, 2008) (Public Health Ontario, 2013) (Alberta Health Services, n.d.)

Team Training and Education

  • Implement formal strategies to recruit, train and develop enough qualified and dedicated infection prevention and control practitioner(s), ensuring:
    • The infection prevention and control practitioner staffing ratio considers current evidence based practice, provincial/territorial guidelines, client population, case mix, volumes, and acuity as well as the potential volume and complexity of the infection prevention and control practitioner(s)’s workload and role to ensure the organization’s IPAC program can address evolving issues (e.g., surge capacity, outbreaks, reprocessing of equipment, staff training/education) (Ministry of Long-Term Care, 2022) (Knighton, Engle, Berkson, & Bartles, 2023) (Australasian College for Infection Prevention and Control, 2023) (Clifford, et al., 2022);
    • Formal job descriptions are in place for all dedicated infection prevention and control professionals.
  • Implement formal strategies to recruit, train and develop enough qualified and dedicated staff for medical device reprocessing.
  • Implement formal current evidence-based/best practice strategies to develop, support, and enhance Board of Directors (where in place), staff (employed, travel, and agency), independent contractors, volunteers, and learners’ knowledge, skills (technical and non-technical) and practice experience regarding infection prevention and control practices.
  • Ensure the organization’s IPAC training and education strategies facilitate effective knowledge transfer and practical application to the person’s roles and responsibilities (for example, what enhanced and expanded knowledge do frontline healthcare workers and staff from medical device reprocessing need in order to apply current evidence-based infection prevention and control practices to their work) (Public Health Ontario, 2024) (Infection Prevention and Control Canada, n.d.) (Infection Prevention and Control Canada, n.d.).

 

Monitoring and Measurement

  • Implement a formal strategy to ensure timely corrective action plans are created (documented), implemented and evaluated following all:
    • Routine, random internal and external infection prevention and control-related assessments, audits, alerts, recalls and advisories;
    • Outbreak, pandemic and emergency preparedness and response tabletop exercises, skill drills and/or simulations.
  • Implement formal strategies to monitor and measure the effectiveness and efficiency of, and adherence to the organization’s infection prevention and control program and guidelines.

 

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Date last reviewed:
This is a resource for quality assurance and risk management purposes only, and is not intended to provide or replace legal or medical advice or reflect standards of care and/or standards of practice of a regulatory body. The information contained in this resource was deemed accurate at the time of publication, however, practices may change without notice.