Healthcare Associated Infections (HAIs)
Sectors: Chronic Care, Complex Continuing Care, Long Term Care, Nursing Homes, Personal Care Homes, Rehabilitation
Healthcare associated infections (HAIs) are infections that are acquired during the delivery of health care (also known as nosocomial infection). Inadequate infection prevention and control (IPAC) practices are directly linked to HAIs; which can negatively impact patients/clients/residents quality of life and morbidity outcomes. The trend toward shorter hospital stays has resulted in more complex care being provided outside of the hospital. Patients/clients/residents are often sicker and have more invasive devices and/or require invasive procedures which make them more vulnerable to infections, which in turn cause serious complications. The rates of HAIs are high and as HIROC claims reveal, it is often extremely difficult to determine exactly how and where along the care continuum the infection transmission occurred. Healthcare providers (HCPs) should focus on screening patients/clients/residents risk assessment, and risk reduction strategies including: clean hands, clean equipment, personal protective equipment, clean environment and education for HCPs and patients/client/residents to mitigate risk.
Common Claim Themes
- Low compliance with IPAC policies/ guidelines;
- Lack of monitoring of IPAC measures/ interventions;
- Failure to isolate/cohort suspected and/ or confirmed infected client/residents;
- Inadequate management of outbreaks;
- Inadequate environmental cleaning measures (e.g. wrong type and/or improper application of surface and equipment cleaning products);
- Failure to isolate client/patient/resident when required;
- Delayed performance of screening/ testing;
- Delayed action/communication regarding:
- Positive screening/test results to ordering practitioners and/or IPAC;
- The presence and/or severity of an outbreak to internal and external stakeholders.
Case Study 1
Following a double lung transplant, a patient with significant co morbidities was admitted for further support at a rehabilitation facility. During this admission, the patient became ill with a bacterial infection. The patient’s spouse subsequently launched a series of complaints related to the cleanliness of the facility, stating her spouse’s room was “filthy” and subsequently alleged the environmental conditions of her husband’s room had contributed to his infection. The patient’s spouse also questioned whether the infection was nosocomial, transmitted via the contaminated hands of involved healthcare providers. Ultimately, the patient’s spouse demanded the discharge of the patient and transfer of the patient to a tertiary care facility, where the patient was diagnosed and received treatment for sepsis. Expert review of the patient’s chart was generally supportive of the care provided to the patient in the rehabilitation facility, finding no evidence of negligence on the part of the involved healthcare team. Expert review suggested the source of the patient’s bacterial infection was unclear, and may have been contracted prior to the patient’s admission to the rehabilitation facility.
Case Study 2
While admitted to a quaternary care hospital for treatment related to an abnormal heart rhythm, a geriatric patient developed persistent diarrhea. Subsequent laboratory testing ruled out a suspected diagnosis of Clostridium difficle infection. Upon the patient’s discharge from the hospital, the patient was transferred to a chronic care facility for step-down care. Following the patient’s admission, the patient continued to exhibit persistent diarrhea. While repeat laboratory results again failed to identify the presence of Clostridium difficle, the patient began to precipitously deteriorate, necessitating emergency transfer to acute care. Following the patient’s transfer, the patient was determined to be critically ill, suffering acute kidney failure and exhibiting symptoms of significant dehydration and digoxin toxicity. The patient was admitted to intensive care, where she then tested positive for Clostridium difficle. A computerized axial tomography (CAT) scan later revealed diffuse ischemic colitis. Shortly thereafter, the patient died. Expert review of the case was critical of several aspects of the care, noting that apparent failure of the healthcare team to manage the patient’s deteriorating status. Furthermore, expert review questioned the chronic care facility’s failure to initiate antibiotic therapy, despite ongoing symptomology consistent with Clostridium difficle infection.
- HIROC claims files.
- Canadian Committee on Antibiotic Resistance. (2007). Infection prevention and control best practices for long term care, home and community care including health care offices and ambulatory clinics.
- College of Nurses of Ontario. (2009). Practice standard: Infection prevention and control.
- Dancer S. (2009). The role of environmental cleaning in the control of hospital-acquired infection. J Hosp Infect. 73(4): 378-385.
- Goldberg T. (2005). Reprocessing of reusable medical devices: Some developments since the MOHLTC’s request for an audit of infection control practices. The HIROC Connection, 3: 5-6.
- Goldberg T. (2011). Class actions for nosocomial infection: Recent developments [webinar].
- Office of the Chief Coroner for Ontario. (2007). Review of SAH C. difficile outbreak.
- Provincial Infectious Diseases Advisory Committee (PIDAC). (2013). Best practices for cleaning, disinfection and sterilization of medical equipment/devices in all health care settings (3rd Ed.). Public Health Ontario.
- Provincial Infectious Diseases Advisory Committee (PIDAC). (2014). Best practices for hand hygiene in all health care settings (4th Ed.). Public Health Ontario.
- Provincial Infectious Diseases Advisory Committee (PIDAC). (2012). Best practices for infection prevention and control programs in Ontario in all health care settings (3rd Ed.). Public Health Ontario.
- Provincial Infectious Diseases Advisory Committee (PIDAC). (2015). Infection prevention and control for clinical office practice. Public Health Ontario.
- Provincial Infectious Diseases Advisory Committee (PIDAC). (2012). Routine practices and additional precautions in all health care settings (3rd Ed.). Public Health Ontario.
- Provincial Infectious Diseases Advisory Committee (PIDAC). (2012). Best practices for environmental cleaning for prevention and control of infections in all health care settings (2nd Ed.). Public Health Ontario.
- Provincial Infectious Diseases Advisory Committee (PIDAC). (2013). Annex C: Testing, surveillance and management of clostridium difficile in all health care settings. Public Health Ontario.
- Public Health Ontario. (2016). Updated guidance on the use of multidose vials.
- Zingg W, Holmes A, Dettenkofer M, et al. (2015). Hospital organization, management, and structure for prevention of health-care-associated infection: A systematic review and expert consensus. Lancet Infect Dis. 15(2): 212-224.
- Zoutman D E, Ford B D, Sopha K. (2014). Working relationships of infection prevention and control programs and environmental services and associations with antibiotic-resistant organisms in Canadian acute care hospitals. Am J Infect Control, 42(4): 349-352.
Note: The Mitigation Strategies are general risk management strategies, not a mandatory checklist.
Reliable Care Processes
- Ensure HCPs receive orientation, in-service education and are familiar with Infection Prevention and Control (IPAC) policies and procedures and best practice guidelines.
- Establish expectations with respect to IPAC measures and are in keeping with the chain of transmission and the application of ‘Routine Practices and Additional Precautions’ in all non-acute healthcare settings at all times.
- Establish multifaceted, multidisciplinary, facility-wide hand hygiene (HH) program for staff, practitioners, volunteers, client/patient/resident, family/visitors. HH program will focus on education on 4 moments of HH, availability of alcohol-based hand rub (ABHR)( 70 – 90% alcohol) or hand washing sinks at point of care, hand care program, leadership support, auditing of practice.
- Ensure numbers/locations of hand wash sinks /ABHR dispensers at point of care.
- Adopt and implement a risk assessment and screening (surveillance) process for all of client/patient/resident to identify any risk of transmission of infectious agents with client/resident contact (e.g. including screening for infectious diseases, fever, respiratory symptoms, rash, diarrhea, excretions and secretions).
- Ensure a standardized definition for an outbreak and adopt a precautionary approach for the prevention, surveillance, and management of an outbreak by implementing protocols for reporting and managing an actual or suspected outbreak including:
- Expectations for timely notification of external stakeholders (e.g. government/Public Health as required by provincial/territorial legislation);
- Creation and retention of detailed records including internal communications, notification of external stakeholders, and consultations with IPAC experts).
- Ensure risk reduction strategies, which provide reduced exposure in the presence of communicable diseases, are followed and monitored including:
- Patient/client/resident placement;
- Availability of personal protective equipment (PPE) including proper use and removal of PPE;
- Safe handling of sharps including point-of-care puncture resistant sharps containers;
- Following best practice and manufacture’s recommendations for single use devices, cleaning, disinfection and sterilization of client/patient/resident equipment;
- Following best practice recommendations for safety engineered devices, maintaining medication sterility, not using multi-dose vials;
- Following best practice recommendations for environmental cleaning and proper handling of waste.
- Ensure administrative controls, healthy workplace policies (i.e. HCP immunization, respiratory etiquette), education and audits of practice are implemented and monitored.
- Establish clear expectations that HCP do not come to work when acutely ill with signs and symptoms likely due to a transmissible infection (e.g. fever, cough, influenza-like symptoms, runny nose, sore throat, vomiting, diarrhea, rash or conjunctivitis).
Patient/Client/Resident and Family-Centred Care
- Ensure patient/clients/residents and families are aware of the expectations and adherence with IPAC risk mitigation strategies.
- Provide patient/clients/esidents and families with education on HH and IPAC risk mitigation strategies.
- Ensure complete, consistent and timely documentation of IPAC risk screening assessments; as well as documentation of risk reduction strategies.
Monitoring and Measurement
- Implement formal strategies to help ensure consistent adherence to patient client/resident IPAC monitoring policies/practices (e.g. periodic chart/e-record audits, analysis of reported incidents/events, learning from medico-legal matters). Specifically, education attendance records, incidents of HAI and outbreaks, hand hygiene compliance rates and equipment and environmental cleaning compliance