Bacterial screenings at Stockholm’s Karolinska University Hospital enabled researchers to identify and alleviate infection risks.
Up to one in 10 hospital patients will develop a healthcare-associated infection (HAI) over the course of their stay.1-3 In addition to causing harm and suffering to the patient, incidences of healthcare-associated infections extend the duration of care and increase costs to society.4,5 The Swedish Health and Medical Services Act emphasises the importance of good quality healthcare, conducted to high standards of hygiene and security, in order to meet the best interests of the patient.6 Many patients suffer from an underlying condition or are immunocompromised by the treatment they are receiving, meaning they are at a heightened risk of contracting healthcare-associated infections.
Within the healthcare sector, contact infections – which are primarily spread indirectly through temporarily contaminated hands – are the most common source of infection.7,8 In the mid-19th century, Florence Nightingale showed that bacteria spread between patients;9 while in the same period, the Hungarian physicist Ignaz Semmelweis demonstrated the importance of hand disinfection in maternity care.10 Both were met with scepticism by their contemporaries; and even today some hygienic principles are questioned despite the presence of substantial evidence in their favour.11
A wealth of evidence compiled by the World Health Organization (WHO) indicates that hand disinfection is the single most effective measure in infection prevention.12-14 In spite of this, compliance with hygienic guidelines on the part of healthcare staff remains troublingly low.8
The importance of cleaning in the prevention and control of healthcare-associated infections has been well established.15-17
In a healthcare setting, contamination of surfaces by microorganisms can be spread to patients via direct or indirect contact: between 20% and 40% of all HAIs are thought to be caused by contamination on the hands of clinical staff; while high-touch surfaces in healthcare environments are a significant vector in the spread of such bacteria as Clostridium difficile.17
Regulation compliance use case: Karolinska University Hospital
Karolinska University Hospital in Stockholm typically achieves on average 65% compliance with infection control guidelines, according to consecutive national surveys. Data gathered by the Swedish Association of Local Authorities and Regions (SALAR) indicates that patients’ risk of developing a healthcare-associated infection at Karolinska is between 12% and 14%.19 The hospital agreed to participate in a research project21 funded by Sweden’s national innovation agency, Vinnova, in order to identify its key areas of risk and – ideally – reduce the spread of infection.
Bacterial screenings and surface cultures
Initial bacterial screenings were conducted in order to identify areas within day-to-day clinical operations which could pose risks for the spread of microorganisms. Each screening entailed two observers – a doctor or nurse employed by the hospital and a second person with another background, such as an industrial designer or psychologist – following a patient through the ward for four hours. Two pilot screenings were conducted at clinics elsewhere to further optimise the method.
These bacterial screenings were conducted on the neonatology, paediatric medicine, urology, haematology and thoracic surgery wards; as well as in patient transports and the premises of external cleaning companies, with the goal of producing data which would be representative of the risk of infection throughout the entire spectrum of healthcare at the hospital. The relevant department heads responded positively towards participating in the project.
Each of the pairs of observers produced a joint report on their screening, with photographic illustrations indicating risk areas which the observers particularly wanted to highlight. The seven reports were analysed individually and then collectively by all participants to identify the key risk areas. Based on the results of the screenings, baseline cultures were conducted at 10 to 15 distinct sites on each of the five wards to assess potential sources of infection. The samples were analysed in a microbiology lab affiliated with the project.
The key risks identified through the bacterial screenings varied to some degree between wards, with the focus and purpose of each ward apparently affecting its vectors of infection: for example, screenings of the paediatric ward identified parents and siblings as a major risk factor for the spread of infection; while observers conducting screenings of the urology ward reported a significant risk of infection associated with urinary catheters. Similar risk factors which were specific to other wards included breathing apparatuses on the thoracic ward, immunocompromised and immunosuppressed patients on the haematology ward, and incubators in the neonatology ward. Other risk factors identified by the observers were common to all the screened wards, and included:
- Incorrect cleaning processes: cleaning staff did not use hand sanitiser or change their gloves between tasks. Some furniture was difficult to move, meaning that staff were unable or unwilling to clean under or behind cumbersome items. Cleaning staff did not appear to have been fully briefed as to which cleaning tasks were their responsibility and which tasks fell under the purview of hospital staff, meaning some surfaces may not have been cleaned at all by either team
- Lack of compliance with necessary infection control processes: staff were observed wearing the same plastic apron while making beds, dressing wounds, and feeding patients, leading to a heightened risk of infection spread
- Widespread overuse, underuse, and misuse of protective gloves
- Patients, their family members and caregivers were not informed about the importance of good hygiene or how to establish an effective hygiene routine
- Surfaces in patients’ rooms were described as ‘packed’ with items: patients’ personal toiletries, specimen bottles, medicine cups and glasses. Rather than moving these items to clean – or, where relevant, disposing of them – cleaners simply cleaned around them
- The structure of containers dispensing single-use plastic gloves and aprons made it difficult for users to take a single apron or pair of gloves without getting extras – users would simply push the extra items back into the boxes, thus compounding the issue for the next user and compromising the hygienic integrity of the aprons and gloves which had been touched
- Textile draperies were rarely laundered
- Urinary catheter tubes were left on the floor
- Unprotected input ports contaminated with aggregate substances could be placed near patients’ mouths or near babies’ nappies
- Staff operating patient transports were insufficiently trained on basic hygiene and disinfection routines
Across the wards, observers found bacteria including Enterococcus spp, Staphylococcus, Enterobacteriaceae spp, Pseudomonas spp and Clostridium difficile. Methicillin-resistant Staphylococcus (not aureus) was found at several sample sites. The wards with the highest levels of compliance with basic hygiene routines were found to have the lowest number of surface bacteria, while the highest number of bacteria were found in the wards with the lowest rates of compliance.
One factor which swiftly became apparent was the overall lack of structure in terms of cleaning standards and processes. Some areas were routinely cleaned every day, while others were not cleaned at all; hospital staff and cleaning staff both reported a lack of clarity as to the division of cleaning responsibilities.
Identifying room for improvement
In a strategy informed by the results of the screenings and cultures, the hospital shifted its focus to ensuring the cleanliness of the ‘near-patient environment’ and continuing to develop its improvement plan. The wards developed and adopted new evidence-based cleaning routines and enhanced their efforts to enforce compliance with existing hygiene measures. The hospital switched its cleaning services contract to a new company and mandated that its new cleaning contract staff must be trained in the fundamentals of infection prevention and control, antibacterial measures, and the necessary standards of hygiene within healthcare environments.
The hospital continued to evaluate the effect of its improvement efforts by taking monthly culture samples at the sites in each ward which had initially been identified as having a high bacterial load. A second observational study conducted nine months after the first found that, on four of the five wards, compliance with basic clinical hygiene routines had risen by an average of 16 percentage points (the fifth ward was not covered by the second study due to a ‘severe’ lack of staffing resources).
The hospital worked to develop updated cleaning routines and establish checklists to ensure each cleaning task was documented. Hospital staff were detailed to clean the ‘near-patient environment’ – the equipment used near the patient and while caring for the patient, such as the bed, bedside table, bedside lamp and wheelchair – according to the hospital’s cleaning regulations, as well as conducting all cleaning tasks requiring disinfectant. The remaining cleaning duties were to be performed by a cleaning company. Both the hospital’s personnel and the cleaning operatives were trained or retrained in basic infection control cleaning and disinfection processes. The fabric drapes, which had represented a significant vector of infection, were replaced with screens which were less bacteria-retentive and substantially easier to clean. Hospital management found that making staff aware of the initial screening results had rendered them more motivated to improve their compliance with hygiene regulations, leading to positive trends in all the wards which were observed.
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