‘Number of patients acquiring HAIs is more than those with cardiac problems, cancer and AIDS’

Dr Victor D Rosenthal, Founder and Chairman, International Nosocomial Infection Control Consortium (INICC) talks about the prevalence of HAI infections in India and the measures that healthcare providers can adopt to reduce their incidence, in an interview with Sanjiv Das

What is the incidence of healthcare associated infections (HAIs) in India? How does India as a country compare with global numbers?

Mortality rate of HAIs is between 20-40 per cent. The number of patients acquiring HAIs is more than those with cardiac problems, cancer and AIDS. The HAI rate from public sector in India is unknown and higher than the private sector. HAI rates of private sector, as an example for central line associated bloodstream infections (CLABSIs) is around five CLABSIs per 1000 vascular catheter days, meanwhile, in the US the CLABSI rate is one per 1000 vascular catheter days. While India has lower HAI rates than most other developing countries, such infections are on the rise in the country because of various reasons such as limited awareness among health workers. For patients, it will mean longer hospital stay and enduring medical costs.

What are the key findings and recommendations of the India-based study conducted by the International Nosocomial Infection Control Consortium (INICC) on CLABSI rates in India?

A recent study was conducted in India between April 2012 and August 2014 on 1096 patients. The study was carried out in five medical surgical adult ICUs in two tertiary-level hospitals, published in the American Journal of Infection Control (2015) has proved that usage of open connectors and conventional practices such as manual preparation of intravenous fluids – increased CLABSIs (catheter associated blood stream infections). Adoption of advanced technology namely, split septum needle less connectors and single use pre-filled flush helped in reducing CLABSI rates, shorten hospital stay and cost savings.

Which parameters did you keep in your mind while conducting the study?

INICC receives HAI rates data from 20 cities of India, the most recent published report has a representation of data from the year 2003 – 2014, and the CLABSI rate for this duration was five CLABSIs, which is five times more than in the US. Then we reviewed all interventions to control CLABSI rates and found that the interventions in India are different than in US, and this explains why the rate of CLABSIs is five times of the US. Thus we decided to analyse the impact of two interventions (split septum and single use flush) in India. As a result, we achieved a rate of 2.2 CLABSIs, which is lower than India’s mean CLABSI rate of five CLABSIs and closer to the US mean rate of one CLABSI.

How can the findings of the study be utilised by hospital managements in India to reduce HAIs?

In order to achieve lower CLABSI rates, hospital managements and healthcare professionals should adopt catheter care bundles – defined as a ‘group of best practices that individually improve care, but when applied together result in substantially greater improvement’, these bundles consists of behavioural as well as technology elements.

• Hand hygiene
• Maximal barrier precautions upon insertion of vascular catheters
• Clorhexidine skin antisepsis
• Optimal catheter site slection, with avoidance of the femoral vein in adult patients
• Daily review of line necessity with prompt removal of unnecessary lines
• Sterile dressing care at insertion site
• Clorhexidine impregnated dressing at insertion site
• Closed IV containers
• Split Septum as a connector
• Single use pre-filled flushing
• Disinfection of catheter hub, connector, and injection port before they are accessed
• Bath with chlorhexidine

By adopting latest technology, health professionals may prevent much unnecessary medical and financial distress to their patients.

What are some of the biggest barriers to reducing HAIs: cost, mindset of healthcare practitioners or other factors?

Awareness of bundles for HAI prevention, compliance to best practices, research and resources.

Give us some details of the surveillance tool that you are currently working on which could change the way hospitals manage infections?

The INICC surveillance programme includes surveillance of device-associated – HAI rates (rates of CLABSI per 1000 vascular catheter days), use of invasive devices, their adverse effects, including length of stay, mortality rates, micro-organism profile, and bacterial resistance, and patient characteristics, such as age, sex, average severity illness score (ASIS), and underlying diseases. Investigators are required to complete outcome surveillance forms at their ICUs. CLABSI definitions and surveillance methods were performed applying the definitions for HAI developed by the Centers for Disease Control and Prevention (CDC) and National Healthcare Safety Network (NHSN) programme.

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