Healthcare Associated Infections: A Global Patient Safety Challenge

Healthcare Associated Infections: A Global Patient Safety Challenge

- Dr Rahul Kamble

Consultant Microbiologist & Infectious Diseases Specialist

“Bacteria often find their way into patient’s bodies

through the lines and tubes that doctors use to deliver drugs and nutrition.”

-Consumer Reports. America’s antibiotic crisis

Enhancing quality, promoting patient safety and ensuring value is the healthcare industry's current trifecta, but there are many more imperatives from a regulatory perspective, including shifting from volume-based to value-based reimbursement, enhancing transitions and reducing hospital readmissions, and improving patient satisfaction and engagement. In concert with these efforts comes the prevention of adverse events and infections. In today's environment of transparency and reform, understanding legal liability for healthcare-acquired infections (HAIs) is more critical than ever for infection preventionists as they assist their risk managers and patient safety officers with quality improvement initiatives

Healthcare-associated infection (HAI) is a serious patient safety issue, as it continues to occur, and leads to morbidity, mortality and escalating healthcare expenditure. World Health Organization (WHO) estimates HAIs to occur among 7-12% of the hospitalized patients globally, with more than 1.4 million people suffering from infectious complications acquired in the hospital at any time. 

If you know how to prevent infections, you know how to protect patients from most adverse events

Many preventive measures have been recommended which include:

1) Elimination of endogenous healthcare associated pathogens to reduce oropharyngeal, intestinal and skin colonization.

2) Use of methods to prevent cross contamination and to control various sources of healthcare associated pathogens that can be transmitted from patient to patient or from personnel to patient

3) Use of antibiotic prophylaxis in post operative and high risk patients.

The Joint Commission established the National Patient Safety Goals (NPSGs) in 2002 to address specific areas of concern in regards to patient safety. Goal 7 was created to address healthcare personnel education and compliance with hand hygiene and the inclusion of healthcare-associated deaths and disability as sentinel events, requiring root cause analysis and follow-up. This NPSG was substantively expanded upon in 2009 to include patient education regarding multidrug-resistant organisms and patient and family engagement in patient safety related to HAIs. Additionally, this goal requires facility implementation of evidence-based practices to prevent device and procedure-associated infections

The WHO World Alliance for Patient Safety has chosen the prevention of healthcare associated infection as the first Global Patient Safety Challenge. The World Health Organization (WHO) launched the first Global Patient Safety Challenge in 2005 and introduced the ‘5 moments of hand hygiene’ in 2009 as an attempt to reduce the problem of health care associated infections. In order to prevent healthcare associated infections, a high level of hygiene is essential, which includes practicing 5Cs in patient care

Ø CLEAN HANDS

Ø CLEAN PRACTICES

Ø CLEAN PRODUCTS

Ø CLEAN ENVIRONMENT

Ø CLEAN EQUIPMENT    

The ‘National Health Policy’, addresses antimicrobial resistance as one of the key issues and prioritises development of guidelines regarding antibiotic use, the over-the-counter use of antibiotics, restricting the use of antibiotics as growth promoters in livestock, and pharmaco-vigilance including prescription audit inclusive of antibiotic usage in the hospital and community. Hospital based programs dedicated to improving antibiotic use, commonly referred to as Antimicrobial Stewardship Program (AMSP) have been found helpful in improving the quality of patient care and safety through increased infection cure rates, reducing treatment failures, and increasing the frequency of correct prescription for therapy and prophylaxis.

Medicolegal aspects related to HAI:

Healthcare associated infection is the infection that occurs in a patient in whom it was not present or incubating at the time of admission to the hospital. The very definition of HAI implies a potential for medicolegal problems. Healthcare providers owe a legal duty of care to their patients. They must exercise the degree of care and skill that could reasonably be expected of a normal, prudent practitioner, and they also have an ethical obligation to act in the best interest of patients. Similarly, healthcare organizations have a duty not only to establish necessary systems and protocols to promote patient safety, but also to take reasonable steps to ensure that the healthcare staff complies with systems, protocols, policies, and procedures.

Patients also owe a duty to comply with all medical instructions both during hospital stay and afterwards. In a malpractice lawsuit, a patient may be held responsible for contributory negligence, if the patient did not comply with the medical instructions, resulting in harm related to HAI. For example, if a patient failed to receive recommended follow-up treatment to change wound dressings, or did not take recommended antibiotic medications, a court may determine that the patient is entitled to reduced quantum of compensation or even no compensation at all.

Many countries like UK, US, and Germany have specific legislations and protocols related to HAI which is considered to be in the domain of public health legislation. No such legislation exists in India.

Several provisions of The Indian Penal Code which could be applicable in case of HAIs includes:

· Section 304A IPC (Causing Death by Negligence)

· Section 337 IPC (Causing Hurt by Act Endangering Life or Personal Safety of Others)

· Section 338 IPC (Causing Grievous Hurt by Act Endangering Life or Personal Safety of Others)

· Section 269 IPC (Negligent Act Likely to Spread Infection of Disease Dangerous to Life)

· Section 270 IPC (Malignant Act Likely to Spread Infection of Disease Dangerous to Life)

In a malpractice lawsuit with allegation of harm suffered as a result of HAI, the complainant may be required to prove that a reasonable healthcare provider / hospital would have foreseen the likelihood of such harm in the absence of certain steps necessary to prevent the infection, and that the healthcare provider / hospital failed to foresee the impending harm and take the preventive steps. Healthcare providers and hospitals will be held liable for failing to implement adequate infection control measures where such a failure resulted in harm to the patient. The evaluation for negligent conduct in this context is measured against the behavior of a reasonably competent healthcare provider/ hospital in a similar position.

An intentional failure to implement adequate infection control measures may indicate that the hospital or hospital managers concerned had either ‘actual’ or ‘eventual’ intention not to implement such infection control measures. In cases where ‘actual’ or ‘direct’ intention is present, the wrongdoers decide not to provide certain infection control measures and know that this is wrong. On the other side, in cases where ‘eventual’ intention is present, the wrongdoers subjectively foresee the likelihood of harm to patients if adequate infection control measures are not implemented and do not care whether or not such harm occurs, i.e. they act with reckless disregard for the consequences of such failure.

In the context of HAIs, what constitutes reasonable practices and protocols may be a moving target during an outbreak, particularly as infection prevention measures are revised to reflect new evidence about disease virulence, transmission routes, and key control methods. There are many guidelines and recommendations for prevention of infection, and failure to meet those indicates a failure in appropriate standard of care. In many areas of practice, courts often look to guidelines or standards of practice to determine the legal standard of care. If a patient has been harmed or exposed to risk of harm, providers have a duty to disclose that information to the patient or family. When errors have occurred, or when some risk of harm exists, there must be hospital policies available to guide disclosure of patient identifiable health information to regulatory authorities, accrediting bodies, or other government agencies.

The healthcare organizations should have standard updated well-documented protocols for prevention of infection according to the recent evidence of disease virulence, transmission routes, and key control methods. Proper communication of the lawsuit summaries to the healthcare providers can help the Infection Control Committee in enhancing patient safety and prevention of HAI. Greater awareness needs to be created so as to highlight the potential legal implications of HAI.