WHO is setting your IPC agenda

who-guidelines-hai-infographic

The World Health Organisation has updated its 2009 Guidelines on Core Components of Infection Prevention and Control Programmes. The report highlights eight ‘core components’ for IPC:

  1. IPC programme. The bottom line here is that there should be an IPC programme at a national and facility level. Although this seems obvious, this will be useful in developing healthcare economies, where there may not be established programmes. It is also interesting to ask who exactly is responsible for delivering the IPC programme on a national level. For example, in England, is it central government, the Department of Health, Public Health England, NHS England or other? The other point that struck me here is financial: the report recommends that the IPC team ‘should have a protected and dedicated budget according to planned IPC activity and support by national authorities and leaders’. I wonder how many IPC teams have a protected budget in the current challenging financial climate?
  2. Guidelines. There should be evidence based guidelines on a national and local level. The quality of scientific evidence underpinning IPC practices is generally poor due to the paucity of properly controlled trials. Whilst some high-quality cluster RCTs are coming through, these are currently few and far between. This is illustrated by the fact that even these WHO Core Components were mostly ‘strong recommendations’ that were underpinned by ‘very low quality’ evidence. Therefore, IPC guidelines need to combine the rigour of evidence-rated guidelines with a healthy dose of pragmatism. The main section of the guidelines includes a helpful list of areas that should be covered by local IPC policies.
  3. Education and training. All staff should receive some IPC training, which should be supported on a national level. However, is there a defined career path for infection control practicioners? And where is the national IPC curriculum? The report suggests that all staff should receive bedside and simulation IPC training, which is a significant challenge, especially for large and complex organisations!
  4. Surveillance. Surveillance of key pathogens, key presentations of HCAI, and the prevalence of AMR should be performed on a local and national level. There are some studies showing that improved surveillance reduces HCAI – but those with inadequate surveillance systems would be wise to brief their colleagues that it will get worse before it gets better when surveillance is enhanced! Whilst most of the recommendations were agreed unanimously amongst the guideline writing group, the recommendation for national surveillance of HCAI was not – several felt that it was not feasible to implement (perhaps they had been involved in setting up a national HCAI surveillance programme…!).
  5. Multimodal strategies. Multimodal strategies should be implemented locally, and supported nationally, with a consideration to implement nationally successful strategies. Some more detail on exactly what is meant here would be useful. I get the feeling that this is directed towards hand hygiene improvement strategies, but this is not specified. Another problem here is that, despite the evidence base for this recommendation being one of the strongest, most of the studies evaluated a set of multimodal interventions, so it’s not possible to determine which element of the bundle was the most effective, and whether there were any redundant elements sapping valuable resource.
  6. Audit and feedback. We should monitor whether staff are complying with IPC practices locally, and national systems should be in place to monitor key practices (e.g. hand hygiene). A little more information on what exactly should be audited, how, and when would have been useful in this section. I do wonder whether ‘audit fatigue’ should be considered here. If the same thing is audited for in the same way for too long, people lose interest. Perhaps a snappy rotating audit programme would be a better approach? One month on hand hygiene, one month on PPE use etc? Hand hygiene was a recommended national indicator of IPC practice. This doesn’t happen at the moment, although the latest government announcements suggest that it may happen soon; I worry that unrealistically high levels of hand hygiene compliance may be reported, which would make this potentially helpful development counterproductive.
  7. Workload, staffing, and bed occupancy. The recommendation that bed occupancy should not exceed the standard capacity of the facility is an interesting one, and doesn’t really help if the bed occupancy capacity doesn’t match the estate! It seems remarkable that this section should begin with recommending one patient per bed – you would think that this would go without saying! I thought the recommendations could have been stronger here, but I guess this report has to work in low- middle- and high-income settings. The report recommends a minimum of one full time IPC doctor or nurse per 250 beds, and consideration of a lower ration of one per 100 beds. Looking at the level of staffing in most acute NHS hospitals, it is a lot higher than this, and there is still much to do!
  8. Built environment, materials, and equipment. Much like the previous section, the required breadth of the report meant that this section is not really specific enough to be that useful in a developed healthcare setting. We take the basics of a hospital for granted: a supply of clean running water, power, light, waste disposal, and the availability of basic equipment (e.g. PPE and sharps containers). The report does highlight the need for an adequate ratio of single rooms, but rather unhelpfully does not specify a minimum standard for this! I find it rather imbalanced that there is an entire section dedicated to providing adequate materials and facilities for hand hygiene (which is entirely appropriate by the way), and a very short 200 word section on cleaning of the environment embedded in the built environment section. Surely there is much more to say about the importance and challenges of providing a clean, and appropriately disinfected healthcare facility?

The report contains some challenging recommendations, even for pretty well-developing IPC services. For example, the recommendation to regularly evaluate the effectiveness of IPC training and education, hands-on simulation based IPC training for all staff, policies on preventing key HCAI manifestations as well as specific organisms on concern (e.g. SSI, CLABSI), advice to evaluate the impact of interventions, having early warning systems in place to detect outbreaks, and providing regular feedback of audit data on an individual level.

Self-assessment tool

In order to help match our IPC programme with the suggestions in a review by Shekelle et al., and Zingg et al., in addition to these WHO guidelines, I have produced a simple tool that you can download here (designed for a facility-level self-assessment). I found this useful to track the details of our programme with these recommendations, in order to identify any gaps. Please let me know if you find it useful or not.

Summary

The ambitious set of guidelines tries to cover recommendations on both a national and local level; I wonder whether it may have been better to provide separate guidelines for each – or at least split the guideline in half rather than address them at the same time. Also, the guidelines try to be relevant for all healthcare facilities and countries, which has to encompass a huge range of funding levels and general infrastructure. It was a shame not to see more on reducing the inappropriate use of anti-infectives, which are such an important driver for HCAI and AMR. There were a couple of refrains that resonated throughout: “Due to varied methodologies and different outcomes measured, no meta-analysis was performed.” This illustrates, again, the poor quality of evidence that we are working with! And “No study was found on patient values and preferences with regards to this intervention.” Perhaps we need to do a better job of understanding what patients think about IPC! Still, WHO and the group of experts involved should be commended for putting together this useful set of guidelines.

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2 thoughts on “WHO is setting your IPC agenda

  1. For me the all concerning comment was this one, from Section 8 on Built Environment, Materials & Equipment:

    “… and a very short 200 word section on cleaning of the environment embedded in the built environment section. Surely there is much more to say about the importance and challenges of providing a clean, and appropriately disinfected healthcare facility?”

    Two immediate responses to this come to mind ..

    (1) There is a desperate need to totally re-evaluate the cleaning products and protocols used in healthcare facilities. The problem being addressed is biological in nature, and the conventional chemistry solutions, (bleaches, quats, oxidizers and enzymes), do not address the presence of biofilm on surfaces.

    Even when combined with some for physics (wiping with microfiber, vacuuming et al) their efficacy is both limited, and also offers no ongoing protection.

    Given the underlying philosophy of these protocols is to indiscriminately attempt to “Kill Everything”, both healthy beneficial bacteria as well as harmful pathogens, a vacuum is often created that is immediately available to the re-habitation and re-colonization of unwanted pathogens.

    Add to this scenario that these conventional cleaning chemistries and protocols are also relatively ineffective at addressing the presence of biofilm. The result is that whilst surface bacteria (beneficial and harmful) are reduced, those still resident in residue biofilm very quickly re-colonize (within a matter of a couple of hours) and so the problem of pathogens quickly represents itself.

    Furthermore many of these conventional cleaning chemistry offerings are becoming less effective over time, resulting in the need for ever stronger versions of them (we are now on 6th generation quats) in an effort to maintain the already unacceptable status quo.

    Increasing the strength poses a number of problems in of its self:

    (a) They are potentially more harmful to those applying them, and also to some of the patients and staff in healthcare facilities.

    (b) By their nature many pose a risk of being damaging over time to the surfaces to which they are applied.

    (c) There is growing concern that these chemistry based cleaning solutions are contributing to the mutation by pathogens.

    Finally on this point, there has been a growing body of research over the past five years demonstrating the importance of the interior microbiome of a facility to the health / well being of occupants.

    This same research has demonstrated that the microbiome of the interiors of mechanically ventilated buildings, (even Platinum LEED Buildings), is significantly less diverse, with a higher concentration of pathogens, than the microbiome of the people coming in and out of these facilities and the outdoor areas around the building.

    Now whilst this may seem logical, this research when viewed in the context of my earlier comments, further illustrates that current cleaning practices, (chemistry and equipment), are likely contributing to a less healthy indoor environment given they also attack the much needed beneficial bacteria.

    One of the solutions is to consider the use of cleaning products that incorporate a beneficial biological solution to address what is essentially a biological problem.

    One such option is in the form of probiotic cleaning agents.

    Probiotic cleaners are based upon the principle of Competitive Exclusion by introducing healthy, safe, beneficial probiotic bacteria into the cleaning equation in a manner that over populates the surface with probiotics, that then out consume the pathogens for the available food source, and in so doing they also breakdown the biofilm.

    A protective layer of self regulating probiotics is then left on the surface, (they remain as long as there is an available food source) that effectively makes the surface in-hospitable / hostile to the re-habitation / re-colonization of pathogens.

    (2) Another area not addressed is the HVAC systems in healthcare facilities.

    These can be major sources of problems in the spread of infection in a healthcare facility.

    I have seen HVAC coils that are serving multiple operating rooms (ORs) that are totally contaminated with pathogens.

    Its often a case of “out of sight, out of mind”, but to me it is ironic that these very units that are meant to keep the environment in ORs within optimal ranges of temperature and humidity are potentially “blasting” pathogens into the OR.

    Like

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