Prevention and Control of Infections in Hospitals- Practice and Theory ( PDFDrive ).pdf

Prevention and Control of Infections in Hospitals Practice and Theory Bjørg Marit Andersen 123 Prevention and Control of Infections in Hospitals Bjørg Marit Andersen Prevention and Control of Infections in Hospitals Practice and Theory Bjørg Marit Andersen Department of Hospital Infections Oslo University Hospital Oslo Norway Faculty of Health and Social Science University of South-Eastern Norway Oslo Norway Original Norwegian edition published by Elefantus Forlag, Moss, 2016 ISBN 978-3-319-99920-3 ISBN 978-3-319-99921-0 (eBook) https://doi.org/10.1007/978-3-319-99921-0 Library of Congress Control Number: 2018963171 © Springer Nature Switzerland AG 2016, 2019 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Preface Prevention and Control of Infections in Hospitals: Practice and Theory deal with infection control, surveillance and hygienic routines and key topics, both practical and theoretical. The book is adapted to a necessary level of infection prevention to cope with today’s emerging and resistant microbes, hygienic challenges and emergency preparedness in practical work. It updates current knowledge about infection protection as basic for selecting routines and guidelines to prevent hospital infections. Healthcare-associated infection (HAI) is primarily a patient safety issue, causing more than 90% of patient injuries. Leaders at all levels in the healthcare system are responsible for patient safety and infection control, from the director of the hospital to the health minister and government, and this should be warranted by law. Lack of management is associated with overcrowding, understaffing, corridor-beds, poor maintenance of buildings and equipment, inadequate cleaning and basic hygienic measures which often lead to HAIs. Hospital infections may occur in 5–20% or more of hospitalized patients. In Europe, at least 7.5 million patients acquire HAI each year, and more than 147,000 patients die directly or indirectly from HAIs each year in European hospitals. Hospital infections are detected more often after discharge, due to shorter and shorter stay in hospitals. This may lead to spread of resistant bacteria between healthcare levels and less favourable outcome for the patient with infection. Virus like influenza and norovirus follow the patient and may spread like “fire in dry grass”. Entire departments with patients and personnel will be “sick-reported” and must shut down all activity for 2–3 weeks. The spread of resistant and/or particularly pathogenic, contagious microbes poses a risk to patients, employees, visitors and society as a whole. Dangerous microbes often have a global spread pattern, which requires continuous readiness with effective, limiting measures against epidemics or pandemics. The book is focused on practical measures against severe hospital infections such as postoperative wound infections; intravascular, blood-borne infections; infections in lower respiratory tract, urinary tract, skin and gastrointestinal tract; and infections in neonates and premature and in other patients with impaired infection defence. A good hygiene is important to protect patients, visitors and employees against infections. Good hygiene routines, personal infection protection, cleanliness, textile v vi Preface treatment, sterility, disinfection and high professional hygiene standards for patient care increase patient safety and protect the working environment. Daily infection surveillance, infection detection and adequate contraceptive measures and information are required to stop the spread of infection. The book is intended to be an aid and an optimal standard in practical work to reduce the incidence of serious hospital infections and spread of infection. This increases the quality of patient treatment; patient safety is better taken care of, and infection control becomes a natural part of measures around hospital patients and employees. Prevention and Control of Infections in Hospitals: Practice and Theory is updated from earlier (1996, 1999, 2003, 2008, 2016) Norwegian handbooks in infection control, lastly published in 2016 (Elefantus forlag, Moss). Each chapter has a practical part and a background information and documentation part. Thanks to the following colleagues for professional advises and comments: Infection control nurses, Mette Rasch and Kjersti Hochlin; chief physician, Kjell Olafsen; and professor in medicine, PhD, Inggard Lereim. In addition, I am grateful to my family, friends and colleagues for friendly assistance and positive support during the writing period. However, my greatest and most enthusiastic fan, my dog, Tito, left forever in May 2018. Target groups: health professionals; doctors, nurses and other health professionals; students in health-related subjects, hospital leaders and health agencies; and patients and their relatives. Oslo, Norway Bjørg Marit Andersen June 2018 Contents Part I Introduction (Surveillance, Microbes and Pathways, Tracing and Preventing) 1 Patient Protection Is Patient Safety 3 1.1 Lack of Leader Competence and Responsibility 4 1.2 Hospital Organization Is Important for Hospital Infections and Patient Safety 5 1.3 A Future for Healthcare 10 References 10 2 Hospital Infections: Surveillance 13 2.1 Prevalence and Incidence Surveillance of HAI 13 2.2 Effect of Registration 15 2.3 The Burden of Healthcare-Associated Infections 18 References 20 3 Microbes, Transmission Routes and Survival Outside the Body 23 3.1 Microbes are Mostly Normal, Nonpathogenic Flora 23 3.2 Pathogenic Microbes: New and Old 24 3.3 Transmission Routes: Spread of Infection 24 References 27 4 Antibacterial Agents and Drug Resistance 29 4.1 Antimicrobials: Sensitivity and Resistance 30 4.2 Reasons for Resistance Development 31 4.3 Multidrug-Resistant Organisms (MDRO) Are Worldwide Problems 33 4.4 Practical Measures 35 References 40 5 Tracing and Preventing Infections 45 5.1 Purpose 45 5.2 Comprise 46 5.3 Responsibility 46 5.4 Practical Measures 46 5.5 Background Information 54 vii viii Contents 5.6 Notification and Warning on Suspected Infection and Dissemination 58 References 59 Part II Infection Control for Health Care Workers 6 Staff Uniforms and Uniform Policy 65 6.1 Purpose 65 6.2 Comprise 66 6.3 Responsibility 66 6.4 Practical Measures 66 6.5 Background Information 67 References 69 7 Vaccination and Control of Employees 71 7.1 Purpose 71 7.2 Comprise 71 7.3 Responsibility 72 7.4 Practical Measures 72 7.5 Hepatitis A/B vaccines 72 7.6 Polio Vaccine 73 7.7 Influenza Vaccine 73 7.8 Rubella Vaccine 74 7.9 Varicella Zoster Vaccine 75 7.10 Mumps Vaccine 75 7.11 Measles Vaccine 75 7.12 Other Viral Vaccines 75 7.13 Diphtheria and Tetanus Vaccines: Duo-Vaccines—Optionally Including Pertussis (Tdap) 75 7.14 Pertussis Vaccine 76 7.15 Pneumococcal Vaccines 76 7.16 Haemophilus Influenzae Type B Vaccine 77 7.17 Meningococcal Vaccines 77 7.18 BCG Vaccination 77 7.19 Other Bacterial Vaccines 78 7.20 Vaccine Combinations to Children 78 References 78 8 Employees with Infections or Carrier Status 79 8.1 Purpose 79 8.2 Comprise 79 8.3 Responsibility 80 8.4 Practical Measures 80 8.5 Background Information 80 8.6 Actual Infections or Carrier State 81 References 85 Contents ix 9 Pregnant Employee Exposed to Infection 87 9.1 Purpose 87 9.2 Comprise 87 9.3 Responsibility 88 9.4 Practical Measures 88 9.5 Basic Information 89 References 89 10 Tuberculosis: Prevention 91 10.1 Purpose 91 10.2 Comprise 91 10.3 Responsibility 92 10.4 Practical Measures 92 10.5 Basic Information 94 References 94 11 Accidents with Blood or Tissue 97 11.1 Purpose 97 11.2 Comprise 98 11.3 Responsibility 98 11.4 Practical Measures 98 11.5 Background Information 104 11.6 Occupation-Associated Blood-Borne Infection and Disease 106 References 107 12 Hand Hygiene and Glove Use 111 12.1 Purpose 111 12.2 Comprise 112 12.3 Responsibility 112 12.4 Practical Measures 112 12.5 Background Information 119 References 125 13 Protection of Upper Respiratory Tract, Mouth and Eyes 129 13.1 Purpose 129 13.2 Comprise 129 13.3 Responsibility 130 13.4 Practical Measures 130 13.5 Background Information 135 13.6 Conclusion 143 References 143 Part III Isolation 14 Microbes, Transmission and Protection 149 14.1 Isolation at Risk of Spread of Infection 149 x Contents 15 General Information 153 15.1 Purpose 153 15.2 Comprise 154 15.3 Responsibility 154 15.4 Practical Measures 154 15.5 Background Information 163 References 163 16 Contact Isolation 167 16.1 Purpose 167 16.2 Comprise 167 16.3 Responsibility 168 16.4 Practical Measures 168 16.5 Background Information 176 References 176 17 Blood-Borne Pathogens 179 17.1 Purpose 179 17.2 Comprise 179 17.3 Responsibility 180 17.4 Practical Measures 180 17.5 Background Information 184 References 184 18 Airborne/Droplet Infection Isolation 187 18.1 Purpose 187 18.2 Comprise 188 18.3 Responsibility 188 18.4 Practical Measures 188 18.5 Background Information 195 References 195 19 Strict Isolation 197 19.1 Purpose 197 19.2 Comprise 198 19.3 Responsibility 198 19.4 Practical Measures 198 19.5 Background Information 199 19.6 Strict Isolation Unit 199 References 209 20 Protective Isolation 213 20.1 Purpose 213 20.2 Comprise 214 20.3 Responsibility 214 20.4 Protective Isolation 214 20.5 Background Information 214 20.6 Practical Measures 214 References 221 Contents xi 21 Background Information: Isolation Routines 223 21.1 Isolation 223 21.2 History 223 21.3 Hospital Infections that Should Be Treated in Isolates 225 21.4 New and Old Microbes Increase the Need for Isolates 225 21.5 Particular Issues Around Infection and Isolation 226 21.6 Lack of Infection Isolates 226 21.7 Administrative Responsibility for Isolation Treatment 233 21.8 Contact Isolation: “Contact Precautions” (CP) 235 21.9 Airborne and Droplets: Isolation 237 21.10 Strict Isolation for High-Risk and Dangerous Pathogens 240 21.11 Protective Isolation 240 21.12 Protecting Staff Against Serious Infection 242 21.13 CDC Isolation Guidelines - Overview - Selected by the Author 244 References 246 Part IV Patient Care 22 Personal Hygiene and Care of Patients 255 22.1 Purpose 255 22.2 Comprise 255 22.3 Responsibility 256 22.4 Practical Measures 256 22.5 Background Information 259 References 263 23 Oral Hygiene 265 23.1 Purpose 265 23.2 Comprise 265 23.3 Responsibility 266 23.4 Practical Measures 266 23.5 Background Information 269 References 271 24 Wound Care: Skin and Soft Tissue 273 24.1 Purpose 273 24.2 Comprise 274 24.3 Responsibility 274 24.4 Practical Measures 274 24.5 Background Information 275 References 276 25 Prevention of Infected Pressure Sores 279 25.1 Purpose 279 25.2 Comprise 280 25.3 Responsibility 280 25.4 Practical Measures 280 25.5 Background Information 282 References 284 xii Contents Part V Respiratory Infections 26 Prevention of Respiratory Infections 289 26.1 Purpose 289 26.2 Comprise 290 26.3 Responsibility 290 26.4 Practical Measures 290 26.5 Background Information 293 26.6 Important Microbial Causes of Pneumonia 297 26.7 Ventilator-Treated Patients and VAP 304 References 307 27 Chest Physiotherapy and Mobilization: Postoperatively 313 27.1 Purpose 313 27.2 Comprise 314 27.3 Responsibility 314 27.4 Practical Measures 314 27.5 Background Information 316 References 319 28 Suction of Respiratory Tract Secretions 323 28.1 Purpose 323 28.2 Comprise 323 28.3 Responsibility 324 28.4 Practical Measures 324 28.5 Background Information 327 References 330 29 Care of the Ventilator Patient and Equipment 333 29.1 Purpose 333 29.2 Comprise 333 29.3 Responsibility 334 29.4 Practical Measures 334 29.5 Background Information 338 References 342 30 Respirator and Anaesthesia Equipment 345 30.1 Purpose 345 30.2 Comprise 346 30.3 Responsibility 346 30.4 Practical Measures 346 30.5 Background Information 349 References 351 31 Respirator in Intensive Treatment 355 31.1 Purpose 355 31.2 Comprise 356 31.3 Responsibility 356 Contents xiii 31.4 Practical Measures 356 31.5 Background Information 358 References 361 32 External CPAP: Cleaning Procedures 365 32.1 Purpose 365 32.2 Comprise 366 32.3 Responsibility 366 32.4 Practical Measures 366 32.5 Background Information 368 References 371 Part VI Surgery 33 Prevention of Postoperative Wound Infections 377 33.1 Purpose 377 33.2 Comprise 378 33.3 Responsibility 378 33.4 Practical Measures 378 33.5 Background Information 389 References 423 34 Surgical Hand Disinfection 439 34.1 Purpose 439 34.2 Comprise 440 34.3 Responsibility 440 34.4 Practical Measures 440 34.5 Background Information 443 References 450 35 Operation Department: Infection Control 453 35.1 Purpose 454 35.2 Comprise 454 35.3 Responsibility 454 35.4 Practical Measures 454 35.5 Background Information 477 References 485 36 Newly Operated Patient 491 36.1 Purpose 491 36.2 Comprise 491 36.3 Responsibility 491 36.4 Practical Measures 492 37 Care of Wound Drainages 495 37.1 Purpose 495 37.2 Comprise 495 37.3 Responsibility 495 xiv Contents 37.4 Practical Measures 496 37.5 Background Information 499 References 499 Part VII Dialysis 38 Peritoneal Dialysis (PD) and Diagnostic Peritoneal Lavage 503 38.1 Purpose 503 38.2 Comprise 503 38.3 Responsibility 503 38.4 Practical Measures 504 38.5 Background Information 507 References 510 39 Haemodialysis (HD) 513 39.1 Purpose 513 39.2 Comprise 513 39.3 Responsibility 514 39.4 Practical Measures 514 39.5 HD Performed as Self-Dialysis Under Surveillance 521 39.6 Background Information 523 39.7 Summary of Practical Guidelines from The Renal Association for Haemodialysis 530 References 531 Part VIII Bloodstream Infections 40 Peripheral Intravenous Catheters 535 40.1 Introduction (BI) 535 40.2 Peripheral Intravenous Catheter 536 40.3 Purpose 536 40.4 Comprise 536 40.5 Responsibility 536 40.6 Practical Measures 537 40.7 Background Information 542 References 544 41 Central Intravascular Catheter (CVC) 547 41.1 Purpose 548 41.2 Comprise 548 41.3 Responsibility 548 41.4 Practical Measures 548 41.5 Background Information 555 References 565 42 Central Implanted Venous Access Port 569 42.1 Purpose 569 42.2 Comprise 570 Contents xv 42.3 Responsibility 570 42.4 Practical Measures 570 42.5 Background Information 577 References 579 Part IX Special Patient Groups 43 Urinary Tract Infections: Prevention 583 43.1 Purpose 583 43.2 Comprise 583 43.3 Responsibility 584 43.4 Practical Measures 584 43.5 Background Information 597 References 606 44 Premature and New-Borns 611 44.1 Purpose 611 44.2 Comprise 611 44.3 Responsibility 612 44.4 Practical Measures 612 44.5 Background Information 624 References 627 45 Intensive Patient Treatment 631 45.1 Purpose 631 45.2 Comprise 632 45.3 Responsibility 632 45.4 Practical Measures 632 45.5 Background Information 635 References 641 46 Cystic Fibrosis: Infections and Prevention 645 46.1 Purpose 645 46.2 Comprise 646 46.3 Responsibility 646 46.4 Practical Measures 646 46.5 Background Information 655 References 658 Part X Special Infections: Prevention 47 Admittance to Hospital 663 47.1 Purpose 664 47.2 Comprise 664 47.3 Responsibility 664 47.4 Practical Measures 664 47.5 Background Information 671 References 673 xvi Contents 48 Healthcare Professionals 677 48.1 Purpose 677 48.2 Comprise 678 48.3 Responsibility 678 48.4 Practical Measures 678 48.5 Background Information 679 References 679 49 MRSA Prevention 681 49.1 Purpose 682 49.2 Comprise 682 49.3 Responsibility 682 49.4 Practical Measures 682 49.5 Background Information 697 References 705 50 Vancomycin-Resistant Enterococci Prevention 713 50.1 Purpose 713 50.2 Comprise 714 50.3 Responsibility 714 50.4 Practical Measures 714 50.5 Background Information 718 References 724 51 Multidrug-Resistant Gram-Negative Rods 729 51.1 Purpose 730 51.2 Comprise 730 51.3 Responsibility 730 51.4 Practical Measures 730 51.5 Background Information 735 51.6 Remember! 740 References 740 52 Gastrointestinal Infections 745 52.1 Purpose 746 52.2 Comprise 746 52.3 Responsibility 746 52.4 Practical Measures 746 52.5 Background Information 750 References 753 53 Clostridium difficile 755 53.1 Purpose 756 53.2 Comprise 756 53.3 Responsibility 756 53.4 Practical Measures 756 53.5 Background Information 760 References 762 Contents xvii 54 Norovirus and Other Viral Gastroenteritis 765 54.1 Purpose 765 54.2 Comprise 766 54.3 Responsibility 766 54.4 Practical Measures 766 54.5 Background Information 769 54.6 Norovirus 769 54.7 Rotavirus 772 References 772 55 Prion Diseases: Infection Protection 775 55.1 Purpose 775 55.2 Comprise 776 55.3 Responsibility 776 55.4 Practical Measures 776 55.5 Background Information 778 55.6 New Prion Diseases 780 References 780 56 Tuberculosis: Control in Hospitals 783 56.1 Purpose 784 56.2 Comprise 784 56.3 Responsibility 784 56.4 Practical Measures 784 56.5 Background Information 788 References 797 57 Scabies: Control in Hospitals 799 57.1 Purpose 799 57.2 Comprise 800 57.3 Responsibility 800 57.4 Practical Measures 800 57.5 Background Information 801 References 805 Part XI Disinfection, Sterilization, Cleaning, Control 58 Disinfection of Skin and Mucous Membranes 809 58.1 Purpose 809 58.2 Comprise 810 58.3 Responsibility 810 58.4 Practical Measures 810 58.5 Background Information 812 References 812 59 Disinfection of Instruments and Equipment 815 59.1 Purpose 815 59.2 Comprise 815 xviii Contents 59.3 Responsibility 816 59.4 Practical Measures 816 59.5 Prion Inactivation: Prion Diseases 826 59.6 Background Information 827 References 831 60 Endoscopes and Other Special Equipment 835 60.1 Purpose 835 60.2 Comprise 836 60.3 Responsibility 836 60.4 Practical Measures 836 60.5 Background Information 843 References 846 61 Sterilization 849 61.1 Purpose 849 61.2 Comprise 850 61.3 Responsibility 850 61.4 Practical Measures 850 61.5 Background Information 855 References 858 62 Sterilization: Control and Quality 859 62.1 Purpose 859 62.2 Comprise 859 62.3 Responsibility 860 62.4 Practical Measures 860 62.5 Background Information 861 References 862 63 Sterile and Clean Equipment: Storage 863 63.1 Purpose 863 63.2 Comprise 864 63.3 Responsibility 864 63.4 Practical Measures 864 63.5 Background Information 867 References 868 64 Medicine Storage and Preparation Room 871 64.1 Purpose 871 64.2 Comprise 872 64.3 Responsibility 872 64.4 Practical Measures 872 64.5 Background Information 878 References 879 Contents xix Part XII Internal Service 65 Cleaning of Rooms in Wards 883 65.1 Purpose 883 65.2 Comprise 884 65.3 Responsibility 884 65.4 Practical Measures 884 65.5 Background Information 890 References 893 66 Disinfection of Rooms and Surfaces 897 66.1 Purpose 897 66.2 Comprise 897 66.3 Responsibility 898 66.4 Practical Measures 898 66.5 Background Information 901 References 902 67 Hospital Textiles 907 67.1 Purpose 907 67.2 Comprise 908 67.3 Responsibility 908 67.4 Practical Measures 908 67.5 Background Information 914 References 915 68 Patient Beds 919 68.1 Purpose 919 68.2 Comprise 919 68.3 Responsibility 920 68.4 Practical Measures 920 68.5 Background Information 921 References 922 69 Hospital Waste 923 69.1 Purpose 923 69.2 Comprise 923 69.3 Responsibility 924 69.4 Practical Measures 924 69.5 Background Information 926 References 928 70 Food and Beverages 929 70.1 Purpose 929 70.2 Comprise 929 70.3 Responsibility 930 70.4 Practical Measures 930 70.5 Background Information 934 References 941 xx Contents 71 Water and Water Systems in Hospitals 943 71.1 Purpose 943 71.2 Comprise 944 71.3 Responsibility 944 71.4 Practical Measures 944 71.5 Background Information 947 References 949 72 Technical and Medical Technical Equipment 953 72.1 Purpose 953 72.2 Comprise 953 72.3 Responsibility 954 72.4 Practical Measures 954 72.5 Background Information 957 References 957 73 Laboratories 959 73.1 Purpose 959 73.2 Comprise 959 73.3 Responsibility 960 73.4 Practical Measures 960 73.5 Background Information 964 References 967 74 Transport in Hospitals 969 74.1 Purpose 969 74.2 Comprise 969 74.3 Responsibility 969 74.4 Practical Measures 970 References 971 75 Ambulances, Emergency Medical Service (EMS) and Other Transports of Patients 973 75.1 Purpose 973 75.2 Comprise 974 75.3 Responsibility 974 75.4 Practical Measures 974 75.5 Background Information 980 References 982 Part XIII Hospitals: Areal and Function 76 Hospital Buildings—Construction Projects 987 76.1 Purpose 987 76.2 Comprise 988 76.3 Responsibility 988 76.4 Practical Measures 988 76.5 Background Information 991 References 993 Contents xxi 77 Hospital Kitchen 995 77.1 Purpose 995 77.2 Comprise 995 77.3 Responsibility 996 77.4 Practical Measures 996 77.5 Background Information 998 References 998 78 Disinfection Room: Cleaning Room 1001 78.1 Purpose 1001 78.2 Comprise 1001 78.3 Responsibility 1002 78.4 Practical Measures 1002 78.5 Background Information 1003 References 1004 79 Internal Infection Control: Checklist 1007 79.1 Purpose 1007 79.2 Comprise 1007 79.3 Responsibility 1007 79.4 Practical Measures 1008 79.5 Background Information 1016 Part XIV High-Risk Microbes 80 Dangerous Microbes 1021 80.1 Dangerous Microbes 1021 References 1027 81 Emergency Preparedness 1029 81.1 Purpose 1029 81.2 Comprise 1029 81.3 Responsibility 1030 81.4 Practical Measures 1030 References 1034 82 Scenarios: Serious, Infectious Diseases 1039 82.1 Purpose 1039 82.2 Comprise 1040 82.3 Responsibility 1040 82.4 Practical Measures 1040 82.5 Scenarios 1041 References 1049 83 Isolation: Serious, Infectious Diseases 1053 83.1 Purpose 1053 83.2 Comprise 1053 83.3 Responsibility 1054 83.4 Practical Measures 1054 References 1060 xxii Contents 84 Personal Protective Equipment (PPE) 1061 84.1 Purpose 1061 84.2 Comprise 1061 84.3 Responsibility 1062 84.4 Practical Measures 1062 84.5 Emergency Preparedness Stocks 1063 References 1064 85 Communication, Information and Advice 1065 85.1 Purpose 1065 85.2 Comprise 1065 85.3 Responsibility 1066 85.4 Practical Measures 1066 References 1067 86 Triage: Serious Infections 1069 86.1 Purpose 1069 86.2 Comprise 1069 86.3 Responsibility 1070 86.4 Practical Measures 1070 References 1071 87 Patient Management: Logistic 1073 87.1 Purpose 1073 87.2 Comprise 1073 87.3 Responsibility 1074 87.4 Practical Measures 1074 References 1075 88 Viral Haemorrhagic Fever (VHF) and Other Serious Viral Infections 1077 88.1 Purpose 1078 88.2 Comprise 1078 88.3 Responsibility 1078 88.4 Practical Measures 1079 88.5 Background Information 1084 88.6 Lack of Infection Control Routines 1087 References 1090 89 Biological Terror: Anthrax-Suspected 1093 89.1 Purpose 1094 89.2 Comprise 1094 89.3 Responsibility 1094 89.4 Practical Measures 1094 89.5 Background Information 1097 References 1097 Contents xxiii 90 Preparedness in Connection with Biological Weapons 1099 90.1 Purpose 1099 90.2 Comprise 1099 90.3 Responsibility 1100 90.4 Practical Measures for Treatment of Suspected Mail: During Threats 1100 Reference 1101 91 Dangerous Infectious Agents Combined with Hazardous Chemicals 1103 91.1 Purpose 1103 91.2 Comprise 1104 91.3 Responsibility 1104 91.4 Practical Measures 1104 References 1107 92 Infection Control Resources 1109 92.1 Purpose 1110 92.2 Comprise 1110 92.3 Responsibility 1110 92.4 Background Information 1117 References 1119 Definitions 1123 References 1127 Part I Introduction (Surveillance, Microbes and Pathways, Tracing and Preventing) Patient Protection Is Patient Safety 1 Abstract Patient safety is dependent on the quality of care, treatment and protection against adverse events. Healthcare personnel should do their work in a good, safe and effective way. Hospital leaders have the responsibility to protect all patients against adverse events, like hospital infections, and ensure that hospital resources are sufficient. Keywords Healthcare-associated infections · HAI · Hospital infections · Patient safety Overcrowding · Understaffing · Bed occupancy · Hygienic measures · Infection control · Leadership · Administration · Organization · Health resources Lack of patient safety and protection in hospitals may result in adverse events and injuries. Hospital-associated infections (HAIs) cause more than 90% of all these adverse events [1, 2]. In US hospitals, it is estimated that more than 110,000 patients (ca. 37 million admissions) die from medical failures each year; and 99,000 of these deaths are attributed to HAIs [2, 3]. In Europe, HAIs may cause 37,000 attributable deaths, and contribute an additional 110,000 every year [1, 3]. It is estimated that HAIs may cost up to 16 million extra days in European hospitals each year [1, 3]. Patient safety is dependent on knowledge and skill of the personnel, proper use of guidelines, political choices and priorities, healthcare resources and a competent management. Conditions associated with adverse events like HAIs are as follows: overcrowding of patients, high bed occupancy rates (more than 85%), too many beds in one room (single-bed room becomes two-bed room), corridor patients, transfer- ring patients to another department that does not have the “right” speciality, too early discharges because of shortage of patient beds, understaffing, inadequate monitoring of sick patients and lack of hygiene and cleanliness. These are © Springer Nature Switzerland AG 2019 3 B. M. Andersen, Prevention and Control of Infections in Hospitals, https://doi.org/10.1007/978-3-319-99921-0_1 4 1 Patient Protection Is Patient Safety well-known and well-documented causal factors for serious hospital infections and other injuries [1, 4–14]. Overcrowding and understaffing are associated with increased number of HAIs, especially among children and patients with immunodeficiency, often with repeated outbreaks in neonatal wards and in overcrowded departments [5–8]. In 2008, overcrowding at the NHS hospitals in England led to widespread resistant bacterial infections among the patients. The surgeons at the hospitals warned the patients against admissions in the hospitals with problems. “Persistent overcrowding on NHS hospital wards is causing an uncontrollable spread of superbugs and other forms of infection, the Royal College of Surgeons warned last night. Its leaders called on the government to publish the bed occupancy rate-, allowing patients to choose—where conditions are safe. Surgeons should become whistle-blowers to alert the public to the risk of infection by overcrowding. Sixty percent of hospitals in England are failing to deal with superbug infections effectively. Wards where patients stay overnight should not have an occupancy rate of more than 82%. The staff-to-patient ratio should be high enough to ensure proper care in isolation beds”. “Un-acceptable—to be infected by the NHS- hospitals”. Poor maintenance and functionality of the hospital, like structural damage with leakages and growth of fungi and lack of single-bed rooms, toilets, bathrooms, isolates, etc., are associated with reduced patient safety with risk of spread of infections between patients and extra burden on the staff [1, 4–9, 15]. A rehabilitation effort must be made for hospital buildings, and the maintenance budget (10% of the budget) should be used as dedicated. Inadequate cleaning, lack of basic hygiene measures and accumulation of resistant microbes and dirt in the environment may increase the risk of infections and carrier state [6–14]. Quality of cleaning is highly vulnerable when hospitals are going to save money [8, 10–16]. Infection control is very expensive for the hospital, patients and the society. Hospital infections such as pneumonia, sepsis, urinary tract infections, wound infections, etc. lead to prolonged stay—with occupancy of beds for 4–14 extra days—isolation costs, overuse of antibiotics and development of resistance [1–3, 15, 16]. This may slow the patient through-put, occupy the most expensive treatment beds on intensive care units (ICU) and even block the surgical activity. 1.1 Lack of Leader Competence and Responsibility The hospital’s state of patient safety and prevalence of hospital infections reflect the leader competence. The responsibility for patient safety is on the leaders in all levels, from the head of the department and the hospital director all the way to the council of health and the government. Hospital injuries such as infections, invalidity and death should be prevented by good management, local and central. It is as important as ensuring good treatment of the patient’s actual disease. The management is also responsible for protecting personnel against infections and workplace injuries. 1.2 Hospital Organization Is Important for Hospital Infections and Patient Safety 5 The incidence of healthcare-associated infections can be linked to management: Too large span of control for managers A weak leadership with unclear routines and responsibilities Unclear roles and responsibilities for infection control personnel and the absence of infection control team Lack of active support from the management concerning infection control measures Other aspects of leadership are of great importance: High personnel turnover Low personnel morale—“blindness to risk” High patient turnover Understaffing High patient bed occupancy rate ≥85% Postoperative wound infections can be influenced by management factors at the hospital and used as a quality factor. Incorrect savings—most determined by management—can lead to life-threatening hospital infections. For example, sharing of single-dose medicaments like propofol between several patients, with subsequent severe sepsis caused by contaminated dosing vessels. Extreme leaders can be exemplified by savings that resulted in major infection outbreaks at Good Hope Hospital in England in 2007. Reuse of bed clothing by turning the bed linen between patients, to save annual wash costs of £ 500,000, promptly led to a sharp increase in MRSA and doubled the number of patients with Clostridium difficile infections. The matter ended up in the house: “Is it all the safety of a patient’s life is worth? 0.275 pence?”. Part-time work is a major management problem and results in increased spread of infections by personnel working at different healthcare institutions during the same period (hospitals and nursing homes), also in different countries [5–8, 21]. Neither hospital managers nor the Public Health Department seem to cope with this very important problem. 1.2 ospital Organization Is Important for Hospital H Infections and Patient Safety The healthcare system has been through major changes during the last 50 years, all over the world. More patients are treated for more serious and life-threatening diseases, at higher ages and in more sophisticated and expensive ways, than ever, in the history. This health revolution has several weak sides that may increase the risk for patients and personnel concerning infections and other adverse incidents. 6 1 Patient Protection Is Patient Safety 1.2.1 The Norwegian Example Also Norway, with 5.5 million inhabitants, went through several major changes in the healthcare organization from the 1970s. At that time there were approximately 70 hospitals (30–1200 beds). The local hospitals, county hospitals, central hospitals and specialist hospitals served the communities in rural districts and cities. Five university hospitals ensured the country’s medical top specialities. With a few exceptions, all hospitals were public hospitals. Patients received treatment required according to “good medicine and present research” and usually without regard to costs. The patient was in focus. Few dangerous or resistant microbes threatened in the horizon and antibiotics worked. The staff generally followed good hygiene guidelines and had time for the patient who stayed often (too) long at the hospital. Hospital management and leaders changes. In the 1980s, the doctors’ “sole right” to lead hospitals and departments and corresponding power over financial resources weakened. The economic basis for hospital management was set under debate. Many physicians were ousted by nurses with education in leadership. Public wage levels disappeared, and the wage rise became a personal hassle between managers and employees. Business economists and other non-health professionals often became leaders for hospitals. The leadership prospered, and the economy came into focus, while the patient began to fall out of focus. At the same time, many Norwegian hospitals developed a building-related decay and were in poorly maintained state because of lack of resources [23–26]. Most of the budget for repair and maintenance of hospital buildings was used for patient care, “firefighting measures” and ad hoc solutions [23–26]. Hospital budgets were often made during or after the actual budget year. This revealed a miserable financial planning and management of resources and poor leadership. The same problems are present today [25–28]. Economic savings. In the 1990s, economic savings came in response to rapid development in medical disciplines, new medical technology, increasing patient demand and increasing payroll costs in the form of “personal” salary. While the pay packet rose, the “factory patient” was established with cost analyses for the patient’s diseases—from heart attack to ingrown toenails. It was done time-use-, ordering-, and cost analyses of many activities, resulting in a huge bureaucracy [25–28]. This resulted in many hospitals becoming introverted, self-centred, structural slums [23, 24]. The patient’s role was on the way out;—first on the corridor, secondly, often prematurely discharged [1, 5, 6, 29]. New hospitals. A number of new hospitals were built in Norway, such as the regional hospital in Tromsø, children’s hospital at Ullevål University Hospital, a new “Rikshospitalet” in Oslo, St. Olav’s Hospital in Trondheim, Sørlandet Hospital in Kristiansand, Akershus University Hospital outside Oslo and Østfold Hospital. The huge expenses for new building usually went beyond the normal health budget. 1.2 Hospital Organization Is Important for Hospital Infections and Patient Safety 7 Nevertheless, an unknown part was taken from the hospital’s yearly health budget by retaining resources for maintenance, reconstruction and necessary new building in existing hospitals. Reduced activity. Despite all seven new hospitals for the last 20 years, one fifth of all patient beds have been removed in Norwegian hospitals, to save money! From 1990 to 2017, 3840 somatic beds (22%), in Norwegian hospitals, disappeared com- pletely (Fig. 1.1). Reduced treatment capacity. During the period from 1990 to 2017, the total number of patient beds was halved from 6 to 3 per 1000 inhabitants. This caused a reduced processing capacity in Norwegian hospitals for both somatic and psychiatric patients. Somatic beds were reduced from 4 to 2.5 per 1000 inhabitants (Fig. 1.2). There is a significant lack of patient beds per 1000 inhabitants, in spite of an increasing number of inhabitants, more elderly people and patients with multiple complex diseases. 20,000 15,000 10,000 5000 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Fig. 1.1 Numbers of somatic patient beds in Norwegian hospitals,1990–2017. (Source: Statistic Central Bureau, Norway) 4,5 4,0 4,0 3,8 3,7 3,7 3,7 3,7 3,7 3,7 3,6 3,5 3,6 3,5 3,5 3,5 3,5 3,4 3,4 3,4 3,3 3,2 3,1 3,0 3,0 2,9 2,7 2,7 2,7 2,62,6 2,5 2,0 1,5 1,0 0,5 0,0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Fig. 1.2 The number of somatic patient beds per 1000 inhabitants in Norway, 1990–2017 (Source: Statistic Central Bureau, Norway) 8 1 Patient Protection Is Patient Safety New public management (NPM). In the last 20 years, Norway’s health expendi- ture as a share of gross national product (GDP) has been on average—or below— compared to 35–40 other OECD countries (Table 1.1). Still, there has been a continuous misunderstanding among healthcare leaders that “Norwegian healthcare system is too expensive” [32–35]. This misinformation made the basis for the entrance of industry philosophy into the Norwegian healthcare system. NPM Table 1.1 OECD results for Norway (2008–2012–2016) OECD Indicator Norway mean Comment Bed occupancy rate, activity and employees (2009–2010) Hospital beds/1000 inhabitants 3.3 5.3 Norway has sixth lowest rate (29/35) Occupancy of beds in acute 91.6 76.1 Norway has third highest rate medicine Number of days per stay 4.5 6.9 Norway second shortest, only Turkey has shorter Healthcare persons General practitioner per 1000 4.1 3.4 Norway is third after Greece and inhabitants Austria Specialists doctors as a 40 62 Norway is the second lowest, 34/35, percentage of total after Ireland Doctor consultations per 5.2 6.3 19 out of 35 countries had more capita consultations than Norway Practicing nurses per 1000 14.4 7.9 Norway at fifth place after Denmark, inhabitants Belgium, Switzerland and Iceland Ratio between nurses and 3.5 2.5 Norway in 8th place together with the doctors United Kingdom Health economics (2010–2011–2016) Total health expenses, as a 9.3 9.3 15 out of 35 countries have higher GDP percentage of GDPa (10.5) (9.0) than Norway in 2011 (in 2016) Health costs per capita, public 5669 3339 Norway is number 1 in Europa, 2011, + private—USD 6647 4003 due to high living costs, and no. 3 in 2016 % of health expenses for 56 61 Norway uses less proportion for treatment in and outside treatment of patients in hospitals hospitalsb % of health expenses for 31 31 Less than a third goes to the hospitals treatment in hospitals Preventive health work as a 2.5 2.9 11 out of 24 countries pay more than percentage of GDP Norway for prevention in 2011 Figures from the OECD Report 2012 and some figures from the OECD Report 2013 and 2017 (compiled by BM Andersen) Health at a glance 2012: OECD indicators @OECD 2012, as well as some data from 2013 and 2017 a GDP = gross domestic product—corresponds to gross national product b OECD has not included expenses for long-term institutions, medical equipment and joint services 1.2 Hospital Organization Is Important for Hospital Infections and Patient Safety 9 became a top priority for politicians, hospital leaders and health agencies, who mis- led the Norwegian population. Industrial language took over with the use of words like “healthcare company”, “product” and “profit” instead of hospital, patient and reduced treatment. Five health regions were formed in 2002 and changed to four in 2007, each with its regional health company (RHF), with the aim of increasing the “profit” while “the patient should be in the focus”. Mergers, demergers, “buying up” hospitals and closure of hospitals and of workplaces became the new words in the “health store”, but the “profit” disappeared in merger breakdowns [33, 35–40]. For example, Oslo University Hospital (OUS) merging started in 2009 with the fusion of the four Oslo hospitals into a separated mega concern, Oslo University Hospital [38, 40–48]. From the experiences from the industry, fusions usually break down [40, 44]. Severe problems emerged at OUS in 2011 with the “collapse” of the hospital, closure of the country’s single children’s hospital and distribution of sick children among adult patients in other clinical overburdened wards, to be more effective [38–42]. Two of the four hospitals were further tried to be put down, shaping an ever higher instabil- ity, conflict of authority and departmental rivalry, resulting in flight of health experts to other hospitals [38–42]. OUS became larger and less profitable and had fewer employees compared to the number of patients, more debt and less time to their patients than the best hospitals in the United States [44, 43, 46, 49]. Health companies. Within the four large healthcare regions in Norway, with four RHFs, smaller hospitals were merged to subregional healthcare companies (HFs) with many transversal and chaotic leadership levels [25–28, 36, 40]. The RHFs and HFs were responsible for the use of healthcare resources in hospitals, but were not juridically responsible for patients or personnel. On the other side, the hospital man- ager was juridically responsible for patients and personnel but had no control of the budget. The infection protection responsibility is changed. From 2005 on, legal authority and responsibility for hygiene and infection control were transferred from individual hospitals to the RHFs. The RHFs should ensure that the regulations on infection control were followed by each individual health company (HR). This resulted in that necessary resources for hygiene, infection protection and control were withheld from the hospitals. Hygiene procedures, like cleaning, textile treatment, patient care, etc. that would ensure infection protection for patients, personnel and visitors, disappeared. The burden of resistant microbes increased in the hospital environment and among the patients, following the patients and staff to the primary care. The patient safety was severely impaired. Even the hospital statutory Infection Prevention and Control Program disappeared in many hospitals [40, 50]. Reform of more interaction between specialist and primary healthcare came in 2012 with the requirement of the primary healthcare to receive patients after finish- ing diagnosis and primary treatment in specialist hospitals to save money. Hospital patients were often in a very bad condition after a few days in the hospital and still too sick to be declared finished from the hospital. Because of shortage of nursing homes and competent personnel, there were several negative effects, including lack of infection control, and the Directorate of Health expressed concern about 10 1 Patient Protection Is Patient Safety the reform [40, 50–53]. Studies from Sweden show a clearly increased risk of death within 30 days postoperatively for hip surgery patients at short postoperative hospital stay (≤10 days). Patient Prioritization Committee followed the fall 2014 with some priority criteria that were adapted to the NPM model. This means that the “user” becomes “val- ued” against hospital costs before any hospital treatment. 1.3 A Future for Healthcare Today there are many healthcare and administrative levels that the patients and personnel may go “through” by the interaction reform between hospitals and primary health service. This entails a formidable increase in travel and transport costs, additional laboratory tests at the different levels, additional work and time spent in the various levels that will follow up and familiarize themselves with the patient’s disease and treatment, additional expenses due to lack of patient overview and additional expenses due to patient injuries, malpractice and misunderstandings. At least one fifth of the budget for somatic hospitals is likely to result in bureaucracy and waste of resources. The administration of RHFs takes annually 2 out of 140 billion NKr of the total specialist budget. About 10% of somatic health resources go to travel expenses between different healthcare levels. Travel expenses increase due to regionalization and merging of hospitals. This leads to an even longer travel time to hospitals than before, resulting in a different offer of emergency medical assistance—with a different chance of survival. A large part of the resources goes to laboratory tests which are often unnecessarily repeated at various levels for many patients. Hospital patients with a complicated and bad condition often end up in nursing homes with a low level of medical competence. These patients may occupy the beds that should be used for ordinary nursing home patients. In addition, the large bureaucracy located in regional- and small-scale healthcare and cross-border clinics around the country may use a large share of the health resources. The result is fewer resources to patient care and preventive healthcare and more health administration and bureaucracy. Good leadership is particularly important in the field of infection protection, illustrated by a study where removal of management at a department reduced staff performance of hand hygiene prior to contact with the patient, from more than 50% to 6%. References 1. Andersen BM. Occurrence, costs and mortality of hospital infections. In: Handbook of hygiene and infection control in hospitals. Part 1, vol. 2014. Bergen: Fagbokforlaget. p. 26–30. 2. Klevens RM, Edwards J, Richards CL, Horan TC, Gaynes RP, Pollock DA, Cardo DM. Estimating healthcare associated infections and deaths in U.S. hospitals, 2002. Publ Health Rep. 2007;122:160–6. References 11 3. Alleganzi B, Bagheri S, Castillejos GG, Kilpatrick C, Kelly E, Mathai E. Report on the burden of endemic health care-associated infection worldwide. Geneva: WHO Patient Safety; 2011. 4. Hamel M, Zoutman D, O'Callaghan C. Exposure to hospital roommates as a risk factor for healthcare-related infection. Am J Infect Control. 2010;38:173–81. 5. Larsen BI, Skretting P, Farstad T. Corridor patients - consequences for treatment quality and patient integrity. Tidsskr Nor Legeforen. 2000;120:2636–8. 6. Andersen BM, Lindemann R, Bergh K, Nesheim BI, Syversen G, Solheim N, Laugerud F. Spread of methicillin-resistant Staphylococcus aureus in a neonatal intensive unit associated with understaffing, overcrowding and mixing of patients. J Hosp Infect. 2002;(1):1–7. 7. Grub C, Holberg-Petersen M, Medbø S, Andersen BM, Syversen G, Melby KK. A multi-drug resistant, methicillin-susceptible strain of Staphylococcus aureus from a neonatal intensive care unit in Oslo, Norway. Scand J Infect Dis. 2010;42:148–51. 8. Andersen BM, Seljordslia B, Hochlin K, Rasch M, Syveren G. A predicted outbreak in an overcrowded, administratively neglected and run-down haemodialysis unit as an offer of “New Public Management” in Norwegian hospitals. J Hosp Admin. 2013;2:15–24. 9. Carvel J. NHS overcrowding is spreading superbugs, say surgeons. John Carvel, Social Affairs Editor The Guardian, Friday; 2008. 10. Dancer SJ. Mopping up hospital infection. J Hosp Infect. 1999;43:85–100. 11. Smith B. Britain: rise in «superbug» cases linked to decrease in hospital cleaning staff. Oak Park: World Socialist Web Site, wsws.org; 2005. p. 22. 12. Boyce JM. Environmental contamination makes an important contribution to hospital infection. J Hosp Infect. 2007;65:50–4. 13. Denton M, Wilcox MH, Parnell P, Green D, Keer V, Hawkey PM, et al. Role of environmental cleaning in controlling an outbreak of Acinetobacter baumannii on a neurosurgical intensive care unit. J Hosp Infect. 2004;56:106–10. 14. Andersen BM, Rasch M, Kvist J, Tollefsen T, Lukkassen R, Sandvik L, Welo A. Floor cleaning: effect on bacteria and organic materials in hospital rooms. J Hosp Infect. 2009;71:57–65. 15. Andersen BM, Rasch M, Hochlin K, Tollefsen T, Sandvik L. Hospital-acquired infections before and after healthcare reorganization in a tertiary university hospital in Norway. J Pub Health. 2009;7:1–7. 16. Andersen BM. Economic consequences of hospital infections in a 1,000 bed university hospital in Norway. Infect Control Hosp Epidemiol. 1998;19:805–7. 17. Griffiths P, Renz A, Hughes J, Rafferty AM. Impact of organization and management factors on infection control in hospitals: a scoping review. J Hosp Infect. 2009;73:1–14. 18. Gastmeier P, Sohr D, Breier A, Behnke M, Geffers C. Prolonged duration of surgery: an indicator of complicated surgery or of surgery? Infection. 2011;39:211–5. 19. Muller AE, Huisman I, Roos PJ, et al. Outbreak of severe sepsis due to contaminated propofol: lessons to learn. J Hosp Infect. 2010;76:225. 20. Martin D. Don’t wash sheets --- turn them over! Astonishing order at a hard- up hospital. UK: Good Hope Hospital, Daily Mail; 2007. 21. Sie I, Thorstad M, Andersen BM. Infection control and methicillin-resistant Staphylococcus aureus in nursing homes in Oslo. J Hosp Infect. 2008;70:235–40. 22. Andersen BM. Local hospital - important for the infection protection. Oslo: Dagsavisen; 2010. p. 28. 23. Andersen BM, Bøe E. Ullevål Hospital must be reconstructed. Oslo: Aftenposten; 1996. p. 16. 24. Andersen BM. Hospital buildings in a state of disrepair. Oslo: Aftenposten; 2007. 25. Andersen BM. Health reform - Does the state overtake a bankruptcy estate? Oslo: Aftenposten; 2002. 26. Andersen BM. Health Reform for whom and for what price? Oslo: Aftenposten; 2002. 27. Heldal F, Sjøvold E. Change in hospital - a matter of management. TidsskrNorLegeforen. 2015;135:144–6. 28. Andersen BM. Norwegian health care - from the ash to the fire? Oslo: Aftenposten; 2002. 29. Norstein J. Corridor patient functions in Norwegian hospitals. Tidsskr Nor Legeforen. 2008;128:24–7. 12 1 Patient Protection Is Patient Safety 30. Statistic Central Bureau, Oslo Norway. 31. OECD reports. Health at a glance 2012, 2013, 2014, 2017. 32. Andersen BM. Norwegian hospitals are not more expensive than hospitals in other OECD countries. DagensMedisin; 2013, p. 10. 33. Mjaaland O. Twelve years with miscalculation. VG; 2013, p. 14. 34. Andersen BM. OECD report: inadequate hospital capacity and health economics. DagensMedisin; 2013. 35. Andersen BM. Norwegian health care is cheaper than its reputation. Dagbladet; 2014. 36. Andersen BM. Efficiency of hospitals - without any financial gain?. DagensMedisin; 2008. 37. Andersen BM. Map and terrain in Norwegian health care. Dagsavisen.Recent opinions; 2011. 38. Bredeli A. The hospital collapses. Today's business; 2011. 39. Slagstad R. Sykemelder Hospital fusion. Klassekampen; 2011, p. 14. 40. Andersen BM. Infection control is patient safety. Handbook in hygiene and infection control for hospitals. Elefantus Forlag. 2016:19–26. 41. Andersen BM. Complete hospital services for children disappear at Oslo University Hospital. DagensMedisin; 2012, p. 16. 42. Andersen BM. Oslo University Hospital. The game should be stopped. Aftenposten; 2012, p. 28. 43. Andersen BM. Where are the best hospitals in Norway? DagensMedisin; 2012. 44. Andersen BM. A no profitable hospital merger. The merger of Oslo hospitals will cause more and worse patients while cutting the number of positions. Sykepleien. 2012;7:62–3. 45. Slagstad R. The health-care- area’s strategies. Tidsskr Nor Legeforen. 2012;132:1943. 46. Andersen BM. OUS - Look at the United States! The best hospitals in the US have better time for patients, more employees, and better economic than OUS. Sykepleien; 2012. 47. Flugsrud GB. A devastating process. Tidsskr Nor Legeforen. 2012;132:1942–3. 48. Andersen BM. Put down OUS. Sykepleien; 2012. 49. Andersen BM. American hospital ranking. OUS - bigger than most and best hospitals in the United States. Dagens Medisin; 2014. 50. Anthonsen Eide S. The former chief physician give the infection alarm. VG; 2014. 51. Andersen BM. Weaknesses in the reform. DagensMedisin; 2011. 52. Andersen BM MRSA in Norway. A challenge for the interaction reform. DagensMedisin; 2012. 53. Guldvogs blog. The municipalities under pressure. DagensMedisin; 2015. 54. Nordstrøm P, Gustafson Y, Michaelsson K, Nordstrøm A. Length of hospital stay after hip fracture and short-term risk of death of discharge: a total cohort study in Sweden. BMJ. 2015;350:h696. 55. NOU. Open and fair - priorities in the health services; 2014. 56. Lieber SR, Mantengoli E, Saint S, Fowler KE, et al. The effect of leadership on hand hygiene: assessing hand hygiene adherence prior to patient contact in 2 infectious disease units in Tuscany. Infect Control Hosp Epidemiol. 2014;35:313–6. Hospital Infections: Surveillance 2 Abstract Healthcare-associated infections (HAIs) may affect up to 5–20% of hospitalized patients. It is estimated that in Europe, at least 7.5 million patients (3.5 in acute hospitals and 4.2 million in long-term care facilities) acquire HAI each year. More than 147,000 dies directly or indirectly from HAI each year in European hospitals. The most common forms of HAI are urinary tract infections, respiratory tract infections, infections after surgery, bloodstream infections and other infections (skin, intestines, etc.). Outbreaks in healthcare are often caused by spread of Clostridium difficile and drug-resistant bacteria. MRSA is isolated from 5% or more of all cases of HAI in Europe. Epidemic viruses like norovirus and influenza may also cause large outbreaks. HAIs usually appear 48 h after admittance up to 30 days after discharge (most common within the first 7 days) and up to 1 year after prosthesis operations. Superficial infections are most often harmless, while the deep infections may cause readmittance and treatment with antibiotics. Surveillance by registering infections is a method to control HAI caused by treatment and stay in a hospital. Results are used as indicators for the quality of hospital care and treatment. It has been a long way to go to raise healthcare-associated infections up from “something that only happens” to a potential severe or deadly injury which in most cases could be avoided by effective and targeted infection control in 20–70% of the cases. Keywords Healthcare-associated infections · HAI · HCAI · Prevalence · Incidence · Infection control · Hygiene · Surveillance 2.1 Prevalence and Incidence Surveillance of HAI Healthcare-associated infections (HAIs) usually appear 48 h after admittance up to 30 days after discharge (most common within the first 7 days) and up to 1 year after prosthesis operations. Hospital infections (nosocomial infections) are measured by © Springer Nature Switzerland AG 2019 13 B. M. Andersen, Prevention and Control of Infections in Hospitals, https://doi.org/10.1007/978-3-319-99921-0_2 14 2 Hospital Infections: Surveillance national and international prevalence and incidence studies [1–17]. In high-income countries, the prevalence of HAIs in mixed patient populations may be 7–10%. Prevalence of infections is usually implemented as point prevalence, a pre- defined day and time (08:00 in the morning), 2–4 times a year. For each department the number of patients with HAI is recorded by the responsible nurse and doctor after certain, often modified CDC definitions [1–4, 15]. Recorded are all microbes involved in the infections. This is done to monitor the burden, type and drug resistance of microbes in the department and the hospital [8–13, 15]. Registered are also all infections that the patient has received outside the healthcare to get an overall view of the infectious load in each hospital department. The use of antibacterial agents in the department, both prophylactic and therapeutic, is registered [8–13, 15]. It is specified how many patients are hospitalized, how many operated and how many with postoperative infections and type of infections. Point prevalence represents a snapshot of the infection situation in each department, is easy to implement, is easy to understand and focuses on important measures for the individual hospital and department. Results are gathered and evaluated by infection control personnel for the actual institution. In Norway, some of the results are posted on the Internet, helsenorge.no, and are available to all. However, the interpretation and evaluation of the results are not included, so that small departments or hospitals with few patients and randomly coinciding events may get too big impact on the rate of infection. Up to year 2000, all types of hospital infections were registered in Norway according to the National Institute of Public Health’s modified CDCs guideline [1, 2, 4–13, 15]. Today, Norway, like many other countries, is recording only four types of infection: respiratory tract infections, postoperative wound infections, blood- borne infections and urinary tract infections. International registration methods are, in addition, changed from 2008 onwards [3, 14, 15]. Therefore, prevalence is not comparable over periods or in real time today, since different methodologies are used and the total number of HAIs is not recorded [3, 14, 15]. Incidence of infections is a continuous record where each patient is observed over a defined period. Surgical site infections (SSI) are monitored up to 30 days after surgery/discharge and up to 1 year after prostheses operation [3, 16, 18]. Incidence registering is laborious; goes for long periods of time, often with no feedback to those concerned; and is not reported by some hospitals. Incidence studies are most often used for surgical patients and especially prosthesis operations. Microbes are recorded in local, national and international registers, if defined as important for patients and for the society in general. In Norway, drug-resistant and other problem bacteria and defined viruses are recorded in national registers like MSIS or NORM (human and veterinary microbes and the use of antibiotics) and further sent to the ECDC register for Europe. Registration of hospital infections was started as systematic studies in the United States around 1975 and was a major breakthrough according to quality and patient safety in healthcare, both in hospitals and nursing homes [1–3, 15–39]. Norway started national prevalence surveys in 1981. Incidence studies started some 2.2 Effect of Registration 15 20 years later, but were used as early as 1970 in some hospital centres as “event register/accident registry.” 2.2 Effect of Registration The intention of registering HAI is to control and monitor patient safety. Actions triggered by findings can lead to the reduction of infections by informing results to current healthcare professionals, patients and family [2, 18–39]. Effects of HAI measurements are described below: A 10-year-incidence study in the United States by Cruse and Foord of 63,000 surgical (clean) wounds. Registering SSI led to the reduction from 2.5% postoperative wound infections in 1968 to 0.6% in 1977. A national registration of all SSI was conducted from 1999 to 2006 in France. A total of 150,440 operations were followed 30 days postoperatively at 550 surgery departments. During the 6-year period, SSI was reduced from 3.8 to 1.7% with a relative reduction of 50%; p < 0.0001. The reduction in infections was significantly for most types of operations. MRSA was registered in France in the period 2001–2006. Prevalence of MRSA-infected patients was reduced by 47% in university hospitals, 37% in central hospitals, 62% in psychiatric hospitals, 11% in local hospital, 24% in military hospitals, 53% in rehabilitation centres and 41% in cancer centres. The total prevalence was reduced from 0.49 to 0.29%. Results from 14,500 hospitals in the United States, in 2015 , demonstrated that between 2008 and 2013, there were: –– 46% reduction of blood-borne infections. –– 19% reduction of SSI among ten selected procedures. –– 6% increase of catheter-associated urinary tract infections. –– 8% reduction in hospital-started MRSA bacteraemia (2011–2013). –– 10% reduction in hospital-initiated C. difficile diarrhoea (2011 and 2013). Pennsylvania State had the lowest infection rate in the United States. The registration was estimated as laborious, required a lot of computer skills and clear definitions but delivered large and robust results. In a point-prevalence study of 183 hospitals in the United States (2014), had 4% of the patients one or more HAIs. The most common types of infections were pneumonia, SSI and gastrointestinal infections. C. difficile diarrhoea was the most common infection, 12% of all infections. In Norway, regional point-prevalence studies of all types of HAI included 14 hospitals in four counties from 1996 to 2000 [9, 11]. –– 6.5% of 32,250 patients had HAI, with a decreased percentage from 7.7% in 1996 to 5.9% in 1998 in both operated and non-operated patients. There was a decrease of infections in urinary tract, in lower respiratory tract and of SSI, while the rate of bacteraemia remained stable. 16 2 Hospital Infections: Surveillance Table 2.1 Occurrence of hospital infections at Ullevål University Hospital for a period of 17 years, 1991–2007 Overall Somatic Psychiatry Surgery Non-surgery Number of patients examined 57,360 46,194 11,166 12,430 41,865 Number of hospital infections 3934 3725 209 1665 2093 Percentage of hospital 6.9% 8.1% 1.9% 13.4% 5.0% infections Source: Andersen et al. J Public Health 2009; 31: 98–104 Ref –– The smaller hospitals in the region (3.2 million extra hospital days, >38,000 deaths and >1.5 billion USD in direct and indirect costs per year. 20 2 Hospital Infections: Surveillance The overall economic impact of the development of antibacterial resistance is high—and with reduced consumer income, employment and savings and increased national investment and spending in healthcare delivery. The result for most developed countries is a reduced gross domestic product (GDP) by 1.4–1.6%. References 1. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial Infections, 1988. Am J Infect Control. 1988;16:128–40. 2. Haley RW, Culver DH, White JW, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in university hospitals. Am J Epidemiol. 1985;121:182–205. 3. Horan TC, Andrus M, Dudeck M. 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Andersen BM, Hannestad Ree M, Hermansen W, Holta Ringertz S, Høystad MW, Lelek M, Norman BI, Næs B, Petersen T, Andersen Rød K, Røed RT, Solheim N, Tandberg S, Bjørklund U, Skoog Hansen K. The number of hospital infections decreased last year. Tidsskr Sykepleien. 1998;2:52–4. 10. Scheel O, Stormark M. National prevalence survey on hospital infections in Norway. J Hosp Infect. 1999;412:331–5. 11. Andersen BM, Holta Ringertz SH, Petersen Goldord T, Hermansen W, Lelek M, Norman BI, Tilrem Nystad M, Anderson Red K, Røed RT, Smidesang IJ, Solheim N, Tandberg S, Halsnes R, Høystad MW. A three-year survey of nosocomial and community-acquired infections, antibiotic treatment and rehospitalization in a Norwegian health region. J Hosp Infect. 2000;44:214–23. 12. Andersen BM, Rasch M, Tollefsen T, Kvist J, Bentsen L. Point prevalence studies during 10 years; study of nosocomial infections in a tertiary university hospital in Norway. J Hosp Infect. 2006;64(Suppl 1):70. 13. 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Hospital and Societal Costs of Antimicrobial-Resistant Infections in a Chicago Teaching Hospital: Implications for Antibiotic Stewardship. Clin Infect Dis. 2009;49:1147–84. Microbes, Transmission Routes and Survival Outside the Body 3 Abstract Microbes like bacteria, virus, parasites and fungi may naturally colonize skin and mucous membranes without any sign of illness, for a longer or shorter period, in all humans, animals, fish, parasites, plants and all other living beings. Some types may be more invasive in human tissue than others. Many microbes are free- living in the environment—in water, soil and air and on equipment—as a part of the normal microbial flora on the Earth. Most of them are not dangerous and live in peaceful symbiosis with other living beings and may also be transferred between living species, from man to animal or man to plants and environment— and vice versa. New and old human pathogenic microbes are increasing all over the world. Some agents, like drug-resistant bacteria and highly pathogenic viruses, are more dangerous than others, and some microbes may cause chronic devastating diseases. Transmission routes depend on the robustness of the microbe in the environment, virulence, infectious dose, anatomical site in the body, etc. Pathogenic microbes are spread by contact, air, water, food, beverages, contaminated equipment and environment and are more seldom vector-borne, by insects or animals. The following chapter is focused on the most frequent pathogenic microbes, their preselected localization in the body, transmission routes and survival in the environment. Keywords Microbes · Pathogenic microbes · Virulence · Predilection · Biological material · Anatomical site · Environment · Survival · Transmission · Spread of infection 3.1 Microbes are Mostly Normal, Nonpathogenic Flora Microbes like bacteria, virus, parasites and fungi may naturally colonize skin and mucous membranes without any sign of illness, for a longer or shorter period, in all humans, animals, parasites, plants and all other living being [1–6]. Some types may © Springer Nature Switzerland AG 2019 23 B. M. Andersen, Prevention and Control of Infections in Hospitals, https://doi.org/10.1007/978-3-319-99921-0_3 24 3 Microbes, Transmission Routes and Survival Outside the Body be more invasive in human tissue than others, partly via mucous membranes and lesions in the skin. Many microbes are free-living in the environment—in water, soil and air and on equipment—as a part of the normal microbial flora on the Earth. Most of them are not dangerous and live in peaceful symbiosis with other living beings and may also be transferred between living species, from man to animal or man to plants and environment—and vice versa [1–6]. Microbes, like bacteria, may outnumber us by a factor of 1022, are heavier than us by a factor of 108, have existed on Earth more than 1000 times longer than us and may undergo 500,000 generations in just one of our generations. The existence of humans and animals is dependent on a rich and active bacterial flora in the gut, participating in the decomposition of food substances to energy and growth. Large amounts of bacteria in the gut (1–2 kg) and on the skin is a normal condition. Humans are releasing microbes into the environment and air wherever they move and—at the same time—are picking up new microbes from the environment. 3.2 Pathogenic Microbes: New and Old Pathogenic microbes cause illness in most humans if introduced into sterile tissue. “Opportunistic” microbes may cause problems in people with reduced immune defence and/or if large amounts are introduced in sterile tissue. Nonpathogenic microbes nearly never cause illness in humans [1–3]. Human pathogenic microbes often survive for a long time outside the body—in the environment [1–6]. Therefore, they are special threats to patients, personnel and visitors in healthcare institutions where there often is an accumulation of infectious diseases. New and old human pathogenic microbes are increasing all over the world. Some agents, like drug-resistant bacteria (methicillin-resistant Staphylococcus aureus, MRSA, multidrug-resistant tubercle bacilli and others) and highly pathogenic viruses (Ebola, SARS and others), are more dangerous than others. Other viral agents may cause chronic devastating diseases like HIV and hepatitis B and C. Microbes may have preselected locations and tissues in the host, like influenza virus, pneumococci and tuberculosis mostly in lungs, hepatitis viruses in the liver and blood, Clostridium difficile and norovirus in the gut, coagulase negative staphylococci on the skin, etc. 3.3 Transmission Routes: Spread of Infection The transmission routes of microbes are many and different and depend on the robustness of the microbe in the environment, climate and temperature, virulence, infectious dose, etc. Pathogenic microbes are spread by contact, air, water, food, beverages, contaminated equipment and environment and are more seldom vector- borne, by insects or animals. Drug-resistant microbes and/or resistance genes are 3.3 Transmission Routes: Spread of Infection 25 common on the global food market for humans, animals and fish [8–11]. In addition, increased mobility, climatic changes, overcrowding, war and disasters, poor hygiene and poor infection control are increasing the transmission rate. Prudent use of antimicrobial drugs, proper hygiene and good infection control for humans, animals and fish are essential for stopping spread of infections [12–19]. Microbes: pathways and survival outside the body—in environment Transmission Lifetime in the Biological material—location/microbes routes environment1 Wound Staphylococcus aureus C/A 3–10 months Methicillin-resistant S. aureus (MRSA) C/A 3–10 months Gram-negative rods (Escherichia coli, Klebsiella, C/(A) 2 days–16 months Enterobacter, Serratia, Proteus, Pseudomonas, Acinetobacter, etc.) Multidrug-resistant gram-negative rods C/A 2 days–16 months – ESBL: E. coli, Enterobacter, Citrobacter, Klebsiella, Serratia, etc. – Others: Pseudomonas, Acinetobacter, Klebsiella > 2.5 years Stenotrophomonas maltophilia – New multidrug-resistant with NDM-1 gene; resistant to carbapenem and most other antibiotics Enterococci, including VRE C 2 months–4 years Groups A, B, C, G streptococci C 1–7 months Prosthesis, foreign body Coagulase-negative staphylococci C/A 3 months S. aureus and MRSA C/A 3–10 months Gram-negative rods C 2 days–16 months Enterococci, including VRE C 2 months–4 years Candida C Several months Blood and tissue fluids Hepatitis A, B, C, D, E B (C) 3 days–year HIV B (C) 3–14 days Other retroviruses (HTLV-I, HTLV-II) B Days Parvovirus B19 and others B > 1 year Cytomegalovirus B/C Hours to days Prions B4 Infinite? Malaria and other blood parasites B, insects Varies Yellow fever virus B, mosquito Varies Haemorrhagic fever virus B/C/A, insects Varies—long? Respiratory tract infections Pneumococci, including penicillin resistant C/A Hours–20 d Gram-negative rod bacteria (E coli, Klebsiella, C/A 2 days–16 months Enterobacter, Acinetobacter, Serratia, Pseudomonas, Morganella, etc.) Haemophilus influenzae C/A Hours–12 days S. aureus C/A 3–10 months (continued) 26 3 Microbes, Transmission Routes and Survival Outside the Body Transmission Lifetime in the Biological material—location/microbes routes environment1 Chlamydia pneumoniae/Mycoplasma C/A L Hours–days pneumoniae Legionella pneumophila, etc. A/C/water Water: infinity Mycobacterium tuberculosis (tuberculosis) C/A 1 year Neisseria meningitidis; meningococcus C/A Hours Pertussis; Bordetella pertussis C/A 3–5 days Influenza viruses A, B, parainfluenza, adeno, C/A Hours–20 d rhino, entero, corona RSV (respiratory syncytial virus) C/A

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