Often considered a negative fallout of modern medical care, Hospital- Acquired Infections (HAI) are rarely highlighted but remain an ever-present danger for patients and an enormous challenge for hospitals today. Also called Nosocomial infections, HAI refers to an infection not present in the patient at the time of admission into hospital but which begins two or more days later. Depending on the condition of patient, this infection increases morbidity, requires additional treatment and extends hospital stay, even proving fatal in some cases.
The incidence of HAI ranges from 5 to 10 per cent in developed countries but can be as high as a staggering 25 per cent in developing countries. In India, current data is limited but the overall incidence can be extrapolated from studies done in hospitals in Mumbai, Delhi and other places. The picture that emerges is deeply disturbing.
Medical personnel are aware of the enormity of this issue but the burden of work, economic constraints and pressure from management have blunted their response. Unsuspecting patients, unaware of the cause of HAI, adopt a fatalistic approach to hospital infections that can, in fact, be prevented and controlled.
The most common HAIs are surgical wound infection, urinary tract infections, respiratory tract infections, vascular infections and septicemia. The pathogens involved are gram-positive and gram-negative bacteria, pseudomonas, anaerobic organisms, viruses and fungi. In immune compromised patients, as in hepatitis and cancer, even harmless bacteria within the body can become the source of infection. HAI may occur during surgery, introduction of catheters, contaminated dressings and unhygienic handling of patients by hospital staff. In Intensive Care Units (ICU) the infection rates are higher due to increased invasive procedures and handling. Patients in ICU usually have compromised immunity and cross-infection between patients is a grave possibility.
The problem of HAI is compounded by antibiotic resistance, which is reaching crisis proportions due to irrational use of antibiotics, self-medication and over-the-counter availability of drugs. Most alarming is the emergence of ‘Super bugs’, drug resistant bacteria like MRSA and NDM-1 that can overwhelm the body’s immunity and spread rapidly in hospitals, undeterred by the present armamentarium of antibiotics. The race to develop ‘super-drugs’ to combat such bacteria is ongoing and may be lost, unless a concerted effort is launched to rationalise drug use and bring HAI under control.
HAI is one of the leading causes of hospital morbidity and mortality. The quality of the hospital is quantified by its adherence to standards of asepsis, cleanliness, awareness of care protocols and personnel commitment to protection of patients from nosocomial infections. However, HAI statistics are rarely published by hospitals, leaving patients in the dark. Unflattering reports on HAI rates by WHO and journals of epidemiology in the media have greatly tarnished the image of India as a Health Tourism destination.
Safety promotion
The health ministry responded with regulations that mandate the accreditation of all hospitals and health care services by the National Accreditation Board for Hospitals (NABH), a quality control organisation. An important quality standard is infection control, requiring meticulous cleanliness, asepsis and infection control protocols including periodic testing and reporting. Even under threat of losing license to operate, the response to NABH has been slow, with only 200 hospitals out of 16,000 receiving accreditation so far, of which only 15 are state-run healthcare institutions!
Government budget outlay for health will need to be far higher that the present 4 per cent to improve conditions of public hospitals. It is insurance companies who are driving NABH accreditation and quality control in order to keep down healthcare costs that threaten to erode profits and drive up the insurance premiums. The social, economic and personal repercussions of HAI are immeasurable.
Uninsured patients have to personally bear the cost of the additional stay in hospital, medications, loss of workdays and physical malaise. Such healthcare burdens remain the primary cause for the slide into poverty in India.
Is quality and patient safety being viewed by hospitals as an expense rather than a responsibility? The excuse that it will drive up healthcare cost is lame, at best, as patients themselves have to bear the cost of HAI. In western countries, where there is higher awareness of safety standards, hospitals are slammed with lawsuits in cases of nosocomial infections. Why do our patients meekly accept the catastrophe of HAI when it occurs? When NABH protocols of patient care and infection control exist in India, it is totally unethical to allow profit concerns to dictate safety practices. It should not require a public interest litigation to prioritise patient safety.
In response to the HAI crisis, the NABH has organised specific certification programmes like ‘SAFE-1’ that enable health organisations to upgrade their infection control practices. The Medical Council of India has recommended an 18-hour teaching module in the undergraduate curriculum from next year on this aspect of patient safety. Hospital Infection Society of India (HISI) is an association of medical professionals with a special interest in prevention and control of hospital infections working to build awareness, provide training and disseminate best practices in this area. If one out of four hospital patients are victims of HAI in our country, this is a healthcare concern that simply cannot be ignored.
(The writers are Bangalore-based specialists)