1212 infection control & hospital epidemiology october 2015, vol. 36, no. 10
(42%–100%) with 1 score less than 50%. Sterilization and disinfection of instruments and equipment scored a median of 27% (5%–52%) with 5 sites scoring less than 50%. This section included a table that addressed how each instrument was sterilized and disinfected, although points were lost if instruments were disposable and did not apply. Autoclave sterilization was used by all 5 sites, with a median score of 70% (0%–100%) adherence to recommended practices and 2 sites scoring less than 50%. High-level chemical disinfectant was used by 5 of the sites with a median of 46% (31%–92%) and 3 sites scoring less than 50%. The Greek hospital scored less than 50% for sections on policies and procedures (0%), sterilization and disinfection of instruments and equipment (5%), and steam/pressure sterilization (0%). This site also did not use high-level chemical disinfection. The hand hygiene module addressed availability of hand
hygiene equipment and supplies with a median score of 77% (42%–100%). Two sites in the low-income category scored less than 50% with reports of fewer than 1 handwashing station per 6 beds with no available liquid soap or waterless alcohol-based hand antiseptic. That site also reported multiple- use cloth towels as a drying practice. The section on hand hygiene practices had a median score of 69% (0%–91%), including sections on reported routine use of hand hygiene. The Greek hospital scored 63% for hand hygiene equipment and supplies, which highlighted that soap and alcohol-based anti- septic were occasionally available, dispensers were topped off without cleaning, and there was fewer than 1 dispenser for every 4 beds. This site reported a score of 0% for hand hygiene practices, reporting no routine handwashing, no policy for covering skin lesions or short nails, and usual practice of gloving without washing. Hand hygiene observation was assessed by 1 site in a low-middle-income country, reporting 53% adher- ence to handwashing or alcohol-based rub prior to patient contact and 80% adherence following patient contact.
discussion
Our results indicate that adherence to recommended IC practices is suboptimal across a wide variety of sites. Oppor- tunities for cost-effective improvement of SSI rates exist with major areas for development including (1) hospital-wide IC programs and surveillance, (2) antibiotic stewardship, (3) written and posted guidelines and policies across a range of topics, (4) surgical instrument sterilization procedures, and (5) improved hand hygiene. Overall, IC programs had various limitations in these sites
and HAI surveillance was not consistently performed at many sites. One site, for example, has an IC committee focused just on outbreaks of hospital infections without committee discussion of surveillance or endemic HAI. This site reported that no financial support was available for IC programs despite concerns regarding the potential financial impact of HAI.17 An effective HAI surveillance program is recommended for all acute care hospitals as part of a complete strategy for the
reduction of SSI.18 Suggested models to reduce the incidence of SSI for hospitals in low- and middle-income countries use a validated system for measuring SSI rates.7 SSI poses a unique but achievable challenge for surveillance and IC programs because many infections develop following discharge, making postdischarge surveillance an important component.19 Despite this, only 1 of the sites returning full survey data in our study reported performing postdischarge surveillance. Our data highlight a need to establish robust IC programs. Perioperative antibiotic administration was another area of weakness with a large opportunity for improvement. Points were deducted for sites with no or limited written policies or guidelines on proper antibiotic use, no monitoring for adher- ence to guidelines, inaccessibility of antibiotic prophylaxis, and improper administration of antibiotics. One site in our study, for example, reported patients and families usually purchase prophylactic antibiotics outside the hospital prior to surgery. Antibiotic stewardship programs have an increasingly important role in low- and middle-income countries where many of the antimicrobial-resistant organisms originate.20 Implementation of antibiotic stewardship programs should reduce adverse events and limit healthcare costs due to poor antimicrobial use and antimicrobial-resistant infections.9 Despite these concerns, in developing countries there is antibiotic misuse and lack of effective IC programs.20,21 This is a challenge in many parts of the globe, including our study sites.22–25 Simple changes, such as the implementation of checklists for confirmation of sterility and antibiotic prophylaxis prior to incision, have been shown to be effective in reducing adverse outcomes10 and would likely reduce HAI and anti- microbial resistance through the interdisciplinary team approach as part of an antibiotic stewardship program. Our data show that guidelines for perioperative antibiotic
prophylaxis either may not exist in some facilities or are not readily accessible. With a global increase in use of total and “last-resort” antibiotics and increasing concern for resistant organisms,21,26 the appropriate use of antibiotics with guide- lines readily available in surgical areas should be a priority. The problem of absent or inaccessible guidelines occurred not only in antibiotic stewardship programs but also in other areas of surgical care, including preoperative preparation of the patient, cleaning of the surgical area, and surgical area traffic. For multiple sites, there were also no written policies or procedures for sterilization and disinfection of equipment. Sterilization and disinfection of equipment was another area
of concern highlighted by our study. The sterilization and disinfection of equipment and autoclave sections received low scores and this may be due to a limitation of the ICAT not accounting for disposable equipment. Despite this issue, individual responses highlighted a lack of defined policies and procedures for some sites, with some areas of improper instrument sterilization and disinfection technique. One site used nonrecommended practices, including chemical ster- ilization of oxygen masks, chemical and high-level disinfection of surgical instruments, storing sterile instrument packs
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100 |
Page 101 |
Page 102 |
Page 103 |
Page 104 |
Page 105 |
Page 106 |
Page 107 |
Page 108 |
Page 109 |
Page 110 |
Page 111 |
Page 112 |
Page 113 |
Page 114 |
Page 115 |
Page 116 |
Page 117 |
Page 118 |
Page 119 |
Page 120 |
Page 121 |
Page 122 |
Page 123 |
Page 124 |
Page 125 |
Page 126 |
Page 127 |
Page 128 |
Page 129 |
Page 130 |
Page 131 |
Page 132 |
Page 133 |
Page 134 |
Page 135 |
Page 136 |
Page 137 |
Page 138 |
Page 139 |
Page 140