The lowbury lecture 2016: can intersectional innovations reduce hospital infection?

Saint, S. The Journal of Hospital Infection. Published online: November 28, 2016


Preventing healthcare-associated infection remains an international priority given the clinical and economic consequences of this largely preventable patient safety harm. While important strides have been made in preventing hospital infections over the past several decades, thorny issues remain, including how to consistently improve hand hygiene rates and further reduce device-related complications such as catheter-associated urinary tract infection.

Rather than relying solely on directional innovations – incremental changes that continue to serve as the bedrock of scientific advancement – perhaps we should also search for “intersectional innovations,” which represent breakthrough discoveries that emanate from the intersection of often widely divergent disciplines. Several intersectional innovations that have the potential to greatly impact infection prevention efforts include human factors engineering, sociology, and engaging the senses. Indeed, Professor Edward Joseph Lister Lowbury, the namesake of this lecture, exemplified intersectional thinking in his own life having been both an accomplished bacteriologist and poet. By incorporating approaches outside of traditional biomedical science we will hopefully provide patients with the safe care they expect and deserve.

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Chlorhexidine bathing and health care-associated infections among adult intensive care patients

Frost, S.A. et al. Critical Care. Published online: 23 November 2016


L0075034 An intensive care unit in a hospital.
Image source: Robert Priseman – Wellcome Images // CC BY-NC-ND 4.0

Background: Health care-associated infections (HAI) have been shown to increase length of stay, the cost of care, and rates of hospital deaths . Importantly, infections acquired during a hospital stay have been shown to be preventable. In particular, due to more invasive procedures, mechanical ventilation, and critical illness, patients cared for in the intensive care unit (ICU) are at greater risk of HAI and associated poor outcomes.

Conclusion: This meta-analysis of the effectiveness of CHG bathing to reduce infections among adults in the ICU has found evidence for the benefit of daily bathing with CHG to reduce CLABSI and MRSA infections. However, the effectiveness may be dependent on the underlying baseline risk of these events among the given ICU population. Therefore, CHG bathing appears to be of the most clinical benefit when infection rates are high for a given ICU population.

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Reducing infections in the NHS

Department of Health | Published online: 10 November 2016
Image source: David Gregory & Debbie Marshall – Wellcome Images // CC BY-NC-ND 4.0

Image shows electron micrograph of Escherichia coli close-up

Plans to prevent hospital infections include more money for hospitals who reduce infection rates and publishing E. coli rates by local area.

Health Secretary Jeremy Hunt has launched new plans to reduce infections in the NHS. He announced government plans to halve the number of gram-negative bloodstream infections by 2020 at an infection control summit.

E. coli infections – which represent 65% of what are called gram-negative infections – killed more than 5,500 NHS patients last year and are set to cost the NHS £2.3 billion by 2018. There is also large variation in hospital infection rates, with the worst performers having more than 5 times the number of cases than the best performing hospitals.

Infection rates can be cut with better hygiene and improved patient care in hospitals, surgeries and care homes, such as ensuring staff, patients and visitors regularly wash their hands. People using insertion devices such as catheters, which are often used following surgery, can develop infections like E. coli if they are not inserted properly, left in too long or if patients are not properly hydrated and going to the toilet regularly.

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Global guidelines on the prevention of surgical site infection

WHO | Published online: November 2016

Image source: WHO

Health care-associated infections (HAI) are acquired by patients while receiving care and represent the most frequent adverse event affecting patient safety worldwide.

Recent work by the World Health Organization (WHO) shows that surgical site infection (SSI) is the most surveyed and frequent type of HAI in low- and middle-income countries and affects up to one third of patients who have undergone a surgical procedure. Although SSI incidence is lower in high-income countries, it remains the second most frequent type of HAI in Europe and the United States of America (USA).

Many factors in the patient’s journey through surgery have been identified as contributing to the risk of SSI. Therefore, the prevention of these infections is complex and requires the integration of a range of preventive measures before, during and after surgery. However, the implementation of these measures is not standardized worldwide. No international guidelines are currently available and inconsistency in the interpretation of evidence and recommendations among national guidelines is frequently identified.

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Promoting health workers’ ownership of infection prevention and control: using Normalisation Process Theory as an interpretive framework

Gould, D.J. et al. Journal of Hospital Infection. Published online: October 13 2016

boy-1299626_960_720Background: All health workers should take responsibility for infection prevention and control (IPC). Recent reduction in key reported healthcare-associated infections in the United Kingdom is impressive but determinants of success are unknown. It is imperative to understand how IPC strategies operate as new challenges arise and threats of antimicrobial resistance increase.

Methods: We undertook a retrospective, independent evaluation of an action plan to enhance IPC and ‘ownership’ (individual accountability) for IPC introduced throughout a healthcare organisation. Twenty purposively selected informants were interviewed. Data were analysed inductively. Normalisation Process Theory (NPT) was applied to interpret the findings and explain how the action plan was operating.

Findings: Six themes emerged through inductive analysis. Theme 1: ‘Ability to make sense of ownership’ provided evidence of the first element of NPT (Coherence). Regardless of occupational group or seniority, informants understood the importance of IPC ownership and described what it entailed. They identified three prerequisites: ‘Always being vigilant’ (Theme 2), ‘The importance of access to information’ (Theme 3) and ‘Being able to learn together in a no blame culture’ (Theme 4) Data relating to each theme provided evidence of the other elements of NPT that are required to embed change: planning implementation (cognitive participation), undertaking the work necessary to achieve change (collective action) and reflection on what else is needed to promote change as part of continuous quality improvement (reflexive monitoring). Informants identified barriers (e.g. workload) and facilitators (clear lines of communication and expectations for IPC).

Conclusion: Eighteen months after implementing the action plan incorporating IPC ownership there was evidence of continuous service improvement and significant reduction in infection rates. Applying a theory that identifies factors that promote/inhibit routine incorporation (‘normalisation’) of IPC into everyday healthcare can help explain success of IPC initiatives and inform implementation.

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Risk of healthcare associated infections in HIV positive patients.

Abstract HIV positive patients are a high risk population due to the alteration in their immune status. Health-care associated infections (HAI) have not been well described in this population, with some risk factors reported inconsistently in the literature. The aim of this study was to describe the epidemiology as well as the underlying risk factors for HAI, specifically urinary tract infection (UTI), bloodstream infection (BSI) and respiratory tract infection (RTI). This was a retrospective cohort study conducted at an academic health system in New York City which included three hospitals over a two year period from 2006 to 2008. There were 3,877 HIV positive patient discharges in 1,911 patients. There were a total of 142 UTI, 106 BSI, and 100 RTI. The incidence rates were 4.35 for UTI, 3.16 for BSI and 2.98 for RTI. CD4 count and antiretroviral therapy were not associated with HAI. Significant predictors of UTI included urinary catheter, length of stay, female gender, steroids and trimethoprimsulphamethoxazole (TMP-SMX); of BSI were steroids and TMP-SMX; and RTI were mechanical ventilation, steroids and TMP-SMX. Multivariable analysis indicated that TMPSMX was significantly associated with an increased risk of infection for all three types of HAI [BSI odds ratio 2.55, 95% confidence interval (1.22-5.34); UTI odds ratio 3.1, 95% confidence interval (1.41-7.22); RTI odds ratio 5.15, 95% confidence interval (1.70-15.62)]. HIV positive patients are at significant risk for developing HAI, but the risk factors differ depending on the specific type of infection. The fact that TMP-SMX is a risk factor in these patients warrants further research as this may have significant health policy implications.

Risk of healthcare associated infections in HIV positive patients. Mitha M, Furuya EY, Larson E. J Infect Prev. 2014 Nov 1, vol 15, no 6, p214-220.