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Original Article

Control of hospital acquired infections in the ICU:

A service perspective

Col Shivinder Singh a,*, Col Rakhee Goyal b, Brig G.S. Ramesh, VSM (Retd)c,
Maj Gen V. Ravishankar, VSMd, Gp Capt R.M. Sharma e,
Maj D.V. Bhargava f, Lt Col S.K. Singh g, Maj M.K. John h,
Surg Lt Cdr Anoop Sharma h
a
Senior Adviser (Anaesthesiology & Critical Care), Command Hospital (Western Command), C/O 56 APO, India
b
Senior Advisor (Anaesthesiology), Command Hospital (Southern Command), Pune 411040, India
c
Ex-Professor & Head, Dept. of Anaesthesiology & Critical Care, Armed Forces Medical College, Pune 411040, India
d
Commandant, Command Hospital (Southern Command), Pune 411040, India
e
Associate Professor, Dept. of Anaesthesiology & Critical Care, Armed Forces Medical College, Pune 411040, India
f
Clinical Tutor, Dept. of Anaesthesiology & Critical Care, Armed Forces Medical College, Pune 411040, India
g
Assistant Professor, Dept. of Anaesthesiology & Critical Care, Armed Forces Medical College, Pune 411040, India
h
Resident, Dept. of Anaesthesiology & Critical Care, Armed Forces Medical College, Pune 411040, India

article info abstract

Article history: Background: The service setting has some unique strengths and weaknesses that must be
Received 2 January 2014 kept in mind when organizing Hospital acquired infections (HAI) prevention interventions.
Accepted 8 August 2014 Methods: Following an initial study to gather data regarding HAI in the Surgical intensive care
Available online 16 October 2014 unit (ICU) we put into place various infection control interventions. The present study was
carried out to analyse the effect of these interventions on the incidence of HAI in the ICU.
Keywords: Results: The total admissions to the ICU were 253 patients. Eighty eight patients (34.78%)
Hospital acquired infections were admitted for more than 48 hr, 165 patients stayed for less than 48 h. The frequency of
Catheter related blood stream HAI was 7.95% (95% CI 3.54, 15). Hospital acquired pneumonia was observed in 2 of the 88
infection patients (2.27%) (95% CI 0.38, 7.30) which amounted to 9.70 infections per 1000 ventilator
Ventilator-associated pneumonia days. Bloodstream infection was detected in 3 out of 88 patients (3.4%) (95% CI 0.87, 8.99)
Catheter associated urinary tract amounting to 6.54 fresh infections per 1000 Central Venous Catheter days. Urinary tract
infection infection was observed in 2 (2.27%) (95% CI 0.38, 7.30) at 2.86 fresh infections per 1000
catheter days. As compared to the previous study we found that there was a decline of HAI
ranging from 60 to 70%.
Conclusion: Our study demonstrated that by meticulously following infection control pro-
tocols especially tailored to the service setting the incidence of HAI's can be reduced.
However, the challenge is in maintaining the gains achieved since there is a rapid turnover
of manpower in the ICU and a lack of a structured ICU design model.
© 2014, Armed Forces Medical Services (AFMS). All rights reserved.

* Corresponding author.
E-mail address: sshivinder@hotmail.com (S. Singh).
http://dx.doi.org/10.1016/j.mjafi.2014.08.008
0377-1237/© 2014, Armed Forces Medical Services (AFMS). All rights reserved.
 m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 1 ( 2 0 1 5 ) 2 8 e3 2 29

Introduction 3. To sensitise the staff to the problem of HAI and to keep the
issue of HAI in the forefront.
Hospital acquired infections (HAI) have assumed worrisome
proportions in healthcare scenarios all over the world, be it Patients and methods: This hospital-based observational
the developed or developing world, the civil or service setting. study was conducted from June to December 2012 at a 10 e
The service health care setting, however, has its own as- bedded surgical intensive care unit (ICU) of a tertiary service
pects which must be kept in mind while organizing infection hospital. Patients who were shifted out of the ICU within 48 h
control interventions. With the advent of systematic central of admission were excluded from the study. All patients who
procurement of equipment, decentralization of drug pro- were above 16 years of age, admitted in the surgical ICU with
curement with local purchase funds available at the hospital different complaints and presentations and developed clinical
level, the non availability of state of the art equipment and evidence of infection that did not originate from patient's
quality drugs is now passe . The area of concern, however, is original admitting diagnosis, were included in the study. A
the paucity of trained manpower to achieve the basic nurse to proforma was designed and used for data collection. All data
patient ratio for nursing care. items were collected for all patients in the ICU, irrespective of
With the above background, after a preliminary study to their length of stay. Data for all patients who developed an
confirm the incidence of HAI in the surgical ICU, we instituted infection was collected, irrespective of when the infection
interventions towards control of HAI.1 Thereafter, we occurred. Infections studied were CRBSI, CAUTI, and VAP.
observed the incidence again to see the effects of the This did not influence any aspect of clinical diagnosis and
interventions. clinical decision-making.
Interventions: Regular interactive discussion with nursing HAI definitions: In this survey an HAI was an infection
staff highlighting the important aspects of infection control, which arose 48 h or more after admission to hospital and
designating one nursing officer as infection control nurse in which was not present or incubating on admission. A preva-
rotation, demonstration of hand washing, installation of flexi- lent HAI was considered present when the patient had signs
boards demonstrating the technique of hand washing, and symptoms which met one of the centers for disease
installation of bedside white boards for each patient and control (CDC) definitions as had been used in the previous
noting “FASTHUG”.2 (A mnemonic to enumerate all the daily study.3 The assessment, diagnosis and management of the
actions required in the management of critical patients. patients was done as in the previous study.1
Developed by Jean Louis Vincent in Belgium it is a short
mnemonic that highlights seven evidenced based best prac-
tises for critical care. It is a tool used to ensure that the seven
Results
essential evidence based aspects of patient care are not
forgotten by the ICU team. These stand for F ¼ early enteral
Statistical analysis to calculate 95% confidence intervals for
Feeding A ¼ assessment of Analgesia S ¼ assessment of
incidence of infections was done using Epi-Table and chi
Sedation T ¼ Thromboembolic prophylaxis H ¼ Head of bed
square test for linear trend applied to length of stay and
elevation U ¼ stress Ulcer prophylaxis G ¼ Glycaemic control).
incidence of infection along with calculation of odds ratio was
In addition the dates of insertion of catheters and lines,
done using EPI Info software.
institution of ventilator-associated pneumonia bundle (VAP),
The total admissions to the ICU were 253 patients. While 88
catheter related blood stream infection (CRBSI) bundle, cath-
patients (34.78%) were admitted for more than 48 h, 165 pa-
eter associated urinary tract infection (CAUTI) bundle, use of
tients stayed in the ICU for less than 48 h. There were a total of
subglottic suction, use of closed suction, attention to isolation
28 deaths. There were 161 (63.64%) males and 92 (36.36%) fe-
of infected cases within the ICU. Introduction of shoe covers
males. Only seven 7.95% (95% CI 3.54, 15) out of the eighty
for all entrants to the ICU as mopping of the floor every 2 h
eight (88) patients were identified to acquire infection during
wasn't possible.
their stay in the ICU. 128 patients of the 253 had central lines
placed for a total of 459 days thus the average duration of
indwelling CVCs was 459/128 that is 3.59 days per patient.
Similarly for urinary catheters it was 699/218 that is 3.21 days
Material and methods per patient.
Details of patients who acquired nosocomial infection are
The aim of the study was to analyse the effects of structured summarized in Table 1. Hospital acquired pneumonia was
interventions, tailored to the service setting on the incidence observed in 2 of the 88 patients (2.27%) (95% CI 0.38, 7.30) all of
of HAI in our hospital ICU. The results would be compared these had undergone or were on mechanical ventilatory
with the results of a prior study.1 support. The total number of days that all patients were
The objectives of the study were to answer the following ventilated amounted to 206 days. Thus it amounted to 9.70
questions. infections per 1000 ventilator days. They developed signs of
consolidation after 3e5 days and we categorized them as
1. To assess the feasibility of implementing the interventions ventilator-associated pneumonia (VAP). The identified path-
in the service setting. ogens on broncho-alveolar lavage (BAL) in such patients were
2. To analyse the effect of the various interventions on the Acinetobacter sensitive only to imipenem and polymixin in
incidence of HAI as compared to the earlier data? both the patients.
30 m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 1 ( 2 0 1 5 ) 2 8 e3 2

Table 1 e Details of patients with nosocomial infections.

Type of infection Total no. & % 95% Confidence interval Infections per 1000
intervention days
Patients admitted 253
Patients who stayed more than 48 h 88 (100%)
Patients with nosocomial infections 07 (7.95%) 3.54, 15 7/1364* 1000 ¼ 5.13
Pneumonia 02 (2.27%) 3.54, 15 02/206* 1000 ¼ 9.70
Blood stream infection 03 (3.41%) 0.87, 8.99 3/459* 1000 ¼ 6.54
Urinary catheter infection 02 (2.27%) 0.38, 7.3 2/699* 1000 ¼ 2.86

Blood stream infection was detected in 3 out of 88 (3.4%) bundles has been shown to decrease HAI's.8 A comprehensive
95% CI 0.87, 8.99 patients. The source of such blood stream systems approach targeted at efforts involving both process
infections was central venous lines. The total number of days improvements and culture change, has been identified to
that all patients had indwelling Central Venous Catheters enable sustainable change at the unit level.9
amounted to 459 days. Thus it amounted to 6.54 fresh in- The service setting with a structured regimented work force
fections per 1000 Central Venous Catheter days. is unique as regards implementation of interventions. How-
Urinary tract infection was observed in 2 (2.27%) 95% CI 0.38, ever, the frequent turnover of staff and the shortage of trained
7.30 of the patients. The total number of days that all patients nursing staff in the ICU with a nurse to patient ratio of 1:3e1:5
had indwelling Foley's catheters was 699 days. Thus it amounted at the best of times can be quite challenging. Consequently, we
to 2.86 fresh infections per 1000 catheter days. Only one was adopted a multi-pronged approach to this problem. We liaised
detected to be culture positive with Escherichia coli grown. with the administration of the nursing services and minimised
The total number of patients who stayed for less than 5 the turnover of staff to the bare essential. Interactive sessions
days in the ICU was 209 out of which 1 developed HAI (Fig. 1). with the nursing and paramedical staff outlining the current
Three of the 35 patients who stayed from 5 to 10 days devel- evidence based recommendations were started. All fresh
oped HAI and of the 9 patients who stayed more than 10 days 3 nursing and paramedical staff in the ICU were made to read
developed HAI (Table 2). This data was subjected to statistical and understand the infection control protocols in place. In-
analysis using chi square test for association between length terventions aimed at increasing awareness about hand
of stay and the risk of developing HAI. Chi square value for washing were also implemented.
linear trend was found to be 28.64, p value < 0.000, odds ratio 1 Recognising the fact that our nurse to patient ratio at the
for stay less than 5 days, 18.0 for stay between 5 and 10 days best of times would be far from ideal we instituted in-
and 69.67 for stay beyond 10 days (Fig. 2). Proving that as the terventions that would be less labour intensive like use of
length of stay in the ICU increased the risk of developing HAI closed suction catheters and continuous subglottic suction of
became highly significant. secretions. The closed suction catheters were replaced after a
week10 or in case they were visibly soiled.
The VAP rates declined by nearly 70% from 32/1000 to 9.7/
1000 ventilator days as compared to the previous study,1 the
Discussion CRBSI rates by nearly 61% from 16/1000 to 6.54/1000 central
line days and the CAUTI rates by nearly 70% from 9/1000 to
Evidence based interventions for prevention of HAI are well 2.8/1000 urinary catheter days (Table 3, Fig. 3)
established.4 Inspite of the knowledge of the interventions We achieved a more rapid turnover of patients in the pre-
required for minimization of HAI, they continue to be a major sent study as compared to the previous one, 34.78% in the
problem especially in the ICU setting. Difficulties in imple- present study as compared to 69.6% patients in the prior study
mentation of these guidelines have been found at the unit stayed for more than 48 h in the ICU.1 Thus part of the results
level and have been termed as change implementation fail- achieved may have been because the stay of patients in the
ure.5e7 The impact of teaching interventions involving the ICU ICU was minimized. Since a number of interventions had been
staff regarding hand hygiene and the various HAI prevention instituted at the same time, we cannot postulate the effect of
each specific intervention towards the final result.
This brings us to the more pertinent question of suste-
nance of the gains achieved. This is possible by ensuring that
the interventions become part of the protocol and are firmly
embedded in the day to day functioning of the ICU.
Needless to say, the elephant in the room too needs to be
addressed at an administrative level which is the model of
service ICU's. There is enough evidence supporting the fact
that closed and semi closed ICUs have better outcomes in
terms of HAI, mortality and morbidity.11e13 Indian Society of
Critical Care Medicine (ISCCM) in their guidelines discourages
Fig. 1 e Length of stay. the adoption or continuance of open ICUs.14 To monitor
 m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 1 ( 2 0 1 5 ) 2 8 e3 2 31

Table 2 e Length of stay and HAI.

Serial No of Patient staying No of infections less Patients staying No of infections Patient staying No of infections
no patients <5 days than 5 days stay 5e10 days 5e10 days stay more than more than
10 days 10 days stay
Neuro 99 78 e 19 2 4 2
Onco 41 39 e 2 1 e e
GI 43 32 1 7 e 2 1
Gynae 4 4 e e e e e
Uro 11 10 e 1 e e e
Ortho 8 8 e e e e e
Vasc 1 1 e e e e e
Gen Sx 33 26 e 4 e 3 e
ENT 3 3 e e e e e
RSC 10 8 e 2 e e e
Total 253 209 1 35 3 9 3

to all other hospital acquired infections in the near future.17

Recently, the Centers for Medicare and Medicaid Services
(CMS) announced its decision to cease paying hospitals for
some of the care made necessary by “preventable complica-
tions” which includes some HAI's.18 This has raised concerns
that patients experiencing complications listed as non-
reimbursable serious hospital acquired conditions will be
inaccurately told that those never events are based on negli-
gence or medical errors, leaving medical practitioners open to
the attendant risk of litigation for negligence.19
The limitation of the study is that there was a lack of a
concurrent comparison group with the intervention group.
Although the study settings are similar and measurement bias
Fig. 2 e HAI as compared to length of stay. has been effectively taken care of since the present study was
done on the same lines as the previous one with which the
results are being compared.1 However, since it would not have
standards of quality of care in ICUs as per national guidelines, been ethical to subject one group of patients to inadequate
it is imperative that the “ownership” of service ICUs is clearly care as compared to the interventions being implemented we
defined ensuring that a specific team has full control and more decided to use the previous study for comparison. Moreover,
importantly, therefore, also the responsibility to deliver the even though the interventions instituted are known facts,
quality and outcomes desired.15 there is hardly any data regarding the incidence of nosocomial
More so, in view of the fact that hospital acquired in- infections in service ICU's or the effect of infection control
fections constitute preventable or never events which are interventions in the service setting.
serious, largely preventable patient safety incidents that In conclusion, our study demonstrated that by meticu-
should not occur if the available preventative measures have lously following relevant infection control protocols especially
been implemented.16 Hospitals in the US are now mandated tailored to the service setting the incidence of HAI's can be
by the Centers for Medicare and Medicaid to report central reduced. It is feasible to implement specific interventions.
line-associated bloodstream infections and selected surgical However, the challenge is in maintaining the momentum in
site infections (e.g., colon surgeries, hysterectomies, and ce- view of the rapid turnover of manpower and lack of a struc-
sarean delivery), these requirements are expected to expand tured ICU design model.

Table 3 e Comparison of data May 2010 vs Dec 2012.

Type of infection Total no. & (%) Infections per 1000 intervention days 95% Confidence interval
2010 2012 2010 2012 2010 2012
Total admissions to ICU 293 253
Admitted for more than 48 h 204 88
Pneumonia 18 (8.8%) 2 (2.3%) 32/1000 9.7/1000 22, 45 3.54, 15
Blood stream infection 10 (4.9%) 3 (3.4%) 16/1000 6.54/1000 9, 26 0.87, 8.99
Urinary catheter infection 8 (3.9%) 2 (2.27%) 9/1000 2.86/1000 4, 18 0.38, 7.3
Total infections 36 (17.64%) 7 (7.95%) 31/1000 5.13/1000
32 m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 1 ( 2 0 1 5 ) 2 8 e3 2

6. Agency for Healthcare Research and Quality. HHS Awards $17

Million to Fight Health Care-associated Infections; 2009. Retrieved
from www.ahrq.gov/news/press/pr2009/haifund.htm.
7. Nembhard I, Tucker AL, Edmondson AC. Implementing new
practices: an empirical study of organizational learning in
hospital intensive care units. Manag Sci. 2007;53(6):894e907.
8. Zingg W, Imhof A, Maggiorini M, Stocker R, Keller E, Ruef C.
Impact of a prevention strategy targeting hand hygiene and
catheter care on the incidence of catheter-related
bloodstream infections. Crit Care Med. 2009;37:2167e2173.
9. Pronovost PJ, Goeschel CA, Colantuoni E, et al. Sustaining
reductions in catheter related bloodstream infections in
Michigan intensive care units: observational study. Br Med J.
Fig. 3 e Incidence of HAI DeceMay 09 Vs JuneDec 12. 2010;340:309.
10. Stoller JK, Orens DK, Fatica C, et al. Weekly versus daily
changes of in-line suction catheters: impact on rates of
ventilator-associated pneumonia and associated costs. Respir
Care. 2003;48(5):494e499.
Conflicts of interest 11. Topeli A, Laghi F, Tobin MJ. Effect of closed unit policy and
appointing an intensivist in a developing country. Crit Care
All authors have none to declare. Med. 2005;33:299e306.
12. Carson SS, Stocking C, Podsadecki T, et al. Effects of
organizational change in the medical intensive care unit of a
teaching hospital: a comparison of ‘open’ and ‘closed’
formats. JAMA. 1996;276:322e328.
Acknowledgement
13. Multz AS, Chalfin DB, Samson IM, et al. A closed medical
intensive care unit (MICU) improves resource utilization
The authors acknowledge Dr. SR Patrikar, Lecturer in Biosta- when compared with an open MICU. Am J Respir Crit Care Med.
tistics & Demography, Dept of Community Medicine, Armed 1998;157:1468e1473.
Forces Medical College, Pune 40. 14. Divatia JV, Baronia AK, Bhagwati A, et al. Critical care delivery
in intensive care units in India: defining the functions, roles
and responsibilities of a consultant intensivist
Recommendations of the Indian Society of Critical Care
references Medicine Committee on defining the functions, roles and
responsibilities of a consultant intensivist. Indian J Crit Care
Med. JanuaryeMarch 2006;10(1).
1. Singh S, Chaturvedi R, Garg SM, Datta R, Kumar A. Incidence 15. Ray B, Samaddar DP, Todi SK, Ramakrishnan N, John G,
of healthcare associated infection in the surgical intensive Ramasubban S. Quality indicators for ICU: ISCCM guidelines
care unit of a tertiary service hospital. Med J Armed Forces for ICUs in India. Indian J Crit Care Med. OctobereDecember
India. 2013;69:124e129. http://dx.doi.org/10.1016/j.mjafi.2012. 2009;13(4).
08.028. 16. Milstein A. Ending extra payment for “never
2. Vincent JL. Give your patient a fast hug (at least) once a day. events”dstronger incentives for patients' safety. N Engl J Med.
Crit Care Med. 2005 Jun;33(6):1225e1229. 2009;360:2388e2390.
3. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance 17. Hospital-acquired Conditions (HAC) in Acute Inpatient Prospective
definition of health careeassociated infection and criteria for Payment System (IPPS) Hospitals; May 2012. Available at: http://
specific types of infections in the acute care setting. Am J www.cms.gov/Medicare/Medicare-Feefor- Service-Payment/
Infect Control. 2008;36:309e332. HospitalAcqCond/downloads/HACFactsheet.pdf. Accessed
4. Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis 11.06.12.
campaign: International guidelines for management of severe 18. Medicare program: changes to the hospital inpatient
sepsis and septic shock: 2012. Crit Care Med. prospective payment systems and fiscal year 2008 rates. Fed
2013;41(2):580e637. Regist. 2007;72:47379e47428.
5. Landrigan C, Bones BB, Goldman DA. Temporal trends in 19. Lembitz A, Clarke TJ. Clarifying “never events and introducing
rates of patient harm resulting from medical care. N. Engl J “always events”. Patient Saf Surg. 2009;7:26. http://dx.doi.org/
Med. 2010;363(22):2124e2134. 10.1186/1754-9493-3-26.