Journal of Hospital Infection 90 (2015) 12e14 Available online at www.sciencedirect.com

Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin

Commentary

Mandatory public reporting of healthcare-associated infections in developed countries: how can developing countries follow? M. Biswal*, A. Mewara, S.B. Appannanavar, N. Taneja Postgraduate Institute of Medical Education and Research, Chandigarh, India

A R T I C L E

I N F O

Article history: Received 13 May 2013 Accepted 21 December 2014 Available online 7 January 2015 Keywords: Public reporting Mandatory Healthcare-associated infections India

S U M M A R Y

The threat posed by increased transmission of drug-resistant pathogens within healthcare settings and from healthcare settings to the community is very real and alarming. Although the developed world has taken strong steps to curb this menace, there has been little pressure on developing countries to take any corrective action. If the reporting of alarming rates of healthcare-associated infections (HCAIs) from hospitals in India and many other developing countries was made mandatory, it would help to force stakeholders (e.g. healthcare workers, legislators, administrators and policy makers in hospitals) to acknowledge and tackle the problem. This would introduce quality control in a long neglected area of health care, and enable patient empowerment which is practically nonexistent in India. Healthcare institutions should commit towards enforcing ‘zero tolerance’ towards lapses in prevention of HCAIs. Public pressure would force the Indian Government to acknowledge the problem, and to allocate more funds to improve resources and infrastructure; this could substantially elevate the standard of health care given to the average Indian. Despite the numerous challenges, overall public benchmarking of HCAIs is a commendable goal that would go a long way towards tackling this menace in developing countries such as India. ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Healthcare-associated infections (HCAIs) are a huge public health problem all over the world, but particularly in the developing world. The developed world has woken up to this threat, and many countries have taken the commendable positive step of introducing laws to monitor and control HCAIs. In the UK, mandatory reporting of meticillin-resistant Staphylococcus aureus (MRSA) bacteraemias for National Health Service (NHS) hospitals was introduced in 2001 after considerable media and public interest about this so-called * Corresponding author. Address: Department of Medical Microbiology, PGIMER, Chandigarh 160012, India. Tel.: þ91 1722755151, þ91 9463307825; fax: þ91 1722744401. E-mail address: [email protected] (M. Biswal).

‘superbug’.1 In 2004, the mandatory reporting scheme was extended to Clostridium difficile diarrhoea, followed by meticillin-susceptible S. aureus bacteraemias in January 2011, and E. coli bacteraemias six months later, despite the fact that a smaller proportion of the latter are healthcare associated.2,3 Recently, in France, a legal framework has been drawn up to implement antibiotic stewardship in hospitals and mandatory disclosure of the same to the public.4 In the USA, both the public and legislators are demanding legislation in every state for hospitals to publicize HCAI rates.5 Some US health maintenance organizations no longer reimburse costs relating to HCAIs, such as ventilator-associated pneumonia, on the grounds that such HCAIs are preventable.6 In France, there was a substantial reduction in C. difficile infections after the

http://dx.doi.org/10.1016/j.jhin.2014.12.011 0195-6701/ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

M. Biswal et al. / Journal of Hospital Infection 90 (2015) 12e14 introduction of mandatory reporting (26.7%; 95% confidence interval 21.4e31.6%).7 HCAI surveillance and benchmarking are associated with major organizational changes and strengthening of infection control efforts wherever they are implemented. In developing countries where the burden of HCAIs is 20 times greater than in developed countries, such a move would have substantial benefits.8 However, given the poor compliance with infection control policies and inadequate infrastructure in developing countries, would it be possible to introduce such a landmark move to induce transparency and improve the quality of healthcare delivery? Most hospitals have no rules mandating HCAI control programmes, and accreditation is rarely insisted upon. Under such circumstances, what would be required and what problems (and possible solutions) are envisaged? As a first step towards this goal, introducing legislation is the strongest motivation for improving health care in any country. The best example of this is the change brought about by introducing a legal framework for biomedical waste management in India in 1998, which led to regulation of waste disposal in hospitals throughout the country.9 Introducing legislation could dramatically streamline HCAI reporting throughout the country. All government and private hospitals in India should be encouraged to participate in HCAI surveillance. If it were not feasible to make reporting of such data mandatory, a voluntary and confidential system could be adopted, as in the UK in the 1990s.10 Alternatively, mandatory reporting without public disclosure of HCAI rates could be introduced for hospitals with reservations about participation.11 The Indian Ministry of Health and Family Welfare launched the Integrated Disease Surveillance Project (IDSP) for epidemic-prone diseases in 2004. Under the IDSP, surveillance units (SUs) for epidemic-prone diseases have been established in all 35 states and union territories of India. Weekly surveillance data on epidemic-prone diseases are collected from reporting units such as subcentres, primary health centres, community health centres, hospitals (including government and private sector hospitals) and medical colleges. The weekly data are analysed by state or district SUs for disease trends to enable quick detection and control of outbreaks. Therefore, a national reporting network is already in place. The IDSP could be expanded to include HCAIs in its remit. Alternatively, a similar far-reaching network would have to be designed and implemented for HCAI surveillance. The second step would be to decide which type of surveillance to adopt. There could be three approaches to this. e HCAI rates could be used, but which to choose? Standardized definitions would have to be agreed and adopted universally, or else the results would be meaningless for benchmarking purposes. e As a way of circumventing this, quality measures, perhaps linked to outcomes (e.g. compliance with hand hygiene, existence of an infection control committee), could be considered.12e14 An expert group of infection control leaders from 34 European countries recently concluded that process indicators, rather than infection rates, should be reported with data validation and external audits.15,16 However, to be meaningful, these indicators must be linked to outcomes (change in HCAI rates).

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e Laboratory-based reporting of bloodstream infections stratified by specialty (intensive care units or general wards; adults or paediatric patients) would also be a good starting point. MRSA bloodstream infections have been a core performance indicator for NHS hospital trusts in the UK for more than a decade, and this has been associated with a huge reduction in the number of cases.17 The third step would be to set accountability. Who should be made accountable? Legislators, administrators and policy makers in hospitals, the doctor or nurse in direct contact with the patient, the hospital epidemiologist, or the infection prevention and control specialist? There should be clear-cut guidelines to clarify responsibility and accountability for each of the above-mentioned healthcare personnel. Annual targets for reduction of key indicator organisms should be set, as the UK Government did for reducing MRSA bacteraemias by 50% in NHS hospital trusts in 2004.1 Fines may be imposed on hospitals who fail to meet pre-decided annual targets, while appreciation in the form of more funding etc. may be given to those that comply. The Indian media has been known to sensationalize issues, and this unwanted publicity could detract hospitals from disclosing their HCAI rates or, worse, encourage them to release falsified data about their HCAIs or infection prevention and control compliance with process indicators. The fear of being punished may give rise to deliberate under-reporting of HCAI rates. Yuji et al. reported an incident where the police intervened to control an outbreak of Acinetobacter baumannii infection in Japan.18 The paper raised a very valid fear of hospitals not owning up to excessive HCAI rates, or refusing to admit carriers of multi-drug-resistant pathogens as a backlash against such punitive action. Such instances are likely to disrupt the entire process of public reporting of HCAIs.19 Many challenges to public reporting are foreseen in India. Maintenance of accuracy and consistency in data collection are the major challenges. At present, all the states in India make their own laws related to health care. Therefore, the process would not be controlled centrally, and there would be considerable variation between data from different states.20,21 This problem was surmounted when the Ministry of Environment and Forests passed the Bio-Medical Waste (Management and Handling) Rules in August 1998, and all states and union territories in India began to follow strict criteria for waste collection, transport and disposal laid down by this law. However, public HCAI surveillance may not be so simple. Therefore, much care and deliberation would be needed to standardize definitions for surveillance of HCAIs, and to choose an ideal HCAI as the quality indicator for all healthcare institutions throughout India. There are also substantial differences in access to resources and heterogeneous cost structures across government and private hospitals in India. This would have a direct bearing on any national HCAI surveillance programme, and adequate funds would need to be allocated for the development of infrastructural and human resources. India’s gross domestic product allocated to health care should be increased, and some of the monies should be diverted towards HCAI surveillance. Nongovernmental organizations should be allowed to assist with supporting the Government in these efforts.22

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M. Biswal et al. / Journal of Hospital Infection 90 (2015) 12e14

To conclude, the introduction of public reporting of HCAI rates in India would lead to quality control in a long-neglected area of health care, and enable patient empowerment which is practically non-existent in India. The management of healthcare institutions should commit towards enforcing ‘zero tolerance’ towards lapses in the prevention of HCAIs.5 Public pressure would force the Indian Government to acknowledge the HCAI problem and allocate funds to improve resources and infrastructure. Therefore, despite the numerous challenges that would be encountered in establishing a national benchmarking system of HCAIs with public reporting of results, this should be seen as an attainable and vital goal that will go a long way towards tackling the threats posed by HCAIs in developing countries such as India. Conflict of interest statement None declared. Funding sources None.

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References 1. Johnson AP, Davies J, Guy R, et al. Mandatory surveillance of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia in England: the first 10 years. J Antimicrob Chemother 2012;67:802e809. 2. Wilson AP, Kiernan M. Recommendations for surveillance priorities for healthcare-associated infections and criteria for their conduct. J Antimicrob Chemother 2012;67(Suppl. 1):i23ei28. 3. Underwood J, Klein JL, Newsholme W. Escherichia coli bacteraemia: how preventable is it? J Hosp Infect 2011;79:364e365. 4. Dumartin C, Rogues AM, Amadeo B, et al. Antibiotic stewardship programmes: legal framework and structure and process indicator in Southwestern French hospitals, 2005e2008. J Hosp Infect 2011;77:123e128. 5. Jarvis WR. The Lowbury Lecture. The United States approach to strategies in the battle against healthcare-associated infections, 2006: transitioning from benchmarking to zero tolerance and clinician accountability. J Hosp Infect 2007;65(Suppl. 2):3e9. 6. Wunderink RG. Ventilator-associated tracheobronchitis: publicreporting scam or important clinical infection? Chest 2011;139:485e488. 7. Daneman N, Stukel TA, Ma X, Vermeulen M, Guttmann A. Reduction in Clostridium difficile infection rates after mandatory

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hospital public reporting: findings from a longitudinal cohort study in Canada. PLoS Med 2011;9:e1001268. Pittet D, Allegranzi B, Storr J, et al. Infection control as a major World Health Organization priority for developing countries. J Hosp Infect 2008;68:285e292. Ministry of Environment and Forests, Notification N. S.O.630 (E). Biomedical waste (management and handling) rules, 1998. The Gazette of India, Extraordinary, Part II, Section 3(ii), 27th July 1998. Cooke EM, Coello R, Sedgwick J, et al. A national surveillance scheme for hospital associated infections in England. Team of the Nosocomial Infection National Surveillance Scheme. J Hosp Infect 2000;46:1e3. Arias KM. Mandatory reporting and pay for performance: health care infections in the limelight. AORN J 2008;87:750e758. Tokars JI, Richards C, Andrus M, et al. The changing face of surveillance for health care-associated infections. Clin Infect Dis 2004;39:1347e1352. Lilford RJ, Brown CA, Nicholl J. Use of process measures to monitor the quality of clinical practice. BMJ 2007;335:648e650. Pittet D, Zingg W. Reducing ventilator-associated pneumonia: when process control allows outcome improvement and even benchmarking. Crit Care Med 2010;38:983e984. Oh JY, Cunningham MC, Beldavs ZG, et al. Statewide validation of hospital-reported central line-associated bloodstream infections: Oregon, 2009. Infect Control Hosp Epidemiol 2012;33:439e445. Martin M, Zingg W, Hansen S, et al. Public reporting of healthcareassociated infection data in Europe. What are the views of infection prevention opinion leaders? J Hosp Infect 2013;83:94e98. Pearson A, Chronias A, Murray M. Voluntary and mandatory surveillance for methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) bacteraemia in England. J Antimicrob Chemother 2009;64(Suppl. 1):i11ei17. Yuji K, Oiso G, Matsumura T, Murashige N, Kami M. Police investigation into multidrug-resistant Acinetobacter baumannii outbreak in Japan. Clin Infect Dis 2011;52:422. Fung CH, Lim YW, Mattke S, Damberg C, Shekelle PG. Systematic review: the evidence that publishing patient care performance data improves quality of care. Ann Intern Med 2008;148:111e123. Uckay I, Ahmed QA, Sax H, Pittet D. Ventilator-associated pneumonia as a quality indicator for patient safety? Clin Infect Dis 2008;46:557e563. Haustein T, Gastmeier P, Holmes A, et al. Use of benchmarking and public reporting for infection control in four high-income countries. Lancet Infect Dis 2011;11:471e481. Gravelle H, Sivey P. Imperfect information in a qualitycompetitive hospital market. J Health Econ 2010;29:524e535.

Mandatory public reporting of healthcare-associated infections in developed countries: how can developing countries follow?

The threat posed by increased transmission of drug-resistant pathogens within healthcare settings and from healthcare settings to the community is ver...
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