If we talk about the host, there are immune-compromised patients who are vulnerable to infections. There are transplant patients; there are patients on long term steroid therapy, extremes of age who are most susceptible to infection, diabetes and cancer patients. India is diabetes capital of world with largest number of diabetes who are highly susceptible to infection.
Dr Shah: Prevention and precautions can certainly help reducing infections and there is no doubt about it. In fact, prevention practices are the reason why surgeons can perform very complex surgeries like transplant, intensivists can bring back a patient from multi-organ failure and babies less than 500g birth weight can survive. Infection prevention practices are proven scientifically in various studies and hence is accepted by WHO. However, in India, we do have a long way to for implementation of prevention measures in all the health care facilities.
Infection can spread from one patient to another; from environment of hospital like table, trolley or stethoscope to the patient, from health care personnel to the patient and also from patient to health care personnel. This is due to lack of hand hygiene, incomplete adherence to standard (universal) aseptic precautions, incomplete vaccination, inadequate isolation when indicated and breach in infection prevention and control practices.
What are the methodologies used and what is lacking?
Dr Mamtora: The methodologies are common sense and commitment for improvement. We have to provide basic infrastructure such that it avoids overcrowding, proper maintenance of HVAC systems in hospitals, use of building materials which provides smooth non porous surfaces, appropriate zoning in OT, CSSD and transplant facilities and process flow should be from clean to dirty area unidirectional to avoid cross contamination, appropriate ventilation facilities especially airborne isolation facilities with negative pressure rooms for preventing tuberculosis, preventing moisture and dampness in the hospital especially in humid conditions like coastal areas and many such small detailing related to infrastructure is of foremost priority. Cost of infrastructure
even though huge is in the form of one-time investment.
In India, we don’t give importance to having proper designated person for infection control. Often, skilled workers face harassment in the hospitals. Either medical microbiologists or senior clinicians or infection control nurses are given the responsibility. Since there are always double or multiple responsibilities, expert advice itself is compromised. Sometimes meetings related to infection control are not effective to implement standard guidelines due to delay in budget approval or staff resistance. When hand hygiene needs to be implemented on priority basis, in many places, there is no hand-washing facility or there is water shortage.
Another challenge is there are different guidelines from different associations and the executive summaries may be at times contradictory because these are evidence-based guidelines, so extrapolation of guidelines should be suitable for given settings and they have to be thoughtfully implemented. As we all know majority of these guidelines come from western countries which is developed, and privileged world and we are still developing world.
Many places infection control is neglected and there is no dedicated budget or no annual planning. Benchmarking & standardization for India for infection control parameters is still in infancy. Also, Indian healthcare is divided between government three tier healthcare system and private sector and data records are massive. However, till, there is no appropriate utilization of data because we are still left with basic problems like providing cleanliness and hygiene.
Recently NABH accreditation has started collecting data on quality parameters from hospitals but still majority of hospitals are not participating for accreditation programs as it is purely voluntary participation. The scenario is changing since NABH has developed Pre-Accreditation Entry Level Certification for CGHS schemes. However, journey is long, but it cannot be predicted due to low. If there is more participation from hospitals and especially from the government sector, which has large bed strength hospitals including ICU beds, then the data will be more representative of population data and actual rates of hospital acquired infections can be known.
There is also lack of standardization of processes. Every institute follows different practices and protocols.
Sometimes they may be overdoing which leads to unnecessary wasteful expenditures. Sometimes it may happen that organizations are insisted upon certain practices to be followed which are though subjective but are implemented. If we look at the challenges, there are manifold. It needs appropriate staffing, appropriate resources, proper planning of what is best suited in given scenario and willingness for implementation.