Australian Infection Control Guidelines: preventing and managing infection in health care

The Australian Infection Control Guidelines: preventing and managing infection in healthcare were released this year in October. The Guidelines were developed by the National Health and Medical Research Council (NHMRC) on behalf of the Australian Commission on Safety and Quality in Healthcare as one of the five arms of the Commission’s Healthcare Associated Infection priority program. The Guidelines provide the evidence base for the implementation of a coordinated approach to the management of healthcare-associated infection in Australia.

Approximately 200 000 healthcare-associated infections occur in Australian acute healthcare facilities each year.¹ This makes healthcare-associated infection the most common complication affecting patients in hospital. As well as causing unnecessary pain and suffering for patients and their families, these adverse events prolong hospital stays and are costly to the health system. The problem does not just affect patients and workers in hospitals – healthcare-associated infection can occur in any healthcare setting, including office-based practices.

Healthcare-associated infection is a potentially preventable adverse event rather than an unpredictable complication. Successful approaches for preventing and reducing harms arising from healthcare-associated infection involves applying a risk-management framework to manage ‘human’ and ‘system’ factors associated with the transmission of infectious agents.

Effective infection prevention and control is central to providing high-quality healthcare for patients and a safe working environment for those that work in healthcare settings. The Guidelines emphasise the fact that infection control is everybody’s business and the responsibility applies to everybody working and visiting a healthcare facility, including administrators, staff, patients and carers.

The target audience of the Guidelines is clinicians, ancillary staff and administrators across Australia’s acute care and office-based practices. The Guidelines aim to assist healthcare workers and managers to focus on the delivery of safe and quality care which essentially promotes and facilitates the overall goal of infection prevention and control.

Given the Guidelines provide the evidence base and the core principles of infection control, it is anticipated that the evidence can be readily adapted into a companion resource to suit other healthcare settings, including primary and community care.

The Guidelines differ significantly from the Department of Health and Ageing (DoHA) Infection control guidelines for the prevention of transmission of infectious diseases in the health care setting (2004) because they are written from a care delivery perspective rather than being disease and setting specific.

The core principle of the Guidelines is that the creation of safe healthcare environments is achieved through the implementation of practices that minimise the risk of transmission of infectious agents.

The adoption of this risk management approach in the development of the Guidelines stems from the feedback received from extensive preliminary scoping conducted by the Commission and NHMRC before commencing the production of the Guidelines.

The primary users of the Guidelines indicated that they needed a national reference document that was evidence-based and focussed on the infection control risks, risk management strategies and processes that are relevant for day-to-day practice in all healthcare settings across Australia. The areas of environment cleaning of healthcare facilities, the management of multidrug-resistant organisms; and management of staff health, that is, immunisation requirements of healthcare workers and the management of healthcare workers with an infectious disease, were all identified as areas requiring a national approach.

The NHMRC process for guideline development was used to ensure that these Guidelines are based on the best available evidence and knowledge of the practicalities of clinical procedures. The Guidelines draw on the evidence obtained from systematic literature reviews conducted by NHMRC to inform areas of clinical uncertainty. For established areas of clinical practice, published international infection control guidelines and national discipline-based infection control guidelines were utilised for the development of recommendations.

Information was also drawn from the Commission’s National Surveillance Strategy and Hand Hygiene initiative as well as the two previous national infection control guidelines.^2,3 Where there was a paucity of published scientific evidence to support established practice, good practice points were developed by the NHMRC Infection Control Guidelines Steering Committee (ICGSC) and supported by successful case studies sourced from various jurisdictions. Further information on how the recommendations were developed and their underpinning evidence is available in the process report on the NHMRC website: http://www.nhmrc.gov.au/node/30290.

An essential element of the Guidelines development process was the establishment of partnerships with key users of the Guidelines such as the Australian Infection Control Association, state and territory quality and safety/communicable disease units, the Australian Dental Association, the Royal Australian College of General Practitioners, DoHA Office of Health Protection and the Communicable Diseases Network of Australia. These partners provided assistance in identifying and evaluating international infection control guidelines and providing feedback on numerous drafts, which has been pivotal in the acceptance of the Guidelines.

The Guidelines provide 24 key recommendations on infection and prevention in healthcare and are structured into three sections. The first provides an overview of the modes of transmission of infectious agents, the steps involved in the risk management cycle and patient-centred care. Risk management case studies and strategies to involve patients in their care are provided within each section to illustrate the application of the Guidelines.

The second section details the development of effective work practices that minimise the risk of transmission of infectious agents by covering the application of standard and transmission-based precautions, the management of multidrug-resistant organisms and outbreak investigation management. Numerous resources and supplementary information such as a comprehensive recommended routine cleaning frequency table has been developed to enable healthcare workers and healthcare facilities to develop detailed protocols and processes for infection prevention and control specific to local settings.

The final section outlines the governance structures that support the implementation, monitoring and reporting of infection prevention and control work practices. Topics include: clinical governance, staff health, education and training, antibiotic stewardship and the influence of facility design on healthcare-associated infection. In the staff health section, a risk management approach has been implemented to guide screening and immunisation requirements of healthcare workers and management of infected healthcare workers.

The Guidelines make reference to but do not include detailed information on areas of: infectious diseases; pandemic planning; the reprocessing of reusable medical instruments or devices; occupational health and safety; hospital hotel services such as food and laundry services or waste disposal; and engineering/health facility design. The Guidelines do not duplicate information that is regulated or legislated by state health authorities. However, they provide links to relevant infection control tools and resources from professional and specialist websites and identify relevant Australian Standards.

Understanding the modes of transmission of infectious organisms and knowing how and when to apply the basic principles of infection prevention and control is critical to the success of an infection control program. This responsibility applies to everybody working and visiting a healthcare facility, including administrators, staff, patients and carers and is supported through implementation strategies developed by the NHMRC and the Commission to aid in the uptake of the Guidelines’ recommendations. These strategies were approved for use in Australian hospitals by the Health Ministers at Australian Health Ministers’ Conference in November 2010.

The Commission has developed the following tools and resources which are available from their website. http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram-03_ImpGuides-TaR.

An educational program designed to assist with implementation of the Guidelines delivered as a series of workshops conducted in all jurisdictions between November 2010 and mid-2011. The program will bring together implementation strategies and approaches from the implementation guides. It will also enable practitioners to gain practical experience using some of the tools showcased in the toolkit, and to build support networks that can be drawn upon as their implementation work progresses.

An implementation guide which is a ‘change management’ and implementation toolkit incorporating practical implementation methods and approaches, has been developed. The purpose of the ‘OSSIE’ toolkit is to provide clinicians and managers, responsible for infection control practice, with practical tools, resources and information that can be used in a range of healthcare settings to help implement the Guidelines.

A Guidebook for Primary Care was developed in recognition that most healthcare in Australia is provided in primary care settings, but these settings may have fewer resources available than acute care settings. The primary care guide includes practical examples and case studies specific to the primary care context.

While the basic principles of HAI prevention apply, the primary care context is very different from acute care, and issues concerning implementation of the Guidelines will need to be specific to the context. Provision of a resource that provides suggestions and ideas for implementation specific to primary care aims to ease implementation of the Guidelines across primary care settings.

This Guidebook complements the more comprehensive OSSIE toolkit (see above), which has drawn on the work of several documents developed to support guideline implementation in a range of contexts. The guide will be distributed at the workshops and is available on the Commission’s website.

Patient information brochures on what is a healthcare associated infection, Methicillin resistant Staphylococuss aures, Vancomycin-resistant Enterococci and Clostridium difficile, and infection control precautions signs are available for download from the NHMRC website and are suitable for the acute and subacute healthcare settings. The NHMRC clinical educators guide will be available in January 2011 and will assist clinicians responsible for the supervision of students and new graduates, of all disciplines across healthcare, and will cultivate an understanding of a risk management approach to infection prevention and control.

In early 2011, an electronic infection control orientation tool for healthcare workers relevant to all healthcare facilities will be available for use throughout Australia.