Academic journal article Health Sociology Review

Mobilising for Safer Care: Addressing Structural Barriers to Reducing Healthcare-Associated Infections in Vancouver, Canada

Academic journal article Health Sociology Review

Mobilising for Safer Care: Addressing Structural Barriers to Reducing Healthcare-Associated Infections in Vancouver, Canada

Article excerpt

Introduction

Healthcare-associated infections (HCAIs) remain a leading cause of morbidity and mortality in Canada and internationally (McCarter, 2008; Pittet & Donaldson, 2005; Van Iersel, 2007). Approximately one in ten hospitalised patients are estimated to acquire an HCAI in Canada, contributing to approximately 220,000 annual infections and between 8,000 to 12,000 annual deaths (Zoutman et al., 2003). The treatment of HCAIs alone is estimated to cost the Canadian healthcare system approximately $1 billion (CAD) per year (Van Iersal, 2007). At the same time, research evidence supports the effectiveness of infection control programs and policies for reducing the incidence of HCAIs, and 30% to 50% of HCAIs are preventable (Canadian Committee on Antibiotic Resistance, 2007; McCarter, 2008; Peleg & Hooper, 2010; Zoutman et al., 2003). For specific HCAIs, such as catheter-related and central line-associated blood stream infections, studies have demonstrated that more than 60% are avoidable (Centers of Disease Control and Prevention, 2005; Pronovost et al., 2006). Despite evidence that directed programs, policies and reforms reduce HCAIs, structural and other barriers compromise their adoption and effective implementation.

Background

HCAIs result from bacterial, viral or fungal infections, which patients acquire while receiving treatment for other conditions during hospitalisation (McCarter, 2008). Of great concern in this context are bacteria that are resistant to multiple antibiotics (Grgurich, Hudcova, Lei, Sarwar & Craven, 2012, Morgan, Lomotan, Agnes, McGrail & Roghmann, 2010). HCAIs that are associated with high morbidity include infections that affect the respiratory tract, bloodstream, gastrointestinal and intra-abdominal system, surgical site wounds, skin and soft tissues, or multiple body sites (Fabbro-Peray et al., 2007). Examples of causative pathogens include methicillinresistant Staphylococcus aureus (MRSA), Clostridium difficile, vancomycin-resistant Enterococcus (VRE), multidrug-resistant Acinetobacter baumanii, noroviruses, and respiratory viruses.

Numerous evidence-based infection control programs are in place across Canada to prevent the acquisition of HCAIs. Some examples of these initiatives include efforts to improve healthcare worker hand hygiene (Hillburn et al., 2003; Pashman et al., 2007; Pittet, 2000), implementation of checklists (Haynes et al., 2009; Pronovost et al., 2006), and application of barrier precautions (Gravel et al., 2009a; Ofner-Agostini et al., 2007). These programs have all been implemented to some degree in Vancouver-area hospitals (www.picnet.ca), yet have achieved varying success in terms of compliance and execution. Gamage, Varia, Litt, Pugh, and Bryce (2008), for example, report that there is uneven monitoring of HCAIs in British Columbia acute care facilities, including the use of inconsistent surveillance methodologies. Programs in British Columbia include monitoring and public reporting of selected HCAI rates, incentives to improve hand-cleaning by healthcare workers, procedural checklists for ventilator use and catheter insertion, cleaning audits, reducing misuse of antimicrobials, and improved hospital design and re-configuration. Overall, these evidence-based reforms are generally in line with a positive deviance approach to behavioural modification by healthcare workers (Gardam, 2008; Marra et al., 2010). Other kinds of improvements aim to create a safety culture through networks and organisational change, recognising the need to create an accountability culture in hospitals (Jarvis, 2007; Yokoe et al., 2008). Despite these efforts, burnout, systemic non-compliance and other challenges in creating and maintaining longer-term infection control practices remain.

Creating sustained change in healthcare worker practices has been found to benefit from a multidimensional framework (Bouadama et al., 2010). For example, qualitative studies with healthcare workers have found that networks, peer-effects, organisational culture, and personal beliefs have been shown to hinder compliance with hand-hygiene initiatives (Erasmus et al. …

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