ABSTRACT
Hospital acquired infections (HAI) have assumed worrisome proportions in healthcare scenarios all over the world, be it the developed or developing world, the civil or service setting.
The service health care setting, however, has its own aspects which must be kept in mind while organizing infection control interventions. With the advent of systematic central procurement of equipment, decentralization of drug procurement with local purchase funds available at the hospital level, the non-availability of state of the art equipment and quality drugs is now passé. The area of concern, however, is the paucity of trained manpower to achieve the basic nurse to patient ratio for nursing care.
With the above background, after a preliminary study to confirm the incidence of HAI in the surgical ICU we instituted interventions towards control of HAI. Thereafter, we observed the incidence again to see the effects of the interventions.
Interventions
Regular interactive discussion with nursing staff highlighting the important aspects of infection control, designating one nursing officer as infection control nurse in rotation, demonstration of hand washing, installation of flexi-boards demonstrating the technique of hand-washing, installation of bedside white boards for each patient and noting “FASTHUG”. (A mnemonic to enumerate all the daily actions required in the management of critical patients. Developed by Jean Louis Vincent in Belgium it is a short mnemonic that highlights seven evidenced based best practices for critical care. It is a tool used to ensure that the seven essential evidence based aspects of patient care are not forgotten by the ICU team. These stand for F = early enteral Feeding A = assessment of Analgesia S = assessment of Sedation T = Thromboembolic prophylaxis H = Head of bed elevation U = stress Ulcer prophylaxis G = Glycemic control).
In addition the dates of insertion of catheters and lines, institution of ventilator associated pneumonia bundle (VAP) , catheter related blood stream infection (CRBSI) bundle, catheter associated urinary tract infection(CAUTI) bundle, use of subglottic suction, use of closed suction, attention to isolation of infected cases within the ICU. Introduction of shoe covers for all entrants to the ICU as mopping of the floor every 2 hours wasn’t possible.
Aims and Objectives
The aim of the study was to analyse the effects of structured interventions, tailored to the service setting on the incidence of HAI in our hospital ICU. The results would be compared with the results of a prior study. 1

Results
Statistical analysis to calculate 95% confidence intervals for incidence of infections was done using Epi-Table and chi square test for linear trend applied to length of stay and incidence of infection along with calculation of odds ratio was done using EPI Info software.
The total admissions to the ICU were 253 patients.  Eighty eight patients stayed in the ICU beyond forty eight hours and were included in the study. Only seven 7.95% ( 95% CI 3.54 ,15)  out of the eighty eight (88) patients were identified to acquire infection during 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 per patient.
Hospital acquired pneumonia was observed in 2 of the 88 patients (2.27%)  (95% CI 0.38, 7.30) all of these had undergone or were on mechanical ventilatory support. The total number of days that all patients were ventilated amounted to 206 days. Thus it amounted to 9.70 infections per 1000 ventilator days. The identified pathogens on broncho-alveolar lavage (BAL) in such patients were Acinetobacter sensitive only to imipenem and polymixin in both the patients.
Blood stream infection was detected in 3 out of 88 (3.4%) 95% CI 0.87, 8.99 patients. The source of such blood stream infections was central venous lines. The total number of days that all patients had indwelling Central Venous Catheters amounted to 459 days. Thus it amounted to 6.54 fresh infections per 1000 Central Venous Catheter days.
Urinary tract infection was observed in 2 (2.27%) 95% CI 0.38 ,7.30 of the patients. The total number of days that all patients had indwelling Foley’s catheters was 699 days. Thus it amounted to 2.86 fresh infections per 1000 catheter days. Only one was detected to be culture positive with E coli grown.
The total number of patients who stayed for less than 5 days in the ICU was 209 out of which 1 developed HAI (Fig 1). Three of the 35 patients who stayed from 5 to 10 days developed HAI and of the 9 patients who stayed more than 10 days 3 developed HAI (Table 2). Statistical analysis of this data proved that as the length of stay in the ICU increased the risk of developing HAI became highly significant.
Discussion
Evidence based interventions for prevention of HAI are well established. Inspite of the knowledge of the interventions required for minimization of HAI, they continue to be a major problem especially in the ICU setting. Difficulties in implementation of these guidelines have been found at the unit level, , and have been termed as change implementation failure. The impact of teaching interventions involving the ICU staff regarding hand hygiene and the various HAI prevention bundles has been shown to decrease HAI’s. A comprehensive systems approach targeted at efforts involving both process improvements and culture change, has been identified to enable sustainable change at the unit level.
The service setting with a structured regimented work force is unique as regards implementation of interventions. However, the frequent turnover of staff and the shortage of trained nursing staff in the ICU can be quite challenging. Consequently, we adopted a multi-pronged approach to this problem. We liaised with the administration of the nursing services and minimised the turnover of staff to the bare essential. Interactive sessions with the nursing and paramedical staff outlining the current evidence based recommendations were started. All fresh nursing and paramedical staff in the ICU were made to read and understand the infection control protocols in place. Interventions aimed at increasing awareness about hand washing were also implemented.
Recognising the fact that our nurse to patient ratio would not be ideal we instituted interventions that would be less labour intensive like use of closed suction catheters and continuous sub glottic suction of secretions. The closed suction catheters were replaced after a week 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 study1, the 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 2.8/1000 urinary catheter days. (Table 3,Fig 3)
We achieved a more rapid turnover of patients in the present study as compared to the previous one 1 ,  34.78% in the present study as compared to 69.6 % patients in the prior study  stayed for more than 48 hrs in the ICU. Thus part of the results achieved may have been because the stay of patients in the ICU was minimized. Since a number of interventions had been 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 sustenance 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.
Indian Society of Critical Care Medicine (ISCCM) in their guidelines discourages the adoption or continuance of open ICUs. To monitor standards of quality of care in ICUs as per national guidelines, it is imperative that the “ownership” of service ICUs is clearly defined ensuring that a specific team has full control and more importantly, therefore, also the responsibility to deliver the quality and outcomes desired.
More so, in view of the fact that hospital acquired infections constitute preventable or never events which are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. Hospitals in the US are now mandated by the Centers for Medicare and Medicaid to report central line–associated bloodstream infections and selected surgical site infections (eg, colon surgeries, hysterectomies, and cesarean delivery), these requirements are expected to expand to all other hospital-acquired infections in the near future. 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 complications” which includes some HAI’s. 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 negligence or medical errors, leaving medical practitioners open to the attendant risk of litigation for negligence.
In conclusion, our study demonstrated that by meticulously following relevant infection control protocols especially tailored to the service setting the incidence of HAI’s can be reduced. It is feasible to implement specific interventions. However, the challenge is in maintaining the momentum in view of the rapid turnover of manpower and lack of a structured ICU design model.