Infections acquired in hospitals are a major contributor not only to avoidable deaths but also to the cost of health care. Among preventative measures the simple but often neglected practice of hand-washing stands out.
September 13 is World Sepsis Day. “Not another DAY”, you may be thinking. But sepsis occurring in hospitals is a big problem. Sepsis kills.While the global incidence is far higher than in Australia, we have a problem too.
Sepsis can kill mothers soon after they give birth, accounting for 11.4 per cent of maternal deaths in Australia. And the incidence of maternal sepsis has increased.
1n 2015-2016 sixteen children died from sepsis in tertiary children’s hospitals in Australia.
Sepsis refers to severe infections, such as blood steam infection (septicaemia) and septic shock. It is a medical emergency. Part of the problem is the body’s overwhelming inflammatory response to severe infection, injuring the body’s own vital organs, sometimes leading to organ failure and death.
In New South Wales, more than 6,000 patients are hospitalised each year due to sepsis. These patients represent a significant burden on health resources, often requiring intensive care, extensive treatments and investigations. Length of stay in hospital becomes significantly prolonged. Around 18 per cent of these patients will die from sepsis-related complications.
The NSW Clinical Excellence Commission has a Sepsis Kills awareness program that aims to reduce preventable harm to patients through improved recognition and management of severe infection and sepsis in emergency departments and wards. The emphasis is on recognising , signs and symptoms of sepsis, resuscitating and treating within the first hour of recognition of sepsis and promptly referring to expert help.
All patients who have an infection are at risk of developing a life threatening sepsis. These patients can be saved by early intervention. There is now clear evidence from a 2016 study in the Medical Journal of Australia, that the earlier sepsis is recognised and the earlier antibiotics are given, the greater the chance of survival. Delayed treatment is associated with an increased chance of death.
While patients may present to an emergency department with signs of sepsis, sometimes they become infected while in hospital. These are preventable infections. Infections that are caught in a hospital are called Healthcare Acquired Infections, HAIs are totally preventable. They are not unpredictable complications.
Some HAIs lead to severe, life-threatening sepsis and death. Mostly, they can cause increased length of time in hospital, serious complications, discomfort and considerable inconvenience to patients as well as increased health costs.
There are many causes, including environmental cleaning inadequacies, inadequate cleaning and sterilization of equipment and failure to follow policies about cleaning and infection control. But the major cause is poor hand hygiene: from staff at every level and from patients and visitors.
There are about 200,000 HAIs in Australia each year, making this the most common hospital complication. It’s estimated that they account for 2 million unnecessary hospital bed days/year, making this a major component of health costs. They occur in the public and the private sectors.
The biggest cause of infection in hospital is failure to take precautions, with the biggest failure being inadequate hand washing or not washing at all.
We are now learning that hospitals can be dangerous places. Sometimes things go wrong and patients suffer. The Institute for Healthcare Improvement in Boston showed that the risk of death from hospital admission is the same as the risk of death from mountain climbing or bungy jumping. But of course, because hospital admissions are far more common than these sports, the actual number of deaths is far higher.
Of course, many people admitted to hospital are often unhealthy to start with. They may have multiple health problems. Some have supressed immune systems, making them more susceptible to infection. They may undergo complex procedures where there are small margins for error.
A less apparent reason is that not all health professionals practise hand hygiene as well as they should.
Good hand hygiene is probably the most important thing health workers can do to protect their patients from infection.
What can patients do to protect themselves? Asking health professionals if they have washed their hands is a good start.
Audits show that a substantial minority of health professionals don’t wash their hands as often as they should. Campaigns, coupled with surveillance, by Hand Hygiene Australia and other patient safety bodies show that compliance with hand washing is increasing, although slowly.
In 2010, 70 per cent of nurses complied with hand washing regimes, the highest of all health professional groups surveyed. By 2105, their rate had risen to 86 per cent. Even so, would you rest easy if you knew that there was a 14 per cent chance your nurse was one of those who had not performed correct hand hygiene?
Doctors comply less often. In 2010 the hand hygiene rate for doctors was just under half, a worrying 49 per cent. By 2015 their rate had risen to 71per cent. It’s a big improvement but doesn’t help if you are the patient of one of the 29 per cent who has not complied.
What can the patient, do about this? The answer is simple in theory, but difficult in practice. Just ask: “Excuse me, have you washed your hands?”
This is more difficult than it sounds. One study found that 77 per cent of patients would feel uncomfortable asking their doctors if they have washed their hands before examining them. Fifty seven per cent said that they would simply not ask, assuming the doctor had already washed. Twenty per cent worried that asking could be construed as questioning the doctor’s professionalism.
This view from patients is in contrast to the views of doctors about being asked this question by patients. Twenty nine per cent said they would not like to be asked. Twenty seven per cent said they would find it humiliating if they were asked.
The question “Excuse me, have you washed your hands?” is not the responsibility of the patient or of the health professional alone.
Patients need to know it’s OK to ask the question. It shouldn’t cause offence. It’s a basic part of good healthcare. Doctors should not take offence. They should expect and encourage their patients to ask.
One study found that 92 per cent of patients said they would be more likely to ask the question if the health professional made it clear that they were encouraged to ask, such as the doctor wearing a badge saying “Ask me if I’ve washed my hands.”
So patients need to be encouraged to ask and health professionals need to become more comfortable with patients asking the question.
If the aim of health care is to improve the health of the patient, rather than make it worse, it’s pretty obvious that good hand washing is crucial. And patients have a role too. This is why optimum health care occurs when there is a partnership between the person delivering the health care and the person receiving it.
Kim Oates is an Emeritus Professor at Sydney University and a Clinical Advisor to the Clinical Excellence Commission