Healthcare-Associated Infections (HAIs): A Global Challenge

Healthcare-associated infections (HAIs) remain a significant global health issue, affecting patients in hospitals and healthcare facilities around the world. On any given day, approximately 1 in 31 hospital patients acquires at least one HAI [CDC, November 2024].

These infections are largely preventable, and one of the most effective ways to reduce their spread is through proper hand hygiene.

In fact, appropriate hand hygiene can prevent up to 50% of avoidable infections in healthcare settings, making it a crucial component of infection control practices.

Key Statistics on Health Associated Infection (HAI)

Global Impact of HAIs:

• In high-income countries, 7 out of every 100 hospital patients acquire an HAI.
• In low- and middle-income countries, the number increases to 15 out of every 100 patients.
• The European Union and European Economic Area report 8.9 million HAIs annually in both acute and long-term care facilities [W.H.O, 2021].

Hand Hygiene’s Effectiveness:

• Proper hand hygiene can prevent up to 70% of HAIs.
• However, compliance with hand hygiene is often low:
  • In low-income countries, compliance is only about 9% when caring for critically ill patients.
  • In high-income countries, compliance rarely exceeds 70%.

Impact on Mortality:

• Over 24% of patients with healthcare-associated sepsis die each year.
• Infections resistant to antimicrobial treatments increase death rates by 2 to 3 times.

These figures underscore the critical need for robust infection control measures, particularly improving hand hygiene practices across healthcare settings.

What is Health-Associated Infection (HAI)?

HAI stands for Healthcare-Associated Infection. These are infections that patients acquire while receiving treatment for other conditions within a healthcare setting, such as hospitals, clinics, or long-term care facilities.

These infections usually start 48 hours or more after being admitted to the hospital or within 30 days of treatment. Some common HAIs are infections after surgery, pneumonia, urinary infections, and infections in the blood.

HAIs are infections that were not there when the patient first entered the healthcare facility, but they develop while the patient is staying there or soon after they leave.

Healthcare-associated infections are mostly spread through touch.

This is the most common way infections are passed on in hospitals and healthcare settings. Touch can spread infections in two ways:

• Direct contact: When an infected patient or person touches a healthcare worker or another patient.
• Indirect contact: When germs are left on surfaces or objects, like doorknobs or medical equipment, and are later touched by healthcare workers or patients.

Examples of infections spread through touch include:

• MRSA (a type of bacteria resistant to antibiotics)
• VRE (another antibiotic-resistant bacteria)
• Clostridium difficile (a bacteria that causes severe stomach issues)
• Germs that cause skin infections like impetigo and scabies
• Stomach bugs like norovirus

While germs can also spread through coughs or sneezing, touch remains the most common way infections spread in healthcare settings.

Examples of common healthcare-associated infections include:

• Urinary tract infections (UTIs): Often caused by catheter use.
• Surgical site infections: Infections that develop in the wound after surgery.
• Pneumonia: Particularly ventilator-associated pneumonia (VAP) in patients on mechanical ventilation.
• Bloodstream infections: Such as central line-associated bloodstream infections (CLABSI).
• Gastrointestinal infections: Like Clostridium difficile (C. diff) infections, often linked to antibiotic use.

HAIs are a significant concern because they can lead to longer hospital stays, higher medical costs, more severe health complications, and even death.

A study from 2016/2017 estimated that about 834,000 healthcare-associated infections (HAIs) happen each year in NHS hospitals across England [BMJ Journal]. Also, according to the US CDC, nearly 1.7 million patients in hospitals get these infections each year, and more than 98,000 of them die from it.

Preventing and controlling HAIs, primarily through effective infection control measures like hand hygiene, is crucial for improving patient outcomes in healthcare settings.

Common Examples of Healthcare Associated Infections

1. Urinary Tract Infections (UTIs)

• Most common healthcare infection
• Often caused by urinary catheters
• Symptoms: burning feeling, needing to pee a lot, cloudy pee
• Prevention: care for catheters, remove when not needed

2. Surgical Site Infections (SSIs)

• Happen near surgery cuts
• Can show up up to 30 days after surgery
• Symptoms: redness, pain, swelling near the wound
• Prevention: clean wound care, sterile surgery techniques

3. Bloodstream Infections

• Often linked to central lines or IVs
• Can cause serious illness like sepsis
• Symptoms: fever, chills, fast breathing
• Prevention: clean insertion techniques, regular care of lines

4. Pneumonia

• Includes Ventilator-Associated Pneumonia (VAP)
• Happens in patients using breathing machines
• Symptoms: cough, chest pain, trouble breathing
• Prevention: proper body position, clean equipment, oral care

5. Clostridium difficile (C. diff)

• Causes bad diarrhoea
• Often after taking antibiotics
• Spreads easily in hospitals
• Prevention: wash hands with soap, isolation of affected patients

6. MRSA (Methicillin-resistant Staphylococcus aureus)

• A tough infection that resists many medicines
• Can affect skin, wounds, and internal organs
• Spreads by touching infected people
• Prevention: check high-risk patients, use contact precautions

7. Norovirus

• Causes bad vomiting and diarrhoea
• Very contagious in hospitals
• Spreads quickly between patients
• Prevention: wash hands well, isolate infected patients

8. E. coli Infections

• Can affect different body parts
• Often caused by not washing hands properly
• Common in urinary tract infections
• Prevention: wash hands, clean medical tools

Key Prevention Tips:

• Wash hands often
• Use personal protective equipment (PPE) properly
• Clean and disinfect equipment regularly
• Use antibiotics only when needed
• Spot and isolate infected patients quickly

Remember: These infections are more dangerous for:

• Older patients
• People with weak immune systems
• Patients who just had surgery
• People with long-term health problems
• Very young children

Quickly noticing and acting fast helps stop the spread of these infections in hospitals and clinics.

Hand Hygiene Compliance: Variability and Trends

Hand hygiene compliance varies widely across healthcare settings, worker types, and countries. Below are some key findings:

Developed Countries:

• A study in Moscow showed an increase in hand hygiene compliance from 52.3% to 83.3% following the implementation of an action plan.
• During the COVID-19 pandemic, a large US hospital reached a peak compliance rate of 92.8%, with some units achieving 100% compliance.
• A 6-year study showed hand hygiene compliance improving from 76.4% in 2013 to 88.5% in 2018. [PubMed Central]

Developing Countries:

• In sub-Saharan Africa, only 37% of healthcare facilities have access to handwashing facilities with water and soap.
• A study across multiple developing countries found hand hygiene compliance as low as 25.3%, with nurses showing the highest rate (28.5%) and cleaning staff the lowest (9.9%).
• Despite the differences in infrastructure and resources, hand hygiene compliance remains suboptimal in both developed and developing countries. A significant gap exists in basic hygiene services, with about 51% of healthcare facilities in developing countries lacking essential hygiene infrastructure such as clean water and soap.

Specific Challenges in the UK

In the UK, hand hygiene compliance also shows variability, especially across different clinical areas and among healthcare workers:

• A large UK hospital trust reported compliance rates ranging from 58% to 100% across various clinical areas.
• In a 24-hour observational study, overall compliance was 75%:
  • Doctors: 47%.
  • Nurses: 75%.
  • Allied health professionals: 78%.
  • Ancillary staff: 59%.
• A quality improvement project at a UK medical ward demonstrated an increase in compliance from 53% in 2015 to 80% in 2017.

These figures suggest that while progress has been made, there is still room for improvement, particularly among doctors, whose compliance rates lag behind those of nurses and allied health professionals.

Factors Contributing to Low Compliance

Several factors contribute to low hand hygiene compliance, particularly among cleaning staff in healthcare settings:

• Lack of Resources: Not enough hand rub (ABHR), working handwashing stations, or skin care products like moisturisers.
• Time Constraints: Busy schedules and pressure can stop staff from washing hands properly.
• Lack of Awareness: Some staff may not know how important hand hygiene is or when it’s most needed.
• Poor Equipment: Using poor quality soap, hand dryers, or sinks can make it hard to clean hands properly.
• Lack of Accountability: Without enough checks or consequences, some staff might not follow hand hygiene rules.

Ways to Improve Hand Hygiene Compliance

To improve hand hygiene practices, particularly among cleaning staff in the UK, healthcare facilities can implement the following strategies:

Education and Training:

• Give regular training on why hand hygiene is important, how to do it properly, and best practices. Make sure the training is for cleaning staff and include them in infection control meetings.

Improve Product Availability:

• Make sure there is always enough hand rub (ABHR) and soap in all areas, even during night shifts. Put dispensers in easy-to-find spots.

Address Skin Irritation:

• Offer skin-friendly soap and moisturisers to reduce discomfort caused by frequent handwashing. This will encourage cleaning staff to adhere to good hand hygiene practices without the risk of skin damage.

Enhance Facilities:

• Set up proper handwashing stations with warm water, paper towels, and foot-operated bins for drying hands. This is important in areas where staff wash their hands often.

Clear Guidelines:

• Make clear hand hygiene rules that are easy to follow and fit the cleaning staff’s work environment.

Monitoring and Feedback:

• Use electronic monitoring systems to track compliance and provide regular feedback to staff. Regular reminders and feedback are proven to improve adherence to hand hygiene protocols.

Incentivise Compliance:

• Think about giving rewards to staff who follow hand hygiene rules well, like praise or small prizes. This can encourage others to do the same.

Time Management:

• Change cleaning schedules so staff have enough time to wash their hands properly, without affecting their work or patient care.

Behavioural Interventions:

• Implement behaviour change techniques, such as peer-led training or positive reinforcement, to improve compliance among cleaning staff.

Common Prevention Methods for Healthcare Associated Infections

To prevent healthcare-associated infections (HAIs), here are some key strategies:

• Hand Hygiene: Regular hand washing and using hand sanitisers is the easiest and cheapest way to stop infections from spreading.
• Vaccinations: Encouraging flu and pneumonia shots for patients and staff helps prevent infections.
• Active Screening: Testing patients for bacteria like MRSA before surgery and treating those who carry it can reduce infections after surgery.
• Isolation or Cohorting: Keeping infected patients separate helps stop infections from spreading.
• Surveillance Systems: Hospitals need systems to watch for infections and act quickly if needed.
• Antibiotic Stewardship Programs (ASPs): These programs help use antibiotics carefully to avoid resistance and reduce infections like C. difficile.

Proper Use of Medical Devices: Using medical devices like catheters and ventilators only when needed and properly can prevent infections.

These measures, when used properly, can greatly reduce the number of infections in healthcare settings.

Importance of Staff Training in HAI Prevention

Staff training is very important for stopping infections in healthcare settings, from cleaners to nurses and everyone involved. Studies have proven that healthcare-associated infections training helps reduce the number of healthcare-associated infections (HAIs).

1. Better knowledge and skills: Training helps healthcare workers learn how to prevent infections, which leads to better care for patients and fewer infections.
2. Following best practices: Studies show that trained staff are more likely to follow the right infection control steps.
3. Awareness and readiness: Training helps workers stay aware of the risks of infections and be prepared to act.
4. Quick skill improvement: Training helps workers learn the key things they need to know quickly.
5. Team effort: Training should include everyone, from doctors to cleaning staff, to stop infections from spreading.
6. Ready for new challenges: Ongoing training helps staff deal with new health problems or diseases.
7. Legal duty: Employers must train workers properly to make sure they know how to prevent infections.
8. Continuous learning: Regular training helps reduce infections over time.
9. Fixing knowledge gaps: The COVID-19 pandemic showed that some healthcare workers needed more training to fight infections.
10. Protecting workers: Training also helps keep healthcare workers safe from infections.

In short, training helps everyone in healthcare do their job well and protect both patients and staff from infections.

Conclusion

Healthcare-associated infections (HAIs) continue to be a serious issue affecting millions of patients worldwide.

Hand hygiene remains one of the most effective methods to reduce the transmission of infections, but compliance rates remain unacceptably low, particularly in low-resource settings and among certain healthcare workers.

Addressing barriers such as lack of resources, time constraints, and lack of awareness, while providing better education, infrastructure, and support, can significantly improve hand hygiene practices.

By doing so, healthcare facilities can reduce the incidence of HAIs, protect patients, and reduce the strain on healthcare systems, ultimately saving lives, particularly among the most vulnerable populations.

References
[1] https://www.ncbi.nlm.nih.gov/books/NBK2683/
[2] https://www.gov.uk/government/publications/health-protection-in-schools-and-other-childcare-facilities/what-infections-are-how-they-are-transmitted-and-those-at-higher-risk-of-infection
[3] https://pmc.ncbi.nlm.nih.gov/articles/PMC9781912/
[4] https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0073970
[5] https://www.racgp.org.au/running-a-practice/practice-standards/racgp-infection-prevention-and-control-guidelines/introduction-transmission-of-infection-in-health-c