Behavior changes to reduce healthcare-associated infections

Our goal is not to control infections after they happen but to prevent them before they happen

Healthcare-associated infections (HAIs) are infections that occur while receiving health care. Patients with medical devices (central lines, urinary catheters, ventilators) or who undergo surgical procedures are at risk of acquiring HAIs.

HAIs  continue to be a tremendous issue today, however most HAIs are preventable.

The prevention and management of HAIs has advanced greatly over the last decade due to legislative, regulatory and organizational incentives. However, these changes have not resolved the gap between evidence base and clinical practice, particularly in healthcare workers’ (HCWs) behavioural change. Interventions aimed to improve HCWs’ compliance with infection prevention and control (IPC) practices such as hand hygiene have achieved varied success.

Surgical site infections (SSIs) are the most common HAIs among surgical patients. It is obviously important to improve patient safety by reducing the occurrence of surgical site infections. Both the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) have recently published guidelines for the prevention of surgical site infections. Despite clear evidence and guidelines to direct SSIs prevention strategies, compliance is uniformly poor and major difficulties arise when introducing evidence and clinical guidelines into routine daily practice.

High rates of inappropriate IPC practices in surgery continue to be reported in the literature. Due to cognitive dissonance (recognising that an action is necessary but not implementing it), changing behaviour is extremely challenging. In hospitals, cultural, contextual, and behavioral determinants influence clinical practice. Improving behavior in IPC practices remains a challenge. Understanding how to implement healthcare workers’ behavior is fundamental to develop effective reduction in HAIs.

There are generally three primary levels of influence related to behavior modification and infection control in healthcare facilities:

1) Intrapersonal factors;

2) Interpersonal factors;

3) Institutional or Organizational factors.

Including these three levels of influence in IPC interventions may be a key in preventing HAIs.On an individual level, healthcare workers should have the necessary knowledge, skills, and abilities to implement effective infection control practices. Increasing the knowledge may influence their perceptions and motivate them to change behavior. Education and training represent an important component for accurate implementation of recommendations. Education of all health professionals in preventing HAIs should begin at undergraduate level and be consolidated with further training throughout the postgraduate years.

Hospitals are responsible for educating clinical staff about infection prevention and control programs. Active education techniques, such as academic detailing, consensus building sessions and educational workshops, should be implemented in each hospital  worldwide according to its own resources. However, increasing knowledge alone may not be sufficient for effective infection control and may be insufficient to effect sustained change especially considering the multi-factorial nature of the problem of HAIs.

Peer-to-peer role modeling, and champions on an interpersonal level have been shown to positively influence implementation of infection control practices. Many practitioners use educational materials or didactic continuing medical education sessions to keep up-to-date. However, these strategies might not be very effective in changing practice, unless education is interactive and continuous, and includes discussion of evidence, local consensus, feedback on performance (by peers), making personal and group learning plans, etc. Identifying a local opinion leader to serve as a champion may be important because the “champion” may integrate best clinical practices and drive the colleagues in changing behaviors, working on a day to day basis, and promoting a culture in which infection prevention and control is of  high importance. Surgeons with satisfactory knowledge in surgical infections may provide feedback to the prescribers, integrate the best practices among surgeons and implement change within their own sphere of influence interacting directly with IPC team.

Organizational obstacles may influence infection prevention and control implementation. Many different hospital disciplines are typically involved in IPC, making collaboration, coordination, communication, teamwork and efficient care logistics essential. IPC teams have been shown to be both clinically effective improving patients outcome, and cost-effective providing important cost savings in terms of fewer HAIs, reduced length of hospital stay, less antimicrobial resistance and decreased costs of treatment for infections.

Raising awareness of IPC to stakeholders is a crucial factor in changing behaviors. Probably clinicians are more likely to comply with guidelines when they have been involved in developing the recommendations. One way to engage health professionals in guideline development and implementation is to translate practice recommendations into a protocol or pathway that specifies and coordinates responsibilities and timing for particular actions among a multidisciplinary team. There is now a substantial body of evidence that effective team-work in health care contributes to improved quality of care. Leading international organizations, such as the WHO, acknowledge that collaborative practice is essential for achieving a concerted approach to providing care that is appropriate to meet the needs of patients, thus optimizing individual health outcomes and overall service delivery of health care. The use of such approaches reinforces the concept that each one brings with them their particular expertise and is responsible for their respective contributions to patient care. In this context the direct involvement of surgeons may be crucial.