Ethics of Hospital Acquired Infections (HAI)
E10: Ethics of Hospital Acquired Infections, 3 hours, $21
Professor Rudolf Klimes, PhD, welcomes you to this online course. Keep going.
START the course here. TAKE the exam at the end. PAY after the exam.
Course Description: This is a short course that examines the ever emerging Hospital Acquired Infections and the pathways leading to this deathly situation. Covered is basic knowledge relating to HAI topics and ethical principles that can effect moral and decision making. This course is intended for both Healthcare and non-Healthcare workers.
Objectives: At the end of this course, you will 1. define HAIs 2. understand the magnitude of the problem 3. immerse in the “ethical roundtable debate” on HAIs 4. understand the need for Individual Responsibility
Course Format: Online linked resources and lectures that you can use anytime 24/7. One multi-choice test.
Course Developers and Instructors: R. Klimes, PhD, MPH (John Hopkins U), author of a variety of Healthcare articles and Dr. Heather Hawkins, author and avid learner of Epidemiology.
Course Time: Three hours for online study, test taking with course evaluation feedback and certificate printing.
QUESTIONS TO PONDER:
A patient dies from an ICU-acquired infection – how do you defend you case and your team? On the Contrary, as a patient or family of a patient, how does one handle the gravity of the situation? First, lets learn a little bit about the basics of HAIs – hospital associated infections.
SECTION ONE: BASICS OF HAIs (HOSPITAL ASSOCIATED INFECTIONS):
Health care-associated infections, or HAIs, are infections that people acquire while they are receiving treatment for another condition in a health care setting. HAIs can be acquired anywhere health care is delivered, including inpatient acute care hospitals, outpatient settings such as ambulatory surgical centers and end-stage renal disease facilities, and long-term care facilities such as nursing homes and rehabilitation centers. HAIs may be caused by any infectious agent, including bacteria, fungi, and viruses, as well as other less common types of pathogens.
These infections are associated with a variety of risk factors, including:
- Use of indwelling medical devices such as bloodstream, endotracheal, and urinary catheters
- Surgical procedures
- Contamination of the health care environment
- Transmission of communicable diseases between patients and healthcare workers
- Overuse or improper use of antibiotics
SECTION TWO: MAGNITUDE OF THE PROBLEM
HAIs are a significant cause of morbidity and mortality. At any given time, about 1 in every 25 inpatients has an infection related to hospital care. These infections cost the U.S. health care system billions of dollars each year and lead to the loss of tens of thousands of lives. In addition, HAIs can have devastating emotional, financial and medical consequences.
A majority of hospital-acquired HAIs include:
- Urinary tract infections
- Surgical site infections
- Bloodstream infections
The U.S. Department of Health and Human Services (HHS) has identified the reduction of HAIs as an Agency Priority Goal for the Department and is committed to reducing the national rate of HAIs by demonstrating significant, quantitative, and measurable reductions in hospital-acquired central line-associated bloodstream infections and catheter-associated urinary tract infections.
Please visit HAI Agency Priority Goals for more information on HAI specific goals, including the progress made to date.
Please visit HHS Agency Priority Goals for more information on all of the HHS Agency Priority Goals.
SECTION THREE: ETHICS ROUNDTABLE DEBATE:
How would you handle this situation?
An elderly patient dies from septic shock in the intensive care unit. This is perhaps not an unusual scenario, but in this case the sepsis happens to have been due to methicillin-resistant Staphylococcus aureus, possibly related to a catheter, and possibly transmitted from a patient in a neighboring room by less than adequate compliance with infection control procedures. The family decides to sue. A case study published in 2004 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1) discusses how experts from four different countries assess the medicolegal issues involved in this case.
Data strongly suggest that infection control measures such as hand hygiene and patient isolation can prevent the spread of MRSA. Could failure to adhere to such protocols be interpreted as medical negligence? Perhaps but, in defense, it is well accepted that controlling the spread of nosocomial infections is rarely dependent on any one factor but rather on a ‘package’ of surveillance and preventative measures. Pointing the finger of blame at any single individual or infection control strategy, or even groups of them, is unrealistic. Poor catheter insertion practices may contribute to the development of a nosocomial infection, but many other factors influence a patient’s likelihood of developing an infection, including their severity of illness, duration of ICU stay, previous medications and comorbid diseases, among others.
There are still many unanswered questions, partly because of inadequate surveillance and reporting in the past and the poor methodological quality of many of the studies conducted in this field. Why does one patient develop MRSA sepsis but not the next? If staff and patients were routinely screened for MRSA, then would this make a difference to infection rates? Would prophylactic antibiotic therapy in high-risk patients make any difference to infection rates? Establishing causality is difficult; certainly nobody is perfect, but how ‘perfect’ or ‘imperfect’ can physicians and other staff be expected, or allowed, to be? Everyone misses the occasional opportunity to wash his or her hands when leaving a patient, perhaps when they have to run to the next emergency, but how many missed occasions can be considered acceptable? These complex issues are explored here as experts from four countries provide us with their views on a hypothetical, but increasingly common, clinical scenario.
An elderly patient dies from septic shock on the ICU at your hospital. He had been admitted for subarachnoid hemorrhage 2 weeks earlier and had never woken up, although nobody had raised the issue of withdrawal of life support. The patient’s children overhear that the fatal infection had been due to a multiresistant staphylococcus called MRSA and may have been catheter-related. They now say that they remember having seen a nurse leaving the next patient, who was infected with that pathogen (it was written in red on the door), and then entering their father’s room without washing her hands. They remember having seen another nurse briefly enter the next patient’s room without wearing a gown, although this was clearly stated as a requirement in the infection control procedure noted on the door. They also wonder whether their father really needed the catheter that caused the infection. Accordingly, the children decide that the ICU-acquired infection that took their father is the hospital’s mistake. How would one handle the contrasting opinions of the hospital and patients?
Summary of an American Opinion:
Nosocomial infections can be serious and often devastating complications of critical illness, but their presence does not always indicate poor medical care. Many factors other than breaches in infection control and ‘contact precautions’ might have been important here, and if other factors are considered then the role played by these breaches in causing infection might have been negligible. Prevention of infection requires a combination of good care at many stages, a patient who has an underlying illness that responds quickly to therapy, minimizing exposure to invasive devices, and the hospital environment.
A French Opinion:
As with infection itself, it is probably better to prevent complaints than treat them. Explaining to families that nosocomial infections do occur in ICUs, why they occur (especially in long-term ventilated patients), and all that is done to control and contain these infections (in accordance with published and local guidelines) is probably one way to avoid complaints. In this regard, it is somewhat surprising that therapeutic plans and the possibility of withdrawal of life support had not been discussed beforehand with the patient’s family. This discussion would also have been an opportunity to discuss the potential risks associated with a prolonged ICU stay.
A Swiss Opinion:
If we are to defend the hospital and the ICU personnel, then we must take seriously the observations of the children about the way in which their father was cared for. The main issue is to clarify the facts. This will prove useful when discussing the situation with the plaintiffs but also when assessing the legal merits of the case. In this context, we would ask the ICU personnel about their own perception of the case and ask for the patient’s medical record. We would also organize a meeting with the children to give them an opportunity to express their feelings and provide them with as much information as possible. Many complaints are based on misconceptions and poor communication between the parties involved. It is therefore worth being open to criticism and complaint from the relatives in order to prevent further legal action. In the present case, however, it appears difficult to concede liability of the ICU personnel, especially if there was a clear policy on the information provided to the patients about the risks of hospital-acquired infection.
A Spanish Opinion:
The ICU staff made important mistakes in their implementation of isolation precautions. The noncompliant behavior is itself a risk factor for MRSA spread. However, we cannot conclude that there is a causal link between the faults of the staff and the patient’s death.
SECTION FOUR: BEYOND SYSTEMS FAILURES – A RETURN TO INDIVIDUAL RESPONSIBILITY
is good evidence that HAI rates can be reduced by a system wide approach. However, success also depends on the extent to which clinicians embrace measures such as adequate hand hygiene as internalized norms. Most HCWs acknowledge the importance of hand hygiene and often overestimate their compliance. Nevertheless, many patients, relatives and infection control professionals can cite examples of HCWs who repeatedly fail to disinfect their hands and react negatively to reminders. This may be due to ignorance of evidence that the hospital environment and fomites are often contaminated, or due to cognitive dissonance that allows HCWs to believe, despite the evidence, that their hands are uniquely uncontaminated. Hand basins or hand-rub dispensers are not always easily accessible but, even when they are, compliance may not improve. Whatever the reasons, persistent non-compliance of a few influential HCWs can seriously undermine an infection-control program through negative role-modeling.
CALL TO ACTION
There is growing consensus that our ultimate goal should be the elimination of HAIs. To coordinate and maximize the efficiency of prevention efforts, a senior-level Federal Steering Committee for the Prevention of Health Care-Associated Infections was established in 2008. Members include clinicians, scientists, and public health leaders who are high-ranking officials from the HHS, U.S. Department of Defense, U.S. Department of Labor, and U.S. Department of Veterans Affairs. The Steering Committee marshaled the extensive and diverse resources across the federal government, formed public and private partnerships, and initiated discussions that identified new approaches to HAI prevention and collaborations.
In 2009, the Steering Committee developed the National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination (HAI Action Plan). At a meeting held in late 2010, subject matter experts (SMEs) met to discuss strategies to accelerate the progress toward national infection reduction goals. Since the 2010 meeting, several other large national meetings, as well as specific stakeholder meetings have taken place to build upon the strategies discussed at the 2010 meeting.
Healthy People 2020
Complementing efforts to reduce health care-associated infections, Healthy People 2020 includes Health Care-Associated Infections as a new topic area, including two objectives on health care-associated infections:
- Reduce central line-associated bloodstream infections
- Reduce invasive healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA) infections
What Is Healthy People?
Healthy People provides science-based, 10-year national objectives for promoting health and preventing disease. Since 1979, Healthy People has set and monitored national health objectives to meet a broad range of health needs, encourage collaborations across sectors, guide individuals toward making informed health decisions, and measure the impact of our prevention activity.
Designing Healthy People for the Next Decade
Every 10 years, HHS leverages scientific insights and lessons learned from the past decade, along with new knowledge of current data, trends, and innovations. Healthy People 2020 reflects assessment of major risks to health and wellness, changing public health priorities, and emerging issues related to our nation’s health preparedness and prevention.
ETHICAL ROUNDTABLE DELIMMA: SUMMING IT UP
To blame or not to blame – pointing fingers or debating who is at fault should not be the issue. Awareness and “Empowerment of Patients” is the key.
Following an infection-control workshop at which a speaker suggested that compliance with hand hygiene would improve if patients were “empowered” to insist that health care workers (HCWs) disinfect their hands before touching them, a participant recounted a telling (but not unique) personal anecdote.
The participant, herself a HCW, had recently been treated for a rare type of cancer. Her condition created such clinical interest that, during her first assessment at a cancer clinic, she was examined by 15 HCWs — doctors, medical students and nurses. Only the nurses used the alcohol-based hand disinfectant, which was available from any of three dispensers in the consulting room, before examining her. She was warned that her treatment, which would include chemotherapy, surgery and radiotherapy, would entail a high risk of infection. When she expressed concern about acquiring methicillin-resistant Staphylococcus aureus (MRSA), her doctor suggested she consider transferring to a private hospital, which she refused.
During the next 12 months, she and her husband repeatedly asked numerous HCWs who cared for her to clean their hands before touching her. With rare exceptions, the doctors either ignored her or asserted that hand hygiene was needed only after the examination — ignoring evidence that environmental surfaces, which are inevitably touched by HCWs as they move between patients, such as door handles, files and mobile phones, are often contaminated with MRSA. Despite her efforts, she developed an MRSA infection, which complicated and delayed, but fortunately did not ultimately prevent, her remission.
Would “empowerment” of patients improve HAIs? Or, would this just cause further ethical dilemmas between healthcare workers and patients? These are points to ponder as you muse over facts and cases presented in this course. Thank you.
HERE TO TAKE THE EXAM. THANK YOU.
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