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“Optimum conditions require sufficient and qualified personnel“

Hospital Hygiene: “Optimum conditions require sufficient and qualified personnel“


Frauke Mattner

Associate Professor Doctor Frauke Mattner; © private

Many hospital stays go smoothly. Then suddenly complications arise and the patient experiences strange symptoms. The problem is well-known: often this is due to an infection with dangerous, antibiotic-resistant bacteria. A frequent cause is lack of hygiene. Thousands of patients all over the world contract these so-called nosocomial infections. How can this development be stopped? spoke with Associate Professor Doctor Frauke Mattner, Medical Director of Epidemiology for Hospitals and Clinics in the City of Cologne, Germany, about the currently existing hygiene standards and regulations, asked why there is an increase in antibiotic resistance and what possible infection-prevention measures can be taken. Associate Professor Mattner, infections and increased resistance to specific viruses becomes an ever increasing challenge for hospitals. What went wrong in the beginning?

Frauke Mattner: It is a natural process for bacteria to have the ability to change very quickly due to its genetic make up. That’s why you cannot really say that something went wrong. We as humans always try to develop ever new antibiotics to combat bacteria. Bacteria cannot really be tied down, but rather try to adapt through mutation. Consequently, it is also a natural process for resistances to increase. Nevertheless, a targeted treatment with antibiotics and sensible use when prescribing antibiotics should slow down the actual natural development. What other factors play a role for the increase in multi-resistant bacteria like MRSA?

Mattner: Another mainstay for spreading bacteria is neglected hygiene precautions. Especially MRSA bacteria do not actually adapt quite as quickly. The increase in MRSA cases is attributed to bacteria being carried from one patient to another. The most important issue in hospitals often is the lack of hand hygiene. This results in bacteria being able to spread. By now, we know how we can control MRSA bacteria: hospitals must screen patients well and determine whether a patient is a MRSA carrier. We have to make sure that no transmission of bacteria will be possible. For the longest time screening was not paid the necessary attention and the bacteria was able to spread. But we know from examples like the Netherlands or Denmark that this development can be reversed. We are currently active in dealing with this issue. What is going on with new problem-causing pathogenic bacteria such as Acinetobacter baumannii?

Mattner: These bacteria do not spread, but instead are predominantly being imported from countries such as Greece, Portugal and Spain, which register a high rate of antibiotic use. If physicians don’t immediately consider that the patient comes from one of these countries and don’t take the corresponding prophylactic measures, the bacteria can then survive a long time on the surfaces in the patient’s surroundings. This can lead to transmission to other patients. We quickly need to find out whether the patient is colonized with these bacteria. If this is the case, strict hygiene precautions must be applied. Oftentimes this happens in intensive care units. Especially severely ill patients can contract other serious diseases due to these bacteria. How should we envision a patient screening for these bacteria?

Mattner: A screening for MRSA is very well specified. A microbiology swab of the nose and wounds, if wounds are present, is taken. In addition, swabs of respiratory materials are taken from intensive care patients. If a patient tests negative, the likelihood of transmission is very small. Screening for Acinetobacter baumannii is somewhat more difficult. At the laboratory a specific culture medium must be prepared or numerous swaps need to be checked for these bacteria. You should make requirements very exact and differentiated for the microbiology lab. How important is patient structure in hospitals for spreading such infections, and is there a shift towards older patient groups?

Mattner: It plays a role, because the older a patient is, the more frequently he/she stays in hospitals. This increases the likelihood of bacterial transmission. By now it is important to screen for bacteria when older patients are admitted to determine whether bacterial colonization exists or not. What kind of hygiene procedures do currently exist?

Mattner: Hospital hygiene recommendations to prevent transmission of MRSA and infections require patients with MRSA to be isolated. They will then be put up in a single room or a room with other MRSA patients. This means, MRSA patients can be placed in a shared room. These isolation precautions require wearing gloves, lab coats and protective face masks. Do the existing procedures fall short here?

Mattner: More could be done, but it doesn’t help more. You could actually do less, if you know for sure that you have very good hand hygiene or if you regulate compliance with hand disinfection more strictly. In individual cases it is then even conceivable to dispense with isolation in a private room. However, presently hospital hygiene regulations strongly vary.

Mattner: Hospital hygiene regulations vary depending on the state in Germany and no regulation indicates how you should handle MRSA patients in practice. It is pointed out, that the Robert Koch Institute (RKI) guidelines for the handling of MRSA patients should be implemented. In countries that don’t have any hygiene regulations yet, the power of jurisdiction applies. Legal disputes can arise from claims and in these cases compliance with RKI-regulations is being reviewed.

Hygiene measures

To be able to achieve sustainable effects in hygiene, regular training courses for the health personnel should take place; © Prod Given so many differences, how is good hygiene measurable?

Mattner: The hygiene indicators play a role here. In France every hospital is measured based on hygiene indicators. They are based on the use of hand disinfectants per patient day and the number of nosocomial MRSA infections. From this a value is determined, which classifies the hospital into categories A, B or C. This is a type of public reporting. In Germany, a hygiene seal of approval is awarded within the scope of the Euregio network in Münster. All project participants who implement the transfer and recovery of MRSA patients based on the same or explicit specifications, are awarded this hygiene seal of approval. In 2008 a campaign for clean hands was already initiated, which is directed toward hospital nurses and physicians. Nonetheless, it feels like not much has changed. Why is that?

Mattner: There definitely have been some improvements. However, we are dealing with a fundamental psychological issue. Everyone would sanitize their hands more consistently, if the germs could be seen on the hands. To be able to achieve sustainable effects in this case, regular training courses for the health personnel should take place. A one-time explanation of how important hand disinfection is isn’t enough. The result is clearly better, if you keep reminding people and choose different approaches. What kind of steps do hospitals take to stop these developments and what kind of foundation should they lay for the future?

Mattner: Larger hospitals need a sufficient number of qualified personnel –hospital hygienists, medical specialists in hygiene and environmental medicine and hygiene specialists, to be able to take quick measures. Quarterly, we also present the so-called HAND-KISS-data to the respective hospital wards. Here the use of hand disinfectants per patient day is assessed every three months. The continuing gathering of data shows the staff to what extent things have improved or potentially declined. Wards, that aren’t doing well yet, usually request training courses on their own. Afterwards, an increased use and a strict adherence to hygiene guidelines can be observed. These kinds of stimuli must be applied in all wards. A compulsory hygiene lecture for all wards does not achieve the necessary increase in compliance.

In addition, our hygiene staff notices hand-hygiene compliance directly next to patient beds. It is being checked to determine what extent different contact with attending physicians and caregivers and the patient is unsafe. If you record this data and evaluate it, you are able to show at a hospital ward that hand disinfection for instance was only done in half of all cases. If afterwards you show this data to the employees this pertains to, you get an incredible educational effect. Before the parliamentary summer recess, the Cabinet of Germany wants to pass a bill to improve hospital hygiene standards. What new regulations are planned?

Mattner: This law is intended to provide the legal framework for the federal states to determine hygiene regulations for specific important points. This applies to federal states that don’t have hygiene regulations, as well as states with hygiene regulations, which then in turn need to be adapted accordingly. This also encompasses a binding regulation of the RKI guidelines, which today are being determined by the Commission for Infection Prevention. These guidelines will have a significantly more binding character. So there will be a national hygiene standard?

Mattner: If the RKI guidelines have a clearly more mandatory character than is currently the case, in a way it equates a national standard regulation. Besides that, there is room for the federal states to determine more of their own state specific regulations. Despite many continuing education courses for the hospital staff and future stricter hygiene regulations, the human factor plays a crucial part. Theory and reality are often miles apart in this case. This is also called top-down problem. How do you explain this and how can this issue be resolved?

Mattner: The top-down problem occurs if the management level would like to implement hygiene measures, but these are not received on the lower level. We also have the opposite problem: the nursing staff implements great hygiene precautions, but hygiene standards at the higher hierarchy levels leave a lot to be desired. We often have very good suggestions, but they also need to be implemented. An optimal implementation oftentimes can only be carried out by sufficient and qualified personnel. This applies to hygiene staff as well as other nursing staff at the hospital. If four patients in an intensive care unit are tended by only one caregiver, it then becomes difficult to work safely in terms of hygiene. There are varying numbers on patients which acquire hospital infections. How many people annually contract nosocomial infections?

Mattner: We have reliable data from the hospital infection surveillance system (KISS) in Germany. These numbers capture the infection times based on strict definitions. According to these numbers, yearly approximately 400,000 people contract MRSA. This is the most reliable data we have. The death rate is at about 15,000 people. We are often asked whether these numbers are not too low. In this case, a reference to the European environment helps.

Doctor desinfecting hands

The need for qualified personnel such as hygiene specialists and hospital hygienists is very high; © Schweiger What do these numbers reveal in terms of an International or European comparison?

Mattner: The European Centre for Disease Prevention and Control (ECDC) compiled the numbers of its member states. By comparison, Germany ranks well in the middle. However, in most hospital facilities in terms of catheter-associated and ventilator-associated sepsis, we show considerably better numbers and lower rates of infection than the US. In terms of resistance data, Germany’s result is also better than France’s even though France has launched a very successful campaign to reduce antibiotics overuse –due to a high resistance rate situation. By now, the use of antibiotics has also clearly decreased in Germany compared to many other European countries. Yet the goal is to achieve as low a rate as those in the Netherlands or Switzerland, or in other words, to only systematically use those antibiotics that are absolutely necessary and keep treatment periods as short as possible. Countries like the Netherlands, Switzerland and also Slovenia are often mentioned to exemplify low infection rates in hospitals. What can we learn from them?

Mattner: From the Netherlands we can learn that you need well-trained personnel that’s experienced with infections. 20 years ago, the Netherlands also had high resistance- and infection rates. They managed to establish a large national institute with the objective to develop specific measures to change this situation. A lot of money went into the qualification of personnel. In the Netherlands weak spots were correctly analyzed. We often complain without having actual numbers on our hands. At first a clean analysis is always essential to precisely diagnose problems. This pertains to hand disinfection and also very complicated problems, for example how to place which catheter at what time and when to remove it again. Safe handling of different medical devices is crucial. Experts should determine the rules. The implementation then needs to be carried out by trained qualified personnel in the hospital facilities. Are there already International and European strategies for prevention of these kinds of infections?

Mattner: The ECDC determined a large number of ways to reduce nosocomial gastrointestinal infections and the spread of multi-resistant bacteria. The procedures are not yet extensively established. Thanks to the upcoming hygiene regulations we have a wonderful guideline in Germany, but we also need money to be able to create workplaces for specialized personnel. The need for qualified personnel such as hygiene specialists and hospital hygienists is very high. It can only be met through an education initiative. Another requirement is in promoting epidemiological studies, which are aimed at evaluating measures in terms of their preventive effect on infection. So far, the German Federal Ministry of Education and Research (BMBF) unfortunately does not allocate any funds for these kinds of studies.

The interview was conducted by Diana Posth and translated by Elena O’Meara


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