Every hospital admission is associated with a risk of acquiring infection

A hospital-acquired infection (HAI), or nosocomial infection is an infection, which usually occurs 48 hours after admission. It is not related to the original condition and is neither present nor incubating at the time of admission. HAIs are also sometimes called health care–associated infections (HCAIs) to include both hospital and non-hospital settings. HCAIs occur during the process of care in a hospital or other health care facility. They can occur in any type of setting where patients receive care, even after discharge. The most common nosocomial infections include surgical wound infections, respiratory infections, genitourinary infections and gastrointestinal infections.

The most widely accepted definition of HCAIs was given by Friedman et al (BMC Med. 2014;12:40), who defined it as an infection present at hospital admission or within 48 hours of admission in patients that fulfilled any of the following criteria:

·         Received IV treatment at home, wound care or specialized nursing care through a healthcare agency, family or friends; or had self-administered IV medical therapy in the 30 days before the infection

·         Attended a hospital or hemodialysis clinic or received IV chemotherapy in the previous 30 days

·         Hospitalized in an acute care hospital for 2 or more days in the previous 90 days, or

·         Resided in a nursing home or long-term care facility.

As per WHO, of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one health care-associated infection. The endemic burden of health care-associated infection is also significantly higher in low- and middle-income than in high-income countries. More than 20% of all nosocomial infections are associated with ICU stay. In low- and middle-income countries the frequency of ICU-acquired infection is at least 2-3 fold higher than in high-income countries; device-associated infection densities are up to 13 times higher than in the USA.

Prolonged and inappropriate use of invasive devices and antibiotics, immunosuppression and other severe underlying patient conditions, failure to adhere to standard and isolation precautions are some factors that increase the risk of infection in health-care settings. Certain factors are particularly associated with resource-limited health care settings such as understaffing, overcrowding, lack of/poor knowledge, inadequate infrastructure, inappropriate use of invasive devices like catheters, lack of infection control policy. Hospital waste is also a potential source of pathogens. 

More and more diagnostic and therapeutic procedures are being performed every day. There is a risk of acquiring infection in every hospital admission or contact with a health care facility, including nursing home, rehabilitation centers or facilities that provide long-term care because during the hospital stay, the patient is exposed to pathogens, including multidrug-resistant organisms through varied sources namely, the healthcare staff, other infected patients and the environment.

Every patient must be informed about the risk of developing infection during hospital stay. Not doing so may be a ground for malpractice claim since it is unrelated to the patient’s condition which brought him/her to the hospital. Educating them on how to reduce the risk of transmission will also enhance their participation in infection control practices.

Acquiring infections in health care settings are inevitable and needs to be part of routine consent. If not done then every case of infection can end up with a media trial. Every patient and/or relatives need to know that every admission may have up to 10% risk of acquiring a new infection.  

Dr KK Aggarwal

Padma Shri AwardeeVice President CMAAO

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

High bed occupancy rates in hospitals denote inferior quality of care

High bed occupancy rates in hospitals denote inferior quality of care

Dr KK Aggarwal

Padma Shri Awardee

When patients choose a hospital for treatment, they usually judge a hospital by its location, the infrastructure, the amenities and services it provides, quality of care and cost of care.

Bed occupancy rate is an indicator of hospital utilization. It is a measurement of efficiency and effectiveness of a hospital. Bed occupancy rate of a hospital varies at any given point of time. While a ‘full house’ would perhaps appear to be most satisfying, it is not actually so, especially for a hospital.

According to the Australian Medical Association, Irish Medical Organisation, Australasian College for Emergency Medicine and NHS England, a bed occupancy rate above 85% or ‘overcrowding’ is considered to have an adverse effect on patient safety and the operational efficiency of the hospital.

High bed occupancy rate increases the risk of spread of hospital-acquired infections such as MRSA and Clostridium difficile via cross transmission. Such hospitals also run the risk of bed shortages when they are most needed, such as during outbreaks, or disasters. 

Overcrowding means not enough beds for patients from emergency department. A long waiting time for transfer to the appropriate inpatient bed increases mortality and chances of adverse events.

Overcrowding compromises quality of care. Medications may not be administered in time; the chances and frequency of errors increase as well.

Hospitals, in particular Govt. hospitals, have a policy of not denying admission to any patient, even if this means allotting the same hospital bed to two inpatients, or sometimes even three in pediatric wards. The outcome is an inferior quality of care, at the same time, it also creates an impression that we can manage even with inadequate infrastructure and resources available to us.

No hospital, whether Govt. or private, should have more than 85% bed occupancy rate.  Admitting 150 patients in a 100-bedded hospital is not correct. This means that for 50 extra patients, you are compromising care of 100 patients as resources are shared for a much larger number of patients than meant for.

This would also be applicable to govt. hospitals, if they over admit patients in view of the recent govt. notification, which makes it mandatory for all clinical establishments, chemists/pharmacists to notify every case of TB or else face penal provisions under sections 269 and 270 of the Indian Penal Code