NHMRC Public Consultations

Healthcare-associated infection is preventable: discusses HAI's as a result of health care and then talks about them occurring in any health setting and say any person working in or entering a healthcare facility is at risk.

My concern is that this may be construed as excluding ambulance services.  The ambulance setting is not listed as an example and healthcare is not provided in a healthcare setting as such but is accessed by the patient in need in whatever setting they may be in.

Infection prevention and control is everybody’s business: This responsibility applies to everybody working (insert "in") and visiting a healthcare facility,

Scope: good

Summary: the second bullet point would be more relevant to the ambulance setting if it read  "HAIs can occur as a result of the provision of healthcare in any setting. While the specific risks may differ, the basic principles of infection prevention and control apply regardless of the setting"

I can see that the emergency services are included in the definition of a healthcare facility in the glossary but the glossary is not usually read prior to or in conjunction with reading the document. the Oxford dictionary defines a "facility" as A place, amenity, or piece of equipment provided for a particular purpose.  I'm nit picking but normal use of the word facility and the way guidelines are worded to sound facility focused is a barrier to stakeholder engagement in the pre-hospital emergency setting as in the emergency setting healthcare is routinely not provided in a dedicated health care space. I think it is important to set the right tone and ensure stake holder engagement right at the beginning of the document. 

2. Basics of Infection Prevention and Control

How standard precautions are implemented

Preface the use of personal protective equipment with "appropriate"

Preface the handling and disposal of sharps with "safe".

Standard and transmission-based precautions 

Could the first bullet point be re-worded to read "routinely applying basic infection prevention and control strategies to minimize risk to both patients and healthcare workers, such as hand hygiene, appropriate use of personal protective equipment, cleaning and safe handling and disposal of sharps (standard precautions)
 
Again in the table of how standard precautions are implemented can the use of personal protective equipment be prefaced with "appropriate" and can handling and disposal of sharps be prefaced with safe rather than appropriate.

Strategies for implementing transmission-based precautions

It is important to stress the need for dynamic risk assessment in the pre-hospital/emergency setting as well as communication to and from facilities to enable timely interventions. ie allowing the hospital enough time to create a single room or negative pressure room if required.

2.2 Overview of risk management in infection prevention and control

This is good - As healthcare settings differ greatly in their day-to-day function, it is not possible to provide a one size fits all approach to risk management. Even within a single setting (e.g. primary care), increasingly complex care is delivered by a range of health professionals with diverse qualifications and training. All healthcare facilities need to be able to determine the risks in their own context and select the appropriate course of action. Therefore it is necessary for facilities to regularly conduct infection prevention risk assessments within their facility and ensure that all staff understand their responsibility in managing these risks.

Applying the risk management process

In the case study/scenario, can you include something around the risk management pertaining to ambulance transfer/transport of the patient?

2.3.1 Involving patients in their care 

Somewhere in here, possibly with "It’s okay to question a healthcare worker about whether they should be using protective personal equipment or whether they are using it properly", I think it is important to let the patient know that infection control practices/actives may change over the course of their care based on the risk assessment made by the healthcare worker. When infection control measures vary between healthcare workers and or from day to day it leads to confusion and concern.

3.1 Standard precautions

Preface the use of personal protective equipment with "appropriate"

3.1.1

Figure 5. It would be good to have an additional image of an imprint of a gloved hand during an extended episode of care. Paramedics routinely have gloves on (inappropriately) for extended periods of time for the perception of personal safety.

Recommendation 1

The Note: Hand hygiene is also performed after the removal of gloves. This needs to include doing hand hygiene before putting gloves on. This is especially important in the emergency setting to protect clean stock (gloves) in the box from becoming contaminated/soiled before use.

Table 2.

Include before wearing gloves in the before column.

Other aspects of hand hygiene

Please acknowledge the competing priorities of worker health safety in the ambulance setting. Paramedics wear long sleeves for protection from the elements to reduce the risk of illness and skin cancer. Education in managing this variation in practice will encourage compliance with hand hygiene and understanding from other healthcare workers who view it as non-compliance.

Recommendation 6

This is a tricky one in the ambulance setting where access to soap and water out on the road is not always possible.

From the World Health Organization https://www.ncbi.nlm.nih.gov/books/NBK144042/

"Should we remove alcohol-based hand rubs from areas where there is Clostridium difficile infection?

No. Alcohol-based hand rubs are required at the point of care for a number of reasons:

• They are easy to use and therefore more likely to result in greater compliance with the need for hand hygiene by health-care workers.

• They are proven to be effective in killing a range of pathogens and therefore reducing patients’ risk of acquiring health care-associated infection.

• They are effective in killing the non-spore form of C. difficile which may be present in higher numbers than the spores.

• Sinks for handwashing are not always readily available and, even if they were made available right next to a patient, washing takes at least twice as much time than rubbing – all factors that mitigate against full compliance with hand hygiene. Relying on promoting handwashing only in health care is thought to result in lower compliance, lower efficacy and greater risk of continued spread of pathogens.

• Evidence-based research reinforces the need for the presence of alcohol-based hand rubs to ensure maximum patient safety.

• There is no evidence to suggest that their use has been connected with increased C. difficile infections.

  Thus, alcohol-based hand rubs should NOT be removed from health-care settings; to remove them would be likely to result in greater risk to patients from health care-associated infections."

  The recommendation in the ambulance setting needs to be that in regard to C’diff - in the absence of soap and water for hand washing the use of ABHR is an acceptable interim measure until a soap and water hand wash can be performed at an alternate healthcare facility.

  The risk of transmission to other patients in this instance will be low as paramedics generally have one patient per episode of care.

   

  3.1.2

  Recommendation 9 - good

  3.1.4

  In the ambulance setting it would be good to have a recommendation around creating as clean a work space as possible with the use of a "blue sheet" for example.

  Working outside of controlled work places such as on roadways and in the natural environment exposed to the elements creates unique issues with environmental controls.

  Recommendation 15 can present some unique challenges in the emergency setting. Crews clean up as much as possible but the transport and welfare of the patient can be the highest priority with interjurisdictional issues re who will finish the cleanup in the absence of facility cleaners.

  3.1.8 Aseptic technique

  Aseptic technique in the ambulance setting can present some unique challenges. In time critical situations and in incredibly dirty environments where the patient and surroundings may be heavily contaminated the message needs to be- “In the event that asepsis cannot be achieved aim for as clean as possible utilising the principles of aseptic technique.” (Don’t throw your hands in the air and give up).
  Scenario example- septic tanker roll over at the bottom of the SE Freeway Adelaide http://www.adelaidenow.com.au/news/south-australia/second-death-from-fat...

   

  3.2.4 Airborne precautions

  Ambulance setting needs some guidelines..... London ambulance service recommends in addition to appropriate PPE driving with windows open to increase the number of air exchanges

  3.4.2 Intravascular access devices

  Table 16

  "All catheters inserted in an emergency situation (e.g. by emergency ambulance services) should be removed and replaced when the patient is stable and within 24 hours of insertion" - please insert emergency as highlighted. There are paramedics who work in the extended care/hospital avoidance area who are trained and competent in aseptic technique and are inserting catheters in controlled settings (eg nursing homes) under controlled conditions. This is quite different to the time critical device insertion and results in unnecessary removal and reinsertion of devices. This increases the risk for the patient (multiple device insertions) as well as increasing the discomfort for them.

4.6.2 It would be extremely useful if there was some guidance here around vehicle design and air flow. Vehicle airconditioning, air fliters and recirculate functions in the ambulance setting have next to no guidance available. (

This really needs something for the ambulance setting. The lack of an ambulance service based example or scenario undermines the documents credibility in the assertion that these guidelines are for all health services.