PUBLIC POLICIES ON COMBATING NOSOCOMIAL INFECTIONS

Corina FLAISER^[1], Iulia-Elena DIACONU^[1]

e-mail corinaflaiser@yahoo.com

Abstract

Nosocomial infections are a specific problem of our health system, whose main source is the financing of the health system and, implicitly, the funds granted for retrofitting the buildings in which hospitals carry out their activity. The much praised health law, namely Law no. 96 of 2000, which launched a real renovation of the health system, actually regulates the flow of hospital activity and hence of the building it takes place in, through the manner of placement of wards, windows, beds, baths, and the manner visitors and staff consisting of specialized doctors, nurses and orderlies come into contact with the patient, but, regarding the old buildings, this law exists only from a regulatory perspective. The purpose of regulating the flow of activity was to create a specific building where the microbes from external space would be controlled, by establishing how visitors could visit the patients, as well as by controlling how the entire hospital staff dedicated to the accomplishment of the medical act would come into contact with the patient, according to the severity of the patient’s status and the improvement of the medical act.

Keywords: nosocomial infections, healthcare system, financing of health system

In the opinion of authors such as Silviu Rădulescu M.D., the health care system represents the assembly of human, material, financial, informational and symbolic resources used in different proportions and combinations to result in added value to the care and services for improving or maintaining health. In this context, the health system can be viewed as a subsystem, influenced by major factors such as behavioral, environmental and biological ones. [Hospital Management, Edited by the National School of Public Health and Sanitary Management, Public H Press Publishing House, Bucharest 2006]

RESULTS AND CONSIDERATIONS

Public health policies on combating nosocomial infections are in equal close connection with both the accreditation system of hospitals and the patients’ rights, which derive from human rights. The term „accreditation” originates from the word „credo” which in Latin means belief, trust, while the word „accredito” signifies granting, consequently we can say that accreditation is the manifestation of granting trust based on evidence. In the modern system, accreditation is a procedure of external evaluation, by which a recognized accrediting body officially certifies, following a specific analysis made at the request of the organization, its competence in carrying out activities according to generally accepted standards, such as the 2006 standards of the Romanian Foundation for Quality Promotion [Constanţa Mihăescu Pintia, Hospital Management, Public Press Publishing House, Bucharest, 2006].

However, the accreditation system does not have direct effect on the process of care, on medical practice and the outcomes of medical care, usually reflected in the patients’ health status and quality of life. The concern for combating nosocomial infections in hospitals is one of the instruments of quality improvement and patients’ safety, approached in close connection with patients’ rights. Thus, hospitals provide specific procedures for every location, including the operating rooms, which are to be observed in order to minimize and combat nosocomial infections. For example, in Procedure on the CLEANLINESS OF TREATMENT ROOMS Code P.O.3.17.9 the following criteria are taken into consideration:

A. Reference documents

a. Order of the Minister of Health no. 914/2006 regarding the norms on the conditions a hospital must fulfill in order to obtain the sanitary authorization for activity

b. Order of the Minister of Health no. 916/2006 for the approval of the norms for supervision, prevention and control of nosocomial infections in health care facilities

c. Order of the Minister of Health no. 261/2007 on the technical norms of cleaning, disinfection and sterilization in health care facilities

d. *** Prevention of nosocomial infections. Chemical antiseptics and disinfectants  to be used in sanitary facilities

e. *** Guide for cleaning, disinfection and sterilization in medical assistance units; ISP Publishing, Bucharest, 2001

f. ***  WHO Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008

g. *** CCLIN South East – Nettoyage et d’entretien des locaux a hopital; 2000/2001 revised in 2005

B. Basic rules

a. only products approved for use in healthcare shall be used;

b. the manufacturer’s recommendations shall strictly be observed;

c. workplace safety rules shall be obeyed (wearing gloves, goggles, impermeable equipment etc.);

d. containers shall be preserved with labels and airtight seals (the label is to specify the name of the product, the category it belongs, the expiration date, the dilution for use, the date the dilution was made, the service life of the diluted product, maintained under appropriate conditions, with their specification);

e. The mixing of products IS FORBIDDEN;

f. Keeping cleaning products in food packaging IS FORBIDDEN;

g. The empty packages are to be disposed of, only after they were cleaned and/or neutralized;

h. The use of products containing chlorine/acid on the PVC carpet of the health care unit IS FORBIDDEN.

C. General rules for performing disinfection:

a. prophylactic disinfection complements cleaning, but does not substitute it and cannot replace sterilization;

b. the effectiveness of prophylactic disinfection is conditioned by prior thoroug hcleaning;

c. periodic alternation of disinfectant products is recommended in order to avoid microorganisms developing resistance;

d. disinfectants should be used in the concentrations and for the time of action recommended by the manufacturer;

e. in the preparation and use of disinfectant solutions it is required exact knowledge of the concentration of the active substance in products, the use of clean containers, the use of the solutions the same day it was prepared in order to avoid their contamination and degradation/inactivation, the use of the solutions within the stability period indicated by the manufacturer;

f. the use of disinfectants will be done respecting the workplace safety rules which prevent accidents and poisoning;

g. the staff routinely using disinfectants should be trained on new procedures or products and given practical information by the experienced staff.

In Romania, although healthcare plans, models of care or practice guidelines are being used, the practice protocols on the Western model are not very commonly employed, but for specialties such as obstetrics and gynecology, cardiac surgery or infectious diseases. The implementation of practice protocols in clinical activity is recommended by practitioners, protocols which would be possible to achieve in five steps that would entail: finding teams of medical specialists interested to identify and implement them, co-optation of medical professional associations as main support in their implementation, attracting consumer associations for initiating information campaigns among health professionals and patients, the possibility of their implementation by the National Health Insurance House by their inclusion in contracts for purchase of services. An integrated collaboration between these four factors would lead to the fifth step, namely obtaining an integrated system, with interdependent actors who would be successful in any type of medical intervention. These conclusions are also supported by the School of Public Health and Sanitary Management which, in 2006, conducted a comprehensive study dedicated to the success of implementing Law 95/2006 on healthcare reform.

Public health policies on combating nosocomial infections should include the patient’s right to participate in their development. A similar opinion in this regard was expressed the UN in document no. E/12/2000/4 of 11 August 2000 which stated that the right to participate in public policy making of the patient and any interested citizen should be regarded as a determining factor for health. In this context, the Committee on Economic, Social and Cultural Rights urged member countries to adopt a national strategy and a plan of action on public health, which would be reviewed periodically on the basis of a transparent and participatory process. Moreover health promotion involves effective Community action in setting priorities, making decisions, planning, implementing and evaluating strategies to achieve better health. [Human rights in patient care. Guide for practitioners. Romania. Bucharest, December 2015, ISBN 978-973-139-326-1]

CONCLUSIONS

Although the health reform intended by Law 95/2006 provided the development of an innerhospital flow which took into account the coordination and control of persons, goods and services coming from outside hospitals and which also included the medical personnel dynamics depending on their area of work, in reality, this goal has not been achieved. The explanation lies in the old age of Romanian hospitals and in the absence of funds for their retrofitting. Even though, at present, efforts have been made to modernize hospitals, even if they were sanitized, the equipment was replaced with a modern one and the range of in-hospital analyzes widened, from the perspective of the standards imposed by Law 95/2006, most hospitals do not meet them. From the viewpoint of the authors of the study, the closure for a determined period of certain hospital sections, depending on the number of patients, is a requirement for proper sanitation and for combating nosocomial infections. Given that in official reports nosocomial infections are not officially reported, fact confirmed by the study of the National School of Public Health and Sanitary Management, the allocation of funds for this aspect is inadequate and the implementation of appropriate procedures in the internal working protocols of hospitals is also deficient.

Currently, there is not a tendency of bringing actions in court, for civil wrong or of other nature, against the legal representatives of the hospitals, for the damage caused to a potential patient due to lack of implementation or noncompliance with internal protocols, which are indirectly aimed at combating nosocomial infections. At present, these issues are discussed only in civil proceedings as well as in the preliminary procedure taking place at the College of Physicians, which call into question the liability of the treating physician in light of possible malpractice. In this respect, we also consider the cases of the patients from Colectiv Nightclub, which generated a whole debate not only in the media, but also through the official reports prepared on the causes of death occurred in these patients. As de lege ferenda we propose that the legal liability of the legal representatives of the hospitals for their management of the unit be established in the public policies on combating nosocomial infections. It is well known that a doctor may not refuse the patient’s right to be treated and have his life saved through the former’s medical skills and competencies, despite the location in which the doctor has to treat the patient.

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[1] U.M.F. „Gr. Popa” Iaşi