On a Friday evening in November 2019, I was at one of Tamil Nadu’s largest public tertiary-care hospitals, the 3,500-bed Rajiv Gandhi General Hospital in Chennai. At first look, the hospital seemed clean. There was little litter in the spacious corridors. Cleaning staff could be seen intermittently sweeping the floors. A few patient relatives, camped in the corridors, told me they were happy with the hygiene and the facility’s upkeep.
But my impression of a well-maintained hospital collapsed when I entered the toilets. Several patient and staff toilets lacked soap, including one next to an intensive care unit (ICU), where critically ill patients are treated. How do healthcare workers and patients clean their hands, then?
This situation is not unusual for many Indian hospitals, especially overburdened public ones. But poor hygiene in this environment has today become a bigger threat than before. The world is fast approaching a post-antibiotic era, in which pathogens that cause healthcare-associated infections (HAIs) are becoming better at resisting antibiotic and antifungal substances that were once quite effective. (See explainer: What is a healthcare-associated infection?). Patients infected with pathogens that are resistant to more than three drugs – dubbed multidrug-resistant (MDR) – often die or spend heavily on prolonged hospitalisation. (See explainer: Why are drug-resistant infections a problem?)
This is why hospitals today must work extra hard to keep drug-resistant HAIs from spreading from one patient to another. This is a huge and complicated task at the heart of which is improving hygiene. Perhaps the most critical infection-control measure known to medical professionals today is the discipline of washing hands, sometimes up to 20-30 times a day. In addition, there are hundreds of other practices that have been shown to cut HAI rates.
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However, the high prevalence of infections in Indian hospitals indicates they aren’t enforcing these practices. For example, Indian patients on central lines – a tube placed in a large vein, like a jugular, to deliver drugs or to perform medical tests – are at high risk of contracting infections from the lines themselves. A surveillance network of ICUs at 35 Indian hospitals reported that for every 1,000 days that patients were hooked to central lines in 2017-18, they contracted 8.77 bloodstream infections. To compare, a network of 3,586 American acute-care hospitals reported only 0.77 bloodstream infections per 1,000 days in 2018.
One reason so many Indian hospitals are bad at tackling HAIs is that it isn’t legally mandatory for hospitals to maintain a minimum standard of infection control. Even though multiple health agencies have published infection-control recommendations – such as the Indian Council of Medical Research guidelines, the Indian Public Health Standards and the Kayakalp guidelines – neither private nor government hospitals are obliged to follow any of these.
The Clinical Establishments (Registration and Regulation) Act 2010 did include a provision allowing state governments to enforce their own infection-control standards. However, only a handful of Indian states have implemented this Act.
Against this background, several public health experts are calling for mandatory quality accreditation as a way out of India’s HAIs problem. Quality accreditation requires an independent body, like the National Accreditation Board for Hospitals and Healthcare Providers (NABH), to inspect hospitals and ensure they have the minimum safeguards against HAIs.
Accredited hospitals tend to be better at infection control than their counterparts. “Accreditation is how you build quality in a country,” Ramanan Laxminarayan, who studies antimicrobial resistance at Washington’s Center for Disease Dynamics, Economics and Policy, said.
According to Laxminarayan and others, India must follow in the footsteps of other countries that have forced high accreditation rates among hospitals through various mechanisms. For example, insurance programmes like Medicare and Medicaid in the US don’t pay hospitals unless they are accredited.
But widespread accreditation in India might be a long way off. Indian hospitals have abysmally low rates of accreditation today even though the NABH program has been around for 14 years. Government-run hospitals have been particularly reluctant to sign up. Consider this: of an estimated 80,000 facilities in India, a piddly 662 are NABH accredited. Among them, only 20 are government facilities, according to Giridhar Gyani, who helped found NABH and is its former CEO.
Source: The Wire