Background
The current situation of nosocomial infection in Vietnam in general, and at Cho Ray Hospital is alarming. Four main healthcare-associated infections (HAIs), namely, ventilator-associated pneumonia (VAP), catheter line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and surgical site infection (SSI), are higher in Vietnam than in other countries. Importantly, four HAIs are dominant, but the VAP incidence rate is the highest in Vietnam and in Cho Ray Hospital. Nosocomial infection results in increasing medical fees, treatment time, and mortality for inpatients. Moreover, HAIs related to multidrug-resistant organisms (MDROs) are increasing the mortality burden for medical systems in Vietnam and around the world. Jim O’Neill et al.’s study revealed that the deaths attributable to antimicrobial resistance (AMR) every year will be more than the current number of those associated with cancer by 20501. In Vietnam, there are insufficient detailed reports about the current situation and the infection control challenges for nosocomial infection. Therefore, in this cross-descriptive study, we present the current situation and the infection control challenges against HAIs in Cho Ray Hospital and Vietnam. We also provide some orientation on infection control and prevention solutions.
Purpose
To present an overview of the current situation, challenges, and solutions for infection control and prevention of HAI in Vietnam.
Introduction
The current situation of nosocomial infection in Vietnam is alarming. In 2018, the HAI rate was 5%, but some hospitals had higher HAI rates of nearly 10% 2. In Cho Ray Hospital, the incidence rate of HAI was approximately 3% in 2018. However, the HAI incidence rates in developed countries were less than 1% (NHSN). There are differences in geology, climate, and medical system service between Vietnam and other countries, so there are various etiologies causing nosocomial infection.
For developed countries, such as Japan, the microorganism is usually gram-positive, such as Staphylococcus aureus. While in Vietnam, the majority of HAI microorganisms are gram-negative, such as Acinetobacter spp., E.coli, Klebsiella, and Pseudomonas spp. Many hospitals in Vietnam are facing considerable challenges in infection control and prevention, such as overcrowding of inpatients from referral hospitals, lack of personal protective equipment (PPE) and medical facilities used for the isolation of MDROs and emerging infectious diseases, decreasing quality of medical construction, lack of human resources working in infection control, insufficient funding for infection control and lack of awareness of medical staff about infection control. In addition, increasing antibiotic resistance, especially with the appearance of MDROs in ventilated patients in intensive care units (ICUs), has created new challenges for healthcare workers in Vietnam and Cho Ray Hospital. Although there were plenty of initial benefits, such as decreasing VAP rates, medical fees, and mortality rates after applying several interventions, including antimicrobial stewardship (AMS) and nosocomial surveillance, the effect of MDROs on hospitalisation time and mortality rate still remains in complicated progression. According to the Cho Ray Hospital in 2017, the percentage of MDROs was still high at 62% of inpatients and particularly higher in ventilated patients. Another report, which was from the University of Medicine and Pharmacy in Ho Chi Minh City in 2017, revealed the percentage of MDRO as 58.6%3. Magill SS et al. reported that MDROs associated with mechanical ventilators enhance hospitalisation time, medical expenses, and mortality rates4. Research in a university-affiliated hospital for 315 inpatients revealed the high mortality rate of 30.8% (97/315) among CAUTI patients5. Other studies showed that MDRO patients with VAP were associated with gram-negative infections and high mortality rates6–8. In Vietnam, surveys about the current situation and the challenges of infection control and prevention, and research assessing the effect of MDROs on HAI have not been conducted in detail. Therefore, this study presents an overview of the current situation and the challenges for infection control and prevention of HAI in Vietnam through analysing recent and detailed infection control data from Vietnam and Cho Ray Hospital.
Materials and methods
A survey on the current situation and challenges for infection control and prevention of nosocomial infection in Vietnam in recent years.
We used a cross descriptive study to search publications on various websites about the infection control of HAI in 2018 and Cho Ray Hospital surveillance data.
Overcrowding of patients in final referral hospitals
Because of a perceived distinction in specialty degree between referral and local hospitals caused by the belief of patients that the specialty degree of referral hospitals is higher than that of local hospitals, most patients who can receive adequate treatment in local hospitals still wish to be referred to top referral hospitals for diagnosis and therapy. Therefore, referral hospitals, such as Cho Ray Hospital and Bach Mai Hospital, are overcrowded with inpatients and outpatients. Overcrowded patients lead to major challenges for infection control and prevention, such as cross-infection of MDROs or other emerging infectious diseases. According to Cho Ray Hospital data, the hospital has 1,800 planned beds, but there are approximately 3,000 inpatients every day. The daily number of outpatients is about 5,000–6,000, with 150 cases needing operations. Therefore, the distance between two beds is excessively narrow at less than 0.5 m. Sometimes, two patients share one bed, thereby easily leading to cross-infection in the hospital. To solve this problem, hospitals have been cohorting the patients infected with MDROs or emerging infectious diseases and needing isolation in the same areas, using PPE and applying standard precautions or additional precautions based on the route of transmission.
High rate of HAIs
Several reports in Vietnam show that the HAI rate is approximately 5–10%2. Cho Ray Hospital’s surveillance data from 2018 revealed that the HAI incidence rate was nearly 3%. There are four types of HAI that occur frequently, namely, VAP, CLABSI, CAUTI, and SSI. By contrast, the HAI incidence rate in developed countries is less than 1%. A report on HAIs in the USA shows that the CLABSI rate is 0.8/1,000 catheter-day, the VAP rate is 0.9/1,000 mechanical ventilators-day, and the CAUTI rate is 1.7/1,000 catheter-day9. In addition, our research reveals a very high percentage of MDROs in Cho Ray Hospital. We conducted all samples positive culture for the first six months of 2018. According to the results, the percentage of MDROs in the 6,820 positive specimens of the culture was 62%.
Poor hand hygiene compliance
Hand hygiene is a simple and efficient intervention to reduce the HAI rate. However, recent hand hygiene surveillance data from Vietnam reveal that the hand hygiene compliance rate remains low at approximately 50–70%10. In Cho Ray Hospital, the hand hygiene compliance rate increased to 61% in 2018 from 49% in 2017, but this number is still low compared to the requirement of the Vietnamese Ministry of Health (MOH).
Lack of PPE and other facilities for isolating MDROs and preventing transmission of emerging infections
The management of isolating MDROs and emerging infectious diseases in Vietnam and Cho Ray Hospital has been facing many difficulties. First, isolation rooms are insufficient for regular isolation, and negative pressure isolation rooms are likewise not enough for cases with airborne diseases, such as tuberculosis, chicken pox, influenza, and Ebola. Second, the supply of PPE, such as aprons and masks, is insufficient for taking care of MDROs. Cho Ray Hospital supplied PPE for outbreak precaution, but for MDROs, the supply is still limited and not equally distributed to departments in the hospital. Therefore, the efficacy of MDRO isolation is still limited.
Decreasing quality of hospital construction
Most of the public hospitals in Vietnam were built many decades ago, such as Cho Ray Hospital, which is half a century old. Therefore, the quality of hospital construction, patient rooms, facilities, and environment has been deteriorating. Plenty of construction has been added onto the hospitals, causing their environments to have narrow spaces and limited airflow. Therefore, current infection control and prevention of HAI have many challenges in improving hospital environments and HAI prevention in Vietnam and Cho Ray Hospital.
Lack of human resources for infection control
During the past decade, the Vietnamese MOH has focused on HAIs by issuing some detailed national rules for infection control and prevention at medical services, such as Circular 18/2009 and Updated Circular 16/2018. The circular defines the detailed roles of the Infection Control Committee, the Head of Infection Control, and the Infection Control Team. Importantly, the document shows that each person in charge of HAI surveillance has to respond full-time to 150 beds. However, hospitals in Vietnam currently lack infection control human resources for daily HAI monitoring. Cho Ray Hospital has approximately 3,000 beds. Therefore, it needs about 20 staff working full-time in HAI surveillance. According to the WHO, each HAI surveillance staff member needs to support only 100 beds full-time. However, in practice, the Department of Infection Control has only five people serving all patients in the hospital. All hospitals in Vietnam have insufficient infection control staff. This is one of the most severe problems for the infection control team in Cho Ray Hospital and Vietnam, thereby affecting the quality of HAI surveillance.
HAI surveillance in Vietnam, except for that in Cho Ray Hospital, often uses short-term surveillance. In Cho Ray Hospital, HAI surveillance adopts longitudinal surveillance in all departments. Therefore, the result of HAI surveillance is more accurate and thus valuable for finding solutions for HAI intervention.
Poor cognition of infection control of healthcare workers
Awareness about HAIs, infection control, and prevention, and self-awareness regarding HAIs infection control in hospitals are low due to healthcare workers’ poor cognition about the importance and benefits of HAIs prevention and control. For example, the hand hygiene compliance rate of healthcare workers in Vietnam is lower than in developed countries worldwide. The hand hygiene compliance rate of Cho Ray Hospital staff was approximately 61% in 2018, and the hand hygiene compliance rate of doctors was lower than that of nurses. Therefore, infection control staff need to train all staff in the hospital to adopt hand hygiene practices. In addition, maintaining a high hand hygiene compliance rate is also essential, and staff need to persist and have a passion for infection control.
Insufficient funding for infection control
Circular 16/2018 of the Vietnamese MOH defines payment for infection control and prevention. However, this document does not define in detail the amount that patients have to pay for infection control. Therefore, there is no standard amount for all hospitals regarding infection control payment, and each hospital has to calculate it by itself. Hence, funding for hospitals’ infection control is limited by insufficient, incorrect calculations for each patient, or a lack of influence and interest from management in infection control. Consequently, the operation of infection control systems has difficulties and reduced efficiency.
Discussion
HAI is considered the biggest concern of all countries with regard to improving hospital quality, and an important indicator for comparison and evaluation of different hospital services. Therefore, HAI surveillance has been known and practised worldwide for the past couple of decades. This has led to a decrease in the HAI rate of developed countries to less than 1%9; reductions in antibiotics consumption, number of MDROs, and total medical fees; and enhanced survival rates.
On the contrary, medical systems in developing countries, such as Vietnam, are undergoing gradual completion with many difficulties. The development of specialty and administration rules has not been synchronized between referral and local hospitals. HAI surveillance systems are being completed to serve the high-quality medical service needed by patients. As shown by the current situation, challenges include overcrowding of patients in referral hospitals due to the belief of patients that referral hospitals have higher specialty degrees than local hospitals. Hence, patients wish to transfer to the best hospitals, and this is leading to overcrowding of patients in these top hospitals. To solve this problem, we need to develop the same infection control systems in both referral and local hospitals and enhance infection control training for local hospital staff, thereby regaining the trust of patients during their treatment in rural hospitals. The HAI rate in Vietnam was as high as 5–10% in 2018, whereas that of Cho Ray Hospital was 3–5%. In particular, the MDRO rate is also high at a warning point of 62% of positive cultures. Some microorganisms have developed resistance to the antibiotics currently being used. To decrease the HAI and MDRO rates, we have been implementing several complete solutions, such as VAP, SS,I and MDRO care bundles, in all related departments. Additionally, medical staff have been training for improved infection control knowledge, enhanced awareness about the benefits of increased hand hygiene compliance rate. Moreover, we need to conduct additional research and evaluation to supply facilities for isolation patients and medical equipment, such as PPE at ICUs for the care of MDRO patients, and to monitor isolation compliance when medical staff look after MDRO patients. Furthermore, each hospital in Vietnam has to recruit sufficient infection control staff following MOH’s guidelines and enhance the parallel application of Internet technology to improve the efficiency of HAI surveillance and decrease surveillance cost and time consumption. Finally, each hospital has to correctly and sufficiently calculate its medical fees for infection control. Thus, Vietnamese hospitals have to show the annual cost for infection control.
In conclusion, according to the discussed current situation and challenges, HAI infection control in Vietnam has many advantages and disadvantages, and all of the ministry and the MOH full attention is required to support infection control in the near future. With the MOH’s support for infection control, especially for the targeted decrease in HAIs and MDROs, we will definitely obtain good results.
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Publication Date:December 31, 2020
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Category:HAI
