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May 16, 2023
    • The Healthcare sector is representative of the environment where diverse aspects of staffs, patient and services are interfaced. A safe healthcare environment provides quality and satisfying healthcare service to the patients, and well as maintaining healthy well-being for the staffs working in the healthcare sector (Engelhardt 2017). A safe healthcare environment reflects vigilance and sincerity for the care of the patients that is as crucial as the other element of skilled health care. In another word, a safe healthcare environment is the one with a low rate of error in the healthcare service and no harm to the patient’s health outcome (Alonso et al. 2017). Moreover, in terms of working healthcare staffs. the safe environment provides them with all facilities without any risk of harm or conflict. Hence, it is can be said that it is not merely the atmosphere with the absence of any potential threat to the patient and staffs but also a place that supports quality health concerning physical, social well-being and mental status.

      The Healthcare sector is the most leading sector in Ireland due to the increase in the number of patients with chronic illness (Burke et al. 2018). However, with an increase in demand of the healthcare sector, the risk of the infectious organism and its spread is significant. The infectious organism is one that has the potential to cause disease and can be easily spread from one person to another (Kizny Gordon et al. 2017). It is mainly of five types virus, fungi, bacteria, worms and protozoa. The hospitals have various type of patient having a different type of infectious disease and failure in taking precautions and safety protocol, it can be easily spread. There are two forms for the spread of infection, first direct and second indirect contact with the infected person or contaminated material. Suleyman et al. (2018) state that infectious organism can be spread by touching the infected person (having a transmissible disease like flue), coughing and sneezing on an uninfected person, coming in contact with blood (patient with open wound) or body fluid (saliva, semen, vaginal fluids) or cut skin or mucous membrane contact. Leaving the bodily fluid in the open area for unprotected person or staffs to pick up can also spread the infection carried by the fluid. Hoang et al. (2019) state that contact transmission is the most common mode of spread of infection in the healthcare setting. The infectious organisms are spread by being in direct contact with colonized or susceptible patient or healthcare staffs or another person.

      In more depth, it is crucial to know the way the infectious organism harbour the host organism. The term Chain of infection is described as the sequence that an infectious organism follows to spread and the way it moves to cause the disease from person to person (Schrank and Branch-Elliman 2017). The chain of infection includes six links that need to be connected to spread the infection. It includes infectious agent, reservoir, the portal of exit from the reservoir, mode of transmission, the portal of entry into the host and susceptible host. The infectious agents are the microorganism that causes disease which includes bacteria, virus, fungus and parasite. The reservoir is the place where the microorganism thrives and reproduce like food and water (Eoin O’Grady 2017). The microorganisms after reproduction leave the reservoir (portal of exist) through the intestinal tract, urinary tract, respiratory tract, mouth, body fluid and blood. It then transmits from one carrier to another carrier directly (between infectious host and susceptible host) or indirectly (include intermediate carrier like environmental surface). After the mode of transmission, the portal of entry involves the opening through which infectious organism enters the body of the host like an open wound and feeding tubes (Schrank and Branch-Elliman 2017). At the last stage, the susceptible host is the one who is at the risk of getting infection and form disease. The risk factor like age, weak immune system, chronic illness and malnutrition make the person susceptible to acquire the infectious disease.

      Infection Control and Prevention (IPC) has the aim of formation of safe healthcare environment by breaking the chain of infection (Ministry of Health and Sanitation 2020). It applies the strategies like hand hygiene, routine care practices, disinfection and sterilization, using personal protective equipment, decontamination of medical devices, health care waste management, screening and notification. However, despite the effort by the IPC policy, the healthcare sector is prone to a high risk of infection of microorganism which is referred to as hospital-acquired infection (HAI). The common types of infection are linked with surgical wound, chest infection and application of medical device like wound drain (Haque et al. 2018). The microorganism that can directly be transmitted is associated with diarrheal disease, antibiotic-resistant organism, impetigo and abscess, Enterobacterales, (Escherichia coli and Klebsiella pneumonia), Methicillin-resistant Staphylococcus aureus and group A streptococcus are the common type of organism that causes infection in healthcare. However, in the Irish healthcare sector, the burden of Clostridium difficile is the leading cause of infection and continues to impose considerable harm to the patient (Maisa et al. 2019).

      The spread of Clostridium difficile infection (CDI) in the hospital setting is the main focus of this paper. The report by National Clinical Effectiveness Committee (2019) states that prevalence of CDI varies across different Irish hospitals (European average) with the incidence of 4.1 CDI per 100,000 patients’ days per hospital while the Irish weighted mean incidence was 7.3 CDI cases per 10,000 patients’ days; thereby indicating the major issue of CDI in Ireland’s hospital. It mainly causes diarrhoea tosevere disease like toxic megacolon. The risk of CDI is evident from the increase in morbidity and from debilitating and profuse diarrhoea. The infected person transferred to a long-term care facility (LTCF) which increases the length of stay, late recovery and poor health outcome.

      In general, the infection prevention risk arises from the ignorant attitude of the healthcare staffs by not following the IPC policy and other infection control guideline. It is well evident that the spread of infection of microorganism occurs by non-adherence to hygiene guidelines, lack of skilled staffs, lack of education and clinical practice of nurses (Ryan et al. 2017). Some of the common risks are unsafe injection practice, poor sterilization of equipment and others. As the present paper emphasises the risk of the infection of Clostridium difficile in hospitals, the potent infection prevention risks existing in the Irish healthcare which will be the main focus for the paper are lack of hand hygiene, lack of efficient infection control program and poor disinfection of hospital environment.

      Strategy to reduce the risk of infection

      Focusing on prevention infection risk (lack of hand hygiene, lack of efficient infection control program and poor disinfection of hospital environment) of Clostridium difficile in hospitals in Ireland, the strategies will include reducing the above risks which include antimicrobial stewardship, performing hand hygiene and maintaining environmental hygiene.

      Antimicrobial stewardship

      The administration of antibiotic mainly clindamycin, penicillin and cephalosporin are commonly used to prevent CDI (Vardakas et al. 2016). However, it is well noted that with continuous use of the above antibiotics, the formation of a resistant strain of clostridium is highly prevalent resulting in an uncontrolled rate of infection. Antimicrobial stewardship is the set of measures taken by the hospitals with the aim to improvise the quality of the utilisation of antimicrobials. The antimicrobial stewardship program is built that ensure that patient gets the right therapy of antimicrobials in the right dose, duration and route along with the appropriate type of infection types at right time (DiDiodato and McArthur 2016). The CDI is the consequence of collateral damage of the microbial flora of the human guts, which is referred to as the result of the inevitable use of antibiotic (Tan et al. 2020). It is reported that residents having CDI has been exposed to antibiotic treatment within 28 days before the onset of signs (Department of health2020). The risk of CDI increased when used multiple antibiotics by the patient in the hospital. Therefore, to reduce the CDI in Irish healthcare, the strategy of the antimicrobial stewardship program is justified and appropriate. The antimicrobial stewardship program is designed to limit the infection and spread of clostridium difficile by optimizing the duration of therapy, selection of antimicrobial and de-escalation (Bui et al. 2016). The program will include implementation of staffs’ education, hospital-wide guideline, use of electronic health record to control the use of antibiotic and enforcement of the infection control policies.

      The risk of CDI in Irish hospital is common, therefore, in 2009 Health Information and Quality Authority promoted the use of an antimicrobial stewardship program for best usage of antimicrobial agents (Health Information and Quality Authority 2016). The report by National Clinical Effectiveness Committee (2019) highlights recommendation for the implementation of high impact and intervention for antimicrobial stewardship with building appropriate team. The program should comprise antimicrobial prescribing guidelines, list of restrictive antimicrobials, effort to lower the number and duration of prescriptions of antimicrobial agents (Bui et al. 2016). The inclusion of clinical review, antimicrobial surveillance, survey, audit, feedback of prescriber and limited availability of antimicrobials need to be implemented in Irish healthcare. Another grade C recommendation includes having immense knowledge about the CDI risk factor like increasing age, co-morbidity, functional impairment and chronic illness, instigating improved attention to antimicrobial stewardship (Health Information and Quality Authority 2016). The strategy under antimicrobial stewardship will also include isolation of patient with CDI with maintaining contact precaution to break the chain of infection and its spreads to person.

      The evidence for the effectiveness of antimicrobial stewardship in lowering the rate of infection of clostridium difficile in Irish hospital is documented in the report of the National Clinical Effectiveness Committee (2019)under recommendation 71. It states that there is a requirement of antimicrobial stewardship to control the outbreak of CDI in hospital.The research by Tandan et al. (2018) found that with an active antimicrobial stewardship program, the use of antibiotic was brought to limit and reduced the rise of the multidrug-resistant organism that ultimately lowered CDI. A systematic review by Baur et al. (2017) included 32 studies for the meta-analysis of the Antibiotic stewardship program on CDI. It was found that there was a reduction in the incidence of clostridium difficile (32%; 0·68, 0·53–0·88; p=0·0029). It also added that with the inclusion of preventive measures, the antibiotic stewardship programmes are more effective in preventing CDI. Similarly, another research that aimed to study the effect of antimicrobial stewardship intervention found that with six months of post-intervention, there was a reduction of high-risk antimicrobials and at 12 months the CDI cases reduced to 7.0/1000 admission [relative change −24% (95% CI − 55 to 6)] (Patton et al. 2018). Thus, it indicates that the antimicrobial stewardship program helps in controlling the spread of CDI. The evidence gathered all showed a positive impact on reducing the risk of CDI with antimicrobial stewardship program and no evidence found that could any different opinion. However, there was a lack of evidence that could document the use of the program in Irish healthcare.

      The lack of effective implementation of an antimicrobial stewardship program in Ireland is a great challenge. The major barrier or challenges noted with the implementation of these practice in Irish healthcare is lack of skilled healthcare professionals, high prescriptions of antibiotic, staffing constraint, funding and insufficient medicine buy-in (Cataldo et al. 2017). Research by Fleming et al. (2015) has compared the antimicrobial stewardship activities in UK and Irish healthcare. The result found that only 57% of participants (n=51) reported having an antimicrobial management team compared with 82% in the UK (n=273). Ireland had only 69% antimicrobial pharmacist compared with 95% in the UK. Also, the prescriptions of antimicrobial were high in Irish healthcare (85%) than in the UK (72%) indicating a high risk of development of resistant bacteria. The researcher concluded that Irish healthcare lacked having skilled management team and the high rate of use of antibiotic is a major barrier to antimicrobial stewardship program, thereby resulting in a high incidence of CDI. Similarly, another evidence by Donlon et al. (2015) surveyed IPC and antimicrobial stewardship activities in Irish long-term care facilities. 61 public and 8 private healthcare Irish sector had IPC out of which only 51% has a committee on IPC that meet only five times a year. Only 45% of them had medical care and a program to control the infection. Therefore, it indicates a lack of implementation of an antimicrobial stewardship program to control CDI despite the presence of the guidelines on the same. The major rationale noted was the lack of funds and availability of appropriate medicines.

      There is a need to control the spread of CDI in Irish healthcare by ensuring the effective implementation of an antimicrobial stewardship program. It can be facilitated by conducting an audit on the use of the antibiotic in the patient in line with cases of CDI. The information collected can give evidence on the implementation of the program (Baur et al. 2017). The guidelines on the antimicrobial stewardship program in controlling the CDI will be given to healthcare staffs with proper education on the same. It makes them knowledgeable. The daily surveillance on the use of the antibiotics in the patient reporting the time, dose and duration will be done to ensure that all such factor follows the guidelines of the antimicrobial stewardship program.

      Hand hygiene

      Compliance with hand hygiene is another practice in the Irish healthcare sector to reduce the spread of clostridium difficile in hospital. Ragusa et al. (2018) state that hand hygiene is the crucial activity performed by healthcare staffs for preventing the spread of infection within the healthcare sector that in turn ensure the safety of the patients and minimisation the risk of infection. It includes two crucial methods: first rubbing of hand with alcohol-based hand-rub and washing of hand with soap and water. The World Health Organisation (2018) established five moments of hand hygiene which includes washing the hand before accessing the patient with an infection, before cleaning the aseptic procedure, cleaning after touching the patient, after exposure to body fluids and after coming in contact with the surrounding of patients. With the performance of hand hygiene, the chain of infection of clostridium difficile will break which eventually help in preventing its transmission from one person to person. It is noted that in Irish healthcare, the performance of hand hygiene as the practice is possible however, the only requirement is to adhere to the protocol of hand hygiene. Tschudin-Sutter et al. (2018) state that even if gloves are used while assessing the patient or other, washing of hand is crucial with the use of soap and water followed by alcohol-based hand rub.

      The report of the National Clinical Effectiveness Committee (2019) gives evidence for the practice of hand hygiene under recommendation 17. It states that patient with CDI or staffs assessing any such patient should be given information on the hand hygiene and procedure for its right techniques. It also suggests thathand hygiene should be considered in the Irish healthcare sector after antibiotic therapy and when being in contact with a person having diarrhoea. Under recommendation 39, the patient with CDI should be isolated in the room having a hand wash sink indicating the use of hand hygiene in controlling CDI.

      There are a plethora of studies showing evidence on the use of hand hygiene in controlling the spread of infection. Kingston et al. (2017) explore the use of alcohol-based hand rub in clinical practice from 2007 to 2015. It was found that 86% of practitioner were compliant with hand hygiene than 58% in 2007. Similarly, Smiddy et al. (2020) found that with the performance of hand hygiene there was a reduction in the infection rate in the Irish healthcare sector. However, related to Irish healthcare no evidence has been found that could document the application of hand hygiene in the prevention of CDI. Conversely, in other healthcare sectors, hand hygiene practice is considered the best practice to control CDI. Ragusa et al. (2018) found that compliance with hand hygiene has reversed the high number of CDI cases. Similarly, another evidence showed that hand hygiene has a crucial role in the prevention of CDI and with patient hand hygiene there was a significant decrease in CDI (P ≤ .05) (Deyneko et al. 2016).

      There is no differing opinion on the practice of hand hygiene as all evidence suggested its effectiveness in the prevention of risk of spread of CDI. However, in the healthcare sector of Ireland, the performance of hand hygiene is mainly noted only after being exposed to bodily fluid. The major challenges noted in the Irish healthcare sector for implementation of hand hygiene is lack of education, skill and ignorant attitude of the healthcare staffs. Kingston et al. (2018) found that nursing students of Irish hospitals were more compliance toward hand hygiene than medical students and reported to be highest after exposed to body fluid however lowest after touching the patient (99.5% NS, 91% MS) and (61.5% NS, 57.5% MS). To support it, Kingston et al. (2017) surveyed the Department of Nursing and Midwifery at the University of Limerick, Ireland and found positive compliance toward hand hygiene mainly after coming in contact with body fluid (99.5%) and was less complaint after touching surrounding of the patient. 16% of them were unaware of the clinical contraindications for using alcohol-based hand rub and 9% of the staffs did not know about the utilisation of soap and water. The major barrier noted was skin sensitivity, skin damage and time. another evidence by Kingston et al. (2017) dermatological problems, poor acceptance, and poor availability of hand rub products as the major barrier of Irish healthcare in implementing hand hygiene practice.

      To ensure that hand hygiene is practised by the healthcare staffs hand hygiene audit can be conducted by communicating with the facility, observing the practice of the healthcare staffs of Ireland, documenting the finding and analysing the data to improve (National Clinical Effectiveness Committee 2019). Availability of hand rub product needs to be made with the proper facility of handwash sink in every patient’s room and others. the awareness of hand hygiene need be to spread by sharing posters on hand hygiene in every department. The responsibility of the complaint of hand hygiene shall be given to the senior nurse or authority to keep a check on its adherence.

      Environmental hygiene

      Maintenance of environmental hygiene is another evidence-basedpractice to reduce the risk of CDI in Irish hospitals. Regular use of disinfectant for cleaning the environment is crucial to lowering the spread of infection. The strategy to prevent the CDI will involve the decontamination of the area where the clostridium difficile infected person is kept. It includes disinfecting the bed, rooms, used sheets, and other touched appliances (Balsells et al. 2016). Disinfecting the room and area that is prone to high risk of infection of clostridium difficile, will function to break the chain of CDI. It prevents its spread of infection from one person to other. The healthcare environment is regarded as the primary source for the spread of CDI (Longtin et al. 2016). The CDI is easily spread from the colonised patient if touches any material or contaminate any area as a healthy person coming in contact with such contaminated aspects will be subject to a high risk of infection of clostridium difficile. Hence, disinfecting the contaminated area with Clostridium difficile will aid in breaking its transmission.

      The National Clinical Effectiveness Committee (2019) has suggested under recommendation number 43 that the use of chlorine releasing agent of 1000ppm is effective in disinfecting CDI but require routine disinfection. The cleaning of the care equipment used on CDI patient in Irish hospital is significant to prevent the risk of infection. The strategy needs to include thorough cleaning and disinfection of the environment especially the frequently touched sites. The key source of clostridium difficile infection is environmental faecal soiling like bedpans, commodes and toilets, which requires immediate disinfection under the strategy. When clostridium difficile infected person gets a discharge, the used equipment also needs proper cleaning. The used clothes of the infected person should be heat-disinfected (65°C for not less than 10 minutes) (National Clinical Effectiveness Committee 2019). Waste soiled with diarrhoea required to be disposed of safely so that it does not contaminate the other materials.

      The evidence suggesting disinfecting the environment to prevent the risk of CDI are many. Centres for Disease Control and Prevention (2019) stated that more than half of the cases of the CDI can be prevented by disinfecting and decontaminating the environment and referred to it as the most cost-effective strategy. The study by Schoyer and Hall (2020) found that with continuous environmental cleaning there has been a significant decrease in CDI infection. Another study by Chau et al. (2020) have conducted a systematic review to analyse the environmental cleaning bundles applied in hospital in lowering CDI. It found that the surface markers and CDI rooms were lowered significantly with the implementation of the environmental cleaning and disinfection strategy. The gathered evidence does not belong to the Irish healthcare sector which indicates that there is a lack of research or investigation on the environmental disinfection intervention for reduction of CDI. However, the report by National Clinical Effectiveness Committee (2019) well documents the use of environmental disinfection intervention to control the CDI in Irish hospitals.

      There are different opinions on environmental disinfection intervention for the reduction of CDI. The study by Ray et al. (2017) opposed the aforementioned finding. It found that environmental disinfection intervention cleaned the surface but did not reduce the cases of the CDI. The intervention was conducted in 7 hospitals and 8 control healthcare sectors. Despite the effective removal of CDI and its low recovery, the cases of CDI did not improve. Thus, it indicates that there are some barriers to implementing the environmental disinfection intervention.

      The major barrier and issue noted in an Irish hospital in the implementation of environmental disinfection intervention are lack of trained personneland lack of adherent attitude among the healthcare professional. It is evident from the book of Rafferty et al. (2019) chapter number 6 that Ireland face the issue of lack of skilled healthcare staffs that can pose a huge risk of harm to the patient. The report by World Health Organisation (2019) has outlined that there is high migration of the healthcare staffs of Ireland which indicate the presence of a low number of staffs available in the Irish hospitals. Hence, inadequate staffing indicates that maintenance and follow-up of environmental disinfection intervention would be a difficult task due to the high burden of other works as well. Therefore, it is a major issue in the practice of environmental disinfection intervention in an Irish hospital. Moreover, the ignorant attitude of the staffs towards cleaning and disinfecting the healthcare environment is another issue that obstructs its implementation because, despite the presence or existence of a cleaning protocol to lower CDI, the guideline will be failed to be followed by healthcare staffs. Therefore, it is of great importance environmental disinfection intervention supervised and ensured its daily practice in Irish healthcare.

      The process like surveying the Irish healthcare for the healthcare environment and cleaning according to appropriate guideline and protocol by a supervised person can be an approach to ensure the implementation of practice of environmental disinfection intervention for preventing CDI. The daily report needs to be prepared on the cleaning adherence which will help proper evaluation on the process of environmental disinfection intervention.

      Conclusion

      The main aim of the paper was to critically discuss the risk of the spread of clostridium difficile in Irish hospitals. The risk of clostridium difficile is severe in the healthcare sector of Ireland as discussed in the paper that its incidence and burden is high. CDI is a threat to the public health of Ireland due to the fast transmission of infection. However, it increases due to the inconsistency and inefficiency of the Irish healthcare sectors because the prevention and control measures are not in sync with the intensity of transmission. It poses a considerable burden on patient in term of health outcome and healthcare cost. To prevent the risk of the CDI in Irish healthcare the strategy of Stewardship programs for antimicrobials, hand hygiene and environmental disinfection intervention can be effective in reducing or preventing the risk of CDI. The inaccuracy of the guidelines and inability to follow rules by the medical staff elevates the health protection related issues that need to be considered for a better condition of public health. 

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