ABSTRACT
Litle research has been conducted to date on the role of primary health care (PHC) in the prevenion of healthcare associa
-ted infecions (HCAIs). The present aricle is a theoreical study of the principle of
primum non nocere and aims to promote
relecion on the role of PHC in HCAI pre
-venion with emphasis on pracical recom
-mendaions. The indirect and direct roles of PHC in HCAI prevenion are debated in light of this guiding principle. With respect to the indirect role of PHC, we discuss the issues of hospital-centrism and ambulatory care-sensiive condiions. The aricle outli
-nes a number of challenges faced by health services related to PHC’s direct role in HCAI prevenion, highlights seven key compo
-nents of HCAI prevenion programmes wi
-thin the PHC sphere and provides pracical recommendaions for HCAI control and prevenion.
DESCRIPTORES
Cross infecion Paient safety Primary Health Care Community health nursing Models theoreical
RESUMO
O papel da Atenção Primária à Saúde (APS) na prevenção de Infecções Relacionadas à Assistência à Saúde (IRAS) é raramente discuido na literatura. O presente arigo tem por objeivo desenvolver um estudo teórico com base no princípio Primum non nocere, trazendo à luz uma relexão sobre
o papel da APS na prevenção de IRAS com ênfase nas recomendações de práicas. Os papéis indireto e direto da APS na preven
-ção de IRAS são debaidos, considerando este princípio orientador. No papel indireto da APS, discutem-se a questão do hospita
-locentrismo e as internações por condições sensíveis à atenção primária. Referente ao papel direto apontam-se os desaios a se
-rem superados. São indicados sete compo
-nentes essenciais para desenvolvimento de um programa de prevenção de IRAS na APS e respecivas recomendações.
DESCRITORES
Infecção hospitalar Segurança do paciente Atenção Primária à Saúde
Enfermagem em saúde comunitária Modelos teóricos
RESUMEN
El rol de la Atención Primaria a la Salud (APS) en la prevención de Infecciones Rela
-cionadas con la Asistencia a la Salud (IRAS) rara vez se discute en la literatura. El pre
-sente arículo iene como meta desarrollar un estudio teórico con base en el principio
Primum non nocere, trayendo a la luz una
relexión acerca del papel de la APS en la prevención de IRAS con énfasis en las re
-comendaciones de prácicas. Los roles indi
-recto y di-recto de la APS en la prevención de IRAS se debaten teniendo en cuenta este principio orientador. En el rol indirecto de la APS se discuten el tema del hospita
-locentrismo y los internamientos por con
-diciones sensibles a la atención primaria. Con respecto al rol directo se apuntan los retos a superarse. Se señalan siete compo
-nentes esenciales para el desarrollo de un programa de prevención de IRAS en la APS y las respecivas recomendaciones.
DESCRIPTORS
Infección hospitalaria Seguridad del paciente Atención Primaria de Salud Enfermería en salud comunitaria Modelos teóricos
The role of primary care in the prevention and
control of healthcare associated infections
*T
heor
eTical
S
Tudy
Maria Clara Padoveze1, Rosely Moralez de Figueiredo2
O PAPEL DA ATENÇÃO PRIMÁRIA NA PREVENÇÃO DE INFECÇÕES RELACIONADAS À ASSISTÊNCIA À SAÚDE
EL ROL DE LA ATENCIÓN PRIMARIA EN LA PREVENCIÓN DE INFECCIONES RELACIONADAS CON LA ASISTEN CIA A LA SALUD
* Excerpt from the project “Avaliação da vulnerabilidade programática para prevenção de Infecções Relacionadas à Assistência a Saúde nas Unidades Básicas de Saúde da Região do Butantã do Município de São Paulo”. School of Nursing at the University of São Paulo 2011-2013. 1 PhD, Professor of the
Department of Public Health Nursing, School of Nursing at the University of São Paulo, São Paulo, Brazil. 2 PhD, Professor, Department of Nursing at the
INTRODUCTION
The Declaraion of Alma-Ata deines primary health care (PHC) as
essential health care based on practical, scientiically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-relian-ce and self-determination(1).
PHC is considered a key element of healthcare and should not be understood as the anithesis of hospital care, but rather as an integrated response at all levels of the health system(2).
Health systems must meet ever-increasing perfor -mance expectaions and, according to the World Health Organisaion (WHO), unsafe care is one of the ive com -mon limitaions of healthcare services(2). Minimizing the
occurrence of healthcare associated infecions (HCAIs) is therefore a priority for assuring safe care.
The concept of paient safety is the absence of pre-ventable harm to a paient during the process of health care(3), which is based on the axiom primun non nocere, which means irst, do no harm, oten atributed to Hip -pocrates, but whose real origin is unknown(4). This is the
moto of the principle of nonmaleicence which is directly ied to paient safety. Primun non nocere has been widely used and debated as a guiding principle of hospital care since the publicaion of the classic study undertaken by the Insitute of Medicine (IOM) in the United States which highlighted that approximately 98,000 people die every year in the country as a result of medical errors(5). How
-ever, although some studies suggest that this principle is applied to nonhospital care(6), there is apparently litle ad
-herence to this principle in the PHC sphere.
The present aricle consists of a theoreical study of the Primum non nocere principle and aims to analyse pa -ient safety within the PHC sphere focusing on the preven -ion of HCAI. We atempt to promote a relec-ion on the role of PHC in the prevenion and control of HCAI, ques -ion to what extent the current care model embodies this guiding principle, and idenify the main challenges and key components of a pracical approach to HCAI preven -ion within the primary health care context.
Study Development
The focus of this study is the applicaion of the prin -ciple primun non nocere in fulilling the direct and indirect roles of PHC in the prevenion of HCAIs.
PHC is a pivotal component of the health system and plays an indirect role in HCAI prevenion given that its core funcion is disease prevenion and, consequently, the avoidance of unnecessary hospital admissions. PHC
should also assure imely access to health services accord -ing to health needs. Unnecessary health intervenions may cause harm, which is clearly opposed to the ethical precept embodied in the safety principle and adopted worldwide within the healthcare context(7).
Ambulatory care-sensiive condiions (ACSCs) are used as markers to indicate quality of primary care(8-9). A study
carried out in the State of Minas Gerais showed an asso -ciaion between ACSCs and lack of follow-up in the Fam -ily Health Strategy (Estratégia Saúde da Família - ESF)(9).
The authors highlight the major potenial of ESF teams in the prevenion of chronic diseases, which are the main causes of preventable admissions. The prevenion of AC -SCs, which are the main causes of HCAI, leads to a natu -ral reducion in exposure. The primun non nocere precept should therefore be irmly embedded in ACSCs prevenion strategies, since merely prevening healthcare-associated harm is not enough: health promoion is necessary(4).
The phenomenon known as hospital-centrism gives dis -proporional emphasis to resolving health problems through hospital care. Centralising hospital care implies considerable costs related to medicaion and iatrogenesis. From hospital-centric perspecive, when an individual is admited to hospi -tal, the general belief is that the unintended harm or sufer -ing aris-ing from any aspect of health care are directly related to the quality of care delivery. This is a simplisic view of the care process which fails to consider potenially relevant is -sues involving the relaionships between the diferent levels of healthcare including: the actual need for hospital admis -sion; whether adequate treatment of the condiion could avoid the need for hospitalisaion; and, where hospitalisa -ion is really necessary, whether the paient is assured imely access to hospital care or if delays in medical atenion lead to complicaions that could have been avoided? The avoid -ability of a condiion is also related to prehospital care. This situaion is oten aggravated in the case of emergency sur -geries, atending traumas and deliveries where any delay in care increases the likelihood of infecion.
The exaggerated centralisaion of medical care under the intervenionist approach results in the excessive use of technology and technicality, where an increase in the number of tests and sophisicated paient assessments are seen as improvements in care and the adverse efects of invasive tests are oten ignored. There is an induced lack of awareness of the fact that primun non nocere as -sumes a careful deliberaion of when and when not to in -tervene and the possible harm caused by therapeuical or assessment procedures(10). The strict meaning of primun
non nocere within the PHC sphere can be found in the concept of quaternary prevenion, which seeks to avoid harm caused by excessive medical care(7,10). The excessive
Apart from efecive care for ACSCs and imely ac -cess to care, PHC should provide and use a referral and counter-referral system and contribute towards post dis -charge follow-up of HCAIs. From the coninuity of health care perspecive, PHC must encompass the detecion and reporing the contracion of HCAIs in other care service faciliies. This is relaively common, especially in surgical site infecions, and paricularly ater caesarean secions, and is generally only detected ater discharge(11). Another
potenial contribuion is through monitoring the disper -sal of bacteria resistant to animicrobial agents, given that the disseminaion of bacteria from health faciliies to the community is possible(12-14). The disseminaion of bacteria
resistant to animicrobial agents is paricularly relevant to the primun non nocere principle, given that associated risk factors include age extremes and chronic diseases, such as kidney failure, and that PHC plays an essenial role in the care of these individuals(13-14).
PHC is the level of care that is best placed to empower individuals and families, and promote awareness of rights related to health care and engagement in the care pro -cess, the later of which is currently considered an impor -tant element of HCAI prevenion(2,7).
PHC should ideally be capable of ofering personalised primary care to individuals and families that responds to their speciic health needs. Community health should involve the whole life cycle, combat the determinants of diseases, and involve people as partners in the manage -ment of their illness and of the health of the community(2).
Although the irst do no harm principle is embedded in the concept of PHC, it is necessary to broaden the per -specive of paient safety and realise that safety begins before an individual is admited to hospital.
Litle research has been conducted to date on the direct role of PHC in HCAI prevenion. The magnitude of adverse efects related to healthcare worldwide is under -esimated. According to the WHO(2), approximately one in
every 10 paients in industrialised countries sufers from preventable harm and adverse efects related to his or her care, and it is likely that this number is even greater in de -veloping countries(15).
The tradiional term hospital infecions has given way to HCAI which relects a widening of the concept to in -clude infecions acquired in diferent healthcare seings, regardless of where care is delivered(16). This creates the
need to provide informaion regarding prevenive mea -sures to health professionals working in other levels of care, other health staf, such as carers, and even to pa -ients’ families.
However, important diferences exist between hospi -tals and other healthcare seings in terms of risk of in -fecion and recommendaions for prevenion and control. Despite this, few agreed guidelines for the prevenion and control of HCAI in nonhospital seings exist(6,17-18).
Nonhospital care varies greatly in nature and in -cludes a diverse range of seings, including dialysis cen -tres, ambulatory surgery cen-tres, doctors’ and denists’ surgeries, physiotherapy centres and mental health cen -tres. PHC inds itself within this context and is the main focus of this study.
Primun non nocere evokes relecion on quality expecta -ions within PHC and on the following statement made by the WHO: it is not acceptable that, in low-income countries, pri-mary care would be synonymous with low-tech, non-profes-sional care for the rural poor who cannot aford any beter(2).
Litle research has been conducted on the current approaches and challenges of HCAI prevenion based on the principle of primun non nocere under Brazil’s current healthcare model. The following text discusses speciic challenges within the PHC system in Brazil.
a) Diiculies in deining HCAIs: the adopion of target -ed prevenion measures should be bas-ed on evidence of factors that need be controlled or eliminated, which in turn requires epidemiological studies and well-deined criteria for determining diagnosic accuracy of HCAIs. However, epidemiological studies of bacterial populaions in seings other than dialysis centres and ambulatory surgery centres are scarce. Rare cases generally address outbreaks(16) and
an epidemiological surveillance system for HCAI within PHC has yet to be created. One of the obstacles to creaing such a system are the conceptual diiculies involved in ideni -fying episodes of HCAIs associated with PHC procedures and the lack of resources available for accurate diagnosis. The diagnosic criteria for surveillance of HCAI in tradiional hospital seings generally address acute admissions servic -es(19). One of the essenial criteria for determining whether
an infecious process is a HCAI is that the disease was not present at the ime of treatment. However, chronicity in pa -ients and recurrences are limiing factors for determining when an infecion was acquired(12) because, although care
is coninuous over ime, each contact is brief. Furthermore, asymptomaic infecious processes may already exist at the ime of care. In addiion, comorbidiies, such as HIV, that are prone to opportunisic infecions hinder the clear dei -niion of the disease as HCAI among this group. A reliable standardised denominator and indicators to facilitate pro -cess monitoring have yet to be produced(20). The denomina
-tor person-ime at risk, or alternaively, the number of cases per person may be used, while the use of the denominator people at risk apparently does not take into account this type of healthcare.
As a result, surveillance systems involving paients not admited to hospital are oten ime consuming or lack sen -siivity and speciicity(20). So how is it possible to measure
the extent of harm resuling from HCAIs in PHC seings if they cannot be clearly detected? The implementaion of a sensiive, speciic and eicient HCAI surveillance system is therefore a major challenge. Such a system should be simple and pragmaic and focus on the most likely pre -ventable infecions associated with the most common care procedures(12).
b) Mulidisciplinarity: a number of diferent types of professionals are involved in PHC in Brazil, including com -munity health agents, denists, nutriionists, pharmacists, social workers, nurses, physiotherapists, physicians, nurse technicians, and psychologists. The educaion and train -ing of these professionals does not necessarily include the control and prevenion of HCAIs, and therefore cer -tain professionals may not consider HCAIs a potenial problem. There is also a tendency towards detached care pracices, in which professionals apply prevenion mea -sures based on individual knowledge rather than on stan -dardised treatments.
Apart from problems related to immunisaion, litle is known about the risks involved with the most com -mon care procedures in PHC. Procedures with a relaively signiicant level of invasiveness and which may result in adverse efects commonly performed in PHC include col -pocitological tests, inserion of intrauterine devices, cervi -cal cauterizaion, measurement of capillary blood glucose, inhalaion, dressings, and injecions. However, esimates regarding the adverse efects caused by such procedures do not exist. With respect to dental procedures, while there is a recognised risk associated with the acquisiion of viruses such as hepaiis B and HIV, reports of HCAIs caused by bacteria are rare.
The current literature provides litle or no informaion regarding the potenial risk of infecion associated with physiotherapy, except in cases of hydrotherapy(20). As a gen
-eral rule, it is assumed that the risk associated with psychol -ogists, nutriionists, social workers, and other professionals that do not use invasive procedures is minimal. However, the use of toys, special items of furniture and other devices may act as a reservoir for pathogens if they are not made with easily cleanable and disinfectable material.
In PHC healthcare faciliies and seings it is rare to ind trained professionals who are formally responsible for creaing and implemening policy and provide training, supervision and guidance regarding HCAI control and pre -venion measures.
c) Rapid response needs: recent inluenza pandemics clearly revealed the need for rapid response and highlight -ed the importance of an harmonious response organis-ed between the diferent levels of healthcare. With regard to humanitarian disasters and disease outbreaks, it is vital that the health system is prepared to provide a rapid response.
To efecively react to a problem and provide adequate in -dividual care and appropriate guidance to the populaion regarding prevenion, PHC services must be stafed with properly trained and experienced professionals.
A pracical approach to the principle of primun pon nocere: key elements of HCAI prevenion in PHC
The naional literature gives no clear indicaion on how a HCAI prevenion and control programme for PHC should be structured and implemented, and few recom -mendaions are provided regarding out-of-hospital care in general(12,17-18). The main objecive is to protect the pa
-ient, health workers and all other individuals in the physi -cal healthcare environment and the public sector should provide the necessary inancial resources for the imple -mentaion, maintenance and supervision of efecive HCAI prevenion in PHC seings. Eight key components can be highlighted and should be part of any set of measures im -plemented within the PHC sphere.
1. Standard precauions (SPs): SPs are a set of best pracices for prevenion that should be adopted with all paients, regardless of suspected diagnosis or conirmed infecion(21).Adherence to SPs is widely recognised as the
primary strategy for HCAI prevenion(21). The following
procedures relevant to PHC are worth highlighing: Hand hygiene: this is considered the most efecive measure for prevening infecions since it prevents the propagaion of microorganisms in all care seings(22). Currently, the use of alcohol-based hand saniizers on clean hands is preferred and these should be readily available in the care facility. The use of alcohol based products to clean the hands as opposed to washing wi -th soap and water is preferred for a number of reasons: a) alcohol is more efecive as a germicide; b) the ani -microbial acion of alcohol is quicker; c) alcohol-based products dry the skin less. Alcohol gel dispensers are recommended in the recepion of the health facility to promote hand hygiene among service users on arrival and during waiing. Hand hygiene should be performed during home visits and professionals should always carry alcohol-based hand gel with them.
Care with health products:there are two categories of health products: reusable and disposable(23). The later, for
example syringes, needles and plasic vaginal speculum, should be disposed of and their reuse is unacceptable from a safety perspecive and is not jusiiable from a cost-beneit point of view. With regard to reusable items, the relevant recommendaions and norms regarding their use and reuse should be complied with(23-24).
colpocitological tests, dressings, and inhalaion) present lesser risk, because mucous membranes provide certain protecion against pathogenic invasion. In such cases, high level disinfecion is required to ensure that microorgan -isms which are not part of the local microbiota do not penetrate this issue and that pathogens are not trans -ferred from one paient to the other.
Use of personal protecive equipment (PPE): PPE con -sists of gloves, facial masks (common surgical masks), eye protecion, and impermeable gowns that should be read -ily available in the care facility and used in case of contact with blood or when splashes or sprays of blood/body lu -ids are expected(21).
Respiratory eiquete: paients should be advised to cover their nose and mouth when coughing or sneez -ing and perform subsequent hand hygiene. To facilitate this behaviour, paper issues and hand hygiene products should be provided in treatment and waiing areas(21).
Caring for the physical environment: it is the public sector’s responsibility to provide adequate faciliies and equipment for the efecive running of primary healthcare centres(25) and ensure their regular maintenance(25). All
furniture, equipment and toys should be made of clean -able and disinfect-able materials. Matresses and mats used for physiotherapy, relaxaion or other physical acivi -ies should be cleaned between each use.
Waste management:infecious waste requires speciic treatment in accordance with relevant legislaion. The healthcare team should be fully aware of what consitutes infecious waste(21) and special atenion should be given
to sharps waste. Aciviies which frequently generate de -vices or objects used to puncture or lacerate the skin in -clude vaccinaions, dressings, blood and bodily luid sam -pling, tesing for blood glucose levels, and administraion of medicaions. The areas where these aciviies are car -ried out should obligatorily contain special disposal units in accordance with relevant regulaions: improvised bins to dispose of these items are unacceptable. Healthcare waste management related to home care is the respon -sibility of the health professional that provides care and waste items should be returned to the health facility for correct disposal and devices or objects used to puncture or lacerate the skin should be placed in a hard container carried by the professional.
2. Speciic precauions:these comprise addiional rec -ommendaions that should be followed when SPs do not suice to interrupt transmission of pathogens(21). There are
three categories of speciic precauions: contact precau -ions; droplet precau-ions; and airborne precauions(21).
Health condiions treated in PHC seings that most commonly require the adopion of speciic precauions include: pulmonary tuberculosis, varicella (airborne), in -luenza (droplets), and scabies and muliresistant microor -ganisms (contact). Although treatment of these cases may be brief, it is vital to deine speciic procedures to prevent
the transmission of these pathogens. Paients suspected to have such diseases should not wait for treatment in waiing areas and should be given priority treatment us -ing the personal protecive equipment recommended for each speciic precauion(21). During the contagious period,
paients should be advised to use personal items and should not handle items that are for general use.
3. Care with medicaion and use of immunobiologi -cal products: medicaions and immunobiologi-cal prod -ucts should be stored in washable containers under hygienic condiions, in a dry place, never in direct con -tact with the loor and stacked according to the manu -facture’s recommendaions. Cardboard boxes should be disposed of since they are not hygienic and atract insects. Speciic items should be stored in a tempera -ture-controlled refrigerator speciically used for these products. Nonrelated items (food stufs, organic mate -rial, etc...) should not be stored together in the same refrigerator. Hand hygiene products should be readily available in the storage and distribuion area. Injecions should be given safely with rigorous applicaion of the asepic technique. The use of muli-dose vials has been frequently associated with outbreaks of infecions, es -pecially those caused by the hepaiis B and C viruses and gram-negaive bacteria(16,20,26).
4. Occupaional health: occupaional health pro -grammes for health workersare obligatory(27) and should
encompass accidents with potenially hazardous bio -logical agents, provide for a well-managed lux of urgent treatments and vaccinaion in accordance with the Na -ional Immunisaion Programme, which includes hepaiis B, varicella and annual inluenza vaccinaion.
5. Coninuing educaion: all health professionals should receive training and take the necessary precau -ions to prevent infec-ions(16). Writen rouines and con
-inuing educaion are vital for professionals to internalise a sense of responsibility and adhere to the principle of primum non nocere and foster paient and worker safe -ty. At least one professional in a PHC facility should have advanced knowledge and experience of prevenion and control of HCAIs(12). This professional should act as a link
and facilitate the creaion of standards and receive, inter -pret and manage reporing of adverse events in PHC. Ac -cording to a panel of Canadian specialist, this professional should receive regular support from a specialist in control and prevenion of infecions and have access to labora -tory resources to manage special cases(28). Since the size of
many primary health care centres does not jusify the em -ployment of one professional exclusively dedicated to this role, the creaion of a specialised team is recommended to coordinate HCAI prevenion and control among various centres in the same region.
7. Rapid response: during epidemics, professionals trained in HCAI prevenion and control should guide, en -able and supervise measures for limiing risks, focusing on prevenion measures directed at paients, families and health professionals, with efecive coordinaion between PHC services and other services involved in the health sur -veillance system.
8. Paient engagement: knowledge of potenial risks and efecive communicaion with health professionals fa -cilitates paient engagement in HCAI prevenion. Paient engagement is a priority since it is a key to creaing a safe environment and generates conidence in the health pro -vider(3). However, this process requires a change in ai
-tudes of health professionals and a care model which pro -motes paient paricipaion in treatment decision-making and assures paient safety(29). This includes providing infor
-maion to paients about the relevant risks, beneits and uncertainies related to both diagnosic and therapeuic intervenions. Furthermore, evidence-based healthcare
should be paient-centred, and therefore a new concep -tual model to guide research is vital(30).
FINAL CONSIDERATIONS
The premises of Brazil’s Uniied Health System are congruent with the principle of primun non nocere and in line with the general understanding that preventable harm can no longer be tolerated. Despite this, Brazil’s current healthcare model does not give due emphasis to strengthening the role (indirect and direct) of PHC in en -suring paient safety. The present study aimed to broaden the perspecive of HCAI prevenion and highlight impor -tant quesions that deserve further research in the nurs -ing ield in order to overcome the challenges outlined by this study. The pracical approach proposed by this study could provide a useful contribuion to the development of guidelines that provide comprehensive recommendaions for prevening HCAI within PHC seings.
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