Infection Control 

Greek Infection Prevention Program, GRIPP-SNF

The Greek Infection Prevention Program (GRIPP) is a pioneering national program for the prevention and control of hospital-acquired infections and antimicrobial resistance. The program is a five-year long initiative (2021-2026) that aims to transform ten of the largest public hospitals in Greece into hubs of best practice for Infection Prevention & Control (IPC).

The core objectives of the program are:

1. Educating healthcare workers on IPC by developing and delivering a training program that includes certified training of Infection Prevention Nurses on the basic and more advanced principles of IPC, as well as training seminars for clinical liaisons, hospital executive staff and other healthcare workers,
2. Strengthening Infection Control Committees at the ten hospitals with trained Infection Prevention Nurses and continual support throughout the duration of the program,
3. Delivering interventions that improve practices and can reduce HAIs and AMR in the selected hospitals,
4. Improving HAIs and AMR hospital surveillance by developing a national database for systematic monitoring not only to detect problem areas, but also to measure the impact of interventions towards successful control of infections in Greek hospitals.

The program is generously and exclusively supported by the Stavros Niarchos Foundation, as part of the Global "Health Initiative" (ratified by Law 4564/2018 (Government Gazette A170)). It is implemented by the Center for Clinical Epidemiology and Outcomes Research (CLEO), in collaboration with the National Agency for Quality Assurance in Health S.A. (AQAHS.A.), and in partnership with the National and Kapodistrian University of Athens (NKUA), the Greek Ministry of Health (MoH), the National Public Health Organization (NPHO), and the Institute for Healthcare Improvement (IHI).

PHIG Project 2016

PHIG project - Preventing Hospital Infections in Greece 

With PHIG, CLEO expanded the focus of its research and health promotion activiities and developed new partnerships with Children's and General Hospitals throughout Greece. The PHIG project was designed to survey the most common hospital infections and compliance to prevention practices and the use of antibiotics. The project started in January 2016 and was funded by the generous support of the Stavros Niarchos Foundation. PHIG came to an end in December 2019.

The project addressed six core domains of infection prevention:

• Hand Hygiene
• Central Line Associated Blood Stream Infections (CLABSI)
• Catheter Associated Urinary Tract Infections (CAUTI)
• Ventilator Associate Events (VAE)
• Perioperative Antibiotic Prophylaxis (PAP)

The four-year program was separated into three consecutive phases:

1. The Pilot Phase

The following activities were carried out during the pilot phase:

• Adaptation of data collection tools to the specific needs and requirements of each unit; and
• Medical-nursing staff training on the proper use of data collection tools and familiarization with terminology used for infection supervision and control.

The pilot phase for the majority of participating units started in June 2016 and lasted three months. During the pilot phase, data collection and recording was performed using the specially designed tools from the CLEO team to check the validity of this data. Representatives of all units were trained for the proper use of these tools in a 2-day intensive course that was held on March 18-19, 2016 at the National Public Health School amphitheater. In addition, during the pilot phase there was continuous feedback on the program’s progress, uninterrupted audits to ensure the reliability of the data collected and continuing training of unit representatives by the CLEO experts.

Based on the results of the pilot phase, the data collection and filing tools have been adapted to meet the specific needs of each unit and to facilitate the collection of data in the next phases of the program.

2. The Baseline Phase

The following activities were carried out during the initial surveillance phase:

• Assessment of material and technical infrastructure for hand hygiene in each unit;
• Surveillance of compliance with hand hygiene rules;
• Surveillance of CLABSI, CAUTI and VAE incidents;
• Surveillance of antimicrobial drugs use; and
• PAP surveillance.

Following the pilot phase, the baseline surveillance phase of the program began in September, 2016. The baseline surveillance phase for the HH and CLABSI protocols lasted until February, 2017 while for the other protocols (CAUTI, VAE, PAP and Antibiotic Use) until August, 2017.

Also, the analysis of the HH and CLABSI protocols for the 9 months (June 2016 - February 2017) of the pilot and baseline phase together was completed. The relevant results are presented below:

Results

The overall CLABSI rate by type of ward ranged from 3.17 to 7.34 infections/1,000 catheter days in pediatric oncology units and NICUs, respectively. Specifically, the highest CLABSI score was estimated at about 7.34 infections/1,000 catheter days and was noted in the neonatal units. The pediatric oncology units have the lowest CLABSI score, which estimated 3.17 infections/1,000 catheter days, and finally, the percentage of CLABSI in adult and pediatric units, was estimated at 5.65 and 6.03 infections per 1,000 days of catheter, respectively.

The overall HH compliance rate by type of ward ranged from 40.90% in adult units and 72.00% in PICUs. The lowest HH compliance was noted in adult units (40.90%). Conversely, higher compliance was observed in pediatric oncology units (67.70%) and in neonatal units (71.60%), while the highest level of compliance with hand hygiene rules was observed in children's units (72.00%).

Τhe design of CLABSI and HH bundles adapted to the specific needs of every unit has been completed. These bundles include: CLABSI and HH compliance rate feedback to the healthcare staff, posters, cards, booklets, and other material creation aiming to serve as good practices reminders (Appendix 7), analytical implementation plan (Appendix 7), educational seminars using the above mentioned material.

The design of the CAUTI, VAE, PAP/SSI, and Antibiotic Stewardship bundles is currently in progress.

3. The Intervention Phase

In the third and last phase of the project, a series of interventions adapted to the specific needs of each separate department/unit were designed and implemented. Surveillance of hospital infections and antibiotics use continued all throughout this phase.

While interventions were being designed, at the end of March 2017, CLEO delivered a training course to infection prevention champions at our main offices in Athens. The purpose of this "Train the trainers" course was to educate on how best to implement a series of measures (so-called 'bundles') that help increase compliance with good hand hygiene (HH) practices and prevent microbial infections associated with a central line (CLABSI).

Among the core topics of the course, participants learned to discern whom to train (doctors, nurses, new staff etc.), to evaluate training and to monitor trained personnel. They were provided training material on 4 topics (hand hygiene, insertion, access and change of dressing). Indicatively, the new responsibilities of each unit representative trained in the course included conducting training courses for all staff in the department, distributing educational material, poster posting, filling out checklists, and maintaining open communication with the CLEO team for any problems or clarifications.

Overall, the course received highly positive feedback and contributed to strengthening relationships among all participants and CLEO's infection prevention experts. Following the training, interventions on HH and CLABSI started in early April of 2017.

Similarly, training and interventions against CAUTI, VAE, PAP and Antibiotic use started in the Autumn of 2017.

For the implementation of each intervention, CLEO’s infection prevention experts visited each site and first met with hospital administrators, IC committees and clinic leaders not only to disseminate the results from the Baseline phase, as well as to ensure the continued commitment to the interventions planned by all parties. Following the approval and commitment from local leadership, other stages of interventions included the developmennt of specialised educational programs, the dissemination of the educational material (also including poster hanging), routine checks and monitoring through filling out checklists, audits all while receiving feedback from participating units for the success of the interventions.

Infection Prevention Control

Data on Hospital Infections in Greece

Hospital-acquired infections are among the most common complications of hospitalization. Their consequences are significant, both for patients and for the Greek health system, as they extend patient stays, increase hospitalization costs tremendously, and may result in death.

According to available data, over 10% of hospitalized patients in Greece acquire healthcare-associated infections, resulting in over 3,000 deaths per year. Additionally, hospital-acquired infections increase the length of hospital stays and burden the Greek health system with costs of more than 1.2 billion euros annually.

According to the literature, however, hospital-acquired infections can be reduced significantly or even avoided altogether.

Action taken by CLEO to control and prevent hospital infections

From July 2012 through December 2015, CLEO’s work made waves in the sector of hospital infection prevention and control, resulting in a higher level of hospital care for the pediatric patients at the “Aghia Sophia” and the “Panagiotis and Aglaia Kyriakou” hospitals. CLEO’s activities focused on:

SURVEILLANCE AND PREVENTION OF CENTRAL LINE ASSOCIATED BLOOD STREAM INFECTIONS (CLABSIS)

nitial CLEO efforts focused on the prevention of hospital-acquired infections and in particular CLABSIs in neonate intensive care, pediatric intensive treatment, and oncology units.

After 6 months of surveillance, CLEO implemented a series of interventions including:

• Briefing staff on the 6-month long surveillance outcomes;
• Implementing training seminars on the proper insertion and use of central vein catheters;
• Developing and distributing training materials, in cooperation with the Nursing School of the National and Kapodistrian University of Athens, on central line insertion and maintenance; and
• Designing an algorithm to diagnose CLABSI precisely.

The application of this series of interventions led to a 28.5% reduction in CLABSIs.

SURVEILLANCE AND IMPROVEMENT OF COMPLIANCE WITH HAND HYGIENE PRACTICES

The simplest and most effective method of hospital-acquired infection prevention is the implementation of proper hand hygiene practices.

CLEO conducted a prospective two-phase study to assess the efficiency of a simple training intervention, aimed at improving compliance with hand hygiene practices among medical and nursing personnel. Initial surveillance data from thirteen departments selected of the two pediatric hospitals demonstrated low compliance rates (33%). During the second phase of the study, training seminars concerning proper hand hygiene practices were conducted in seven departments, while compliance surveillance continued. Comparative analyses of the two phases showed a substantial increase in compliance within these departments, from 48.3% to 73.9%.

SURVEILLANCE OF PERIOPERATIVE ANTIBIOTIC PROPHYLAXIS (PAS) AND SURGICAL SITE INFECTIONS (SSIS)

SSIs are the second most common hospital acquired infection afflicting adults and children. They have been shown to increase patient morbidity and mortality, as well as hospital care costs.

CLEO conducted a prospective study, in cooperation with the 1st department of Pediatric Surgery of the “Aghia Sophia” General Children’s’ Hospital, aimed at evaluating the effectiveness of a training intervention for PAP administration practices. Initially, practices were recorded and instructions on appropriate PAP administration, including information about the active ingredient and the duration of administration, were developed in collaboration with the hospital’s committee of infections. These instructions were then distributed to the surgeons of this particular clinic. Comparing initial data on PAP practices to data collected after the distribution of instructions, we observed a statistically significant increase in the percentage of the patients receiving the appropriate antibiotic for the right duration, from 6.2% pre-intervention to 77.1% post-intervention.