When caring for children, health service organisations require evidence-based infection prevention and control processes.
Why does this standard need special consideration by health service organisations that provide care for children?
When caring for children, health service organisations require evidence-based infection prevention and control processes. These are largely set out in the Preventing and Controlling Healthcare-Associated Infection Standard. Some risks that relate to children require specific precautions because of:
- Children’s immature immune systems and the different ways that infections affect children18,19
- Children having lower reserves and greater susceptibility than adults if they get an infection
- Children spreading infectious material by the nature of their play, or because they are too young to perform their own hand or respiratory hygiene.20
Criterion: Clinical governance and quality improvement to prevent and control healthcare-associated infections, and support antimicrobial stewardship
Systems are in place to support and promote prevention and control of healthcare-associated infections, and improve antimicrobial stewardship.
Health service organisations are better able to design improvement strategies if they know which groups of consumers are affected by which infections, and how badly. By ensuring that data about healthcare-associated infections are collected with enough detail to enable analysis by relevant demographic characteristics, better systems can be put in place more quickly.
Criterion: Infection prevention and control systems
Evidence-based systems are used to prevent and control healthcare-associated infections. Patients presenting with, or with risk factors for, infection or colonisation with an organism of local, national or global significance are identified promptly, and receive the necessary management and treatment. The health service organisation is clean and hygienic.
Standard and transmission-based precautions
Common healthcare-associated infections that affect children include respiratory tract infections, gastrointestinal infections, intravascular catheter-related bloodstream infections and urinary tract infections.18 Strategies to prevent these infections should be based on the same principles of prevention as in the adult population; however, there are some that require additional consideration for children.
The methods for collecting specimen samples in children may be different from those used in adults. Therefore, the development of policies on specimen collection from children may be required – for example:
- Ensuring that the clinician is competent in collecting specimens from children
- Balancing the reduction in the risk of transmission of infectious diseases by performing the collection procedure in the child’s bed area with the need to keep the bed area a safe, secure space that is free from medical procedures.
Strict adherence to standards and transmission-based precautions is key to reducing the risk of transmitting respiratory infections. This includes the use of:
- Personal protective equipment
- Procedures for commencing and discontinuing isolation
- Outbreak management strategies that consider the use and cleaning of bathrooms, play areas and common areas, as well as contact with families, siblings and other visitors.
Consideration should also be given to the compromised barrier and immune function of the skin of premature babies, including the increased risk of damage. This is because damaged skin can act as a portal for infection to enter the bloodstream.19 The use of topical skin antiseptics, including isopropyl alcohol, povidone-iodine and chlorhexidine, requires special consideration by health service organisations that provide care for children. Complications from misuse or over-use of skin antiseptics on children, especially premature babies, include chemical burns, local irritation, contact dermatitis and systemic absorption.21,22 In extreme cases, absorption of antiseptic agents can lead to thyroid or central nervous system disturbance.22,21 Health service organisations should consider the latest evidence on use of antiseptics on children when developing policies guiding their use in the clinical context.
The management of respiratory infections also requires special consideration by services that provide care for children, because some children, such as those with cystic fibrosis, are at greater risk of contracting and spreading respiratory infections. The consequences of a child with cystic fibrosis acquiring a respiratory infection can be serious and can include permanent deterioration of lung function.23 An example of a strategy to reduce airway infections in children is to implement a policy whereby children with opportunistic infections (such as Burkholderia cepacia complex) are not cared for by members of the workforce who are caring for children who are immunocompromised or with a multidrug-resistant infection (such as Mycobacterium abscessus).23
Strategies to reduce the chance of transmitting respiratory viruses to vulnerable children, including those in neonatal intensive care, include:
- Implementing policies on the leave or deployment of unwell or non-immune clinicians and other members of the workforce
- Ensuring that healthcare workers are immunised against common respiratory and airborne transmitted diseases, including influenza, pertussis, measles, varicella and diphtheria, and that immunisation is offered to non-immunised members of the workforce19,24
- Discouraging unwell visitors, including siblings, from visiting children
- Implementing policies on respiratory hygiene, including ‘cough etiquette’.23
Whooping cough is another type of respiratory infection that needs special consideration by health service organisations that provide care for children, as it can lead to serious illness and even death in newborns and infants who have not yet completed the recommended vaccination schedule.20 Adults and adolescents may contract whooping cough without realising it, making them more likely to unknowingly pass the infection to others with low or no immunity, such as children.20,24 Community outbreaks of whooping cough pose a risk because of the high concentration of susceptible patients, and the relatively large numbers of clinicians, family and visitors who have frequent and close contact with patients who are contagious or susceptible to infection, especially neonates.20
Some strategies to reduce the spread of whooping cough in services that provide care for children include:
- Developing workforce vaccination policies and procedures
- Developing management policies and procedures for members of the workforce diagnosed with whooping cough
- Limiting the access that the workforce and visitors have to wards with children, especially to neonatal intensive care units
- Implementing isolation policies for children with known or suspected whooping cough
- Discouraging family and other visitors from contact with children in hospital other than their own during increased whooping cough activity20
- Recognising the difficulties in diagnosing whooping cough in children
- Developing policies on post-exposure prophylaxis measures.20
Invasive medical devices
The prevention of catheter-related bloodstream infections requires special consideration when inserting, removing and replacing catheters, including umbilical catheters.19 For the use of intravenous devices, policies and protocols may be needed that cover dwelling times, placement, safety devices, the use of pathology collections (including blood culture collections) and volumes to be collected.
Toys, including those used as therapeutic aids, collect and store microorganisms, and may be a source of infection for children. Therefore, health service organisations may consider:
- Ensuring that any toys in areas that provide care for children can be easily cleaned with a neutral detergent and dried
- Cleaning toys regularly, including between patients
- Avoiding the use of toys that retain water and are difficult to clean (such as some soft toys); if these toys are used, health service organisations may consider limiting their use to a single patient only
- Undertaking a risk assessment of toys and therapeutic aids that cannot easily be cleaned to find the best strategy to prevent and control the spread of infection, including discarding a toy if it cannot be cleaned23
- Cleaning books, tablets and laptops.
Criterion: Antimicrobial stewardship
The health service organisation implements systems for the safe and appropriate prescribing and use of antimicrobials as part of an antimicrobial stewardship program.
Antimicrobial prescribing for children in hospitals is common. One Australian study reported that nearly half of children in large tertiary hospitals were prescribed at least one antimicrobial, with variable levels of appropriateness of prescribing.25 In neonatal intensive care units, the critical condition of patients may lead to frequent or prolonged treatment with antimicrobials. This will bring with it the associated risks of harm from adverse drug reactions and development of antimicrobial resistance.19
Many of the principles governing antimicrobial stewardship (AMS) in adult patients are applicable to paediatric settings, including neonatal intensive care units. They are described in detail in the NSQHS Standards. However, there are some important differences in antimicrobial prescribing, dispensing, administration and monitoring for children compared with adults. These include:
- Differences in the absorption, distribution, metabolism and excretion of medicines in children at different ages
- Changes in weight because of growth
- Variable doses of medicines for children, which are commonly based on weight
- Potential difficulties associated with administering medicines to children.
In services that provide care for children, the AMS policy should include guidance on:
- Identifying conditions and circumstances for which paediatric specialist advice should be sought
- Knowing when to seek the advice of paediatric infectious diseases experts, and how to obtain this advice
- Obtaining clinical microbiology advice
- Accessing evidence-based paediatric- and neonatal-specific national or local antimicrobial prescribing guidelines and clinical pathways (for example, sepsis pathways)
- Understanding the antimicrobial prescribing restrictions for children and the procedure for obtaining approval for use of restricted agents
- Reviewing the health service organisation’s approved list of medicines or formulary to ensure that antimicrobials are available in dosage forms and formulations that are suitable for use in children.
Those prescribing, dispensing and administering antimicrobials should:
- Check the appropriateness of the prescribed dose in an up-to-date and evidence-based reference text
- Verify all dose calculations (using a calculator) and the actual dose
- Discuss and clarify the reason for the medicine’s use, the correct dose and instructions for administration with the child’s family, and if appropriate show how to measure and administer the dose.
Services that provide care for children may ensure that the AMS team includes clinicians with paediatric specialist expertise to provide advice and support on selecting and developing AMS strategies for children, and to provide guidance on child-specific issues. If on-site paediatric specialist expertise is not available, this expertise could be sought from the AMS team at a specialist paediatric hospital, or through a network arrangement with a statewide specialist paediatric network.
Specific point-of-care interventions that could be provided as part of post-prescription review of antimicrobial orders for children include:
- Optimising antimicrobial dosing
- Decreasing duration of therapy
- Intravenous-to-oral switching.
Monitoring and analysis of antimicrobial use are critical to understanding patterns of prescribing, and their influence on patient safety and antimicrobial resistance, and to identify where to direct efforts to improve the AMS program. Antimicrobial use can be measured in terms of quantity, expenditure and quality (for example, appropriateness of prescribing according to guidelines).
The usual measure of quantity of antimicrobial use in adult hospitals, the defined daily dose (DDD) per 1,000 occupied bed days, is not suitable for children. Days of therapy (DOTs) and antimicrobial costs may be more relevant options for monitoring the quantity of antimicrobial use in children. Whichever measure is used, hospitals should ensure that the measures and the methods of data collection are consistent across the patient population.
There is currently no national antimicrobial usage surveillance program suitable for children. However, the Commission’s Antimicrobial Use and Resistance in Australia (AURA) National Coordination Unit is currently undertaking work, in partnership with the National Antimicrobial Utilisation Surveillance Program, that will support the measurement of antimicrobial use in children and enable benchmarking of use across paediatric units (see also the AURA website).
The quality of prescribing can be assessed through participation in the National Antimicrobial Prescribing Survey.26 Other indicators of quality of antimicrobial use relevant to paediatric populations are the Antimicrobial Stewardship Clinical Care Standard Indicators and the antibiotic therapy indicators in the National Quality Use of Medicines Indicators for Australian Hospitals.27
Finally, health service organisations that provide care for children should consider auditing documentation of weight and dose calculations for antimicrobials on the medication chart (see also the Medication Safety Standard). This could be part of a general medication chart audit.