The aim of this essay is to discuss the importance of infection control. The essay will begin by looking at the prevalence of infection. This will be followed by a discussion of the infection control measures in place to break the chain of infection whilst evaluating the problems of implementing the various techniques in practice. Reference will be made to wide range of literature which will support arguments and demonstrate evidence-based practice. The essay will then conclude and offer recommendation for future practice.
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With the outbreak of antibiotic resistant infections, infection control is becoming a major concern for health organisations all over the world (Department of Health (DH), 2003). Generally between 4 and 10 % of patients hospitalized in a more economically developed country, such as the United Kingdom (UK), the United States of America (USA) or Australia, develop a hospital associated infection during their time in hospital (DH, 2003). Currently, the DH (2003) estimates that one in ten NHS patients will contract a healthcare association infection whilst staying in an NHS hospital thus giving the UK one of the highest rates of healthcare associated infections in the western world. As well as significantly raising healthcare costs and lengthening hospital stays, it is estimated that hospital associated infections cause 25,000 patient deaths every year (Borton and McCleave, 2000). Although these facts and figures may seem daunting, the situation can be improved by implementing a number of simple measures to break the chain of infection and prevent hospital associated infections occurring.
Huband and Trigg (2000) explain that for a nosocomial (healthcare associated) infection (HAI) to occur there must be a susceptible host, an infectious agent and a means of transmission from the source of the infectious agent to the susceptible host. If any of these components are not present the chain of infection is broken and an infection cannot occur (Mallik et al, 1997). The susceptible host is perhaps the hardest part of the chain to control since patients are generally admitted to hospital as a result of an illness or injury which often leaves them more vulnerable to infection. As well as patients who are immunologically compromised because of illness or injury, there are also patients who are more vulnerable just because of their circumstances. The elderly and the very young (children of a gestational age of less than 32 weeks) are at a high risk because their immune system is not yet fully developed (Huband and Trigg, 2000) and patients undergoing immunosuppressive treatment, or who have an immunosuppressive illness such as human immunodeficiency virus (HIV), may struggle to fight off infections (Hockenberry et al, 2003). Although this means that there will almost always be a susceptible host present, there is still a lot healthcare professionals can do to protect vulnerable patients. Measures are in place to assess each patient individually to uncover their needs and equip nurses with the correct information to produce a protective care plan.
One of the areas in contention, especially in the media is the hygiene practices in hospital and by staff and how they contribute to the problem of HAI’s (REF). Nurses’ actions account for roughly 80 percent of the direct care patients’ receive and usually involves personal and intimate care activities (REF). As such, the chance of infecting a patient with an avoidable HAI is as high as ten percent and some of the infections will be caused by microbes present on the hands of those providing care (REF). Evidence from a review conducted by Pratt et al (2000) concludes that in outbreak situations contaminated hands are responsible for transmitting infections. This is supported by evidence presented in NICE (2003) infection control guideline.
The act of hand hygiene however, is simple but effective against the possibility of cross-contamination between patient-patient or indeed from nurse to patient and vice versa. In a non-randomised controlled trial (NRCT) a hand washing programme was introduced and in the post intervention period respiratory illness fell by 45% (Ryan et al, 2001) A further NRCT, introducing the use of alcohol hand gel to a long term elderly care facility, demonstrated a reduction of 30% in HAI over a period of 34 months when compared to the control unit (Fendler et al, 2002). One descriptive study demonstrated the risk of cross infection resulting from inadequate hand decontamination in patient’s homes (Gould et al, 2000). Despite these findings and hand hygiene being a simple procedure and the rates of compliance should be high; the evidence points to the contrary (REF). A study conducted by Jenkins (2004) found that even when staff did perform hand hygiene 89% missed some part of their hands. In another study Parini (2004) reported that work pressure reduce opportunities for effectively hand hygiene in between procedures or patient handing.
Expert opinion however, is consistent in its assertion that effective hand decontamination which refers to the process for the physical removal of blood, body fluids, and transient microorganisms from the hands, i.e., handwashing, and/or the destruction of microorganisms, i.e., hand antisepsis (Boyce and Pittet, 2002), results in significant reductions in the carriage of potential pathogens on the hands and logically decreases the incidence of preventable HAI leading to a reduction in patient morbidity and mortality (Boyce & Pittet, 2002; Infection Control Nurses Association (ICNA), 2002). Therefore, as an infection control measure hands should be washed before and after each patient contact and before every episode of care that involves direct contact with patients’ skin, their food, invasive devices, following removal of gloves or dressings (iCNA, 2002; NICE, 2003; Jamieson et al, 2002). This may be a full hand wash, using liquid antibacterial soap and water or alcohol rubs (Nicol et al, 2003).
A full hand wash should be carried out before placing gloves on the hands; when the hands are visibly soiled; after contact with contaminated materials, e.g. linen; when performing an aseptic technique; before handling food; after using the toilet and before leaving the ward (Parker, 2002). The NHS Quality Improvement Scotland (2003) and NICE (2003) contend for hand washing, to be reliable, it should take about 20 seconds and should follow the standardised hand washing techniques. Both surfaces of the hands should be washed thoroughly, taking particular care of areas that are usually missed, for example, nail beds, back of thumbs and in-between fingers. The hands should be wetted first, the soap applied and used to wash the hands, then with the hands bring rinsed in clean water and thoroughly dried with disposable paper towels (Stewart, 2002). Hot air dryers or re-usable towels should not be used in the clinical setting as studies have shown the increased contamination after drying, or with the hand dryers, the lack of drying (Parker, 2002). The taps should be turned off with elbow or wrist or in the case of normal taps, a paper towel (Clark, 2004).
Part of modern day hand hygiene procedures now include alcohol rubs which are in widespread use as they are easily used and are effective in destroying the transient microbes found on the hands. They are usually used between hand washes and require no water or paper towels as the alcohol evaporates very quickly. Myers & Parini (2003) explains most contain an emollient to ensure that constant use of the alcohol does not cause skin problems. Alcohol gel rubs however, are not a substitute for hand washing as they are ineffective if used on hands contaminated with body fluids or excreta (Nicol et al, 2003). It also has been shown that without washing the hands regularly when using alcohol rubs causes a build-up of emollient on the hands, which means that the alcohol becomes less effective at killing the transient bacteria (Girou et al, 2002). Kampf and Loffler (2003) showed the use of antimicrobial soap and water along with an alcohol gel sanitizer was the most effective at reducing the number of transient microbes, over 99.99 percent, compared with just fewer than 99.0 percent for antimicrobial soap and water alone, and 99.46 percent for just alcohol gel sanitizer. This highlights the fact that the use of only alcohol gel or hand washing alone still leaves a risk of contamination, albeit a negligible one.
As part of any infection control measure NICE (2003) recommendations the use of personal protective equipment (PPE) by healthcare personnel in primary and community care settings which includes the use of aprons, gowns, gloves, eye protection and facemasks. Under the Control of Substances Hazardous to Health Regulations (Health and Safety Executive, 2002), all healthcare professionals caring for patients are required to make proper use of PPE provided. Correct use of PPE is a key measure in preventing the spread of infection. ICNA (2002) states disposable aprons and gloves reduce the number of micro-organisms on uniforms, clothing and hands, but do not eliminate them. Gould (2010) contends that disposable gloves and aprons should be worn for all contacts with patients with MRSA, but this according to Bissett (2007) is not an excuse for ineffective washing of hands, as hands should be washed even when gloves have been worn. Gloves cannot be guaranteed 100% impervious (Clark et al 2002). Gloves sometimes leak or may tear, especially with prolonged use, and the hands may become contaminated as they are removed (DH 2008). In addition, safe removal of aprons is very important: Aprons must be removed by breaking the ties and rolling the apron inwards to prevent scattering of skin flakes and organisms.
Infection control also relates to the clinical environment. Studies have confirmed that large numbers of bacteria are present in the surrounding environment and that symptomatic carriers contribute to the spread of infection (Mutters et al 2009). The isolation of patients with suspected or confirmed infections such as particularly meticillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C. difficile) in a side room is strongly recommended (DH, 2007; Health Protection Agency (HPA), 2009). Masterton et al (2003) in a joint UK working group reviewing hospital isolation facilities recognised that although isolation may be requested regularly, it is not always possible. Similarly in a prospective study conducted in a large UK hospital over 12 months, approximately one in five requests for patient isolation was not met for a number of reasons, including lack of facilities (Wigglesworth and Wilcox 2006). Hence where isolation facilities are not available, patients should be cohorted (DH and HPA 2009). Isolating patients conversely has some element of psychological risks, for example anxiety, depression and feeling of loss of choice (Gammon 1998) and is something that the nursing staffs need to be aware of and assess regularly.
Specific local infection control guidelines should also be readily available to help support nurses and other healthcare professional carry out effective environmental decontamination. Bacteria can survive on surfaces, so common sense indicates that, if the environment is kept clean, the bacterial load will be reduced (Bissett, 2006). Gould et al (2007) points out that transmission of infection’s such as MRSA can also take place from environmental reservoirs of the bacteria, including bedpans and urinals contaminated with spores. Hence, patient equipment hygiene is another important aspect of infection control in preventing the risk of spread infection.
Although this list is not exhaustive, nurses caring for patients should ensure clean hoists, slings, baths, cot sides, toilet seats, commodes and bed pan holders after each use. Lockers, bed tables and chairs also need regular cleaning. According to WHO (2009) all care equipment must be treated in the same way.
NICE (2003) states widely available approved detergent wipes are useful for cleaning and MRSA prevention. Disinfectants are not cleansers, so equipment needs to be cleaned with a detergent first, unless a sanitizer that combines both cleaning and disinfectant properties is available. Local guidelines on clearing up spillages of blood and body fluids should also be followed, remembering to wear aprons, gloves and eye protection (if required) to ensure safety and reduce the risk of infection for the person cleaning up the spillage.
Nurses working in both hospitals and community settings should be aware of the growing threat of HCAI such as MRSA and acknowledge the need for universal precautions when nursing patients with this form of infection. Moreover, infection control departments have a clear responsibility to provide staff in clinical areas with information on infection control policies and procedures. It is imperative that all nurses and other healthcare professionals are made aware of the existence of such policies and procedures (NICE, 2003).
Registered nurses must be aware that they may be in breach of the NMC’s Code of Professional Conduct (2004) specifically clause 1.4: “You have a duty of care to your patients and clients, who are entitled to receive safe and competent care.” Meaning should a nurse fail to take appropriate precautions when dealing with a patient, for instance disregard for hand hygiene procedures the nurse may be liable for disciplinary procedures by the NMC. This may make nurses more aware of their responsibility with regards to HCAI such as MRSA and infection control. DH (2008) argues staff must take a pro-active rather than a reactive approach to the barriers that they face with implementing infection controls procedures such as hand hygiene. Nurses must ensure that the materials needed are readily available and others can be sourced if the need arises and that their training on infection control is up-to-date (RCN, 2000).
In conclusion, MRSA with its antibiotic resistance has become one of the major challenges to the scientists and researchers in the health and medicine sector since the 1990s due to the increase rate of the number of inpatients who have caught infection due to cross infection. It is integral for nurses, other healthcare professional and visitors to follow the various precaution measures set out according to the hospital policies, procedures and guidelines as this will assist in the prevention of the transmission of MRSA. The high numbers of HCAI’s are putting patients’ lives and well being at risk and it also have significant implication on the NHS finance and resources.
For this reason there is a clear need for nurses and other healthcare professionals to work collaboratively to tackle infection such as MRSA if infection rate are to fall. Improving nurses’ knowledge of the cycle of infection in MRSA is one step in helping to prevent and control this infection. This may be in the form of education and training on the aspects of infection control, with constant up-dates on the current issues that are supported through evidenced-based practice (NMC, 2008). This will not only improve practice and assist in the appropriate use of resources but will also contribute towards to ensuring HCAI’s do not reach epidemic proportions.
The barriers to adequate hand hygiene are apparent, these must be overcome to ensure that Hospital Acquired Infections do not reach epidemic proportions, and as a result there are implications to nursing practice that must be met (Simpson, 1997). This may be in the form of education and training on the aspects of infection control, with constant up-dates on the current issues that are supported through evidenced-based practice (RCN, 2004). This will not only improve practice and assist in the appropriate use of resources but will also contribute towards nurses’ professional profiles for PREP requirements (NMC, 2004). Infection control departments have a clear responsibility to provide staff in clinical areas with information on infection control policies and procedures. It is imperative that clinical staff are made aware of the existence of such policies and procedures (NHS Quality Improvement Scotland, 2004). Registered nurses must be aware that they may be in breach of the NMC’s Code of Professional Conduct (2004) specifically clause 1.4: “You have a duty of care to your patients and clients, who are entitled to receive safe and competent care.” Meaning should they fail to take appropriate precautions when dealing with a patient, for instance disregard for hand hygiene procedures they may be liable for disciplinary procedures by the NMC. This may make nurses more aware of their responsibility with regards to infection control. Staff must take a pro-active rather than a reactive approach to the barriers that they face with hand hygiene. They must ensure that the materials needed are readily available and others can be sourced if the need arises and that their training on infection control is up-to-date. (Scottish Executive, 1998).