Implementing effective infection control in the hospital environment
Complications often result in increased pain for the patient and time away from work or family. There are also increased costs associated with antibiotic therapy and dressings.
VOL: 100, ISSUE: 36, PAGE NO: 46
Sue Wiseman, MSc, RN, Cert(Infection control), is public health protection adviser, Professional Nursing Department, RCN, London
Winning Ways - Working Together to Reduce Healthcare Associated Infection in England (Department of Health, 2003) took a fresh look at the problems of health care-associated infection and set out seven action areas, including:
- Basic infection control;
- Environmental hygiene;
- Surveillance and education;
- Commitment from senior management;
- Local systems;
- A new post to enable infection control issues to be reported directly to the chief executive and trust board.
The report describes actions that are necessary to reduce the relatively high levels of certain HAIs and to curb the proliferation of antibiotic-resistant organisms. Prevention and control of HAI is also a high priority for NHS Scotland.
The Scottish HAI Taskforce has published a code of practice for the local management of hygiene and HAI (NHS Scotland, 2004). This is to be implemented with immediate effect in NHS boards across all clinical areas.
Staphylococcus aureus has been shown to survive for three months on dry cotton lint (Smith et al, 1996) and the survival rate of methicillin-resistant S. aureus (MRSA) in dry conditions appears to be about four weeks longer (Duckworth and Jordens, 1990; Lacey et al, 1986).
The survival of bacteria under dry conditions has serious implications for patients in hospitals or in primary care settings where increasing amounts of equipment are used.
Equipment that has been demonstrated to carry S. aureus in this way includes interferential therapy machines, physician’s stethoscopes and manual handling equipment.
Rampling et al (2001) found that most of the equipment in the ward environment was contaminated with MRSA. S. aureus and Clostridium difficile have also been isolated from bedding, curtains and nurses’ uniforms.
The role of the environment
A relationship between cleaning standards and levels of cross-infection has been identified. Rampling et al (2001) found that a 21-month outbreak of infection and colonisation with MRSA on a surgical ward could not be controlled despite applying aggressive infection control measures.
The outbreak was finally ended by doubling the cleaning hours and allocating responsibility for cleaning the ward and medical/nursing equipment.
The environmental surveillance undertaken for this report found that ward furniture, medical/nursing equipment and radiators were the most frequently contaminated sites. The study demonstrated that a dusty environment and dusty equipment are potential sources of cross-infection, and a high standard of hygiene should be an absolute requirement in hospitals.
It also drew attention to the problems of identifying who is responsible for cleaning and the range of environmental sites and equipment for which no one had a defined responsibility.
The NHS Plan (DoH, 2000) outlined the need to raise standards of cleanliness in the health service. Also, NHS Estates published Standards of Cleanliness in the NHS in 2001, which was updated in 2003.
A Department of Health cleaning manual (DoH, 2004) acts as a benchmark and provides guidance and advice for health care establishments that do not have a local cleaning manual. It includes sections on:
- Infection control;
- Health and safety;
- Methods of cleaning;
- Patient equipment and preferred methods of cleaning.
There are several important areas to consider if cross-infection associated with equipment or the environment is to be avoided:
- Risks associated with the environment and equipment;
- Level of cleaning, disinfection or sterilisation required;
- Agreement and policies on cleaning responsibilities, and education that specifies the correct methods of decontamination;
- Established standards that can be monitored both internally and externally for verification.
The required level of cleaning
It is important to understand the general principles of good decontamination practice.
Cleaning - This is a process that physically removes contamination. It does not necessarily destroy micro-organisms but reduces their numbers and the dust and skin scale on which they survive. Cleaning and/or removal of dust are achieved either manually or by using automated equipment.
On hard surfaces such as floors, vacuuming followed by washing with soap and water is the method of choice. Most equipment such as drip stands, tables, lockers and beds (unless they are electrical) can be washed with soap and water or can be steam cleaned.
Steam cleaning not only removes dust and debris but also uses high temperatures in order to achieve decontamination.
Equipment made of cloth/material must be laundered between patient use or steam cleaned if the fabric can withstand the temperature.
Electrical equipment can be wiped using alcohol wipes and should be returned to a central equipment library, if one is available, to be checked for function and accuracy.
Disinfection - This process is used to reduce the number of micro-organisms, but will not necessarily inactivate bacterial spores and viruses. This can be achieved in the environment on hard (non-electrical) surfaces by using chlorine-releasing agents (in a dilution of 1,000 parts per million). Chlorine-releasing agents are generally used to clean an area where a patient with an infection has been isolated.
Sterilisation - This is a process used to render an object free from viable micro-organisms including bacterial spores and viruses. This level of decontamination is not generally needed for surfaces or equipment that is used on intact skin.
Method, frequency and responsibility
All staff who have contact with patients and use equipment in the delivery of patient care should be aware of the need to decontaminate the equipment or environment between patient use and between procedures.
A local cleaning manual and appropriate education should be made available. It should contain lists of equipment or sites to be cleaned, the preferred method, frequency, risk category (high, medium or low) and who should be responsible.
The risk assessment is made to establish the level of decontamination required and is influenced by the potential for transmission of infection, and the presence of blood or other body fluids.
It is important to remember that ‘low risk’ does not mean ‘no risk’. All patients represent a potential infection risk and therefore all low-risk items have the potential to spread infection.
Cleaning standards and collaborative working with domestic services/estates departments and contractors
The national Standards of Cleanliness in the NHS (NHS Estates, 2003) and The NHS Healthcare Cleaning Manual (DoH, 2004) outline guidance to assist staff in improving cleanliness in health care establishments, regardless of who carries out the cleaning.
These national documents and local policies are the first steps towards taking cleanliness seriously, identifying responsibility, ensuring that adequate education and training programmes exist, and monitoring performance against realistic and achievable targets.
Cleaning must be coordinated between domestic services, housekeeping staff, the estates department and nurses so that the health and safety of patients are not compromised.
Role of the matron and senior sister - Part of the role of the matron and senior sister is to take responsibility for cleanliness and infection control in their clinical areas.
They should be aware of routine cleaning and any circumstances where deep cleaning is required (for example, radiators and walls after there has been an outbreak of infection).
Auditing cleaning standards is a multidisciplinary function and any problems highlighted should be communicated between the departments involved.
It is important to remember that individual nursing and health care staff must also take responsibility for reporting problems regarding standards of cleaning.
Impact of building and equipment design on infection prevention and control
It is important that infection control and decontamination issues are considered at the design and planning stage of any new buildings or refurbishments.
The document Infection Control in the Built Environment (NHS Estates, 2002) considers infection control issues such as overcrowding, separate sinks for clinical use, ancillary areas, engineering services, storage, the requirements of support services, and also effective designs for a safe, clean environment.
Involvement in the design of equipment is much harder to achieve, but it is essential that all equipment that will be used for more than one patient is cleaned to the required standard.
Conclusion - The health care environment can and will influence patients’ sense of well-being, but it will also have an impact on their health and safety. Maintaining high standards of hygiene during handwashing, environmental cleaning and basic equipment decontamination will help reduce the risk of patients acquiring an HAI.