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Why infection control is everybody's business

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Healthcare-associated infections remain a threat to patients. Clare Lomas looks at good infection control practices

Government initiatives aimed at eradicating healthcare-associated infections (HCAIs) have made infection control a key priority in the NHS.

Yet it is still a serious problem in UK hospitals.

Between April 2006 and December 2007, the Health Protection Agency (HPA) received reports of 9,846 cases of MRSA bloodstream infection, and there were more than 90,000 recorded cases of Clostridium difficile in patients over 65 in England.

Quarterly statistics published by the HPA have shown a steady decline in rates of MRSA infection in acute settings over the past few years.

But latest figures, published last month, showed there were 1,087 reported cases of MRSA bloodstream infection in England in the last quarter of 2007 – up by seven cases on the previous quarter – meaning that HCAIs remain one of the biggest threats to patient safety.

‘Around 8–9% of patients acquire an infection while in hospital, some of which are preventable,’ says Judy Potter, president of the Infection Prevention Society.

‘Infection impacts on a patient’s length of stay, which increases problems around bed occupancy, waiting lists and patient throughput. All of these have an impact on infection rates,’ she adds.

Since the National Patient Safety Agency launched the cleanyourhands campaign in September 2004, emphasis has been placed on improving hand hygiene to help reduce the spread of HCAIs.

‘Handwashing is the single, most effective means of hand hygiene,’ says David Tucker, joint deputy director of infection prevention and control at Guy’s and St Thomas’ NHS Foundation Trust in London. ‘It is fundamental to good infection control practice, and high levels of compliance – underpinned by total commitment from all staff – are essential.’

So it is worrying that a survey of all NHS staff by the Healthcare Commission, carried out between October and December of last year, revealed that nearly 40% of NHS staff in England don’t always have access to hand-cleaning equipment, such as hot water, soap, paper towels and alcohol handrub.

‘Trusts have to provide proper handwashing facilities,’ says Ms Potter. ‘If staff have to leave a room to wash their hands, they are less likely to do it.

‘But there is no excuse for not having alcohol handgel by patients’ bedsides – it can be easily provided and staff should also carry it with them.’

Inadequate staffing and work pressure can also impact negatively on infection control.

‘Evidence shows that when staffing levels are low, infection rates increase. And we know that when healthcare staff are busy, corners are cut,’ says Ms Potter.

‘Nurses are under a lot of pressure to work harder and faster to meet government targets but it is crucial that the basic principles of infection control are not forgotten,’ she adds.

In November 2007 the HPA published the first national study into the number of deaths from MRSA in England.

Between October 2005 and March 2006, 612 patients with MRSA died in hospital within 30 days of diagnosis of infection.

An expert review panel, which looked at a sample of 38 of these deaths, considered MRSA to be either the main cause of death or a contributory factor in 22 cases.

In almost half of the cases reviewed, the panel said the main source of the infection was via an invasive device. Yet the study also revealed that only half of the trusts involved were auditing compliance with policies regarding invasive procedures.

‘It is important to recognise that invasive devices can increase the risk of infection, and staff need to be adequately trained in how to deal with these,’ says Mr Tucker.

‘High impact interventions – evidence-based tools outlined in Saving Lives [the Department of Health Cleaner Hospitals programme updated in 2007] should be used by all nurses as a basis for improving infection control practice.’

Indwelling urinary catheters, wounds and ulcers are also breeding grounds for MRSA, which can make infection control particularly challenging for community nurses.

‘We are finding that a large number of [MRSA] bacteraemia are coming from the community,’ says Martin Jones, infection control specialist nurse at Sefton PCT in Liverpool and community network coordinator for the Infection Prevention Society.

‘Changing a wound dressing on your knees on a patient’s carpet can be difficult but community nurses have to make the environment as safe as possible by applying the same principles of infection control used in hospitals,’ he adds.

Patients in nursing or residential homes are particularly prone to MRSA. Many of these patients also have urinary catheters or wounds so the risk of contracting MRSA bacteraemia is significantly increased.

‘Flagging up high-risk patients in the community is an important control measure,’ says Mr Jones. ‘We have to be cautious about who we decolonise but undertaking root cause analysis, increasing surveillance and targeting high-risk patients is something [community nurses]should be looking at.’

In acute settings, providing adequate isolation facilities could also prove key in infection control. But three-quarters of the trusts involved in the national study on deaths from MRSA said they had problems implementing isolation policies due to the number and fitness of isolation rooms.

‘If we don’t isolate infected patients, the risk of cross-infection is increased,’ says Mr Tucker. ‘Ideally, all infected patients should be isolated in single rooms but this is not always possible. There is also the risk that when staff are very busy, they may not follow policy to the letter.’

DH plans to screen all patients admitted to hospital for MRSA by 2011 have been met with mixed reactions. But all agree that infection control is everybody’s responsibility.

‘Good infection control is down to individual practice,’ says Ms Potter. ‘There are a plethora of clinical protocols produced that identify the key elements [of infection control] that need to be followed if we are to get it right every time for every patient.

‘But infection control is crucial at all levels and nurses need support from the top. Many hospitals have made huge improvements but we still have a long way to go.’

Five ways for nurses to improve infection control

  • Always adhere to the rules of hand hygiene and carry alcohol handrub with you when on a shift

  • Always use protective clothing when necessary but be careful not to overuse gloves, which should be worn when dealing with blood or bodily fluids, not when changing beds or washing patients

  • Wear a clean uniform for each shift and always change before and after work

  • Follow all clinical protocols available, including high impact interventions such as advice on the care of invasive devices and risk assessment tools

  • Raise any concerns with your matron or infection control team as soon as you see a problem so that they can start to resolve it

‘Cases of MRSA have come down by 51%’

In July 2007, Barnet & Chase Farm Hospitals NHS Trust in north London became the first NHS trust to be issued with an infection control improvement notice by the Healthcare Commission.

Since then, the trust has made significant improvements to infection control practices and, in December 2007, the notice was officially lifted.

A new infection control training programme was introduced for all staff, and a new infection control campaign – designed around hand hygiene, antibiotic policy, protective clothing, isolation and environmental cleaning – was implemented.

Nurses perform daily checklists of their areas, alcohol handgel is now secured to the ends of patients’ beds and the director of nursing, Louise Ashley, does a daily walkabout of all wards.

‘In March 2007 we had 74 cases of Clostridium difficile,’ says Ms Ashley. ‘This has now decreased by about 65% to 10–15 cases per month.

‘Cases of MRSA have come down by 51% over the past three years and we now have over 90% compliance with hand hygiene across the whole trust,’ she adds.

‘But the biggest change has been to the culture of the organisation. There has been a huge executive buy-in and it is not just left to the nurses anymore.’

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