Keys to Infection Prevention and Control

KEYS TO INFECTION PREVENTION AND CONTROL

There is no single ‘silver bullet’ to solve the challenge of HCAI. Infection prevention and control requires a combination of actions and activities, each of which provides an essential component to the whole.

Management And Organizational Commitment

The commitment of senior management to making infection prevention and control a high priority sets a culture of a health of social care organization. Management should monitor surveillance and audit data at all levels of the organization (‘from board to ward’) and ensure that all the staff play their part. This helps general a culture of pride in delivery of a quality service.

Surveillance

Up-to-date surveillance data on the incidence of key infections should be collected, analysed and returned to the clinical units with minimum delay. In this way the data are seen to be ‘real’ by the staff responsible for the care of the patients. It is now mandatory in several countries to collect surveillance data on MRSA infections (particularly bacteraemias), CDI, and some type of surgical site infections. Although national data collection is focused on whole hospitals or hospital groups, effective action within hospital depends upon the data being assessed and acted upon in individual wards or other clinical units, The essential nature of surveillance data is encapsulated in the dictum ‘you have to measure it to manage it’.

Clinical Protocols

There are two main reasons why patients are at risk of developing an HCAI—their underlying medical condition making them vulnerable to infections and the treatment and clinical interventions they are subjected to. These interventions often include invasive procedures that bypass the normal defences of the skin, urinary and respiratory tract. It is, therefore, essential that clinical staff exercise all due care and attention when performing these procedures. To this end, an approach to clinical practice has been developed variously known as ‘care bundles’ (in the USA in particular) and ‘high-impact interventions’ (HII; the UK approach). These bundles are care protocols setting out in a simple bullet-point format the five or six essential elements needed to minimize the infection risk associated with the individual aseptic procedures. The aim is for each element to be performed correctly on every occasion and the care bundle/HII incorporates a simple audit tool for self-or peer-assessment on a frequent and regular basis of the performance of the clinical staff doing those procedures. The procedures that had been the main focus of the bundles comprise the following invasive interventions:

central intravenous catheter insertion and maintenance (Table 16.3)

•              peripheral intravenous cannula insertion and maintenance

•              renal dialysis catheter insertion and maintenance

•              surgical site infection (wound) care

•              care of ventilated patients

•              urinary catheter insertion and care.

For the HCAI programme in England these were set out in packages called ‘Saving Lives’ for secondary care and ‘Essential Steps’ for primary care use. The packages were complemented by a care bundle for CDI and guidance presented in a similar way based upon key elements for antibiotic prescribing, isolation and cohorting of infected patients and the collection of blood cultures which form the basis of the diagnosis of a bacteraemia.

Isolation And Segregation

One of the most basic and ancient approaches to preventing the spread of infection (or ‘contagion’ in previous centuries) is isolation of the affected patient. Segregation of infected patients from those vulnerable to infection (including various forms of quarantine) is an essential element of all infection prevention and control practice. It is particular important in HCAIs where the infection often occurs in vulnerable or debilitated patients and in a setting where transmission of infection between patients can occur readily. In many hospitals, the number of single rooms available for patient isolation is limited. The best use of the available rooms should be made for those with infections, but where the capacity of single rooms is exceeded by the number of cases of infection, it may then be necessary and appropriate for patients with the same infection to be nursed together in a cohort ward physi-cally separated from other ward areas and with dedicated staff who do not move between the cohort ward and other clinical areas (i.e. cohorting should apply to nursing staff as well as patients).

Hand Hygiene

One of the main routes of transmission of HCAI pathogens such as MRSA is via the hands of healthcare workers as they move between patients. For many years staff were recommended to wash their hands between patient contacts and especially before and after performing clinical procedures. However, very frequent hand washing is time consuming, can damage the skin if done as often as should be required, and can also be quite impracticable when there is inadequate provision of wash-hand basins for staff. The answer to this problem has been the introduction of alcohol hand rubs that can be used repeatedly and quickly at every point of patient contact. Alcohol is highly effective against vegetative bacteria causing HCAI such as MRSA and the Gram-negative bacteria. The hand rubs should be made available at every patient bedside and in every clinical area, and at the entrance to cubicles and single rooms. Personal dispensers can also be carried attached to a belt or the clothing of healthcare staff to use as they move between patients. In many hospitals, alcohol hand rub dispensers have also been placed at the hospital entrance and/or at every ward entrance to emphasize to patients and visitors, as well as staff, the absolute importance of hand hygiene. However, the crucial times and places for hand hygiene relate to direct clinical contact with patients. The hand hygiene campaign based on alcohol hand rubs has been promoted internationally by the World Health Organization (WHO) and in the UK by the National Patient Safety Agency through its ‘cleanyourhands’ campaign. The WHO campaign high-lights the five opportunities (and requirements) for hand hygiene:

• before touching a patient

• before clean/aseptic procedures

• after body fluid exposure/risk

• after touching a patient

• after touching patient surroundings.

The need for effective and appropriate hand hygiene has also been included in all the care bundles/HIIs (see above).

However, in one area of infection prevention and control, hand hygiene with alcohol hand rubs does not replace the absolute requirement for hand washing: this is in relation to diarrhoeal infections caused by norovirus or Cl. difficile. Alcohol is not effective against norovirus or against the spores of Cl. difficile, so for these common diarrhoeal infections, hand washing is essential before and after each patient contact or contact with the environment around infective patients.

The audit of hand hygiene (alcohol hand rub and hand washing) is an important part of monitoring compliance with clinical protocols for infection prevention and control and should include direct observation of all grades of healthcare staff and also measurement of the volume of alcohol hand rub and liquid soaps used as a general proxy measurement of hand hygiene practice.

Environmental Cleanliness And Disinfection

Whenever there are problems or outbreaks of HCAI, there is popular outcry over dirty hospitals, giving the impression that environmental cleanliness equates to prevention of infection. Whereas there is no question that hospitals and other healthcare premises should be clean and that a clean environment promotes good healthcare practice, there is less of a direct correlation between general cleanliness and rates of HCAI. However, there is good evidence that bacteria and viruses from infected patients contaminate the general environment around those patients from where they can be picked up, e.g. on the hands, by other vulnerable patients or by healthcare workers and transmitted to other patients. The evidence is particularly clear with C. difficile spores, which can be found on all environmental services in rooms where there are patients with CDI. They are particularly prevalent around toilets, or on commodes, or near bed pan washers.

General hospital cleaning is based on a detergent and water cleaning regimen, but when there are patients with known HCAIs, it is advisable to supplement detergent cleaning with use of environmental disinfectants. This is particularly the case in outbreaks of norovirus or CDI. The most effective disinfectants for these viruses and for the spores of Cl. difficile are those based on chlorine-releasing agents. These should be used routinely in areas where there are cases of norovirus or CDI.

Antibiotic Prescribing

Good antibiotic stewardship and the prudent use of these valuable drugs is an important part of the prevention and control of HCAI. Most bacterial HCAIs are caused by antibiotic-resistant organisms that flourish under the selective pressure of antibiotic use, and because of the fact that many of the bacteria are resistant to several different types of antibiotic, even the use of individual antibiotics can select for bacteria resistant to a wide range of agents. Furthermore, many of the resistance genes are carried on transferable genetic elements that can transfer among bacterial populations, particularly in a selective environment such as a hospital. There are many examples of links between use of particular antibiotics and cases of HCAI caused by resistant organisms. There are also more general links between use of agents such as the fluoroquinolone antibiotics and the rising incidence of MRSA colonization and infection. With CDI, the link is even more direct with the use of broad-spectrum antibiotics being a key precipitating factor for this disease. Outbreaks of CDI have been linked to widespread use of cephalosporins and, more recently, fluoroquinolone antibiotics when the Cl. difficile strains such as ribotype 027 have been specifically resistant to these agents.

All healthcare organizations should have antibiotic prescribing protocols to promote and audit good stewardship. This is a requirement of the statutory Code of Practice in England. The guidance in the ‘Saving Lives’ package recommends that antibiotic stewardship programme should have the following elements:

• a prescribing and management policy for antimicrobials

• a strategy for implementing the policy

• an antimicrobial formulary and guidelines for antimicrobial treatment and prophylaxis

• decision to prescribe should be clinically justified and recorded

• intravenous therapy should only be used for severe infections or where oral antimicrobials are not appropriate

• intravenous antimicrobials should only be used for 2 days before review and switch to an oral agent where possible and appropriate

• all antimicrobial prescriptions should include a stop date—generally a maximum of 5–7 days without represcription

• daily review of antimicrobial treatment

• antimicrobial treatment reviewed on the basis of microbiological results

• minimize the use of broad-spectrum antimicrobials

• a single dose at induction of anaesthesia for most operations where antimicrobial prophylaxis is indicated

• training in implementing antimicrobial prescribing guidance for all prescribers

Training And Education

The implementation of the range of infection prevention and control practices in any health or social care setting can only be successful if there is a comprehensive approach to staff education and training through which all can learn that everyone has a role to play in preventing HCAI. Basic training in infection prevention and control is mandatory for all staff in many hospitals and healthcare settings in the UK, Europe and North America, usually with regular (generally annual) required updates and specialist training for particular professional groups. Completion of this training is generally a requirement for successful appraisal and performance review for all staff.

Audit

Whereas surveillance of key HCAIs is necessary for monitoring the changing pattern and the incidence of infections, audit of implementation of clinical protocols is equally necessary for maintaining a high level of infection prevention and control practice. There should be regular audits of hand hygiene compliance, adherence to antibiotic prescribing guidelines and the implementation of the clinical protocols in the care bundles/HIIs. The results of these audits should be reviewed in a timely manner at all levels of management in the health and social care organizations so that those implementing the protocols have ownership of the procedures and their effective application. Performance management at all levels depends upon a combination of the data from surveillance of the infections and audit of the clinical practice.