Key learning points:
– Infection prevention and control standards should be the same in primary care settings as they are in hospitals
– Primary care settings have specific challenges
– It is possible to address these challenges to meet recommended standards in relation to hand hygiene and uniform policies
The National Institute for Health and Care Excellence (NICE) guidelines1 for the prevention of healthcare associated infections in primary and community care settings were updated in 2012 due to changes in healthcare provision and the recognition that increasingly complex care was being carried out outside of the hospital setting. The move from the term ‘hospital-acquired’ to ‘healthcare-associated’ infection also reflects this shift. Patients who are at high risk of acquiring an infection are increasingly being cared for in primary and community care settings. Therefore, it is important that standards of infection prevention and control in these settings are comparable with those in an acute hospital setting. While the application of standard precautions with all patients is recommended by NICE1 in primary care as well as by epic32 in hospital settings, and recommendations across all settings remain the same, this article will focus specifically on two hygiene-related issues; hand hygiene and uniform policies. These aspects can have particular challenges outside of the hospital setting, therefore, it is important to consider how community-based staff can meet the same standards in sometimes difficult situations, and comply with national guidance. Although first the extent of the problem of infection in primary care needs to be considered.
Healthcare-associated infection in primary care settings
It is estimated that healthcare associated infections (HCAI) cost the NHS around £1 billion annually, with around £56 million of this estimated to be incurred after discharge into the community. In addition to this, healthcare staff, families and carers can also be at risk of infection when caring for infected people. Infections can additionally be due to the endogenous source, that is, from microorganisms carried by the patients themselves, putting patients with wounds and invasive devices at risk from their own microbial flora. The current estimate of 300,000 patients each year acquiring a HCAI in England is likely to be less than the actual reality due to not all HCAIs being identified or reported as such.
NICE1 states that patients have "the right to expect that those who provide their care meet appropriate standards of hygiene and follow the correct procedures to minimise the risk of healthcare associated infection". The guidelines also identified priority areas for implementation in primary and community care settings, some of which relate to hand hygiene.
As the most important intervention in the control of cross-infection, it is important that hand decontamination is a priority in all healthcare settings. Ensuring that staff decontaminate their hands when they should is one of the key implementation priorities within the NICE guidelines.1 In the past when hand washing was the main hand decontamination approach, this presented particular challenges for community staff, in particular those providing care in patients’ own homes. Hand washing facilities were variable and in some cases it may have been more of a risk to use the facilities. The introduction of alcohol hand rub was particularly useful for community staff, though this was initially recommended for use when handwashing facilities were not suitable or were unavailable. Now, the current recommendation in all healthcare settings is that alcohol hand rub should be the main way of decontaminating hands, except in situations where hands are visibly soiled due to organic matter inactivating alcohol; and in cases of diarrhoeal illness where there is the potential for organisms resistant to alcohol to spread, such as Clostridium difficile.
As the main approach to hand decontamination, it is vital that staff use hand rub correctly to ensure that risks to patients and others are minimised as much as possible. In particular, the application technique needs to mirror the technique recommended for washing with soap and water so that all areas of the hands come into contact with the hand rub. It has been identified in previous research that compliance with hand hygiene can be poor in primary and community care settings.3-6 The literature identifies various reasons for poor practice in relation to hand hygiene, many of which are applicable to primary care. They generally fall into one of the following categories: facility related issues, knowledge and training issues, personal views, the beliefs and attitudes of staff; physical complications, staffing issues, and management issues (see Table 1).
With evidence based guidelines from NICE1 and an increased emphasis on the prevention of HCAI in healthcare, many of these reasons should be easy to address or may not even be real issues except in the minds and perceptions of some staff. NICE clearly states that wherever healthcare staff are delivering care, they must have an appropriate supply of products for hand hygiene – in primary care this might mean appropriate wall mounted soap, paper towels and hand rubs in clinics or supplies of alcohol hand rub for district and other community nursing teams. Of course one of the main issues here is when home nursing teams are in contact with patients whose alcohol hand rub cannot be used and where the home’s facilities are also not appropriate. In this situation, it is acceptable to use wet wipes to clean the hands followed by alcohol hand rub. This also therefore means that community nurses should have access to wet wipes at work. As accountable practitioners, we need to consider what the real barriers are and work with others to reduce these, including other healthcare staff, patients and carers and those who order the supplies of soap, wipes and hand rub. Various aspects of the Nursing & Midwifery Council (NMC) code7 can be used in support of addressing barriers to good practice. Section 6.2, for example, states that nurses must "maintain the knowledge and skills you need for safe and effective practice," which would include knowledge about infection prevention and control (IPC) and hand hygiene. It also states that you should "keep to and promote recommended practice in relation to controlling and preventing infection" and "be aware of, and reduce as far as possible, any potential for harm associated with your practice". In order to meet the requirements of both the code and local IPC policies, the identification and minimisation of barriers to good practice is something that nurses should see as an integral part of their role.
The Department of Health (DH) updated its guidance8 on uniform and work wear after comments and feedback on the previous 2007 guidance. While the updated guidance presented no significant amendments, it offered some examples of both good and inappropriate practice in relation to uniforms and work wear. The objectives of the guidance relate to patient safety, public confidence and staff comfort and while they do acknowledge that there is no conclusive evidence that uniforms have a direct role to play in the spread of infection, the overall aim should be to minimise any risks to patients and clients and to facilitate good practice, such as hand hygiene. The 2007 guidance became widely associated with the term ‘bare below the elbows’ which is now advocated in most hand hygiene and uniform policies. Therefore, in terms of nursing uniform, policies state that staff should wear no hand or wrist jewellery and that their nails should be short and free from nail polish and false nails. These aspects are supported by research evidence that highlights that having any of these items increases bacterial counts on hands and inhibits correct hand decontamination.
The DH8 highlights standards of good practice relating to uniforms, some of which are evidence based and some that are designated ‘common sense’. These include aspects such as:
· Wearing short sleeves.
· Changing uniforms if they become visibly soiled or contaminated.
· Changing into and out of the uniform at work or covering it completely when travelling to and from work (this is not related to evidence of any infection risk but to public perception it may be considered unhygienic).
· Washing uniforms at the highest temperature suitable for the fabric (based on evidence that washing at 60oC for 10 minutes removes most micro-organisms).8
· Changing the uniform each day.
· Washing heavily soiled uniforms separately.
Uniform policies also work within the context of legal requirements such as the Health and Safety at Work Act 1974, The Management of Health and Safety at Work Regulations 1999, and the Health and Social Care Act 2008: Code of Practice for health and adult social care on the prevention and control of infections and related guidance.
Much of the uniform related guidance reflects aspects of the NMC Code7 in terms of promoting professionalism and trust, much of which relates to public perception as opposed to actual evidence of infection risk.
As can be seen, patients are increasingly at risk of infection in primary and community care settings due to growing case complexity, but national guidance is there to support staff in their practice to minimise the risk of infection and cross infection, including that from the DH, NICE and the NMC. We are professionally accountable for our practice and therefore need to consider what we do every day and whether this meets the required standards. We also need to work to improve standards that are not being met and identify and address barriers to good practice to ensure that we are doing the best that we can both for our patients and for ourselves as professionals.
1. NICE. Infection: Prevention and control of healthcare-associated infections in primary and community care. London: NICE; 2012.
2. Loveday HP. National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection 2014;86S1:S1-S70.
3. Bennett, G. & Mansell, I. Universal precautions: A survey of community nurses' experience and practice. Journal of Clinical Nursing 2004;13(4): 413–421.
4. Nazarko, L. Potential pitfalls in adherence to handwashing in the community. British Journal of Community Nursing 2009;14(2):64–68.
5. Smith SM. A review of hand-washing techniques in primary care and community settings. Journal of Clinical Nursing 2009;18(6):786–790.
6. Felembam O, John W, Shaban RZ. Hand hygiene practices of home visiting community nurses: Perceptions, Compliance, Techniques, and Contextual Factors of Practice Using the World Health Organization's “Five Moments for Hand Hygiene” Home Healthcare Nurse 2012;30(3): 152-60.
7. The Nursing & Midwifery Council. The Code: Professional standards of practice and behaviour for nurses and midwives. London: NMC; 2015.
8. Department of Health. Uniforms and workwear: Guidance on uniform and workwear policies for NHS employers. London: DH; 2010.
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