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Clinical governance and infection control

Chrissy Tinson
RGN RM
Specialist Practitioner
General Practice Nursing
Practice Nurse Advisor
Infection Control
Lewisham PCT
E:chrissy.tinson@lewishampct.nhs.uk

Until recently there have been comparatively few infection control resources available to staff working in general practice. My innovative post was developed by the Quality Manager of North Lewisham Primary Care Group (PCG), who saw a need to ensure patient safety, particularly with regard to minor surgery and the application process for accreditation of GPs. I have now been in post since April 2002 with Lewisham Primary Care Trust (PCT), formerly the North Lewisham PCG. I work as part of the clinical governance team within the PCT and also have important links with the communicable disease team at the health authority (HA) and with the infection control nurses at the local acute trust. A steering group based at the HA working across three PCTs in south London also supports this work.
Lewisham is situated in southeast London and is a deprived inner city area. I am employed for 22.5 hours a week, and I also work as a locum practice nurse to maintain my clinical skills and keep up to date with current practice. My main focus is to work with practices across north Lewisham, in particular with practice nurses, to help identify and address infection control issues. Part of my role is to manage the practice infection control audit project.

The practice infection control audit project
Practice nurses may work in more isolation than nurses working in the acute sector. It is presumed that all general practices update and implement changes at the same rate and to the same standards. However, this is not always the case, and information on decontamination and other infection control issues may not always reach practice staff. The aim of the practice infection control audit project is for all practices in north Lewisham to have their infection control procedures audited. Results should highlight areas where changes could be implemented, raise awareness of infection control issues, reduce variations in practice, support practices where standards are not fully met, and facilitate change. It is also important to note that good practice is always highlighted where appropriate.
At the time of my appointment, six of the 27 general practices in the North Lewisham PCG had been visited and audited by the community infection control nurse (CICN), who is based at the HA. I contacted the remaining 21 to ask for an appointment to visit the practice and carry out an infection control audit. In most cases I spoke to either the practice manager or a practice nurse. They often required reassurance that this would not be an inspection and I would not be criticising their clinical practice, nor sharing confidential information outside the clinical governance team. I found that it helped having been a practice nurse; nevertheless some practices did regard my visit as an inspection and asked before I left if they had "passed".
Two local guidelines, written by the CICN, were sent to all practices in April 2001. The first - Infection control guidelines for general practice(2) - includes policies on handwashing, glove usage, universal precautions, protective clothing, sharps management, waste disposal, decontamination and sterilisation, and vaccine storage. The second - Managing incidents involving potential exposure to blood borne viruses in the community(3) - details the procedure to be followed in case of such incidents, and asks each practice to nominate a risk assessor and deputy to whom staff could refer for advice. Both guidelines also contain lists of useful local contacts and websites where more detailed information is available should it be required.
The CICN provided me with basic training on infection control and on how to conduct an audit and write the report. At the first audit visit I observed, but after this I was encouraged to take more of a lead until I was working independently. The practice visit lasts 1-1.5 hours and is conducted with the aid of an audit tool developed by the CICN. This is divided into 14 headings (see Table 1) and forms the basis for the questions and inquiries to establish the baseline assessment.

[[NIP06_table1_53]]

I asked to be taken into all areas of each practice by a senior member to observe infection control procedures throughout the practice. The audit visit also provided an opportunity to address any other infection control issues that may have arisen for the practice nurse - for example, guidelines on decontaminating specific items of equipment. Following the audit visit a report is prepared and sent to the practice. Recommendations for change are detailed in the "Action Plan" (Figure 1), which gives a timescale as a guideline prioritising the proposed changes. When urgent problems such as safety issues are found, these are raised with the practice at the time and dealt with as required in addition to being documented in the report. Evidence to support change is provided in the form of papers, references and booklets documenting best practice. Where appropriate, information is also shared with clinical governance personnel. Many changes may be made with little or no cost implication to practices, although monies have been found to facilitate some changes - for example, through minor improvements funding to buy vaccine fridges.

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Some of the issues raised as a result of the audit visits

Handwashing
Sinks for handwashing should be available in all clinical areas, preferably with wrist or elbow taps. Wall- mounted liquid soap and disposable hand towels should be available for routine handwashing,(4) with antiseptic handwash available for use when appropriate.(5) Reusable handtowels and soap bars should be discarded as they may harbour microorganisms.

Gluteraldehyde
This was found to be in use in a number of practices. Although it is now no longer available in the UK, its use has long been considered inappropriate in general practice.(6) Safe disposal of the gluteraldehyde had to be arranged and alternative methods of decontamination suggested to the practices.

Use of benchtop steam sterilisers
Guidance from the Medical Devices Agency was provided, and practice nurses were encouraged to attend training on the use of benchtop steam sterilisers.(7)

Clinical waste disposal
Safe disposal of waste is governed by the Environmental Protection Act 1990, and it is the responsibility of whoever generates waste to ensure that it is segregated according to national guidelines.(8) Some practices needed to be reminded about the importance of ensuring security of the waste collection points and of the safe siting of sharps containers and their correct assembly.

Next steps
With the recent changes in structure and the integration of community and primary care services, the audits are a good baseline indicator of standards. The reaudit visits are currently underway to establish whether the recommended changes have been made. There is a need to ensure the safety of patient care and the quality of the service provided as well as to provide positive support to practitioners in a safe environment. This could be achieved by an annual infection control audit visit.(9) However, this would depend on resources available. Not all practices have participated in the audit project, but we will continue to work with the clinical governance team to provide opportunities for advice.

Feedback
The feedback I have had from practice staff has generally been very positive; practice nurses in particular have welcomed a resource on infection control. I feel that infection control procedures in North Lewisham have improved, practice staff have worked very hard to effect change, and I have been pleased to provide the evidence to facilitate these changes.

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References

  1. Fuller A. Infection control measures in primary care. Nursing in Practice 2002:4:45-7.
  2. Nicholson B. Infection control ­guidelines for general practice. London: Lambeth Southwark and Lewisham Health Authority; 2001.
  3. Communicable Disease Control Team. Managing incidents involving potential exposure to blood borne viruses in the community. London: Lambeth Southwark and Lewisham Health Authority; 2001.
  4. ICNA. Guidelines for hand hygiene. London: ICNA and Deb Ltd; 1999.
  5. Gould D. Hand decontamination. Nursing Standard 2000;15(6):45-50.
  6. Royal College of Nursing. Good ­practice in infection control: guidance for nurses working in general practice. London: RCN; 2000.
  7. Medical Devices Agency. The purchase operation and maintenance of benchtop steam sterilisers. DB9605. London: MDA; 1997.
  8. Health Service Advisory Committee. Safe disposal of clinical waste. London: HMSO; 1999.
  9. Royal College of Nursing. Good ­practice in infection control:guidance for nurses working in general practice. London: RCN; 2000.

Resources
Infection Control Nurses Association
W:www.icna.co.uk
Medical Devices Agency
W:www.medical-devices.gov.uk
NHS Executive
Controls Assurance
W:www.doh.gov.uk/riskman.htm
NICE
Infection Control Guideline in Progress
W:www.nice.org.uk
Department of Health
W:www.doh.gov.uk