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Community infection control: Where are we now?

Key learning points

 - Many patients being cared for in primary care settings have multiple risk factors for infection

 - Compliance with infection prevention and control precautions is important for patient safety

 - Identifying and addressing barriers to good practice is a vital aspect of the nurse's role in primary care

Healthcare-associated infection (HCAI) is a national and international priority1,2 with financial, physical, social and psychological implications. More than ever before, increasingly complex patients with multiple risk factors for infection are being cared for in primary care settings. This means that infection prevention and control (IPC) is of vital importance in minimising the risk of infection and cross-infection in these settings. This article aims to provide an overview of the most recent guidance for IPC in primary care, enabling staff to apply evidence-based standards in practice.
Patients at risk
When considering the chain of infection, one of the links is the susceptible host. Many factors increase a person's risk of infection, many of which cannot be changed. However, as practitioners we can minimise the risk of infection as far as possible by identifying risk factors and addressing any that can be changed. Risk factors include those shown in Box 1. In addition, we also need to consider the risk posed by poor compliance with IPC precautions and the reasons for this compliance. Overcoming barriers to effective practice is part of the nurse's role and it is therefore important that action is taken immediately if reasons for poor compliance can be addressed.
Hand Hygiene
The application of correct hand hygiene procedures is vital in practice to maintain patient and staff safety. It is not just about the number of times that hands are decontaminated but also about the technique used. National Institute for Health and Care Excellence (NICE) guidelines3 advocate the use of alcohol handrub, except where hands are visibly soiled or in cases where alcohol is not appropriate - such as when a patient has Clostridium difficile, when soap and water should be used. It is important that the handrub is used correctly.
 - The handrub should cover all areas of the hands, in the same way that soap and water should.
 - Gloves should not be donned until hands are dry and the alcohol has evaporated as alcohol can damage the integrity of rubber.
 - Hands should be washed with soap and water every three applications of handrub to prevent emollient build-up.
Alcohol handrubs have both advantages and disadvantages. While they have an immediate action against a wide range of micro-organisms, they have limited activity against bacterial spores, hence their use not being recommended in Clostridium difficile. They are convenient to use as hand washing facilities are not needed and time can be saved. They are particularly useful in community settings where hand hygiene facilities may be limited. It is worth noting, however, that they do make hands sting if skin abrasions are present and they do not have residual activity against micro-organisms like some aqueous antiseptics do.
For effective hand hygiene, the Department of Health4 recommends that hands and wrist of staff should be free from clothing and jewellery, leading to the 'bare below the elbows' requirement of NHS organisations. Jewellery can harbour micro-organisms and impede proper hand decontamination. Long and false fingernails can also harbour micro-organisms, as most microbes on the hands are found on and around the fingernails. They can also tear gloves. 
The World Health Organization's 'five moment' guidance5 should be used to decide when hands should be decontaminated. These five moments are:
  1. Before touching a patient.
 2. Before clean/aseptic procedures.
  3. After body fluid exposure risk.
  4. After touching a patient.
  5. After touching patient surroundings.
  6. These apply even when gloves are worn.
The use of protective clothing
Protective clothing, such as gloves and aprons, should be worn whenever there is a risk of contamination with body fluids, contact with open wounds or contact with mucous membranes. Gloves and aprons are designated as single-use items and should therefore be disposed of after each use. Gloves should be changed between patients and between different activities on the same patient. It has been the case in some settings that the same pair of sterile gloves has, for example, been used to dress ulcers on two legs, causing cross-contamination of the wounds. Gloves should therefore, in this instance, be used for one wound only. It also used to be common practice to re-use aprons on the same patient, folding up the apron and leaving it in a patient's home to use at the next visit. This is no longer seen as good practice and should therefore no longer be the case.
It is important when using gloves that they are suitable for the task at hand. Some gloves, for. example, are not suitable for use in clinical procedures (such as polythene gloves) whereas others are not suitable for blood contact. While it is the employer's responsibility to ensure that appropriate protective clothing is available, staff need to be aware of what items to use for what activities. They should also be able to assess whether sterile or non-sterile gloves are needed for a clinical activity. In general, non-sterile gloves are won for the protection of staff whereas sterile gloves are worn for the protection of patients. Gloves should additionally be well fitting so that they do not interfere with manual dexterity, one of the reasons sometimes given for non-compliance with glove use.6
Protective clothing should be put on immediately prior to the activity and be removed immediately afterwards. Hands should be decontaminated following removal of protective clothing. When removing gloves and aprons, a technique should be used which avoids contamination of the skin and clothing and both should be disposed of as per local policies.
Sharps management
The general rules and guidance for sharps management are the same in community settings as those required in hospitals. When dealing with sharps:
- They should not be passed directly from hand to hand when unsheathed.
 - Handling should be kept to a minimum.
 - Needles should not be resheathed after use.
 - They should not be bent or broken prior to disposal.
 - They should be disposed of immediately after use into an approved sharps container.
When using sharps in a patient's home, it is best to be prepared for use and disposal, ensuring that you have an adequate supply of equipment and that you have a sharps container with you.
Nurses receive many needlestick and sharps injuries in the UK. The majority of these, according to the Health Protection Agency,7 occur in the following circumstances:
 - During use.
 - Between use and disposal.
 - Between procedural steps.
 - During disposal.
 - While resheathing.
With sharps injuries being most prevalent when using intravenous cannulae, butterfly needles and phlebotomy needles. Care should therefore be taken when using sharps.
Where a sharps injury occurs, it is important that staff are aware of the actions to take, including reporting procedures within their area of practice. Documenting such incidents and involving Occupational Health services are important aspects of the procedures. Often staff ignore injuries that they receive but should be encouraged to follow protocols to minimise the risk of infection, particularly with blood-borne viruses.
Some patients will use sharps themselves in their own homes, such as diabetics. Advice about the safe use and disposal of sharps should be provided to these patients. Sharps still need to be disposed of in an approved sharps container, not in other containers such as drinks cans of plastic bottles. Sharps bins are available for patients on prescription. Arrangements for disposal of sharps differ between areas but include the patient taking them to their GP or pharmacy or local waste collections via local councils or the NHS.
Compliance in Infection Prevention and Control
Compliance with IPC precautions can be poor internationally across all groups of healthcare staff, including nurses. While much of the research in this area has been undertaken in the hospital setting, research in primary and community care support the same assessment of compliance (8). This includes activities such as hand hygiene, glove use, sharps management and the re-use of single use devices. As previously mentioned, it is vital that nurses identify barriers to safe practice and work to address them. Reasons for non-compliance identified in the literature include time, workload, a lack of facilities, risk perception, job demands, management commitment and lack of knowledge. Multi-modal interventions which address some of these reasons have been implemented with some success in hospital settings9 and it is therefore likely that such actions would be of benefit in primary care.
There can be many challenges to implementing IPC in primary care, considering the increasing number of patients being cared for in this setting with multiple risk factors for infection. Practicing good IPC and identifying and addressing barriers to good practice should be an important aspect of any nurse's role, reducing the risk of infection to both staff and patients.
1. Ward D. Infection control in clinical placements: experiences of nursing and midwifery students. Journal of Advanced Nursing 2010;66: 533-42.
2. Pittet D, Allegranzi B, Storr J, Bagheri Nejad S, Dziekan G, Leotsakos A, Donaldson L. Infection control as a major World Health Organization priority for developing countries. Journal of Hospital Infection 2008;68:285-92.
3. NICE Prevention and control of healthcare-associated infections in primary and community care. London: NICE; 2010.
4. Department of Health Uniforms and workwear: Guidance on uniform and workwear policies for NHS employers. London: DH; 2010.
5. World Health Organisation WHO Guidelines on Hand Hygiene in Health Care. Geneva: WHO; 2009.
6. Naing L, Nordin R, Musa R. The prevalence of, and factors related to, compliance with glove utilization among nurses in Hospital Universiti Sains Malaysia. Journal of Hospital Infection 2001;32:636-42.
7. Health Protection Agency Eye of Needle: United Kingdom Surveillance of Significant Occupational Exposures to Bloodborne Viruses in Healthcare Workers. London: HPA; 2010
8. Ward DJ. Compliance with infection control precautions in primary care. Primary Health Care 2006;16:35-9.
9. Randle J, Clarke M, Storr J. Hand Hygiene Compliance in Healthcare Workers. Journal of Hospital Infection 2006;64:205-9.