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Healthcare-associated infections in the community

Despite the recently reported record fall of some healthcare-associated infections (HCAIs), they continue to be of interest and concern to the government, healthcare professionals and patients.(1) Lynn Parker considers the challenges that need to be overcome to minimise the incidence of HCAIs within the community

Lynn J Parker
MSc RGN Cert Ed for Teachers of Nursing
ENB 329 (Infection Control)
Infection Control Specialist and Cofounder
Healthcare A2Z

In 2000 a National Audit Office report was published that focused the government's attention on the incident and cost of healthcare-associated infections (HCAIs) to the NHS in England and Wales.(2) The report stated that approximately 9% of hospital patients acquired an infection resulting in approximately 5,000 deaths each year with an annual cost of £1bn. It suggested that by putting into practice existing knowledge and better infection control procedures, the incidence of HCAI could be reduced by 15-30%.
In response, the government published its white paper Winning Ways, aimed at trying to combat public concern and placing HCAI reduction at the top of the Department of Health's political agenda.(3) Within this document the Chief Medical Officer stated that HCAIs were as much a problem for patients in the community as for those admitted to hospital. Although it has been acknowledged that HCAIs cannot be eliminated completely, they can be reduced and should be quickly identified and managed appropriately.(2)

HCAI trends
HCAIs are often considered more of a problem in the acute hospital environment because of the invasive procedures undertaken. However, HCAIs are also of concern to patients in the community as there is always a risk of infection wherever healthcare is delivered. Healthcare professionals working in the community need to be aware of the changing trends that contribute to the spread of HCAIs within this setting. These trends include the changing nature of microbes currently causing HCAIs, the changing population receiving healthcare, the seamless service of healthcare and the changing roles of healthcare professionals.(4)
The most common type of pathogens in hospitals in the 1970s and 1980s were gram-negative bacteria causing hospital-acquired infections. In the 1990s these changed to gram-positive bacteria, most commonly Staphylococcus aureus and Enterococci, which both have the ability to become resistant to antibiotics. About 30% of the general population have Staph aureus living harmlessly on their skin or in their nose and throat - it is when it is found in a wound or intravenous line that serious infection can occur. Concern also arises when the bacteria show resistance to antibiotics, or where there is a risk of crossinfection between patients via staff hands, contaminated equipment or from the patient's surrounding environment.
Methicillin-resistant Staph aureus (MRSA) has often been thought of as a hospital problem. However, over the past 15 years there has been an increase in the number of community-acquired MRSA (CA-MRSA) infections. CA-MRSA is differentiated from hospital-acquired MRSA by having no recent history of hospital admission or link to long-term care or surgery. Enterococci are less well known but can cause severe infections in susceptible patients, especially in those experiencing invasive procedures. Infections and diseases associated with this group of bacteria include septicaemia, urinary tract infections, wound infections and pneumonia (see Table 1). They have become resistant to a number of antibiotics and there has been increased reporting of glycopeptide-resistant enterococci (GRE) from hospitals worldwide, including the UK.

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Where care is delivered
To control such resistant organisms government strategies have focused on providing a safe, clean environment, specifically improving the standard of hospital cleanliness.(3,5,6) In the domestic setting the healthcare worker is a guest in the patient's home and will have little control over standards of cleanliness.(7,8)
There is, however, a recognition not only of the patient's environment, but also of the changing population that receives healthcare, and the blurring of boundaries where that care is delivered and by whom.(4) Not only has the patient population aged, reflecting the increase in the number of people living to an older age, but such patients are sicker, tend to undergo more invasive procedures, and have a lower level of immunity, all of which increases their risk of infection.
Today's patients visit a wide variety of clinical settings where various treatments can be undertaken, such as day surgery and diagnostic treatment centres with the follow-up care undertaken in the community. No longer is it an either/or choice between hospital and community. The current emphasis is on choice for the patient, requiring that there is true continuity of care by healthcare professionals and a seamless service.
If the boundaries have moved in terms of where care is delivered, it has also changed as to whom provides that care. Care within the home is now provided by healthcare assistants, often unsupervised and whose training is limited. Nurses have extended their roles to include activities once considered the role of medical staff, and there is a growing trend of general practitioners expanding their services to include minor operations. Care should be taken to ensure that expanding such services does not compromise the quality of care or patient safety, and that nurses are competent in the different stages of decontamination processes. 
Another change to the nursing role is that of the specialist nurse, who hold their own caseloads and frequently cross the hospital and community divide, providing treatment in both primary and secondary care settings. As such there can be an increased risk of HCAI for patients from the equipment carried by the healthcare worker or via their hands, which may also be contaminated by resistant organisms.(4)
A HCAI can seriously impact on a patient's quality of life. Along with the complexity of care already being received by patients in the community, a HCAI will mean an increase in resources provided by healthcare professionals, including time and prescription costs, as well as loss of patient earnings because of prolonged treatment.(9) One study that looked at postoperative wound infections in the community identified that GP time increased twofold, and district/practice nurse time increased fivefold, and that surgical site infections were increasingly being identified and treated in the community due to the increase in day surgery procedures and short length of stay in hospital.(10)

Reducing the risk
In 2003 the National Institute for Health and Clinical Excellence (NICE) published guidelines for the prevention of HCAIs in the community.(11) These guidelines focused on the application of standard precautions as a means to prevent the spread of HCAIs and have been followed by further guidance and campaigns to help implement the guidance. The National Patient Safety Agency (NPSA) CleanYourHandsCampaign, now in its fourth year, provides a toolkit to promote hand hygiene among healthcare workers, patients and their relatives, encourages the use of alcohol handrubs at the entrance to wards, departments and clinics, and by patients' beds to reduce the incidence of HCAI. This campaign emphasises the importance of hand hygiene and encourages all healthcare professionals to use an effective hand hygiene technique, using either soap and water or alcohol handrub, depending upon the clinical situation.
Other initiatives have focused on specific care practices such as the use of the Department of Health's high-impact care bundles for central venous catheter care, urinary catheter care and reducing the risk of Clostridium difficile.(12) Saving Lives and Essential Steps are aimed at the acute sector and community and primary care sectors respectively.(12,13) Both provide a number of interlinked tools and products to be used within an organisation to help implement best practice in preventing and managing HCAIs.
Ideally all episodes of care that result in a HCAI should be monitored, recorded and investigated to identify why the infection occurred. However, such level of surveillance is often only undertaken within an institution such as a community hospital or care home. What is important is that all healthcare professionals understand the importance of standard precautions and comply with the code of practice, which requires that all staff should demonstrate good infection control and hygiene practice, while recognising that it is not possible to prevent all infections.(14)

Standard precautions
"Standard precautions" refer to the approach that should be followed by all healthcare professionals when providing care to patients in community and primary care settings. Previously known as "universal precautions" they are well established as a set of practices to prevent and control infections (see Box 1).

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While acknowledging that it is difficult for healthcare workers in the community to deliver safe clinical care outside of healthcare settings, the use of standard precautions will help to minimise the risk of HCAI. By applying these standards healthcare professionals will also comply to the Nursing and Midwifery Council (NMC) statement that they have a professional responsibility to protect their patients and deliver safe patient care.(15)

Conclusion
HCAIs continue to be of concern to patients and healthcare professionals alike. Wherever care is delivered it is important to recognise that it is the responsibility of the healthcare professional to minimise the risk of their patients acquiring a HCAI. One way to achieve this is by complying and implementing standard precautions regardless of where a patient receives their care. Delivery of care changes with the increased advances in technology and treatments, and healthcare professionals need to be aware of these advances in the acute sector and their impact on patients' follow-up care once discharged to their own home environment.

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References

  1. Health Protection Agency. MRSA bloodstream infections continue to fall. London: HPA; 2008. Available from: http://www.hpa.org.uk
  2. National Audit Office. The management and control of hospital acquired infection in acute NHS trusts in England. London: NAO; 2000. Available from: http://www.nao.org.uk/publications/nao_reports/9900230.pdf
  3. Department of Health. Winning ways: reducing healthcare associated infection in England. London: DH; 2003. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publications PolicyAndGuidance/DH_4064682
  4. Gould D. The challenge of healthcare-associated infection outside hospital. Br J Community Nurs 2007;12:212-5.
  5. Department of Health. Towards cleaner hospitals and lower rates of infection. London: DH; 2004. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publications PolicyAndGuidance/Browsable/DH_4096315
  6. Department of Health. Revised guidance on contracting for cleaning. London: DH; 2004. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publications PolicyAndGuidance/DH_4097532
  7. Lawrence J. Encouraging best practice in infection control. Br J Community Nurs 2005;10:156.
  8. Cole M. Infection control: worlds apart primary and secondary care. Br J Community Nurs 2007;12:301-6.
  9. Plowman R. The socio-economic burden of hospital acquired infection. London: Public Health Laboratory Service; 1999.
  10. Noel I, Hollyoak V, Galloway A. A survey of the incidence and care of postoperative wound infections in the community. J Hosp Infect 1997;36:267-73.
  11. National Institute for Health and Clinical Excellence. Infection control: prevention in primary and community care. London: NICE; 2003. Available from: http://www.nice.org.uk/Guidance/CG2/Guidance/pdf/English
  12. Department of Health. Saving lives. London: DH; 2007. Available from: http://www.clean-safe-care.nhs.uk/toolfiles/114_SL_letter.pdf
  13. Department of Health. Essential steps. London: DH; 2006. Available from: http://www.clean-safe-care.nhs.uk/public/default.aspx?level=2&load=Tools...
  14. Department of Health. The health act: code of practice for the prevention and control of healthcare associated infections (revised 2008). London: DH; 2006. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/publications PolicyAndGuidance/DH_081927
  15. Nursing, Midwifery Council. The code standards of conduct, performance and ethics for nurses and midwives. London: NMC; 2007. Available from: http://www.nmc-uk.org/aFrameDisplay.aspx?DocumentID=3954