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Infection control: a focus on general practice

Mark Cole
Lecturer, Faculty of Medicine and Health Sciences
Nottingham University

From April 2012 primary care services will need to register
as a provider of healthcare and observe a code of practice
on the prevention and control of infections

Healthcare-associated infections (HCAI) are infections that have been acquired as a result of a healthcare intervention.1 They are associated with increased morbidity, mortality and healthcare costs, and reducing their burden has become a political and clinical priority.2 Traditionally, HCAI have been associated with hospital care; however, increasingly it is recognised that they also occur within GP surgeries, care homes, mental health trusts, ambulances and people's own homes.

‘Infection control is everybody's business' has become a key policy direction and all healthcare settings are expected to embed prevention and control of infection into everyday practice. Central to this discussion is the Health and Social Care Act, which sets out a code of practice on the prevention and control of infections that will apply to all registered providers of healthcare and adult social care in England.3 From April 2012 registration will include primary healthcare services.

Within this strategy there is a sense that having focused on the many problems of secondary care it is now the turn of other providers. The act goes on to provide examples of what it considers to be a proportionate approach from primary care (see Box 1). Although proportionate, this will, nevertheless, raise a number of important questions and challenges. Several clinical practice issues have attracted considerable attention in secondary care and are likely to pose similar debate when considered in general practice.

Box 1. Health and Social Care Act principles for infection control in primary care3

  • Systems to manage and monitor the prevention and control of infection. These systems use risk assessments and consider how susceptible service users are and any risks that their environment and other users may pose them
  • Provide and maintain a clean environment in managed premises that facilitates the prevention and control of infection
  • Provide suitable information on infections to service users and their visitors
  • Provide suitable information on infections to any person concerned with providing support or nursing/medical care in a timely fashion
  • Ensure that people help who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people
  • Ensure that staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection
  • Provide or secure adequate isolation facilities
  • Secure adequate access to laboratory support as appropriate
  • Have and adhere to policies, designed for the individual's care and provider organisations, that will help to prevent infections  
  • Ensure, so far as is reasonably practicable, that care workers are free of and are protected from exposure to infections that can be caught at work. Also that all staff are suitably educated in the prevention and control of infection associated with the provision of health and social care.

Decontamination
Decontamination in the broadest sense simply means the removal of microbial contamination, and it has three levels: sterilisation, disinfection and cleaning. This can be applied to medical equipment, the environment, or the hands of a healthcare worker.

The decontamination of surgical instruments in primary care has always been seen as a potential hotspot. A survey of five GP practices in 1996 found that medium- and high-risk equipment was not decontaminated effectively.4 Since March 2007, primary care practices in England have had a legal obligation to decontaminate surgical instruments in accordance with Medical Directive Devices 93/42/EEC, the Health Act 2006 and the associated Code of Practice for the Prevention and Control of Health Care Associated Infection.5 The guidance therein is unequivocal and the decontamination service offered within primary care must comply with Department of Health policy.

Environment
Something more equivocal is environmental cleanliness. General cleanliness has never been viewed as evidence-based science; however, in the hearts and minds of patients, cleanliness and infection control are inextricably linked. In a recent National Patient Choice Survey, 74% of patients identified hospital cleanliness as an important factor when choosing a hospital.2 It is plausible that the public sees primary care settings in a similar way.

Despite the difficulty in terms of evidence, it is reasonable to suggest that a clean environment promotes comfort and dignity for the public and provides a platform to tackle HCAI. Historically, visual assessment has been used to evaluate the quality of cleaning; however, this has received some criticism as there is a difference between what constitutes aesthetic cleanliness and how this translates to microbiological safety.6
This study found that visual cleanliness does not necessarily offer reliable information on infection risks to patients.
Presumably this is because microbes are invisible to the naked eye. The thing that is important is that work environments should be fit for purpose and easy to clean. Surfaces that are not intact should be replaced and cleaning schedules should be available. As hands are frequently implicated in the transmission of pathogens, particular attention should be paid to the sites that a patient or healthcare worker (HCW) touches.      

Hand hygiene
Hand hygiene is considered to be the single most important measure to prevent infection. However, much to the consternation of infection control professionals, researchers, the public, media and our political masters, compliance with guidelines is generally poor.

In recent years the topic has received considerable attention in secondary care, and in 2004 the National Patient Safety Agency initiated the ‘Clean Your Hands Campaign' (CYHC) in England and Wales. The CYHC is based upon a multi-modal approach that targets the behaviour of HCWs through the provision of alcohol hand rub (AHR) at the point of care, posters, press releases, leaflets, education, training resources and a dedicated website. It also empowers patients through the promotion of the message ‘It's okay to ask'. Central to the strategy is AHR as it addresses many of the reasons for poor compliance. When compared to soap and water, AHR has improved microbial efficacy, is quicker to use and better tolerated by hands. Although AHR is not a cleansing agent and therefore cannot be used on soiled hands, it is now recommended as the gold standard for hand hygiene in healthcare settings.7

Personal protective equipment
Personal protective equipment (PPE) refers to the use of gloves, aprons, eye protection and masks. One detailed review appraised 37 studies into their use and concluded that compliance was suboptimal.8 HCWs tend to practise selective, rather than universal, precautions. Gloves tend to be used more appropriately than masks and eye protection. This may relate to the social norms associated with such equipment; that is, facial apparel is not normative in healthcare settings and its use makes the HCW feel awkward and self-aware.

Alternatively, it may have to do with how individuals perceive risk. Facial contamination through splashing may be seen as low risk for the majority of nurse-patient interactions and this creates a certain mindset. The term ‘re-cueing' has been used to suggest that HCWs learn the benefits of non-compliance, as poor outcomes are not immediately associated with poor practice.

While the use of gloves can be poor, it has been found that HCWs have a tendency to multitask wearing the same pair and do not change them between patients. This apparent anomaly possibly relates to the primary reason why a HCW chooses to wear gloves. Is it for the patient's protection or their own? It would be wrong, however, to take from this that HCWs make safe and rational choices when it comes to their own safety. Percutaneous injuries with hollow bore needles are still widespread and commonly occur through distraction, tiredness, lack of experience and haste.9

Uniform
Whether a uniform constitutes a piece of protective apparel, a part of an organisation's corporate image, or both, has been widely discussed. National guidelines appear to be clear on this matter as they explicitly state that uniforms should not be considered a substitute for protective clothing and plastic aprons should be worn as a component of standard principles.10 This rests with the idea that microbial contamination of a uniform is reduced when the wearer dons a plastic apron. However, HCWs appear to be inconsistent wearers of protective aprons.

In relation to uniforms, a comprehensive literature review examined the impact that they may have on the incidence of HCAI.11 The findings suggest that a HCW's uniform or white coat becomes progressively more contaminated during clinical care. This contamination reaches a saturation level and then plateaus. Interestingly, the majority of this microbial contamination comes from the wearer's own flora and not from the patient or the environment. In essence, a contaminated uniform may be a potential source of infection but there is no compelling evidence to suggest that it actually is. Nevertheless, the Department of Health guidelines use the stock phase, ‘Uniforms should be washed at the hottest temperature suitable for the fabric'.12

Education
Poor compliance with infection control policies, procedures and guidelines is a recurring theme in infection control and this is thought to exacerbate poor performance. According to the World Health Organisation (WHO), successful infection control improvement programmes invariably have a strong educational component, and mandatory infection control training is now common throughout all NHS organisations.7 To comply with best practice HCWs need knowledge and this can be provided through planned education. However, behaviour change is complex and it would be wrong to assume that education will automatically correct poor performance.13 Nor is education likely to be successful if it is an isolated event and seen as a quick-fix solution. Education should be seen as an initiator of change and the foundation on which multimodal designs are based. Detailed guidelines are available that illustrate how to organise educational programmes to enhance the delivery of infection control.7 Excellent online resources exist to facilitate this and the Clean Your Hands Campaign website and the NHS Core Learning Unit are two examples (see Resources). 

Audit
A strong bedfellow of education is audit. Infection has always had a strong tradition of audit. This began with local tools that focused, primarily, on the organisation's environmental infrastructure that supports infection control. This was accelerated through the introduction of the national Control Assurance programme which took a more strategic view of the topic.

In broad terms, Controls Assurance considered whether an organisation fulfilled their statutory managerial responsibilities for infection control. Subsequently, Saving Lives has been launched. This DH programme centres on the behaviour of staff with a focus on their clinical practice through an examination of several high-impact interventions. A theme running through the audit of infection control would seem to be that it is not enough to produce guidelines, policies and procedures, tell staff what they need to do, and expect this to automatically happen. Increasingly, it is recognised that compliance is a complex psychological construct, staff are not necessarily altruistic in the choices that they make, and may at times struggle to regulate their own practice.14 A Big Brother approach to structured observation and feedback now permeates healthcare and is seen as essential to a quality improvement programme.

Conclusion
The NHS reforms of the 1990s gave organisations the incentive to reposition infection control among their priorities. Increasing political regulation, the media's pre-occupation with ‘superbugs' and a public who state that acquiring an infection in hospital is one of their greatest healthcare concerns have been the catalysts that accelerated reform. It is clear from the language of the Health and Social Care Act that attention is now going to fall more explicitly on primary care. These will be challenging times. In 2003 a question was asked, “How much are health providers in primary care prepared to spend on controlling the risks from infection?”15 While change does not necessarily cost money, the procurement of equipment, the education to ensure people know how and when to use it, and audit to ensure they do so effectively, clearly does. Perhaps now is a good time for the debate to begin.

References
1.    Department of Health. Clean, safe care: Reducing infections and saving lives. London: Department of Health; 2008.
2.    National Audit Office. Reducing Healthcare Associated Infections in Hospitals in England. London: The Stationery Office; 2009.
3.    Department of Health. 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. London: Department of Health; 2008.
4.    Finn L, McCulloch J. Infection in GP surgeries: safe practices? Br J Nurs 1996;5:341-8.
5.    McIntyre J, Sim A. Infection control in primary care: part 2. Practice Nurse 2008;35:33-6.
6.    Mulvey D, Redding P, Robertson C et al. Finding a benchmark for monitoring hospital cleanliness. Journal of Hospital Infection 2011;77:25-30.
7.    World Health Organisation (WHO). Guidelines on hand hygiene in healthcare. Geneva: WHO; 2009.
8.    Gammon J, Morgan-Samuel H, Gould D. A review of the evidence for suboptimal compliance of healthcare practitioners to standard/universal infection control practices. J Clin Nurs 2008;17:157-67.
9.    Health Protection Agency. Eye of the Needle: United Kingdom Surveillance of Significant Occupational Exposures to Bloodborne Viruses in Healthcare Workers. London: Health Protection Agency; 2008.
10.    Pratt R, Pellowe C, Wilson J et al. epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS Hospitals in England. J Hosp Infect 2007;65:S1-S64.
11.    Wilson J, Loveday H, Hoffman P and Pratt R. Uniform: an evidence review of the microbiological significance of uniforms and uniform policy in the prevention and control of healthcare-associated infections. Report to the Department of Health. J Hosp Infect 2007;66:301-307.
12.    Department of Health. Uniforms and Work Wear: An Evidence Base for Developing Local Policy. London: The Stationary Office; 2007.
13.    Ward DJ. The role of education in the prevention and control of infection: a review of the literature. Nurse Educ Today 2011;31:9-17.
14.    Pittet D. The Lowbury lecture: behaviour in infection control. J Hosp Infect 2004;58:1-13.
15.    Dover C. Infection control in primary care. Available from: www.touchbriefings.com/pdf/26/ept032_t_antec.pdf

Resources
Clean your Hands Campaign www.npsa.nhs.uk/cleanyourhands
NHS Core Learning Unit www.corelearningunit.com