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Infection control: how clean is your practice?

Carol Pellowe
EdD MA(Ed) BA(Hons) RN
RNT
Deputy Director
Richard Wells Research Centre
Thames Valley University
London
E:carol.pellowe@tvu.ac.uk

Recent government reports highlight the current concern about healthcare-associated infections (HCAIs).(1,2) Although the prevalence of HCAIs in primary and community care settings is not known, the early discharge of patients from hospital, and the increased use of medical devices and invasive procedures being undertaken in primary care, means that infections are increasingly being diagnosed in the community. In addition, new evidence supporting the maintenance of environmental hygiene focuses on the importance of ensuring that the physical environment is free from microbial contamination.(3)
On her appointment as England's Chief Nursing Officer in October 2004, Chris Beasley made it her top priority to improve hospital cleanliness and tackle methicillin-resistant Staphylococcus aureus (MRSA) and other hospital infections. But HCAIs are not just an issue for hospitals: they concern all care settings, and everyone has a role to play. Patients expect to be treated in areas that are visibly clean, and with the Commission for Patient and Public Involvement in Health (CPPH) established in 2003, they are being actively encouraged to make their views and needs known. In addition, the current "cleanyourhands" campaign being organised by the National Patient Safety Agency includes an element of patient empowerment, whereby patients are encouraged to ask healthcare workers whether they have cleaned their hands.

Cleanliness in primary ­practice
General practices and clinics are busy places, and during the day many sick and frail people pass through the building. Although the Matron's Charter(4) is aimed at acute trusts, there are many elements that apply to general practices and ­surgeries.

The practice room
While some practices have contract cleaning arrangements, others depend on local personnel. Whichever, the time agreed may be as little as a couple of hours a week, and the work is often undertaken out of hours and therefore unsupervised. Limited storage facilities may prevent cleaning equipment to be stored correctly (ie, dry). Take a few minutes to consider your practice room:

  • When was it last cleaned thoroughly?
  • Can you see any visible dust?
  • If the room is carpeted, is there a schedule to clean it more thoroughly than just vacuuming?
  • Do you make it easy for the cleaner by removing unnecessary clutter?

Just a few minutes of thought can make a huge difference. Limited storage is frequently an issue, yet stocks that are not properly stored may not be used in correct rotation and may thus restrict cleaning.

Equipment
Most practice nurse rooms will have a couch, which should be washed with soap and water before each session and covered with a disposable paper roll that can be replaced after each use. Any spillages of blood or mucus should be cleaned with a hypochlorite-based rather than an alcohol-based product. Baby scales should be treated in the same way, and the use of aerosol cleaning sprays should be avoided.
The operating temperature of sterilisers and autoclaves should be logged daily and not left to operate unattended. The temperature of refrigerators should also be monitored daily, and those used for storing vaccines should not also be used for food storage.
As regards instruments, the national decontamination policy requires only disposable instruments to be used unless practices can meet the national standard (ie, have a decontamination room with two separate sinks).(5) Consequently, single-use instruments or using a central sterilising service may be more cost-effective. Single-use instruments must not be reused under any circumstances and should be disposed of in the sharps bin. Careful thought needs to be given to where sharps bins are placed. They need to be away from the reach of children, but near enough to the point of sharps use to ensure prompt disposal. Sharps bins should be closed when not in use and, when prepared for disposal, clearly labelled. All practices should have a policy of the steps to be taken in the event of a sharps injury, including where to access prophylactic antiretroviral therapy.

Hand decontamination and personal protective clothing
The NICE guidelines, Prevention of Healthcare-Associated Infection in Primary and Community Care,(6) were issued in December 2003, yet some practices appear unaware of their content.(7) They specify when and how hands should be decontaminated and stress that, when hands are socially clean, a disinfectant hand-rub is sufficient. There is no place for terry cotton towels in clinical settings. They also include advice on the appropriate use of gloves and disposable aprons and stress the importance of removing such items when the task has been completed and, if necessary, changing gloves between different care activities for the same patient.

Resources
All staff should attend infection control training sessions on a regular basis as the evidence in this field is being continually updated. The community infection control nurse is a valuable source of advice, and the Infection Control Nurses' Association has published guidance on infection control in general practices, covering standard (universal) precautions, decontamination, the environment and accidental exposure.(8) Finally, the national cleaning manual provides comprehensive advice on the general cleaning of premises and nonclinical equipment.(9)
With hospital hygiene on the political agenda and in the public view, perhaps this is the time to address hygiene in the practice. Think Clean Day is an opportunity to address any deficits before a patient brings them to your attention.

References

  1. Department of Health. Getting ahead of the curve: a strategy for combating infectious diseases. Report from the Chief Medical Officer. London: Department of Health; 2002.
  2. Department of Health. Winning ways: working together to reduce ­healthcare associated infection in England. Report from the Chief Medical Officer. London: Department of Health; 2003.
  3. Pellowe CM, Pratt RJ, Loveday HP, Harper P, Robinson N, Jones SRLJ. The epic project. Updating the evidence-base for national evidence-based guidelines for preventing ­healthcare-associated infections in NHS hospitals in England: a report with recommendations. Br J Infect Control 2004:5(6):10-16.
  4. Department of Health. The Matron's Charter: an action plan for cleaner ­hospitals. London: Department of Health; 2004.
  5. NHS Estates. National ­decontamination project: a process from commercial involvement in improving NHS decontamination. 2003. Available from URL: http// www.decontamination.nhsestates.gov.uk
  6. National Institute for Clinical Excellence. Prevention of healthcare-associated infections in primary and community care. London:NICE; 2003.
  7. Pellowe CM, Pratt RJ, Harper P, et al and the Guideline Development Group. Evidence-based guidelines for preventing healthcare-associated ­infections in primary and community care in England. J Hosp Infect 2003;55 Suppl 2:1-127.
  8. ICNA. Infection control guidance for general practices. 2003. Available from URL: http://www.icna.co.uk
  9. NHS Estates. The NHS healthcare cleaning manual. 2004. Available from URL: http://www.nhsestates.gov.uk

Resources
NHS Estates
W:www.nhsestates.gov.uk
National Patient Safety Agency
W:www.npsa.nhs.uk
Infection Control Nurses Association
W:www.icna.co.uk
Think Clean Day
W:http://patientexperience.nhsestates.gov.uk/clean_hospitals/ch_content/th...
cleanyourhands campaign
W:http://81.144.177.110/cleanyourhands