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Preventing healthcare-associated infections

Carol Pellowe
MA(Ed) BA(Hons) RN RNT
Deputy Director
Richard Wells Research Centre
Thames Valley University
T:020 8280 5140

Recent government reports highlight the current concern about healthcare-associated infections (HAIs).(1,2) Although the prevalence of HAIs in primary and community care settings is not known, the early discharge of patients from hospital, the increased use of medical devices and invasive procedures being undertaken in primary care mean that infections are increasingly being diagnosed in the community. The recent publication of national evidence- based infection prevention guidelines should enable healthcare practitioners in primary and community care settings to provide safe and competent care.(3)
The significance of HAI
It is estimated that 9% of patients admitted to NHS hospitals in England acquire a HAI, resulting in 100,000 infections and 5,000 deaths annually.(4) HAIs cost the NHS an estimated £1 billion each year, yet many of these infections (15-30%) are preventable.(4) Acquiring a HAI is a particular risk for vulnerable and elderly patients, as it may worsen their existing condition, delay their recovery and adversely affect their quality of life. In addition, there is considerable patient dissatisfaction when they are harmed as a result of our interventions.
In hospitals, urinary tract infections are the most common HAI, whereas bloodstream infections have the highest associated mortality.(5) Both are related to the use of medical devices and poor compliance to hand hygiene. In addition, the increase in resistant microorganisms, such as methicillin-resistant Staphylococcus aureus (MRSA), which may be carried harmlessly in the nose and skin, can cause skin, wound and bloodstream infections.(1) Nearly half the organisms causing surgical site infections are staphylococci, and most of these are diagnosed after discharge from hospital.(1)

MRSA is not the only multiple antibiotic-resistant organism causing concern in healthcare settings. There are now vancomycin-resistant enterococci (VRE) and resistant Klebsiella strains that have caused outbreaks in hospitals in the UK and elsewhere.(1) The only means of addressing these are to adhere to a strict antibiotic prescribing policy and pay meticulous attention to hand hygiene. Extending the controls assurance standard for HAIs into primary care services will promote equivalent practice wherever care takes place.
There are many reasons for HAIs, the most significant being the wide variation in the quality of infection prevention practices. This is due to a lack of evidence in local protocols, which means practice is inconsistent, based solely on experience or ritual.

Clinical governance
Clinical governance is the framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care. The key components of clinical governance are a series of quality attributes that are generated from an organisational culture working towards continuous quality enhancement. Clinical effectiveness is fundamental to clinical governance and requires that care is based upon the best available evidence. National evidence-based guidelines are one way of providing this evidence in an easily accessible form to frontline practitioners. Because evidence-based infection prevention guidelines were developed for acute care services, it was important that community and primary care services were also provided with equivalent guidelines so that infection prevention practices could be informed by current best evidence and patients assured of quality infection prevention care regardless of setting.(6)
National evidence-based guidelines
Evidence-based guidelines are systematically developed broad principles of good practice that assist practitioners' decision-making - in this instance to prevent HAIs. These broad principles need to be adapted and incorporated into local practice guidelines or protocols. A guideline development group representing all major stakeholders - primary and community healthcare practitioners, infection control nurses, a medical microbiologist and a patient representative - were involved in their development. In addition, systematic reviewers and a health economist were part of the group.

Scope and format of the guidelines
The National Institute for Clinical Excellence (NICE) commissioned the guidelines and, following an extensive scoping exercise involving primary and community care practitioners, it was agreed that they should cover:(7)

  • Standard principles, including hand hygiene, ­protective clothing and safe use and disposal of sharps.
  • Care of patients with long-term urinary catheters.
  • Care of patients undergoing enteral feeding.
  • Care of patients with central venous catheters.

Standard principles are the foundation of all healthcare practice and should be used in conjunction with the guidelines on devices. Long-term urinary catheters are the most common cause of device-related HAIs in the community, while central venous catheters cause the most serious infections. The use of enteral feeds in the community has increased rapidly, and contamination of feeds is a key concern.(3)
NICE has established precise methods for developing guidelines. Central to these processes are rigorously conducted systematic reviews that provide evidence for critical appraisal. The evidence is then tabulated and synthesised, and the recommendation is graded according to the strength of evidence upon which it is based (eg, a randomised control trial).
Each section covers a headline statement describing the key issue being addressed, followed by a synthesis of the related evidence, including an economic opinion where appropriate, the guideline recommendation and a bibliography. Each section begins with the educational requirements for patients, carers and healthcare personnel, and suggested audit criteria plus areas for further research are also included.

What the guidelines say
The recommendations on hand hygiene cover when, with what and how hands should be decontaminated.  There is now good evidence that alcohol-based hand-rubs are a suitable alternative to soap and water when hands are not visibly soiled. This is particularly useful when caring for different patients or between different care activities for the same patient.
The selection of protective equipment must be based on an assessment of risk of transmission of microorganisms to the patient, or a risk of contamination of the healthcare practitioner's clothing and skin by the patient's blood or body fluids. Gloves that conform to European Community (EC) standards must be used, and any sensitivity to latex must be documented and alternatives provided. All gloves and plastic aprons should be worn as single-use items for one procedure or episode of care and then discarded as clinical waste.  Hands should be decontaminated after the removal of gloves, because although gloves reduce the risk of contamination they do not eliminate it and hands are not necessarily clean because gloves have been worn.
Sharps injuries continue to be a cause for concern in healthcare practice. Sharps must not be passed directly from hand to hand, recapped, bent or broken before disposal. They must be discarded into a sharps container, which is located in a safe position. This is particularly important in patients' homes where there are children and in primary care settings.
All staff should be provided with adequate supplies of liquid soap, handrub and towels and sharps containers wherever care is provided. Everyone involved in providing care should be educated and trained in standard principles, hand decontamination, use of protective clothing and safe disposal of sharps.
The sections describing recommendations associated with the use of devices cover all aspects of care, including education and training. Considering that many devices are managed by the patient themselves or a non-professional carer, it is essential that they are educated and trained in all aspects of device management and have access to follow-up training and ongoing support for the duration of the device.

Implications for practice
The publication of these guidelines was the first step in preventing HAIs in primary and community care settings, but for evidence to influence clinical practice every healthcare practitioner needs to read and implement them. The guidelines need to be reflected in local protocols, followed by ongoing education and training to ensure everyone understands how they relate to practice. Adherence needs to be audited and the results used to develop further educational initiatives. Many of the recommendations may already be part of practice, but practitioners will now have the evidence to substantiate it. 
Evidence is always evolving, and there are areas where the evidence base could be improved. The suggested areas for research can be used as a basis for undertaking local research projects. NICE reviews the evidence every 2-3 years, so that the guidelines can be regularly updated.
What is clear is that it is no longer acceptable for patients to develop a preventable infection as a result of our care (or lack of it). NICE publishes all its guidelines in a format for the public, and as we live in an increasingly litigious society, patients will rightly expect to receive the standard of care described in national guidelines.


  1. Department of Health. Getting ahead of the curve: a strategy for combating infectious diseases. London: Department of Health; 2002.
  2. Department of Health. Winning ways: working together to reduce ­healthcare associated infection in England. Report of the Chief Medical Officer. London: Department of Health; 2003.
  3. Pellowe CM, Pratt RJ, et al; 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:S1-127.
  4. National Audit Office. Report by the Comptroller and Auditor General - HC 876. Improving patient care by reducing the risk of hospital acquired infection: a progress report. London: TSO; 2004.
  5. 5. Plowman RM, Graves N, Griffin M, et al. The socio-economic burden of hospital acquired infection. London: Public Health Laboratory Services; 1999.
  6. Pratt RJ, Pellowe C, Loveday HP, Robinson N, et al; Department of Health (England). The EPIC project: developing national evidence-based guidelines for preventing healthcare associated infections. Phase I: ­guidelines for preventing hospital-acquired infections. J Hosp Infect 2001;47 Suppl:S3-S82.
  7. Pellowe CM, MacRae ED, Loveday HP, et al. The scope of guidelines to prevent healthcare-associated ­infections. Br J Community Nurs 2002;7:374-8.