Since the onset of COVID-19, we have become acutely aware of the dangers involving infection control. A viral or bacterial infection can spread through various means, such as through touch or airborne transmission. Healthcare professionals are faced with the task of preventing transmission of bacteria or viruses from one patient to another. The Department of Health (2008) defines good infection prevention (including cleanliness) as essential to ensure people using health and social care services receive safe and effective care. For this to be implemented, infection control measures must be regularly and consistenty practiced by healthcare professionals. This depends on how the organisation and management roll out the most effective training and ongoing procedures, fostering high collaborative standards and culture among staff for infection control.
NHS England (2022) recently set out guidance on the topic of infection control. As always, there is an emphasis on hand hygiene; however, patient placement and the assessment of the patient's infection risk are absolutely critical. Therefore, among community nurses, there should be a quick and analytical response to any new patient referrals—if they have an infection or came from an environment where infection was present (such as COVID-19), it is integral that staff assess the risk of accepting the patient and consider risk of infection into their practice. NHS England (2022) states that there must be prompt assessment for infection risk on arrival at the care centre. However, it is preferable that this assessment be undertaken before transferring the patient for admission at the hospital. The patient should be continuously reviewed thereafter. Such assessment should influence placement decisions in accordance with the patient's care requirements (NHS England, 2022).
Patients who carry a clear risk include those with diarrhoea, vomiting, an unexplained rash, fever or respiratory symptoms; a history of multi-drug resistant organism (MDRO) infection, such as Methicillin-resistant Staphylococcus aureus (MRSA); who have been an inpatient in any hospital in the UK or abroad; or who are a known epidemiological link to a carrier of carbapenemase-producing enterobacterales (CPE). Therefore, each community nursing team is likely to take on multiple at-risk patients, and it is important to carefully follow the Trust's guidance (NHS England, 2022) in screening the patients and assessing the necessary restrictions. Where a patient is being accepted back into a care home from a hospital, staff will be required to pay particular attention to ensure that there is no risk being posed to other vulnerable patients in that care home. During the pandemic, this was an observable issue, where thousands of infected patients were discharged back into care homes, subsequently leading to the deaths of excessive numbers of people. If infection control policy had been implemented and prevented the spread of COVID-19, it is likely that infection would not have spread at such rates among vulnerable people. This is a prime example of infection control not being performed, as the crucial element of patient placement was not considered. Therefore, community nurses can collaboratively work with care homes to consider and decide whether to accept a patient from the hospital, back into the community.
Hand hygiene is another important focus for infection control. It is essential to not only wash hands thoroughly and across multiple areas, wrists and nails, but that the hand is dried effectively using paper towels. Pathogens can remain on the hands even after washing, if they are not dried appropriately. The hands are at greater risk of harbouring pathogens if there are skin tears, such as when a nurse has eczema—they would need to report this due to the risk posed to patients, as infection control can be compromised if a healthcare professional has skin breaks. When I first started working in healthcare, there would sometimes be communal tubs of moisturiser (leading to the risk of the tubs harbouring pathogens found on all the hands placed inside it), or none at all! Thankfully, this is a thing of the past and can be avoided as, in most hospitals and care homes, there is now a dispenser to ensure no hands are actively being placed into the moisturiser. However, some community areas may not be as well-equipped as a standard hospital or a large care home, so it is important to be aware of hand moisturising practices and ensure no communal tubs of cream are being used (NHS England, 2022). Staff would need involvement with occupational health if their hands have skin problems, to ensure infection control standards can be met properly.
The Centers for Disease Control and Prevention (CDC) (2019) noted the importance of the types of products used to clean hands. The guidance they produced states that an alcohol-based sanitiser is important to use if the hands are not visibly dirty, as this minimises skin irritation and thus prevents skin breaks. It is the most effective method for killing pathogens, which often cannot be killed using soap, and is also easier to use. However, the CDC (2019) reminds us that alcohol sanitisers cannot kill Clostridium difficile (C. diff)—a common pathogen causing severe diarrhoea. Spores of C. diff can be transferred to patients through the hands of healthcare providers who have touched a contaminated surface or item. Washing hands with soap and water is the best way to get rid of this type of pathogen. Another note on hand sanitiser is to dispel the myth that it contributes to antibiotic resistance—the CDC (2019) confirms that this is not the case.
As personal protective equipment (PPE) is so commonly worn, it is highly likely that all healthcare professionals know the rules pertaining to its use. Nonetheless, the National Institute for Health and Care Excellence (NICE) and Social Care Institute for Excellence (NICE and SCIE, 2018) note the importance of selecting the appropriate PPE ahead of the task at hand, to reduce risk to both practitioner and patient. Single use items, such as gloves and aprons, should be removed appropriately, reducing contact with the side exposed to the patient and disposed of appropriately and promptly after use. Never wear the same PPE items from one patient to another and always change gloves, even between tasks for the same patient—for example, this might be wearing a pair of gloves to help a patient wash and then requiring new gloves to change their dressing, or attending to leg wounds (NICE and SCIE, 2018).
More recently, NHS England (2022) has issued guidance on respiratory and cough hygiene for infection control. It serves a reminder to always wash hands after coughing, sneezing, using tissues, or after contact with objects contaminated by respiratory secretions. Hand wipes can be used if there is no running water at the patient's house, for example, but hand washing should be done properly as soon as there is access to hand washing facilities.
It is common to find reusable equipment such as commodes or other such equipment placed in the home of the patient, in the community setting. This should be decontaminated thoroughly and family or carers must be educated on the thorough cleaning of such equipment. Staff could easily pick up secretion by touching a surface that has not been properly cleaned and transfer it to another patient. This is why so many measures are in place to prevent the spread of infection, as, veering from protocol such as hand washing and equipment decontamination, can unwittingly cause the spread of an infection to other patients. As healthcare professionals, it is our moral obligation to ensure we are well aware of the risks of infection to vulnerable people. Therefore, we must do all we can to manage and prevent its spread. NHS England's (2021) National Standards of Healthcare Cleanlines outline further information on this.
Sharps injuries should always be reported and swiftly dealt with by occupational health. According to NHS England (2022), there is a legal obligation to report all sharps injuries and near misses to line managers and employers, due to the obvious infection control implications such incidents can have.
In terms of policy, the UK Government (2019) has set out an ambitious commitment to tackle the problem of antimicrobial resistance, issuing a 5-year action plan. This relates to prescribing and infection control in equal measures. The plan states that antimicrobials have saved millions of lives, but new drugs of this type have not been discovered since the 1980s, meaning we are a population at risk of becoming increasingly resistant to the various available drugs on the market for bacterial infections. This could result in people dying from infection, as the basic or even newer antibiotics may simply not work due to the multi-drug-resistant pathogen present in the patient. To add to this problem, inappropriate use of the available drugs have increased the rate of resistance in people against antimicrobials.
The UK Government (2019) states that they see infection control as essential and their plan has a strong focus on this issue, with an aim to develop real-time patient-level data so that clinicians can access infection, treatment and resistance histories for each patient. This can optimise life-saving treatment, but will also help manage the assessment of infection risk the patient carries. The plan aims to halve healthcare-associated gram-negative blood stream infections and to reduce the number of specific drug-resistant infections in people by 10% by 2025 (UK Government, 2019).
The plan noted the various actions taken in recent years to improve infection control, including the regulations set out under the Health and Social Care Act (2008); the training of healthcare practitioners in hand hygiene and aseptic technique; use of infection surveillance systems to recognise infection and target action while preventing spread; use of audit practices ensuring policies and procedures are effective; vaccinations of healthcare workers to protect patients from the spread of infection in healthcare settings; decontamination of medical devices; and environmental cleaning (UK Government 2019).
In conclusion, there are multiple ways that practitioners in health and social care settings can improve infection control, with a focus on hand hygiene, clean or aseptic techniques, appropriate PPE, equipment decontamination and appropriate risk assessment when accepting a patient onto the team's patient list. At a time when people are quickly becoming resistant to multiple antimicrobial drugs, staff must remain vigilant, with the awareness that, without following the correct principles, vulnerable people are easily placed at risk.