Infection control must be an important part of all nursing care; it does not stop at the hospital/clinic door. Unfortunately, community nurses face unique challenges working in patients' homes, because they have little control over the environment they work in and need to be innovative. This article discusses the common issues faced by community nurses around infection control and offers practical advice, based on the authors' own practices. Good infection control practices in the community will aid patient safety and improve patient care and can, ultimately, help prevent hospital admissions.
Hand hygiene
Effective hand hygiene remains one of the cornerstones of good infection control. Since its conception in 1979, the, originally six-, now seven-stage, handwashing technique (World Health Organization (WHO), 2009) has proved very effective at decontaminating hands, whether used with soap and water or decontaminating hand rubs. It has been taught widely in healthcare and supported with many campaigns (Ayliffe et al, 2000). However, an equally important element is knowing when to decontaminate hands. The Five Moments of Hand Hygiene (WHO, 2009) is an effective tool to assess when to decontaminate hands. These are detailed as:
- Before contact with a patient and/or their surroundings: before entering a patient's home, hands should be decontaminated; decontaminating hand rubs can be used here. Hands can easily become contaminated as nurses travel between patient homes
- Before clean/aseptic procedure: hands must be clean before any procedure that breaks the body's defensive barrier is undertaken, for example, activities such as wound care, re-catheterisation, administration of intravenous medications and intramuscular injections. This is when the hands need to be cleaned with soap and water. Sanitising gels will sanitise hands and kill microorganisms, but will not remove dirt and contamination from the hands. Because of the raised risk to the patient from clean/aseptic procedures, hands need to have any contaminants and transient microorganisms physically removed, and this is achieved with soap and water.
- After contact/potential contact with blood or body fluids: if there is any risk that the hands have become contaminated with blood or any body fluids, then the hands need to cleaned, because of the high risk of cross-contamination. This must be performed with soap and water to physically remove any unseen contamination. Activities that cause this are catheterisation, wound care, changing urinary catheters, bowel care and specimen collection.
- After having contact with a patient: this is to reduce the chances of cross-infection. Patients' skin will naturally be contaminated with their microorganisms, but it could also be contaminated if they are ill, if their personal hygiene is not appropriate or from a recently performed clinical procedure. Depending on what clinical activity has been performed, decontaminating hand rubs can usually be used for this purpose, but, if there is a risk that the hands have been contaminated with blood or body fluids, then soap and water must be used.
- After leaving a patient's environment: this moment is often combined with moment 4, but it can be a moment on its own. Once a nurse has completed the patient's care, they may need to complete notes or respond to other patient concerns. This can contaminate the skin again, and the nurse would need to decontaminate their hands when leaving the patient's home. Decontaminating hand rubs are appropriate for this if the hands are not physically dirty.
What to do if no sink is available
Very few patient homes have sinks that fully comply with hand hygiene regulations (Department of Health and Social Care (DHSC), 2013a), and sometimes, no sink is available, or the sink is broken, dirty or full of dishes. If there is no available sink, then a hand wipe can be used to physically clean any dirty and/or visible contamination from the hands, and a decontaminating hand rub can then be used to remove any transient microorganisms. Hand hygiene wipes can be very effective at removing even surface dirt, and they allow the hands to dry quickly (Wilkinson et al, 2018). However, the hands need to be washed at the next opportunity.
Personal protective equipment
Personal protective equipment (PPE) protects nurses from contamination and contaminating patients (NHS England, 2019). When performing clean or aseptic procedures, it is essential to wear gloves; these should be clean for clean procedures and sterile for aseptic procedures (NHS England, 2019). Due to the nature of nursing procedures, there is a greater risk of contamination, both for the patient and nurse. Gloves should always be worn when there is a risk of coming into contact with blood or body fluids (NHS England, 2019). It should be noted that gloves may not provide complete protection to the skin (Nazarko, 2014), and hands need to be washed following removal.
Aprons should be worn if there is a risk of the nurse's clothing becoming contaminated (NHS England, 2019). Activities such leg ulcer care and bandaging, especially during washing of the legs, bowel care and dressing changes for heavily exudating wounds can all pose a risk of contaminating clothing.
Facial protection is required to prevent blood, body fluid and/or contaminated fluids being splashed into the nurse's face (NHS England, 2019). In community nursing, the risk of this can be low, but it is not absent. Ear irrigation or tracheostomy care could pose this risk.
PPE is an important part of preventing cross-infection but can be overused (Brown et al, 2019). PPE should be applied just before it is needed and removed as soon as it is no longer required (Brown, 2019). Wearing it inappropriately, especially gloves, can easily contaminate a patient, their home and the nurse. Gloves should not be donned before entering a patient's home; they should be left on for the whole of the visit, regardless of what clinical activity was performed, and only removed after leaving the home. Intact bare skin can be decontaminated easily with appropriate hand hygiene.
If a non-touch technique is being performed and the hands are clean, gloves do not need to be worn (Rowley, 2001). Administering oral medication, instilling eye drops and prompting blister medications can all be done as a non-touch technique. With preparation, many sub-cutaneous injections, such as insulin from a pre-filled syringe, can also be administered as a non-touch technique, provided that neither the injection site nor the administering needle are touched.
Similarly, if there is contact with only intact skin and the procedure does not break the skin barrier, there is no need for gloves. Procedures such as taking a patient's vital signs, putting on a patient's compression stockings and using the SSKIN bundle can all be performed without gloves, as long as the patient's skin is intact.
If gloves are not worn and the hands become contaminated, they must be washed with soap and water or cleaned with hand hygiene wipes as soon as possible.
Box 1 discusses specific considerations for PPE in the context of COVID-19.
Box 1.Personal protective equipment (PPE) consideration in the context of COVID-19
| Always follow local trust's policy/guidelines |
| COVID-19 is a respiratory infection that is spread via respiratory droplets (Master and Gerrard, 2020) |
| Fluid-resistant (type-IIR) surgical masks can be reduce transmission by up to 80% (Cook, 2020); therefore, nurses should wear them with all patient contact, as 18%–81% of all those with COVID-19 are asymptomatic (Nikolai et al, 2020) |
| Because SARS-CoV-2 is spread by respiratory droplets that can survive on surfaces, hand hygiene is very important |
| Hand hygiene should be performed before PPE is put on, before all patient contact, with the face mask used first |
| After patient contact, all PPE should be removed, with the face mask removed last and disposed of. Then, hand hygiene must be performed as the last activity before leaving a patient's home |
| In case of any concerns, advice should be sought from the local infection prevention and control team |
Managing clinical equipment
In community nursing, clinical equipment roughly falls into two categories:
- Equipment taken into the patient's home and then removed, which is used with multiple patients
- Equipment left in a patient's home for single-patient use.
Equipment from both categories will need to be appropriately decontaminated. Equipment taken into the patient's home and then removed is usually the clinical equipment found in a community nurse's bag or backpack and used with multiple patients, for example, blood pressure equipment, stethoscope, glucometer, anaphylaxis pack and tape measure. After use, the equipment must always be appropriately decontaminated (Health and Safety Executive (HSE), 2021); if not, there is potential for cross-infection. Detergent and disinfectant combined wipes are readily available and can be sourced in small and handy packs. These can be tucked in a nurse's bag and used to clean equipment before it is returned to the bag.
More specialist equipment not usually carried by a community nurse but still taken into and removed from a patient's home, such as a Doppler measuring equipment or an ear irrigation pump, will require more specialist decontamination. Some surface wipes may be too harsh or not strong enough; therefore, manufacturer's guidelines should always be followed (HSE, 2021); for example, for an ear irrigation pump, most manufacturers recommend a high level of disinfection.
Equipment left in a patient's home is usually specialist equipment for their specific use, such as VAC pumps, feed pumps, pressure-relieving mattresses, hospital beds, pressure cushions and oxygen compressors. When removed from a patient's home, this equipment will often require specialist decontamination (HSE, 2021), which is generally provided by the company the equipment is rented from. If not, the department the equipment was provided by or the trust's decontamination lead should be consulted. This equipment will often require cleaning while it is in the patient's home, because it is often left there for extended periods. Most of this type of equipment can be cleaned with detergent, either in water or wipes, but this may not be suitable for electrical equipment, such as VAC pumps, feed pumps and pumps for ripple mattresses. If there is any doubt, then the equipment manufacturers' guidelines should be consulted (HSE, 2021). This can be easily achieved through a simple internet search (the manufacturer and equipment name should be typed into a search engine, plus ‘how to clean’ or ‘how to decontaminate’ and the manufacturer's link should be clicked on).
Community nurses will not be the people who actually clean this type of equipment, but they will need to ensure that the people doing so are doing it correctly. It should be ensured that patients, relatives and/or carers know the correct way to clean the clinical equipment left in a patient's home.
Single-use equipment, whether taken into a patient's home or already there when the nurse arrives, must never be reused and always disposed of appropriately and directly after use (Medicines and Healthcare products Regulatory Authority, 2021). These can be identified by the single-use symbol.
Sharps bins are essential for the safe disposal of any sharps (DHSC, 2013b). District nurse team caseloads will have patients on them who require daily injections, whether that is insulin, anticoagulants or other medications. Therefore, these patients will need to have a sharps bin left in their homes. These bins may not be assembled by nurses, especially if they are delivered to the patient's home, but nurses should always ensure that they are correctly assembled, that the lid cannot be removed and that they are correctly labelled. Even if the nurse is not the first person to use it, this should always be checked. They will need to be safely stored and not present a potential sharps injury risk to the patient or other household members when the nurse is absent. It should be ensured that the bin is not stored on the edge of a shelf, table or work surface where it can be easily knocked onto the floor, for example, by a pets. If there are children or adults with cognitive impairment, the nurse must ensure that they cannot access the sharps bin. Ideally, it should be stored in a cupboard, away from domestic activity. The temporary closure of the sharps bin must always be in place when the bin is not in use.
Domestic waste is defined as, ‘… should not contain any infectious materials, sharps or medicinal products' (DHSC, 2013b). Therefore, any waste that is placed into a patient's domestic waste should always be carefully considered. Heavily soiled materials and/or infectious waste may require specialist arrangements for collection. Community nurses should be aware that sanitary waste, toiletry waste, used paper tissues and even waste contaminated with small amounts of blood are frequently placed in household waste in the majority of homes. If in doubt whether an item can go into domestic waste, advice should be sought from the trust's infection prevention and control team.
Managing the environment
Unfortunately, community nurses do not have control over the environments they work in, unlike nurses who work in hospitals and clinics. Patients' homes do not come under the same regulations (HSE, 2021), but community nurses do need to manage the potential risks from this environment.
Community nurses should be aware of environmental risks, such as:
- If using a hard surface to lay out a sterile field, it should first be cleaned with a surface wipe. This can remove any potential contamination
- Dressing packs often contain a second sterile sheet or dressing towel, which can be placed between a patient and the surface they are on to protect the wound when the dressing is changed
- If the patient's skin around a dressing is dirty or soiled, it should be cleaned with a skin care wipe before performing wound care
- Nurses should try not to perform wound care when domestic cleaning has recently taken place, especially vacuuming, because of the risk of dust being disturbed
- If performing wound care on a bedbound patient, nurses should try not to do it immediately after the bedding has been changed, for the abovementioned reason
- If performing wound care, any pets should be kept out of the room, because they could contaminate the wound and/or sterile field
- If clinical equipment or packaging is dusty, it must be cleaned before use
- If re-catheterising a patient, the nurse should ask them to lie on top of a clean towel. This will protect their bedding from any spills and protect the patient from dust and detritus that may be on their sheets
- It should be ensured that catheter bags are attached and do not touch the floor, as contamination can travel up the catheter.
A patient's home can become deeply contaminated through neglect, whether by the patient, their relatives or even their carers. Dirty and unsafe environments should not be ignored. If a patient's home has fallen into this state, then action must be taken. Is the patient no longer able to look after themselves? Are relatives no longer able to look after them? Are carers not performing domestic activities? Are there issues of neglect happening? These concerns should initially be discussed with the patient and/or relatives. If possible, patient care should be discussed with their carers. Social services should be involved at the earliest opportunity. Community nurses should not be afraid to raise a safeguarding alert in these circumstances, as these can be very useful. Further, the trust's safeguarding lead should be contacted for assistance, especially if things appear to be running slowly or concerns are not being appropriately handled (Table 1).
Table 1. Infection control procedures in patients' homes
| Procedure | Risk |
|---|---|
| Administration of intravenous medication | This procedure offers direct access to the bloodstream, especially if the medicines are administered via a long line or central line, which carries a high risk of infection for the patient, which could lead to sepsis. Further, the insertion site carries a high risk for infection |
| Long line/central line care | Same as above |
| Disconnecting a chemotherapy pump | Although this seems a simple enough procedure, it should be kept in mind that the patient's immune system could be severally impaired from the chemotherapy |
| Drainage management, such as pleural drains | The drain goes directly through the body's defences and often into a major organ, and this could be a source of infection. The nurse needs to be careful not to become contaminated with the body fluid that is drained from the patient |
| PEG and NG feeds | These feeds bypass the protection of the mouth and throat and go directly into the stomach, which has the potential to introduce contamination. Nurses need to be careful not to be contaminated with the feed; because of its high glucose content, it can be a very effective culture medium for microorganisms, and those can further contaminate the nurse |
| Intermuscular injections | This process directly breaks the body's defences and introduces fluids into a muscle. Care must be taken that no contamination occurs |
| Urinary catheter changes | The catheter goes directly into the patient's bladder, and there could be a high risk of introducing infection during the process. Nurses need to be careful not to be contaminated with urine |
| Leg ulcer care | Because the patient has poor circulation, there is a greater risk from wound infections. Leg ulcer care, especially compression bandaging and leg washing, can take a long time, and there is a high risk the nurse can become contaminated with wound exudate |
| Bowel care | Nurses must be particularly careful not to become contaminated during this procedure |
Note: PEG=percutaneous endoscopic gastrotomy; NG=nasogastric
Infectious disease management
Often, community nurses are the only health professionals a patient has regular contact with; therefore, the nurse needs to be aware of the patient's general health. If the patient has any signs of infection, then these should be acted on as soon as possible. Any patient on a district nursing caseload will have some degree of immune impairment because of their health condition, and a severe infection could have serious consequences.
Routine specimens and swabs should not be taken from patients; they should only be taken if there are physical signs of an infection (Bowler et al, 2001). Wounds become easily contaminated and colonised with microorganisms (Bowler et al, 2001), especially chronic wounds such as pressure ulcers and leg ulcers. Moisture lesions, because of where they occur on the body, will quickly become contaminated with body fluids. Older patients can generally have abnormal urinalysis dip-test results without a urinary infection, especially if they have a catheter in-situ (Public Health England (PHE), 2020). Therefore, urine samples should only be taken if the patient has physical symptoms of a urinary tract infection or symptoms that suggest it, and not solely on the basis of an abnormal urinalysis.
If a GP receives a positive result for a urine sample, they will not know if the patient's urine is colonised or infected, and they could prescribe unnecessary antibiotics. Therefore, samples and specimens should only be taken when there is a clinical need and the results are followed up. If a patient has an active infection, it might affect their nursing needs.
If a wound is infected, a topical treatment may be required (Chamanga, 2015). Oral antibiotics given to a patient with an infected leg ulcer may take a long time to reach the wound due to impaired circulation. The nurse should consider changing the primary dressing to an antimicrobial one, such as a silver-impregnated one. This will help by working directly on the microorganisms in the wound.
When a patient has a known infection, the point at which they are seen on a nurse's list of patients should be carefully considered, to reduce the risk of cross-infection. Preferably, they should be the last patient on a nurse's list, although this is not always possible. They should not be seen directly before a patient with impaired immunity, such as one receiving intravenous antibiotics or home chemotherapy.
Staff health
Staff health is just as important as patient health, and a member of staff with an infectious illness is just as much a cross-infection risk as a patient with one, in fact, they could carry a higher risk. Therefore, healthcare staff with infections must avoid going to work until they are well. Unfortunately, nurses can feel guilty that they are letting their team down by being off sick; this is when supportive managers play an important role.
Infection prevention and control team
Every NHS trust has to have infection prevention and control (IPC) support available (DHSC, 2015), and this team can be a very useful resource for a district nursing team. IPC teams can advise on specific infections, especially new or unusual ones, and appropriate antibiotics, liaise with GPs, advise on specific infection control issues and procedures and, when processes are not working, they can even intervene if required.
Community nurses should form a rapport with the local IPC team, and it should be ensured that all members of community nursing teams have easy access to the IPC team, either via phone or email as appropriate. If the trust has an infection control link practitioner scheme, it should be ensured that the community nursing team is represented on this. A member of the IPC team can be invited to attend a daily handover, whether in person or virtually. This way, the community nursing team will be able to physically put a face to a name, encouraging contact if needed, and the IPC team will see what issues the former is facing.
Conclusion
Infection control should never be an additional activity, as something that is only performed if nurses have the time to do so; rather, it must be at the heart of all patient care. It is one of the most essential ways to keep patients safe.
Hand hygiene is the most important principle, but is not the only one. The patient, their environment and the clinical equipment used are also important and need to be considered. Simple risk assessments, including the nurse asking themselves what the risks of cross-contamination are, can highlight many risks. Tools, such as the Five Moments of Hand Hygiene, can also be useful.
The trust's IPC team is an extremely useful resource and should be accessed early whenever there is an issue. It is important to share a good rapport with the IPC team, because it can understand the challenges community nursing teams face and advise on proactive interventions to overcome these.
KEY POINTS
- Infection control is the responsibility of all nurses, not just those working in a hospital/clinical environment
- Hand hygiene is one of the most effective ways to prevent cross-infection, but when it is performed is just as important as how it is performed
- Personal protective equipment (PPE) is important in preventing cross-infection, but its inappropriate use can cause cross-infections in the same way as not using it when required
- For all clinical equipment used with a patient, it should be considered who will decontaminate it and how it will be decontaminated or safely disposed of
- Community nurses may not have control over the environments they work in, but steps can still be taken to reduce cross-infection risks
- An infection should never be ignored, whether in a patient, colleague or the nurse themselves
CPD REFLECTIVE QUESTIONS
- What infection control risk assessments do you carry out?
- How does infection control play a part in deciding the order in which patients are visited?
- What would you do if a colleague came to work with symptoms of the flu?
- When would you contact your local infection prevention and control team?