Infection Control: taking the lead

Infection control is a common area for practices to be found wanting when Care Quality Commission inspections take place, and it is often down to one of the practice’s nursing team to take the lead. So how familiar are you with the official guidance?

Infection control is a vital part of our duty of care to our patients. It is a basic tenet of the infrastructure of the NHS and its implementation is the responsibility of all staff. It is incumbent on all healthcare workers to minimise infection by following infection control guidelines set out by the National Institute for Health and Care Excellence (NICE) and the Department of Health.¹

Infection control encompasses a whole range of measures designed to protect patients and staff from healthcare associated infections (HCAIs) in every medical facility, from hospitals, pharmacies and laboratories, to general practices, health centres and dental practices. It is estimated that over 300,000 people a year in England acquire an HCAI as a result of NHS care, at the staggering cost of £1 billion.

Infection control is a many faceted subject and one that, for primary care, has historically seemed unduly complex, under-recognised, unsupported and expensive to implement. It has not, therefore, always received the attention it deserves. In recent years, however, Clinical Commissioning Groups (CCGs) and the Care Quality Commission (CQC) have been far more rigorous in their inspections and advice.

The CQC inspections of primary care practices have, unfortunately, found significant failings in this area and it seems that we, in primary care have considerable ground to make up.

THE CODE OF PRACTICE

In July 2015, The Department of Health published a document,2 as required by The Health and Social Care Act 2008,3 setting out a Code of Practice (The Code) on the prevention and control of infection. The document states that The Code:

‘will apply to registered providers of all healthcare and adult social care in England. The Code of Practice (Part 2) sets out the 10 criteria against which the CQC will judge a registered provider on how it complies with the infection prevention requirements, which are set out in regulations. To ensure that consistently high levels of infection prevention (including cleanliness) are developed and maintained, it is essential that all providers of health and social care read and consider the whole document and its application in the appropriate sector and not just selective parts.’

The Code is a helpful guide to ensure that all registered providers of healthcare in the UK have the same standard of infection control, to ensure that patients and staff are as well protected as possible. There is a specific section on the implementation of the Code in primary care, but the whole document needs to be read for a better understanding of its overall detail.(See Activity 2)

This article will look, in depth, at what is needed to comply with the Code in general practice premises and will demonstrate that implementation is simple and workable if done systematically. It will not deal with specific infection control for urinary catheters, vascular access devices, enteral feeding tubes, or complicated wound or leg ulcer management, or any aspect of secondary care infection prevention.

THE 10 CRITERIA OF THE CODE OF PRACTICE

1. Systems to manage and monitor the prevention and control of infection

These systems use risk assessments and consider the susceptibility of service users and any risks that their environment and other users may pose to them.

This criterion states that each practice must have a dedicated person as the Infection Control Lead. This individual must have appropriate knowledge and skills to take overall responsibility for infection prevention, although it should be stressed that every member of staff also has a responsibility to maintain cleanliness and the cold chain. (see Criterion 9)

The practice needs to formulate an infection prevention policy that is easy to maintain and audit. It also needs to provide written guidance on cleaning the premises, hand washing and decontamination and cleaning in treatment rooms. This information is most often kept in a file in the practice manager’s office but should be available to all medical staff on the practice computer system as well. The Infection Control Lead should carry out a risk assessment of any infection hazards or potential safety concerns on a regular basis. 4

There are many useful checklists for audit that can be found online if your local CCG does not provide one, e.g. the Quality Improvement Tool on the Infection Prevention Society website.⁵ A common failing identified in CQC inspections has been that no action has been taken in response to audit.

Adequate training about the policy, and infection control generally, should be offered regularly to all members of the practice team (including cleaning staff). (See Activity 3)

2. Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections

There is now national guidance on the furnishing and flooring of practices and the adaptation of rooms for treatment and minor surgery.⁶ There must be adequate provision for hand washing, and antimicrobial hand rubs must be available. Paper hand towels and paper covers for examination couches and patients’ modesty should be provided.

Usually the practice manager will have overall responsibility for the cleaning of the premises but in some practices, this responsibility will fall to the Infection Control Lead. There should be a detailed schedule of the cleaning arrangements (including periodic deep cleaning) stating the standards of cleanliness required in each part of the practice premises.⁷ Staff on duty at any one time should also be responsible for keeping areas clean and tidy. Spills packs should be available to clear up vomit, urine and blood and stored where they are easily available. Mops must not be used for bodily fluids.

3. Ensure appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial resistance

Antibiotics are an important part of infection control but bacterial resistance to these agents is worrying, as there do not seem to be any new antibiotics, or alternative ways of treating infection, coming on the market in the foreseeable future. Great care should therefore be taken to prescribe antibiotics only when absolutely necessary. This is called antimicrobial stewardship.⁸ (Box 1) Local prescribing advisors and CCGs will support the practice with an ongoing programme of audit, revision and updates with feedback to prescribers, managers and administrators.

Every opportunity should be taken to educate patients about when they can expect to be given a course of antibiotics (and, equally importantly, when they are not appropriate) and, when they are given, the importance of taking them regularly and completing the course, even when they feel better.

4. Provide suitable, accurate information on infections to service users, their visitors and any person concerned with providing further support or nursing/medical care in a timely fashion

Information for patients on staff roles in infection prevention, the practice policy and any current infection issues (e.g. an outbreak of influenza), should be displayed in the waiting room and on the practice website. Local Healthwatch, Patient Advice and Liaison Services (PALS) and practice patient participation groups may like to be involved in helping to disseminate such information, stressing the importance of compliance with the use of antimicrobial hand rubs on attendance at the practice.

There should also be information for patients on whom to contact with their concerns or complaints about cleanliness and patient safety. The National Patient Safety Agency document Being open – communicating patient safety incidents with patients, their families and carers provides best practice guidance for healthcare teams on open and honest communication.⁹

5. Ensure prompt identification of people who have, or are at risk of developing an infection so that they receive timely and appropriate treatment to reduce the risk of transmitting infection to other people

A healthcare professional who sees a patient with an infection should be able to assess any communicable disease control issues and deal with them accordingly.

All staff should be able to find a list of local contacts for the Public Health England health protection team for reporting incidents or infections, as directed in the Health Protection (Notification) Regulations 2010.¹⁰ These regulations require:

‘…attending doctors (registered medical practitioners) to notify the Proper Officer of the local authority of cases of specified infectious disease or of other infectious disease or contamination, which present, or could present, significant harm to human health, to allow prompt investigation and response. The regulations also require diagnostic laboratories testing human samples to notify Public Health England of the identification of specified causative agents of infectious disease.’

6. Systems to ensure that all care workers (including contractors and volunteers) are aware of and discharge their responsibilities in the process of preventing and controlling infection

Infection prevention needs to be included in staff job descriptions and be included in the induction programmes and staff updates of all employees (and volunteers).

Where nurses or healthcare assistants undertake procedures that require skills such as aseptic technique, they must be trained and demonstrate proficiency before being allowed to undertake these procedures independently.

7. Provide or secure adequate isolation facilities

The practice policy should detail what reception staff need to do when someone with an infectious disease (e.g. chickenpox, mumps) attends the practice. The patient should be isolated from the waiting room to avoid spreading the disease further, and a nurse or doctor informed immediately that the patient is there.

8. Secure adequate access to laboratory support as appropriate

It is useful to find out about the local laboratory facilities, especially who to go to if you sustain a needlestick or sharps injury. They can also discuss with you any problems or queries over the handling and packaging of specimens, and times of collection.

9. Have and adhere to policies, designed for the individual’s care and [for] provider organisations that will help to prevent and control infections

This criterion encompasses all the points that should be included in your practice policy. (Box 2). Many of these have already been described under the 10 individual criteria. Several, however, have not and are detailed here:

• Hand hygiene is the single most important factor in the prevention of the spread of infection (see Box 3 for hand hygiene principles)
• All medical disposable gloves now have a CE mark which means they conform to an international standard. The practice should decide which gloves are most appropriate for which procedure i.e. nitrile gloves for invasive procedures
• Decontamination of reusable medical devices: a list should be made of the devices such as stethoscopes and near patient testing kits that need to be cleaned, by whom and how often. Don’t forget any children’s toys in the waiting room.
• Safe handling and disposal of waste and sharps – description of colour coding.¹¹ It might be useful to put up a poster near the sharps and waste boxes to remind staff what the different colours are for. Make sure that these disposal boxes are never in reach of children, that the lids are firmly attached and that they are not overfilled. The person who assembles or removes a box must sign and date the box.
• Safe handling of sharps – the practice should decide if it wishes to purchase the Safe needles used for phlebotomy to protect its staff.¹²
• Maintenance of the cold chain, vaccine storage and cold chain failure policy due to power cut. This is a very important part of infection prevention. The Infection Control Lead should make sure that everything is done to prevent a break in the cold chain, especially by giving instructions to receptionists about what to do on receiving a vaccine delivery. (See Activity 5)

10. Providers have a system in place to manage the occupational health needs and obligations of staff in relation to infection

Department of Health guidance advises that staff should have access to an occupational health service for identifying and managing healthcare staff infected with hepatitis B, C or HIV and advising about fitness for work and monitoring as necessary.¹³

When advice is needed on procedures that may be carried out by bloodborne virus (BBV)-infected workers, or when advice on patient tracing, notification and offer of BBV testing is needed, then liaison with the UK Advisory Panel for Healthcare Workers Infected with Bloodborne Viruses is useful.¹⁴

The service can also carry out a risk assessment and make appropriate referral after accidental occupational exposure to blood and body fluids.¹⁵

CONCLUSION

We all need to welcome this Code. At a time of increasing antimicrobial resistance and concern about the spread of infection, the Code will enable all practices to attain the same, high standard of infection control. It guides Infection Control Leads through what can be a daunting, but very necessary ‘to do’ list in order to achieve this objective.

This article is not an exhaustive explanation of all that infection control encompasses but will provide you with the basics on which to assess how your practice is doing and what measures are needed to bring it up to the Code's standards.

REFERENCES

1. NICE. Infection prevention and control, 2014 https://www.nice.org.uk/guidance/QS61/chapter/introduction

2. Department of Health. The Infection Control Code of Practice, 2015 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/449049/Code_of_practice_280715_acc.pdf

3. The Health and Social Care Act, 2012. http://www.legislation.gov.uk/ukpga/2012/7/contents/enacted

4. Health and Safety Executive. Risk assessment – A brief guide to controlling risks in the workplace, 2014. http://www.hse.gov.uk/pubns/indg163.pdf

5. Infection Prevention Society. Quality Improvement Tools http://www.ips.uk.net/professional-practice/quality-improvement-tools/quality-improvement-tools/

6. Department of Health. General design guidance for healthcare buildings, 2014. https://www.gov.uk/government/publications/general-design-principles-forhealth-and-community-care-building

7. National Patient Safety Agency. The national specifications for cleanliness in the NHS: Guidance on setting and measuring performance outcomes in primary care medical and dental premises, 2010 http://www.nrls.npsa.nhs.uk/resources/?entryid45=75240

8. NICE. Infection prevention and control, 2014. Quality statement 1: Anti microbial stewardship https://www.nice.org.uk/guidance/QS61/chapter/Quality-statement-1-Antimicrobial-stewardship

9. National Patient Safety Agency. Being open: communicating patient safety incidents with patients, their families and carers, 2009. www.nrls.npsa.nhs.uk/resources/?entryid45=65077

10. Health Protection (Notification) Regulations 2010. http://www.legislation.gov.uk/uksi/2010/659/regulation/2/made

11. Department of Health. Safe management of healthcare waste, 2013 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/167976/HTM_07-01_Final.pdf

12. Needle Stick Safety. Safe needles http://www.needlesticksafety.org/safe-needles

13. Department of Health. Healthy Staff, Better Care for Patients: Realignment of Occupational Health Services to the NHS in England, 2011 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216379/dh_128814.pdf

14. UK Advisory Panel for Healthcare Workers Infected with Bloodborne Viruses https://www.gov.uk/government/groups/uk-advisory-panel-for-healthcare-workers-infected-with-bloodborne-viruses

15. Health and Safety Executive. Reporting accidents and incidents at work: A brief guide to the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR), 2013 www.hse.gov.uk/pubns/indg453.htm res are needed to bring it up to the Code’s standards.