The principle of infection control is something that is becoming increasingly important in hospitals and healthcare settings. This is primarily because of the hardship and suffering it causes to the patient who acquires an infection whilst in hospital and also because of the cost it brings to our already under funded hospitals from increased stays and healthcare workers falling ill.
The author will discuss the principal of infection control and by demonstrating the effectiveness of techniques such as hand washing and universal precautions will determine its relevance. One of the major infections acquired in hospitals, urinary tract infections will also be explored and by referring to relevant research the author will investigate its preventability.
For some infection control is the latest buzzword on hospital wards, however, its significance is somewhat overlooked. Hospital acquired infections (HAI), which are a result of poor infection control account for around 10% in the UK, to date there are no accurate figures for Ireland but it is reckoned to be the same (Rogers, 2000). According to Rizzo (1999), a HAI is usually one that first appears three days after a patient is admitted into hospital. They are also called nosocomial infections. Germany differs somewhat to the occurrence of HAI’s as they have had a holistic strategy in hospital hygiene since 1976 which has resulted in the lowest rates of infection amongst patients compared with the rest of Europe (e.g. Germany 3.5%, France 6.7%, UK 10%) (Exner, Hartemann and Kistemann, 2001).
It is because of infection control that since the beginning of the 20th century life expectancy has increased by more then 30 years along with life quality. The main reasons for these results are improvements of the economic situation of the population, housing and domestic settings, nutritional status, education, motivation to perform personal hygiene, centralized water and sewage systems, availability of highly efficient vaccines and discovery of new drugs (Exner et al, 2001).
As discussed earlier, since the beginning of the century man has had impressive results in increasing life expectancy but according to Exner et al (2001), “after the eradication of small pox led to the belief that the book of infectious diseases could be closed. A systematic reduction of the institutional infrastructure began, and awareness of infectious disease risks in the population declined”. Unfortunately since the eradication of small pox, new pathogens have emerged such as HIV, AIDS, MRSA, Hepatitis A and B and diseases, which were once under control, have now reemerged such as TB. Human behavior has also changed most notably in sexual lifestyles, the once predominant existence of monogamy has ceased and increasingly people are becoming more promiscuous leading to the spread of STD’s/STI’s such as syphilis. All this has presented our hospitals with a huge task of controlling these infections and preventing them from spreading to other patients and health care workers.
Methicillin-resistant staphylococcus aureus (MRSA), which is the antibiotic resistant microorganism, is now an accepted part of both hospitals and nursing homes and has resulted from the misuse of antibiotics, poor hygiene standards such as ward design, lack of isolation, inadequate sterile techniques (Exner et al, 2001). Nurses and doctors sometimes think that infection control is used to protect other patients and themselves from infection but it is also used to prevent the patient with the infection, as they may be immuno-comprimised such as in the case of leukaemia. As the author has demonstrated, infection control is an essential part of preventing the spread of infection, of antibiotic resistance and of the formation of new strains of infection. According to Rizzo (1999), HAI’s result in death in 1% of cases. Infection control techniques will now be discussed to highlight how the spread of infection is minimized.
The author himself spent several weeks on a male surgical ward in the Mercy Hospital, Cork and observed for himself infection control methods and how they are implemented in practice. The major and most common method of infection control was that of hand washing. Although this is such a simple, quick practice there is poor compliance on the wards by RGN’s and especially Physicians. The author will discuss the rationale and effectiveness of hand washing.
Hands are an ideal breeding ground for all sorts of bacteria as they are warm and moist. “The microbial flora of the skin consists of transient and resident microorganisms; resident microorganisms survive and multiply on the skin and can be repeatedly cultured, while transient microbial flora represent recent contaminants that can survive only a limited period of time.” (Centres for Disease Control, 1985). In the Centres for Disease Control’s (CDC) Guideline for Hand-washing and Hospital Environment Control (1985) p.6, they describe hand washing as “vigorous, brief rubbing together of all surfaces of lathered hands, followed by rinsing under a stream of water”. Plain soaps are effective in removing transient microbial flora while antimicrobial hand washes can be used to remove resident microorganisms. In the ward the author worked they used ‘hibiscrub’ which was a Chlorhexidine based antimicrobial and is also used in surgery so is extremely effective in cleaning hands. Chlorhexidine is effective against a broad spectrum of pathogens such as HIV, herpes simplex, influenza and gram positive and negative bacteria (APIC, 1995).
There are no strict indications for hand washing but common sense generally prevails. On the wards, the author observed hand washing after coming on and off duty, before and after breaks, before and after completing any invasive procedure, dealing with immuno-compromised patients, after being in contact with any body fluids and before and after toilet. It was not necessary to wash hands while doing routine tasks such as blood pressures, temperature, and pulse although if the patient was query MRSA then hand washing and barrier protection such as gloves and gown would be necessary.
The CDC recommends washing hands for 15 seconds, however on the wards the author washed his hands as per hospital policy that was displayed over the sink. Although hospital policy within the Mercy Hospital permits the wearing of a wedding ring this is not ideal nursing practice as according to the Association for Professionals in Infection Control (APIC), (1995), total bacterial counts are higher when rings are worn and can make donning gloves more difficult and may cause gloves to tear more readily. However, ritual practice often tends to go against infection control guidelines. The author will now examine urinary tract infections (UTI) that are the most common of all HAI’s.
UTI’s arise where there is an infection of the urinary tract. They tend to be more common amongst women as they have shorter urethras. In the CDC’s
Guideline for Prevention of Catheter-associated Urinary Tract Infections they state that the rate of infection from UTI’s is more than 40% and 66%-86% of these infections are as a direct result of catheterization. UTI’s are caused by a variety of pathogens, including E-coli, Proteus and Pseudomonas to name a few.
Catheterisation is indicated in several circumstances; to re-establish the flow of urine in urinary retention, incontinence, to empty the bladder preoperatively, to allow monitoring of fluid output and to facilitate bladder irrigation (Jamieson, McCall, Blythe and Whyte, 1999). The potential entry points for infection on a catheter are at the drainage outlet, connection to drainage bag and reflux from bag to tubing, sample port, junction between catheter and connection tubing and around the urethral opening (Cassidy, Nurse2Nurse.ie). To minimize infection there are a number of steps that can be taken.
Firstly the nurse or doctor must ask themselves is cathetherisation necessary? If it is required then the correct type of catheter should be utilized. For example, a condom style catheter can be used for a male patient as this decreases the risk of infection as no tube is placed up the urethra. In the female patient closed drainage catheter can be used as this has been shown to reduce infection from 100% to 25% (CDC, 2000). Intermittent catheterization may be used as this has an infection rate of between 1%-5% (CDC, 2000). During insertion of catheter strict aseptic technique should be used by washing hands, wearing sterile gloves and correct insertion technique. The patient should be educated on catheter care and should be told not to allow the catheter tube to kink.
The drainage outlet (if open drainage system is used) should only be opened when necessary, as this will introduce microorganisms and that when bag is being emptied it should not touch off anything. If open drainage system was used, the author wiped the end of the catheter with an alcohol wipe to prevent infection. The preferred method of sampling urine is from the sampling port rather than from the drainage outlet. Daily cleansing of the catheter entry point to the urethra will reduce risk of UTI. Needless to say brief periods of catheterization are preferred to indwelling catheters. Unfortunately, catheterization cannot be avoided and either can some UTI’s but with correct nursing practice the rate of UTI’s can be reduced.
Since 1985, as a direct result of the AIDS epidemic, Universal Precautions (UP) were introduced by the CDC. As more and more cases of HIV/AIDS were diagnosed the CDC felt that there might be a substantial amount of undiagnosed cases. The CDC implemented the UP’s which were, as the name suggests, universally applied as anyone admitted into hospital as they potentially had HIV/AIDS or any other blood borne infection.
The use of traditional barriers, gloves and gowns continued but was updated with the use of masks and eye coverings to protect the mucous membranes. Individual resuscitation devices were also indicated. UP’s were applied to blood and body fluids such as semen, vaginal secretions, amniotic, cerebrospinal, pericardial and synovial fluids. The risk of transmission from faeces, nasal secretions, sputum, sweat or tears was dismissed unless they were visibly contaminated with blood (CDC, 1997). The author observed the use of UP’s as there was an outbreak of the SSRV (small structured round virus).
An isolation room was set up for anyone who was query SSRV infected as the virus was transmitted through vomitus and faeces (Southern Health Board, 2002). Healthcare workers and visitors entering the room had to wear gloves, gowns and masks, as the SSRV was potentially air borne. Visiting restrictions were implemented to avoid the virus entering or leaving the hospital. Student nurses were not allowed into the isolation room as it was considered that they would be in contact with a lot of people in crowded areas such as pubs and nightclubs. All elective admissions were also cancelled (Nelly Bamberry, 2002). The plan of action that the infection control team implemented was successful and resulted in the eradication of the virus from the hospital.
So in conclusion, it has been demonstrated that infection control is a fundamental element of nursing practice. Nurses have a crucial role in preventing transmission of viruses, bacteria and fungi by simply washing their hands regularly. As the author has confirmed, hand washing is the most effective method in infection control. Universal Precautions avoid the risk of blood borne and air borne pathogens being transmitted to healthcare personnel and to the hospital population preventing a local epidemic which can shut down wards, as was the case of the SSRV. The preventability of UTI’s is as simple as reviewing a patient’s suitability and using correct aseptic techniques. Infection control is not rocket science but the question must be asked why do rates of infection reach 10% in this country?
Cassidy, M. “Infection Control: Catheter Care and the Prevention of UTI’s”. http://www.nurse2nurse.ie (March 29th 2002)
Centres for Disease Control (1985). Guideline for Handwashing and Hospital Environment Control, 1985 Atlanta: US Dept. of Health and Human Services
Centres for Disease Control (1997). “Evolution of Isolation Practices”. http://www.cdc.gov Hospital Infection Control Practices Advisory Committee (March 28th 2002)
Exner, M., Hartemann, P. and Kistemann, T. (2001). American Journal of Infection Control: Hygiene and Health-The need for a holistic approach Vol. 29(4) Washington: Association for Professionals in Infection Control and Epidemology, Inc.
Jamieson, M., McCall, M., Blythe, R. and Whyte, A. (1999). Clinical Nursing Practices 3rd ed. London: Harcourt Publishers Ltd.
Larson, E. (1995). APIC Guideline for Hand Washing and Hand Antisepsis in Health-Care Settings Washington: Association for Professionals in Infection Control and Epidemiology, Inc.
Rizzo, T. (1999). “Hospital Acquired Infections”. http://www.galeencyclopediaofmedicine.com Hospital-acquired Infections
(March 28th 2002)
Rogers, T. “Hospital Acquired Infections: Beating the Bugs”. http://www.hospitalmanagement.net Management Informer (March 29th 2002).
Wilson, J. (1995) Infection Control in Clinical Practice London: Baillière Tindall
Wong, E.S. “Guideline for Prevention of Catheter-associated Urinary Tract Infections”. http://www.cdc.gov Issues in Healthcare Settings (March 28th 2002).
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