The aim of this essay is to ascertain what hospital acquired infection entails, the detrimental effects it causes and to highlight the active role nurses can take in the prevention of this type of infection.
Hospital acquired (or nosocomial) infection is: ‘one that originated in the hospital environment; i.e. was not present or incubating on admission and which appeared 48h or more after admission’ (Azzam et al. 2001). Infection is caused by pathogenic organisms which invade the hosts immunological defence mechanism; this can be through wounds left by invasive procedures whereby the host’s natural body defences have been bypassed.
It is the nurses’ responsibility to know the factors that can increase patients’ susceptibility to infection (i.e. age, underlying disease, drug therapy, or if they are undergoing surgery), this enables nurses to be able to assess which patients are most at risk so that they can develop a care plan and therefore they will know what extra, if any, precautions to take and protocols to follow. Sproat and Inglis (1992) cited by Mallett et al. (2000, p, 40) suggest that the assessment of a patient’s risk of infection to others, in nursing care plans, before the commencement of any procedure is a fundamental principle of infection control. The Bowell-Webster risk assessment guide for identifying patients at risk of infection (1990) cited in Alexander et al. (2000, p, 595) can be used to decide which protocols to follow.
Steed (1999) states that not all nosocomial infections relate directly to the patients’ underlying disease but that many are caused by the actions of healthcare workers. Therefore great care must be taken by healthcare workers, especially nurses, who are directly involved in the care of patients. In this essay I am going to discuss the procedures followed by nurses to eradicate, if at all possible, cross infection.
There are two ways of acquiring an infection in hospital: Cross (or exogenous) infection is when the infection has been spread from other people, either patients, visitors, hospital staff or even food and the surrounding environment; whereas self (or endogenous) infection is when the infection is caused by microbes carried by the patient on their body, usually from septic areas.
Compliance with universal precautions should be rigorous as to avoid spread of infection. For example, failure to change gloves between interactions with different patients can lead to the spread of disease (Piro et al. 2001). Ayliffe et al. (1992) contended that the regularity of infection in hospitals, caused by multiple types of bacteria, could increase to epidemic amounts if aseptic and hygienic measures in the hospital collapsed.
According to the Healthcare-associated Infection surveillance Centre (2000) approximately 30% of nosocomial infections are due to urinary tract infections, another 30% are due to bloodstream infections, 20% due to surgical site infections and 20% due to pneumonia. These infections tend to occur during invasive procedures or when the body is very susceptible due to illness.
The NHSSB infection control manual (1996) states that the inter-hospital transportation of infected patients is the main means of spreading infection and in extreme circumstances of spreading an epidemic strain. The spread of infection in hospitals between patients, or between patients and staff, cannot be entirely eradicated but it can be reduced, especially by nurses using methods I will discuss later.
Evidence supporting the importance of infection control can be seen in a study by Worsley (1993) cited in Mallett et al. (2000, p,47) who found that in 1991 out of 175 patients who had developed nosocomial Clostridium difficile diarrhoea, 17 died and the organism was a contributing factor in a further 43 deaths. The cost of managing this outbreak was at least £75000. Also in a study conducted by Plowman et al. (2001) they concluded that approximately 10% of patients will get infected during a stay in hospital and that this can lead to costs of up to one billion pounds per year in the U.K alone. These pieces of evidence and others (Chaudhuri, 1993) demonstrate the prevalence of nosocomial infection, the dire effects of it and also the extreme financial losses it incurs.
Hospital acquired infection has many different consequences, it can: Delay or prevent recovery; Cause increased pain, discomfort and anxiety; Increase the patients stay in hospital which has financial losses due to drugs bills and extra staffing costs; Cause psychological stress as a result of long periods spent in isolation (Knowles, 1993, cited by Mallett et al. 2000, p, 47); it is demoralising for both staff, patients and their families which can lead to decreased public confidence in hospitals and doctors. Mc Millan Jackson (1999) insists that infection prevention and control is essential in healthcare settings to reduce the risks of morbidity and mortality in patients and healthcare workers.
Nurses share responsibility with other healthcare professionals to reduce the risk of infection in patients. Patients have a right to be protected from preventable infection and nurses have a duty to safeguard the well-being of their patients (King, 1998, cited by Mallett et al. 2000, p, 39).
The Nursing and Midwifery Council (NMC) Code of Professional Conduct (2002) outlines the nurses’ professional code, and also has implications for the role of the nurse in infection control, requiring them to protect patients and fellow healthcare workers from risks such as cross-infection. Clause 1 of the code informs nurses that, ‘You have a duty of care to your patients and clients, who are entitled to receive safe and competent care’. To fulfil these criteria, nurses must ensure that care is taken to ensure that dangerous or potentially harmful substances (e.g. drugs) or articles are handled and stored safely and that all equipment and appliances are properly maintained.
Nurses are role models to the people with whom they come into contact, whether it is patients, visitors, students, or any healthcare workers. Therefore they should insist on compliance with basic procedures and practices as part of their job. They must assume responsibility for these practices as they are also held accountable under the NMC code of conduct and so should be at the forefront of efforts to prevent and control infections.
Many infections are acquired through the patient’s own lack of knowledge of the effectiveness of simple procedure, such as hand washing, therefore the nurse has role to fulfil in providing education for patients and their families to give them a greater understanding of the importance of the need for thorough compliance of these procedures. ‘Standard precautions are designed to define a high standard of routine care that will be effective in reducing the transmission of potential pathogens between patients/ clients whilst protecting staff from pathogens carried by patients/ clients’ (NHSSB, infection control policy, 1996).
General principles of infection control which all nurses must adhere to according to the Royal College of Nursing (1995) are, to: Wash hands before and after general patient care; Cover all cuts and abrasions with impermeable dressings; Use disposable gloves and aprons where necessary; Clean up spills and body fluids immediately according to local guidelines; Use and dispose of sharps safely, do not resheath needles; Dispose of clinical waste according to local guidelines; Handle and transport specimens safely by following local guidelines; Handle soiled linen according to guidelines; Use disinfection and sterilisation procedures following guidelines.
Healthcare professionals need to have basic knowledge about the steps in the chain of infection to be able to determine how to control infection itself. These are: the causative agent; the reservoir; the portal of exit from reservoir; the mode of transmission from reservoir to susceptible host; the portal of entry into susceptible host; and the susceptible host. The main ways to interrupt the transmission of infection between humans and therefore break this chain is through the mode of transmission, this is achieved by: hand washing; aseptic technique; sterilisation and disinfection; and isolation procedures.
Overviews of epidemiological evidence (Gould, 1991, Sharir, 2001) have shown that hand washing techniques are often inadequate and infrequent, and that the quality of hand washing is more important than the quantity (Van der Broek et al. 2001). These conclude that hand medicated transmission is a major contributing factor in the current infection threats to hospital patients. According to RCN guidelines (1995) hands should be washed: before and after any duty which involves close contact with a patient; before and after aseptic technique or invasive procedures; after contact with body secretions/ excretions; after handling contaminated laundry or equipment; after removal of gloves, masks and aprons; before administration of food, drink and drugs; and at the end of a span of duty.
Precautions adopted to destroy pathogens, prevent the spread of infection and to protect patients against infection during their stay in hospital, include the use of barrier nursing and the aseptic technique. These are adopted to increase the patient’s resistance to infection, to eradicate the sources or potential sources of infection and to minimise, or if possible stop, the means of bacterial transfer to the uninfected patient.
The idea of barrier nursing is to keep an infectious patient, and materials they have been in contact with, apart from vulnerable others. This can be achieved by isolating the patient in a single room or by isolating a number of infectious patients in a purpose built ward. Another method used is to isolate patients whose immune systems are severely depressed thereby protecting them from harmful organisms. This is usually referred to as reverse barrier nursing.
Aseptic technique is the use of sterile equipment and fluids, when carrying out any invasive procedure that breaches the body’s normal anatomical defences, to prevent contamination of wounds and other vulnerable sites by pathogens in the operating theatre, the ward, and other treatment areas.
These procedures can only be effective if the healthcare professional, i.e. nurses who are in contact with the patients adhere to the general policies relating to the care of patients, especially infectious ones, such as hand washing and protection of personal clothing. It is my personal responsibility as a student nurse to ensure that I am fully immunised against common diseases, and diseases I may be in contact with in the healthcare setting, if there is a vaccine available. If I feel that I am ill and suspect that my illness may put patients at risk of infection, it is my duty to inform the necessary people and to stay off work. It is also my duty to remove any jewellery (with the exception of a wedding ring) before work, to keep my nails short and clean, and to keep my hair (if long) tied back. Recent studies have proven the importance of wearing a clean uniform each day to work, and that you should ensure that your uniform is laundered at as high a temperature as the garment allows (Perry et al. 2001).
During my clinical placement I had to adopt barrier nursing techniques due to a patient on my ward having Methicillin Resistant Staphylococcus Aureus (MRSA). I was therefore required to adhere to more thorough precautions when dealing with this particular patient. Source isolation was partially used to deal with this patient as I was working in an open mental health ward, therefore the patient could only be segregated to a certain degree. The nursing staff then needed to be aware of this patient’s movement so that we were effectively able to disinfect the areas she came into contact with as detailed in the local procedure we used.
During meal times this patient had her meal brought into the ward to her on a tray, once she was finished I had to follow the local procedure by washing my hands with chlorhexidine gluconate 4% before donning gloves, I then had to place her used tray in an alginate polythene bag (which dissolves in the dishwasher), where it would then have been brought to the kitchens to be cleaned separately and at a higher temperature from the usual dishes. Next I had to change my gloves and then disinfect the table and chair, at which the patient had been sitting, with Haz tab solution, then rinse the area with fresh water and let air dry. Finally I remove and dispose of my gloves appropriately and wash my hands, with chlorhexidine in 70% Isopropyl alcohol solution, and dry with paper towels. In this way staff and the other patients are protected from contamination.
As I have shown many hospital acquired infections can be easily prevented by the compliance of simple procedures, thereby reducing the extra costs hospital trusts and governments have had to pay, and most importantly reducing the ill effects caused to patients and their families. Not all hospital acquired infection can be prevented, but with nurses and other healthcare workers working together in the constant assessment and evaluation of all techniques utilised, so that they remain consistent and be improved if necessary, there is no reason why they cannot be severely reduced. In conclusion it is clear to see that it is the nurse who has the primary role in implementing procedures used for the control and prevention of infection, with the intension to curb its spread and thereby ensuring that all patients are able to be cared for in a safe environment, as is their right.
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