Healthcare associated infections
February 2006
Strategies for improvement: role of the healthcare professional
High standards of hygiene in clinical practice
Hand hygiene
Attention to simple preventive strategies can significantly reduce disease transmission rates. In order to prevent the spread of infection from one patient to another or from the environment or healthcare staff to a patient, all healthcare professionals are duty bound to comply with hand washing and other hygienic practice protocols. There is considerable evidence that patient contact results in contamination of healthcare professionals’ hands by pathogens that cause HCAIs, including antimicrobial-resistant microbes.[Go to notes 21, 22] Staff not wearing gloves and dressing wounds infected with MRSA have an 80 per cent chance of carrying the organism on their hands for up to three hours. [Go to note 23] Compliance with hand hygiene protocols, including the appropriate use of gloves (see section on personal protective equipment), limits the spread of infection by removing these pathogens. [Go to note 23] A systematic review of the evidence has not revealed any compelling evidence to favour the general use of antimicrobial hand-washing agents over soap, or one antimicrobial agent over another. [Go to note 21]
It is vital that healthcare professionals consider the need to remove transient hand flora and use an appropriate preparation to decontaminate their hands. Effective handwashing with a non-medicated liquid soap generally will remove transient micro-organisms and provide adequate hand decontamination for everyday clinical practice. Due to their residual effect, antimicrobial preparations should be used for invasive procedures and in outbreak situations because they provide hand antisepsis. Although alcohol does not remove dirt and organic material, alcohol-based handrubs are a highly acceptable alternative to handwashing when the hands are not grossly soiled and are recommended for routine use. There is, however, no evidence that alcohol-based handrubs are effective in killing C.difficile spores on hands, but they can be removed with soap and water. [Go to note 24] Healthcare professionals must wash their hands with non-medicated liquid soap and warm water in addition to using alcohol hand gels where C.difficile infection is confirmed or suspected. [Go to note 24]
In maintaining high standards of hand hygiene, the use of elbow-operated or no-touch taps should be used to limit the spread of HCAIs by preventing recontamination of the hands after washing. [Go to note 25] Effective hand hygiene is paramount and the single most important intervention in infection control. The DH recommends that each clinical team demonstrate consistently high levels of compliance with hand washing and hand disinfection protocols (see box 3). [Go to note 1] Low rates of compliance with hand hygiene protocols have been reported and identifying mechanisms to ensure compliance by health professionals remains a perplexing problem. Many factors are involved, including a lack of awareness of the risk of cross-transmission of pathogens, personal and organisational attitudes towards hand-washing, and various logistical barriers. [Go to notes 19, 26, 27] The issue is no longer whether hand hygiene is effective, but how to produce a sustained improvement in compliance. Feedback, behavioural and educational interventions might achieve this goal in conjunction with the influence of senior staff who should act as role models. The National Patient Safety Agency (NPSA) reports that increased compliance with hand washing from healthcare professionals could result in reductions in infection rates ranging from 10 per cent to 50 per cent, [Go to note 28] while a study using feedback and encouraging the use of alcohol-based handrubs reported improved levels of compliance by 20 per cent. [Go to note 29]
Box 3: Guidelines on the standard principles of hand hygiene
- Hands must be decontaminated immediately before each and every episode of direct patient contact/care and after any activity or contact that could potentially result in hands becoming contaminated.
- Hands that are visibly soiled or potentially grossly contaminated with dirt or organic material must be washed with liquid soap and water.
- Apply an alcohol-based hand rub or wash hands with liquid soap if hands are visibly soiled, between caring for different patients and between different care activities for the same patient.
- Remove all wrist and hand jewellery before regular hand decontamination. Cuts and abrasions must be covered with waterproof dressings. Fingernails should be kept short, clean and free from nail polish.
- An effective hand-washing technique involves three stages: preparation, washing and rinsing, and drying. Preparation requires wetting hands under tepid running water before applying liquid soap or an antimicrobial preparation. The handwash solution must come into contact with all of the surfaces of the hand. The hands must be rubbed together vigorously for a minimum of 10 to 15 seconds, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers. Hands should be rinsed thoroughly before drying with good quality paper towels.
- When decontaminating hands using an alcohol handrub, hands should be free from dirt and organic material. The handrub solution must come into contact with all surfaces of the hand. The hands must be rubbed together vigorously, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers, until the solution has evaporated and the hands are dry.
- An emollient hand cream should be applied regularly to protect skin from the drying effects of regular hand decontamination. If a particular soap, antimicrobial hand wash or alcohol product causes skin irritation an occupational health team should be consulted.
Source: The epic project – developing national evidence-based guidelines for preventing healthcare associated infections (DH, 2001)
The NPSA has introduced a hand-washing campaign aimed at improving compliance with hand hygiene in healthcare. The ‘cleanyourhands’28 campaign aims to improve patient safety by reducing the risk of infection through a toolkit of measures including:
- placing disinfectant handrubs near to where staff have patient contact, enabling staff to clean their hands at the right time and in a quick and effective manner
- displaying posters and promotional materials where they will influence staff and patients. Posters are changed monthly and some of the posters display photographs of staff champions who give their support to the campaign
- involving patients in improving hand hygiene by providing information leaflets, posters and stickers.
Safe use and disposal of sharps
Sharps such as needles, scalpels, stitch cutters and glass ampoules are a significant source of cross infection when handled inappropriately, with the main hazards of sharps injury including hepatitis B, hepatitis C and HIV. In the UK, 16 per cent of occupational injuries in hospitals are attributable to sharps, [Go to note 21] while 7 per cent of the occupational exposure to bloodborne viruses between 1997-2001 occurred in healthcare personnel in primary and community care. Go to note 22 Safe disposal of sharps at the point of use is vital to reduce the risk of injury, exposure to bloodborne viruses and cross infection (see box 4). Some procedures carry a higher risk of injury including intra-vascular cannulation, venepuncture and injection.
Box 4: Guidelines on the safe disposal of sharps
- Sharps must not be passed directly from hand to hand and handling should be kept to a minimum.
- Needles must not be recapped, bent or broken prior to use or disposal.
- Needles and syringes must not be disassembled by hand prior to disposal.
- Used sharps must be discarded into a sharps container (conforming to UN3291 and BS 7320 standards) at the point of use. These must not be filled above the mark indicating that they are full.
- Containers in public areas must not be placed on the floor and should be located in a safe position.
- Consider the use of needle stick-prevention devices where proper risk assessment indicates that they are likely to reduce the risk of injury.
- Conduct a rigorous evaluation of needle stick-prevention devices to determine their effectiveness, acceptability to practitioners, impact on patient care, and cost benefit prior to widespread introduction.
Source: The epic project – developing national evidence-based guidelines for preventing healthcare associated infections (DH, 2001)
The Safer Needles Network has set up a new initiative ‘Safer Needles Now!’ [Go to note 30] to support the full implementation of the 2005 guidance issued by NHS Employers on the minimisation of needlestick injuries in the NHS. [Go to note 31] The Safer Needles Network aims to reduce the number of needlestick injuries by promoting preventive measures and safer systems of working including the provision of safer needles, improved training and education, use of standard (universal) precautions, and better monitoring of the incidence of needlestick injuries and safer disposal of sharps. Further information on the Safer Needles Network can be found on its website here at www.needlestickforum.net.
Personal protective equipment
Personal protective equipment is used to protect both healthcare staff and patients from the risks of cross-infection and includes items such as gloves, aprons, masks, goggles and/or visors. As with hand hygiene, patient contact results in contamination of protective equipment by pathogens that may lead to cross-infection if hygiene protocols are not adhered to (see box 5). Personal protective equipment of an approved standard should be used in every appropriate clinical care situation and properly disposed of after use. As there is a paucity of evidence that they are effective in preventing HCAIs, the unnecessary wearing of aprons, gowns and masks in everyday clinical settings is not recommended. [Go to notes 21, 22, 23]
Box 5: Guidelines on the use of personal protective equipment
- Select protective equipment on the basis of an assessment of the risk of transmission of micro-organisms to the patient, and the risk of contamination of healthcare practitioners’ clothing and skin by patients’ blood, body fluids, secretions, and excretions.
- Gloves must be worn for invasive procedures, contact with sterile sites, and non-intact skin, mucous membranes, and all activities that have been assessed as carrying a risk of exposure to blood, body fluids, secretions and excretions; and when handling sharp or contaminated instruments.
- Gloves should be worn as single use items. Put gloves on immediately before an episode of patient contact or treatment and remove them as soon as the activity is completed. Change gloves between caring for different patients, or between different care/treatment activities for the same patient.
- Gloves must be disposed of as clinical waste and hands should be decontaminated following the removal of gloves.
- Gloves conforming to European Community (CE) standards and of an acceptable quality must be available in all clinical areas.
- Alternatives to natural rubber latex (NRL) gloves must be available for use by practitioners and patients with NRL sensitivity.
- Powdered and polythene gloves should not be used in healthcare activities.
- Disposable plastic aprons should be worn when there is a risk that clothing or uniform may become exposed to blood, body fluids, secretions and excretions, with the exception of sweat.
- Full body, fluid repellent gowns should be worn where there is a risk of extensive splashing of blood, body fluids, secretions and excretions, with the exception of sweat, on to the skin of healthcare practitioners.
- Plastic aprons should be worn as single use items for one procedure or episode of patient care and then discarded and disposed of as clinical waste.
- Face masks and eye protection should be worn where there is a risk of blood, body fluids, secretions and excretions splashing into the face and eyes.
- Respiratory protective equipment should be used when clinically indicated.
Source: The epic project – developing national evidence-based guidelines for preventing healthcare associated infections (DH, 2001)
Dress code in the clinical setting
Research has shown that pathogenic micro-organisms including S.aureus, C.difficile and GRE are frequently carried on clothes, representing a potential source of cross infection in the clinical setting. [Go to notes 33, 34, 35, 36] Maximum contamination occurs in areas of greatest hand contact (eg pockets and cuffs) thereby resulting in re-contamination following hand washing. [Go to note 37] Certain clothes such as ties are rarely laundered but worn daily, commonly outside the healthcare environment. Ties perform no beneficial function in patient care and have been shown to be colonised by pathogens. [Go to note 36] They are regularly handled by the owner and come into contact with numerous objects. Ties have the potential, therefore, to act as a vector for the transmission of HCAIs. Studies have shown that closely woven cotton is suitable for wearing in clinical practice as it has a low bacterial transfer rate that minimises cross-infection and is durable enough to be washed at high temperatures. [Go to notes 38, 39]
Healthcare professionals have a responsibility to minimise the spread of HCAIs by wearing appropriate clothes in the clinical setting. As outlined above, aprons or gowns should only be worn when there is a risk that clothing or uniform may become exposed to blood, bodily fluids, secretions and excretions. Under all other circumstances, the Board of Science suggests that healthcare professionals should:
- wear clothes that minimise the spread of infection (eg those made from closely woven cotton) and that are laundered frequently
- refrain from wearing functionless clothing items such as ties
- where possible, change clothes when leaving the clinical setting and avoid unnecessary journeys outside the healthcare environment
- travel directly between locations when working in the primary or community healthcare setting
- ensure that clothes are thoroughly laundered and remain separate from other clothing items
- presume some degree of contamination, even on clothing which is not visibly soiled.
To reduce the spread of HCAIs, healthcare professionals must ensure that they demonstrate consistently high levels of compliance with the standards of hygiene and aseptic technique set out above. To improve patient outcomes and reduce healthcare costs, it is essential that this is achieved across the healthcare setting.
Further information
- Further information on the NPSA ‘cleanyourhands’ campaign can be found on the NPSA website here at www.npsa.nhs.uk/cleanyourhands
- NHS Education for Scotland has launched a ‘Cleanliness Champions’ initiative to promote the prevention and control of HCAIs in NHSScotland. This provides a major educational resource designed to equip staff with the skills and knowledge they need to ensure good practice in preventing HCAIs. Further information can be found on its website here at www.space4.me.uk/hai
- More detailed information can be found in Winning ways: working together to reduce healthcare associated infection in England (Department of Health, 2003), Infection control: prevention of healthcare-associated infection in primary and community care (NICE, 2003) and The epic project – developing national evidence-based guidelines for preventing healthcare associated infections (Department of Health, 2001).