Healthcare associated infections
February 2006
Strategies for improvement: role of the healthcare professional
Reducing reservoirs of infection
The risks of healthcare associated infection are greatly increased by extensive movement of patients within the hospital, by very high bed occupancy and by an absence of suitable facilities to isolate infected patients. For a person to become infected with an HCAI there has to be a source or reservoir of the micro-organism that can cause the infection and a vector or means of transmission. Reducing reservoirs of infection is particularly important and encompasses healthcare building design and procurement, high standards of cleanliness, engineering standards (eg ventilation), decontamination of surgical instruments, and organisational management. For example, to facilitate adherence to hand hygiene protocols, it is vital that there is sufficient access to sinks and basins close to each patient.
The spread of HCAIs is associated with high bed occupancy rates and movement of patients. The increased throughput of patients to meet performance targets has resulted in considerable pressure towards higher bed occupancy, which is not consistent with good infection control and bed management practices. In England, the average daily bed occupancy of general and acute beds has risen from 80.8 per cent in 1996-97 to 85.8 per cent in 2004-05. [Go to note 44] In 2004, 71 per cent of NHS trusts were operating with bed occupancy rates above the 82 per cent target set by the DH. [Go to note 2] Analysis of performance indicators by the NAO found that lower bed occupancy rates were associated with lower rates of MRSA infection in 2002-03. [Go to note 2]
A large body of clinical evidence derived from case reports and outbreak investigations links poor environmental hygiene with the transmission of micro-organisms causing HCAIs. [Go to note 21] A review of international literature highlights a growing recognition of the relationship between the effective cleaning of hospitals and the spread of infection. [Go to note 2] Good hygiene standards in healthcare environments are an integral and important component of a strategy for preventing HCAIs. Hospital environmental hygiene encompasses a wide range of routine activities including cleaning, decontamination, laundry and housekeeping, safe collection and disposal of general and clinical waste, and good kitchen and food hygiene. Recently, attention has focused on falling standards in hospital cleanliness and concern over the introduction of compulsory comprehensive tendering of cleaning contracts, the reduction in the number of cleaners in the healthcare environment and the rapid turnover of cleaning personnel over time. According to the public service union UNISON, the number of cleaners in the NHS has fallen over the last 20 years from 100,000 to a low of 55,000 in 2003-04. [Go to note 45] Cleaning staff endure low pay, poor conditions, inadequate cleaning equipment, an intensification of work and a decline in job satisfaction that in turn leads to a high turnover of cleaning staff. [Go to note 45] Since 2000, recognition of concerns over cleaning standards has been translated into a number of initiatives including the publication of national standards of cleanliness, an NHS Healthcare Cleaning Manual, infection control guidelines on the planning and design of healthcare facilities, and annual inspections of hospitals by Patient Environment Action Teams (PEATs).
It is vital that healthcare managers, infection control teams, clinical teams and non-clinical staff work together to ensure that infection control considerations are an integral part of healthcare environmental cleanliness, surgical instrument decontamination and bed management policies. Healthcare professionals have responsibilities to ensure that:
- the hospital environment is visibly clean, free from dust and soilage, and acceptable to patients, their visitors and staff
- any equipment used for more than one patient (eg commode, bath hoist) is cleaned following each and every episode of use
- statutory requirements are met in relation to the safe disposal of clinical waste, laundry arrangements for used and infected linen, food hygiene and pest control.
Further information
- Action areas and guidelines on reducing reservoirs of infection can be found in Winning ways: working together to reduce healthcare associated infection in England (Department of Health, 2003).
- NHS Estates has produced a number of guidance documents including National standards of cleanliness for the NHS (NHS Estates, 2001), Housekeeping: a first guide to new, modern and dependable ward housekeeping services in the NHS (NHS Estates, 2001), A guide to decontamination of reusable surgical instruments (NHS Estates, 2003), Revised guidance on the contracting for cleaning (NHS Estates, 2004) and The NHS healthcare cleaning manual (NHS Estates, 2004).
- Details of the action being taken to improve hospital cleanliness are outlined in the DH publications Towards cleaner hospitals and lower rates of infection – a summary of action (Department of Health, 2004) and A matron’s charter: an action plan for cleaner hospitals (Department of Health 2004).
- Recommendations from the National Audit Office (NAO) on the strategic management of HCAIs can be found in The management and control of hospital acquired infection in acute NHS trusts in England (NAO, 2000) and Improving patient care by reducing the risk of hospital acquired infection: a progress report (NAO, 2004).
- Guidance developed by the HAI Task Force of the Scottish Executive Health Department on the specifications for cleaning services can be found in NHSScotland national cleaning services specification (SEHD, 2004).
- Further information on the PEATs can be found here at http://patientexperience.nhsestates.gov.uk/clean_hospitals/ch_content/home/home.asp