Hospital Acquired Infection (HAI).
Hospital Acquired Infection (HAI), or as it is sometimes referred to as Nosocomial infection; is an infection occurring in patients after admission to hospital that was neither present nor incubating at the time of admission. This student will discuss the role of the nurse in preventing hospital acquired infection while on clinical placement, define HAI, and look at the causes of HAI and how it is spread. This student will also show in order to minimise these risks, systems must in place, understood and implemented by all concerned.
Plowman (1997) claimed that, 6,000 deaths per year are caused by HAI, with significant financial costs for the NHS and personal costs for patients' families. Other factors include separation from family, anxiety, sense of isolation and stigma. Glynn et al (1997) investigated the effects on the rate of infection of certain known risk factors such as age, underlying disease, and length of hospital and the use of invasive procedures. He found that it was in the use of invasive devices, which increased the infection rate from one HAI per 100 patient's episodes to 7.2, and goes on to state "this is important for nurses because they manage invasive devices, such as urinary catheters, intravascular cannulae, epidural cannulae, nasogastric tubes, and peg tubes, which often identify the early signs of infection" (McCullach, 1998).
The (NMC 2002) states "nurses have a duty to safeguard the wellbeing of patients and have a due regard for the environment of care" Code of professional conduct. Nurses must be sure that they do not contribute to infection risks and must take care to prevent infection whenever possible. Much of this is through basic nursing care such as ensuring the patient is clean and their skin is intact, the mouth is healthy, promoting mobility, promoting continence, improving the patients' nutritional and hydration status and promoting wound care.
This can only be done if Universal precautions are adhere to, which not only protects heath care staff from infections, but also prevents transmission of organisms between patients (See routes of transmission in appendix 1). The most important and the least expensive are using good hand washing techniques at the appropriate times. Hand washing is universally considered to be the most basic as well as the most vital infection control measure, as well as the most neglected of practice. Larson and Killien, 1982 comments on the reasons for non-compliance which included "too busy", "not at risk of acquiring infections from patients ", hand washing agent detrimental to skin", "wearing gloves", and not practiced by peers". (Wolinksy et al (1960) cited by Plowman (1997), confirmed the role of unwashed hands in the transmission of Staphylococcus aureus between newborns in a nursery; other studies have shown the contamination of hands by Gram-negative organisms and its relationship to Nosocomial infections (Knittle et al, 1975; Guenther et al, 1987). "The hand of the carer, so frequently used to comfort and treat patients becomes a lethal weapon in transferring pathogens to susceptible patients" (Horton, 1995 p, 936). Thus effective hand washing can reduce the incidence of HAI in all settings. (See appendix 2 for good hand washing technique).
Nurses must be sure that they do not contribute to infection risks and must take every step to prevent infection when ever possible. They must have a sound knowledge of using aseptic technique for wound care and invasive procedures; there must also be a range of sterile equipment for invasive devices; sterile dressings for wounds and IV sites. Replaced when contaminated and decontamination of the patients' skin before invasive devices are inserted or dressed. Many other elements of nursing care are also concerned with the prevention of infection. Once again universal precaution comes into play, which requires staff ...
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Nurses must be sure that they do not contribute to infection risks and must take every step to prevent infection when ever possible. They must have a sound knowledge of using aseptic technique for wound care and invasive procedures; there must also be a range of sterile equipment for invasive devices; sterile dressings for wounds and IV sites. Replaced when contaminated and decontamination of the patients' skin before invasive devices are inserted or dressed. Many other elements of nursing care are also concerned with the prevention of infection. Once again universal precaution comes into play, which requires staff to protect themselves from contact with any potentially infectious substances they encounter. For example, wearing gloves and an apron, while handling any body fluids, diarrhoea, or when in contact with a patient who has methicillin staphylococcus auraus. Protective clothing, if not used correctly, can itself help to transmit infection. Nurse's uniforms usually provide an indication of one's profession which inevitably become contaminated with micro-organisms in the course of the day. In 1998 the Nursing standard reported the findings of a study into the effectiveness of plastic aprons in preventing contamination of nurses' uniforms. The author decided to examine levels of contamination on nurses' uniforms, and the role if any, that plastic aprons might in the reduction of these levels of contamination by acting as a barrier between the uniform and the patient (Callaghan 1998). She also made some recommendations which where based on her research findings that plastic aprons do become contaminated, and may be therefore give a false sense of security; clean uniforms are not clean, and may, therefore contribute to Nosocomial infections; existing laundering, handling, and storage practices are contributing to uniform contamination. See other research Lidwell and Towers (1994) and (Hambraeus 1973, Ransjo 1979, Wong et al 1991). The author also mentioned that nurses "awareness" of the various means of transmission of Nosocomial infection was generally poor, and the standards of hand washing hygiene was very low. She goes on to comment that they are not aware of the potential relationship between the carriage of bacteria on uniforms or aprons and Nosocomial infections, and appear to have difficulty in relating theory to clinical practice (Callaghan, 1998). Buchonan, confirms this, where studies identified the knowledge deficit of nursing staff with the regard to specific infection control procedures. The two main areas of concern were vene-puncture practices and hand hygiene and skin care (Buchonan 2001).
Nursing Staff must also be ware that they may be libel to prosecution if they do not adhere to the policies which meet the requirements of current regulations on the safe disposal of waste those hospitals and trusts have implanted. Waste disposal is regulated by a number of regulations and Acts of Parliament, including the Environmental Protection Act of 1990 (McCulloch 1998). The control of substances hazardous to health, (COSHH) regulations, which came into force in 1989, covers all potentially hazardous substances (Dimond 1995), and nurses have a responsibility, along with other employees to dispose of waste safely. (See COSHH regulations in appendix 3). Contaminated sharps, also carries a high risk of causing infection with Hepatitis B and C, human immunodeficiency virus, and other infections. For this reason sharps must be always be disposed of immediately, by the user into an approved sharps container which complies with BS7320 AND UN391. In a critical review of literature, Hanrahan and Reutter 1997) indicated that sharps injuries are the most common causes of blood-borne cross infection in health care professionals.(Bailie 2001). (See sharps policy in appendix 4). Brewer states that the key to reducing sharps injuries has to be the use of safer practice by everyone; however, the risk could be further reduced by the mandatory availability of safety devices (Brewer 2003). This would save nursing staff the trauma for waiting for test results showing whether they have contacted a disease. This also goes for clinical waste which can carry potentially infectious substances such as blood, faecal matter and human tissue. (See waste disposable policy appendix 4). Current health and safety legislation already requires employers to carry out a risk assessment where people are exposed to hazardous substances, and to prevent or control the risk (Brewer 2003). This student has just touched on this subject briefly; policies are at the back of the appendix, even though this is an important subject.
In health care there are infection risks for both patients and staff, and in order to minimise these risks infection control systems such as barrier nursing must be put in place and implemented by everyone concerned. Nurses have an important role because they are the ones that will carry out the direct care to be delivered to the patient. Nurses have a professional responsibility under the (NMC 2002), code of professional conduct to give patients the highest possible standards of care, this will include that will not be compromised by infections especially, in older people. Staph aureus is the most common cause of pyogenic (pus-forming) infection; transmission is through contact, mainly via the hands (Gould and Chamberlain 1995). A high proportion of older people in hospital carry Staph aureus and significant numbers become clinically infected (Parnaby et al 1995, cited by Gould 2001).
Staph aureus first became a significant cause of infection in hospitals in the late 1940's and has been responsible for many outbreaks leading to ward closures, disrupted services and considerable morbidity and mortality (Gould and Chamberlain 1995). Penicillin-resistant strain has evolved and today a very high proportion of staphylococcal infections remain resistant to this antibiotic. However, careless prescribing and lack of attention to infection control policies and procedures soon promoted the emergence of methicillin-resistant Staph aureus (MRSA), (Gould 2001). The difference between MRSA and MSSA is that MRSA is much more of a problem to treat because it is resistant to nearly all antibiotics in common use and is difficult to eradicate (Keane et al 1991, cited by Gould 2001). Patients infected with MRSA in hospital, and often those carrying it, tend to be isolated in single rooms. This has a severe impact on their well being, especially if they are elderly. They become lonely, feel stigmatised, sometimes disorientated and their mobility is restricted. Isolation is therefore not the ideal environment in which to provide care. MRSA infections are also to be avoided because they are very expensive to treat (Parnaby 1996) and are associated with poor recovery in any patient, irrespective of age (Morrison and Stolarek 2000, cited by Gould 2001).
Patients have a right to be protected from preventable infections (DoH/PHLS 1995). Patients expect a clean, safe environment and healthcare providers are legally bound to provide this. In the (NMC 2002) nurses have a duty to safeguard the well being of patients and have due regard for the environment (King 1998). Precautions which help to prevent this type of infection are generally simple and inexpensive. The likes of equipment which can be used for invasive procedures, has been identified as a source of infection, which maybe decontaminated, which reduces the numbers of micro organisms to a safe and relatively safe levels; sterilisation which causes the destruction of all living micro-organisms. Nurses are responsible for the decontamination of all equipment they use. Fleming showed nurses had a poor understanding of the principles of decontamination and would continue ritualistic practices (King 1998). Nurses need to be aware of the policies and procedures and liaise with colleagues to ensure decontamination is safe. Decontamination is applicable to all areas of clinical nursing practice because it affects patients care. Having the knowledge of the principles of decontamination enables nurses to meet patient's expectations, legislation and professional responsibilities (King 1998).
The NMC code of professional conduct states" we have a duty of care to your patient and clients, who are entitled to receive safe and competent care", it also states that "we are accountable for ensuring that you promote and protect the interests and dignity of patients" (NMC 2002). Unless these latest Statistics change, which states 9 percent of patients admitted to hospitals acquire an HAI, resulting in 100,000 patients and 5,000 deaths annually (department of health 2001; Taylor et al 2000, cited by Pellow 2003). The author also refers that infections cost the NHS about £1bn a year, but 15-30 percent of them are preventable (Taylor et al 2000, cited by Pellow 2003). HAI is preventable and the lines of the code of professional conduct which I have just quoted must stand out in the mind of the nurse when doing any invasive procedure, or any procedure at all with a patient. That they adhere to the guide lines at ward level or in clinical practice that have been put in place to protect patients and staff. Applying the principles of infection control should be an integral part of patient care, rather than an add-on activity. Such precautions need not be expensive, and in applying these precautions the role of the nurse will be reducing the cost of infection as well reducing the suffering and inconvenience for the patient and their family. The code of professional conduct for the role of the nurse is being adhered to and maybe HAI can be eradicated within the hospital setting.
