With so much pressure placed on the government about the importance of infection control from an international level and that of the media and public, a new local policy Healthier people, excellent care: A Vision for South East Coast (South East Coast NHS, 2008) aims that by 2011 there will be no avoidable cases of MRSA and less than 2,000 cases of C.Diff. It is influenced by national policies such as Our NHS, Our future: NHS next stage review- Interim report (Great Britain. Department of Health, 2007) and the Health and Social Care Bill (Great Britain. Parliament. House of Lords, 2007) which places fines on hospitals that fail to meet hygiene standards. The local Trust Policy (2008) based on infection control corresponds with certain aspects of the statute (Great Britain. Health Act 2006) as it sets out eleven duties of the local Primary Care Trust (PCT) which relates to the code of practice included within the law (Great Britain. Health Act 2006). The "Clean your hands campaign" organised by the National Patient Safety Agency (2007) is a nationally organised initiative which is delivered on a local level within hospitals and throughout the community. This initiative has impacted on the development of local policy (2007) which states that hands should be washed when visibly dirty, before and after routine tasks in the clinical area, before and after any clinical procedure, on arrival and departure from clients homes, before and after touching patients, before and after touching food, before contact with susceptible sites, after contact with blood or bodily fluid, after any cleaning procedure, after bed making, after removing gloves, after removing an apron, after using the toilet, after blowing nose, couching, sneezing and smoking. This policy will impact on the way clinical practice is carried out and ensures that the transmission of infection is minimised through hands.
The publication High quality care for all: NHS Next Stage Review final report (Great Britain. Department of Health, 2008) states that the budget for the NHS in England 1996-1997 was £33 billion it has now risen to £96 billion in 2008-2009, and HAI can place an immense burden on this budget. In 1999 a report The socio-economic burden of hospital acquired infection (Great Britain. Department of Health, 1999) stated that at any one time one in ten patients contracted a HAI. It also focuses on the financial aspect which states that an average person who contracts a HAI will on average cost £3154 extra out of the NHS budget and the average length of stay through HAI is fourteen daysAH. The estimated amount of days lost through HAI to the workplace is between five and six. This means that the burden placed on the NHS through HAI is severe and the British economy is also placed under stress through sickness days at work. As alcohol gel and hand cleansing agents are supplied on a local level and prices can vary but the WHO (2006) through a case study suggest that to initially set up a 500 bed hospital with alcohol gel at the end of each bed would cost £3000. So therefore it would be cost effective if just one patient did not contract a HAI. The National Patient Safety Agency (2007) have stated within the "Clean your hands campaign" that through effective hand-washing to reduce the possibility of patients contracting HAI will save the NHS over £140 million and save 450 lives a year.
The epidemiology of HAI varies from country to country as stated within Hawker, Begg, Blair, Reintjes and Weinberg (2005). The possibility for these differences in prevalence and incidence can be related to many factors such as geology, climate, physical surroundings, biological factors, crowding, sanitation and availability of health services. Sanitation which is a mainly economic factor is a very important variable in hand hygiene poor sanitation which can be seen in third world countries increases the risk of HAI.
There have been many cultural changes to the NHS in regards to hand-washing and infection control the publication Getting ahead of the curve: A strategy for combating infectious diseases (including other aspects of health protection) (Great Britain. Department of Health, 2002) discusses ways in which infection control can be addressed. It includes a need for greater clinical governance, standards, surveillance systems and stronger infection control policies. Another cultural change to the NHS was the implementation of A Matrons Charter: An action plan for cleaner hospitals (Great Britain. Department of Health, 2004) which saw the development of the matrons role in infection control and the generation of new matron positions across the country.
There can be many social and cultural barriers when trying to implement effective hand-washing. Among health professionals the views of hand-washing are very different as is shown by the compliance level on a world wide basis by the report WHO (2006). They also state that nurses are generally more likely to comply with hand-washing policy compared to doctors or health care assistants (HCA). This view is shared by Priest (2003) who comments upon how doctors move from one patient to another without a thought for cross-infection. As seen in this incident discussed earlier the doctors all complied with the hand cleansing policy so within this clinical area the doctors are mindful of infection control policies and the impact of HAI on patients.
Religion and religious beliefs can cause barriers to effective hand hygiene as seen within the Hindu religion as individuals are not allowed to use standard soap because it contains animal fat, this barrier can be counteracted as non-animal fat soaps can be purchased. Many religions have rules regarding the use of alcohol this causes a great many problems when the hand cleansing product of choice for most health professionals is alcohol gel. Strict Muslims are not allowed to have any physical contact with alcohol and because alcohol gel is absorbed by the skin into the body a Muslim could refuse to use it for religious reasons. Although this is possible there is currently no decisive research to arrive at a conclusion on this aspect of hand hygiene.
A social barrier to effective hand-washing is education, if people do not know the dangers of not washing their hands between patients and before and after procedures they may not comply with guidelines. Also individuals may not recognise the opportunities available for hand-washing. Through the large amount of mediated press on MRSA and C.Diff outbreaks and the campaigns that use posters in hospitals, education levels on the dangers of poor hand hygiene seems to be less of a challenge than it was ten years ago.
There are many technological factors that now influence infection control and hand hygiene. The production of alcohol gel has increased the compliance of infection control policy immensely. Before alcohol gel was readily available in the NHS the major barrier to effective hand hygiene was time. As the use of alcohol gel has been implemented time is no longer a factor in healthcare within the NHS. It only takes a couple of seconds to apply the alcohol gel and allow it to be absorbed by the skin this can be done "on the go". Which compared to effective hand washing techniques as stated by Infection control training manual (Great Britain. Department of Health, 2008) that need to take between fifteen and thirty seconds to decontaminate your hands successfully. Another benefit with the compliance level through using alcohol gel rather than other hand sanitizers such as Hibiscrub(tm) and soap and water is the lower cases of skin irritation as stated by Larson, Girard, Pessoa-Silva, Boyce, Donaldson and Pittet (2006). Therefore health professionals are more willing to sanitise their hands with alcohol gel.
There has been a large amount of finance generated into the development of further training in infection control; within the local NHS Trust an infection control online learning portal (On Click) is part of the mandatory training for all NHS staff. This computer based learning tool has derived from The epic project: developing national evidence-based guidelines for preventing healthcare association infections phase 1: guidelines for preventing hospital acquired infections (Great Britain. Department of Health, 2001) which has enabled all NHS staff to become more aware about the dangers of poor hand-washing techniques and poor infection control.
The development of infection control research has been of definitive guidance to the development of policy and has greatly increased the knowledge into effective infection control. Research funding can come from many different areas although with regards to hand hygiene products it usually comes from the producers of soaps and the hand hygiene products according to Boyce, Larson and Weinstein (2002) such as Procter and Gamble, 3M, Johnson and Johnson and Steris. This can occasionally cause bias among results as the company funding the research wants their product to succeed.
There has been a technological development in infection screening, such as the MRSA screening programme that is currently being randomly tested in certain hospitals within NHS Trusts. The policy guidelines Screening for Meticillin-resistant Staphylococcus aureus (MRSA) colonisation: A strategy for NHS trusts: a summary of best practice (Great Britain. Department of Health, 2006) requires for all NHS trusts to expand on their implementation of MRSA screening guidelines and to improve wherever possible. MRSA screening will eventually become universal procedure for all patients admitted into hospital within the NHS. An article (Lomas, 2008) debates the usefulness of MRSA screening following research into is effectiveness in Sweden where 22,000 surgical patients were studied. The study showed no significant difference in transmission rates with and without MRSA screening. So at present the impact of MRSA screening on hospital admission is un-conclusive.
This incident described within the beginning of this assignment is a positive one. Without all of the present health professionals and members of the public washing their hands and using effective hand hygiene procedures at every given opportunity the transmission of HAI would have been possible. In Carol's case if she had contracted a HAI it would possibly prove fatal as even a simple common cold can cause serious problems for a patient receiving auto-immune intra-venous treatment. Without the nurse recognising that the member of the public had not sanitised their hands on entering the ward could have caused terrible consequences for Carol. Without the research and development in the effectiveness of hand hygiene and infection control it would not be possible to have known about the dangers that Carol or other patients may face in the transference of HAI. If any of the patients within the ward had contracted a HAI it could have caused a longer stay within the hospital and a slower rate of recovery. HAI can cause fatalities even patients that are reasonably fit and healthy. Without the infection control policies in place the situation for Carol could be dangerous every time she entered hospital.
To conclude, the observed incident has been analysed and critiqued using the PEST analysis tool. The assignment has shown the effect of how international, national and local policy effects practice, health professionals, patients and the public. It has reviewed policies and how they meet the needs of individuals, communities and populations. It is shown that through continuous development of infection control policies that the government is aiming to maintain good standards within the NHS and to consistently lower the possibility of patients contracting HAI.
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Great Britain. Department of Health (2006) Screening for Meticillin-resistant Staphylococcus aureus (MRSA) colonisation: A strategy for NHS trusts: a summary of best practice. London: The Stationary Office.
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Great Britain. Department of Health (1999) The socio-economic burden of hospital acquired infection. London: The Stationary Office.
Great Britain. Health Act 2006: Elizabeth II. Chapter 28. (2006) London: The Stationary Office.
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Hawker, J. Begg, N. Blair, I. Reintjes, R. and Weinberg, J. (2005) Communicable Disease Control Handbook. 2nd edn. Oxford: Blackwell Publishing.
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Larson, E. Girard, R. Pessoa-Silva, C.L. Boyce, J. Donaldson, L. and Pittet, D. (2006) "Skin reactions related to hand hygiene and a selection of other hand hygiene products", American Journal of Infection Control, 34 (10), pp. 627-635 OVID [Online]. Available at: http://www.gateway.uk.ovid.com/ (Accessed: 21 June 2008).
Local Trust Policy (2007) - Anonymised according to university protocol.
Local Trust Policy (2008) - Anonymised according to university protocol.
Lomas, C. (2008) "MRSA screening usefulness in doubt", Nursing Times, 104 (12), pp.7.
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Marketing Teacher (2008) Available at: http://www.marketingteacher.com/ (Accessed: 05 June 2008).
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Priest, N. (2003) "Doctors not getting the cross-infection message", Nursing Standard, 18 (1), pp.30 OVID [Online]. Available at: http://www.gateway.uk.ovid.com/ (Accessed: 15 June 2008).
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PEST Analysis Tool
Marketing Teacher (2008)
Lewisham Observation Tool (LOT)
National Patient Safety Agency (2007)
Mail Online Article (2007)
Dirty wards, feminism and the tragic end of Florence Nightingale's ethos of patient care.