HLTINF006 Readings

Infection prevention and control in the healthcare setting

Contracting a healthcare associated infection

Most infectious agents are microorganisms. These exist naturally everywhere in the environment, and not all cause infection (e.g., ‘good’ bacteria present in the body’s normal flora). Parasites, prions and several classes of microorganism—including bacteria, viruses, fungi and protozoa—can be involved in either colonisation or infection, depending on the susceptibility of the host:

• With colonisation, there is a sustained presence of replicating infectious agents on or in the body, without causing infection or disease.
• With infection, invasion of infectious agents into the body results in an immune response, with or without symptomatic disease.

Transmission of infectious agents within a healthcare setting requires all of the following elements

• causative agent (pathogen)
• reservoir
• portal of exit
• means of transmission
• portal of entry
• a susceptible host.

Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019) - National Health and Medical Research Council (NHMRC)

Infectious agents transmitted during healthcare come primarily from human sources, including patients, healthcare workers and visitors. Source individuals may be actively ill, may have no symptoms but be in the incubation period of a disease, or may be temporary or chronic carriers of an infectious agent with or without symptoms. Infection is the result of a complex interrelationship between a host and an infectious agent and people vary in their response to exposure to an infectious agent:

• Some people exposed to infectious agents never develop symptomatic disease while others become severely ill and may die.
• Some individuals may become temporarily or permanently colonised but remain asymptomatic.
• Others progress from colonisation to symptomatic disease either soon after exposure or following a period of asymptomatic colonisation.

Important predictors of an individual’s outcome after exposure include:

• His or her immune status at the time of exposure (including whether immune status is compromised by medical treatment such as immunosuppressive agents or irradiation)
• The person's age (e.g. neonates and elderly patients are more susceptible)
• Their health status (e.g. when a patient has other underlying disease such as diabetes or is a smoker)
• The virulence of the agent
• Other factors that increase the risk of transmission of infection (e.g. undergoing surgery, requiring an indwelling device such as a catheter or remaining in hospital for lengthy periods).

Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019) - National Health and Medical Research Council (NHMRC)

In healthcare settings, the most common susceptible hosts are patients and healthcare workers. Patients may be exposed to infectious agents from themselves such as bacteria residing within the skin, in the respiratory or gastrointestinal tract (endogenous infection) or from other people, instruments and equipment, or the environment (exogenous infection). The level of risk relates to the healthcare setting (specifically, the presence or absence of infectious agents), the type of healthcare procedures performed, adherence to hand hygiene, immunisation status and the susceptibility of the patient.

Healthcare workers may be exposed to infectious agents from infected or colonised patients, instruments and equipment, or the environment. The level of risk relates to the type of clinical contact healthcare workers have with potentially infected or colonised patient groups, instruments or environments, adherence with standard and transmission-based precautions, and the health status of the healthcare worker (e.g., immunised or immunocompromised).

In healthcare settings, the main modes of transmission of infectious agents are contact (including blood borne), droplet and airborne. The modes of transmission vary by type of organism. In some cases, the same organism may be transmitted by more than one route (e.g., norovirus, influenza and respiratory syncytial virus (RSV) can be transmitted by contact and droplet routes).

Contact transmission

Contact is the most common mode of transmission, and usually involves transmission by touch or via contact with blood or body substances. Contact may be direct or indirect:

• Direct transmission occurs when infectious agents are transferred from one person to another—for example, a patient’s blood entering a healthcare worker’s body through an unprotected cut in the skin.
• Indirect transmission involves the transfer of an infectious agent through a contaminated intermediate object or person—for example, a healthcare worker’s hands transmitting infectious agents after touching an infected body site on one patient and not performing proper hand hygiene before touching another patient, or a healthcare worker coming into contact with fomites

Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019) - National Health and Medical Research Council (NHMRC) (e.g., bedding) or faeces and then with a patient. Examples of infectious agents transmitted by contact include multi-resistant organisms (MROs), Clostridioides difficile (Clostridium difficile or C. difficile), norovirus and pathogens which cause highly contagious skin infections/infestations (e.g., impetigo, scabies).

Droplet transmission

Droplet transmission can occur when an infected person coughs, sneezes or talks, and during certain procedures. Droplets are infectious particles larger than 5 microns in size. Respiratory droplets transmit infection when they travel directly from the respiratory tract of the infected person to susceptible mucosal surfaces (nasal, conjunctival or oral) of another person, generally over short distances. Droplet distribution is limited by the force of expulsion and gravity and is usually no more than 1 metre. Examples of infectious agents that are transmitted via droplets include influenza virus and Neisseria meningitidis (meningococcal infection).

Airborne transmission

Airborne transmission may occur via particles containing infectious agents that remain infective over time and distance. Small- particle aerosols (often smaller than 5 microns) are created during breathing, talking, coughing or sneezing and secondarily by evaporation of larger droplets in conditions of low humidity. Aerosols containing infectious agents can be dispersed over long distances by air currents (e.g., ventilation or air conditioning systems) and inhaled by susceptible individuals who have not had any contact with the infectious person. These small particles can transmit infection into small airways of the respiratory tract. An example of infectious agents primarily transmitted via the airborne route are M. tuberculosis and rubeola virus (measles).

Standard and transmission-based precautions

Successful infection prevention and control involves implementing work practices that reduce the risk of the transmission of infectious agents through a two-tiered approach, including:

• Routinely applying basic infection prevention and control strategies to minimise risk to both patients and healthcare workers, such as hand hygiene, appropriate use of personal protective equipment, cleaning and safe handling and disposal of sharps (standard precautions).
• Effectively managing infectious agents where standard precautions may not be sufficient on their own—these specific interventions control infection by interrupting the mode of transmission (transmission-based precautions; formerly referred to as additional precautions).

Standard precautions

All people potentially harbour infectious agents. Standard precautions refer to those work practices that are applied to everyone, regardless of their perceived or confirmed infectious status and ensure a basic level of infection prevention and control. Implementing standard precautions as a first-line approach to infection prevention and control in the healthcare environment minimises the risk of transmission of infectious agents from person to person, even in high-risk situations.

Standard precautions are used by healthcare workers to prevent or reduce the likelihood of transmission of infectious agents from one person or place to another, and to render and maintain objects and areas as free as possible from infectious agents. Guidance on implementing standard precautions is given in Sections 3.1, 6.2 & 6.3.

How standard precautions are implemented:

• Personal hygiene practices, particularly hand hygiene, aim to reduce the risk of contact transmission of infectious agents (see Section 3.1.1).
• Appropriate use of personal protective equipment, which may include gloves, gowns, plastic aprons, masks/face-shields and eye protection, aims to prevent exposure of the healthcare worker and patients to infectious agents (see Section 3.3).
• Safe handling and disposal of sharps assists in preventing transmission of blood-borne diseases to healthcare workers

(See Section 3.1.2).

Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019) - National Health and Medical Research Council (NHMRC)

• Environmental controls, including cleaning and spills management, assist in preventing transmission of infectious agents from the environment to patients (see Sections 3.1.3 and 4.6.1).
• Appropriate reprocessing of reusable equipment and instruments, including appropriate use of disinfectants, aims to prevent patient-to-patient transmission of infectious agents (see Section 3.1.4).
• Practising respiratory hygiene and cough etiquette reduces risk of transmission of infection (see Section 3.1.5).
• Aseptic technique aims to prevent microorganisms on hands, surfaces or equipment from being introduced into a susceptible site (see Sections 3.1.6).
• Appropriate handling of waste and linen assists in reducing transmission of infectious agents (see Sections 3.1.7 and 3.1.8).

Transmission-based precautions

Any infection prevention and control strategy should be based on the use of standard precautions as a minimum level of control. Transmission-based precautions are recommended as additional work practices in situations where standard precautions alone may be insufficient to prevent transmission. Transmission-based precautions are also used in the event of an outbreak (e.g., gastroenteritis), to assist in containing the outbreak and preventing further infection.

Transmission-based precautions should be tailored to the particular infectious agent involved and its mode of transmission. This may involve a combination of practices.

Guidance on when and how to implement transmission-based precautions is given in Sections 3.2, 3.5 and Appendix 2 (Section 6.3).

Types of transmission-based precautions:

• Contact precautions are used when there is known or suspected risk of direct or indirect contact transmission of infectious agents that are not effectively contained by standard precautions alone (see Section 3.2.2).
• Droplet precautions are used for patients known or suspected to be infected with agents transmitted over short distances by large respiratory droplets (see Section 3.2.3).
• Airborne precautions are used for patients known or suspected to be infected with agents transmitted person-to-person by the airborne route (see Section 3.2.4).

Strategies for implementing transmission-based precautions:

• dynamic risk assessment in the pre-hospital (emergency) setting to anticipate and communicate the potential need for transmission-based precautions on patient arrival
• allocating a single room inclusive of bathroom facilities and closing door to patient with a suspected or confirmed infection (isolation)
• placing patients colonised or infected with the same infectious agent and antibiogram in a room together (cohorting)
• wearing specific personal protective equipment
• providing patient-dedicated equipment
• using sodium hypochlorite or an appropriate Therapeutic Goods Administration-listed hospital-grade disinfectant with specific claims
• using specific air handling techniques
• restricting the movement of both patients and healthcare workers.

Each NHS organisation has a team of people responsible for IPC. This team has a variety of roles within the organisation, but work together to support its IPC infrastructure and services, reporting to the Trust Board and the chief executive. They are often all members of the IPC committee which meets on a regular basis and produces the organisation's annual programme for IPC activity and annual report to provide information to the Board about where the organisation is in relation to its programme, what healthcare-associated infections have been an issue within the previous year and what actions need to be taken to improve things in relation to IPC. It is a requirement under the Code of Practice which is part of the Health and Social Care Act 2008 (DH, 2015) that healthcare organisations either have or have access to an appropriate mix of expertise in relation to IPC – the IPCT fulfils this requirement. As can be seen here, it is not only NHS organisations which need to have access to such expertise. Non-NHS organisations may have their own IPCT or may contract for the use of a local NHS team, in particular in relation to microbiology advice. The IPCT in the NHS includes people such as the IPC doctor, consultant microbiologist (these two may be the same person) and IPC nurse/ practitioner (IPCN/P).

The Infection prevention and control doctor

Within NHS organisations, someone is designated as the infection control doctor. This might be the consultant microbiologist, public health doctor or infectious diseases consultant. Whoever this person may be, they are seen as the lead for the IPCT. The role of IPCD is not full time but this person often chairs the infection prevention and control committee and liaises closely with the infection prevention and control nurse.

The Infection prevention and control nurse/practitioner

This person may often be the only full-time member of the IPCT. In many organisations there is now a team of nurses within the IPCT; in smaller organisations, such as Mental Health or Care Trusts there may only be one. The IPC nurse/practitioner fulfils a variety of roles including the provision of IPC related advice to all staff within the organisation, clinical audit, risk management, surveillance, staff education, outbreak management and policy and guideline development (Quattrin et al., 2004; Weston, 2013). The IPCP is usually the first point of contact for IPC advice within organisations and is the most visible clinical person within the IPCT. IPCPs work differently within organisations. In some NHS Trusts, IPCPs are allocated to specific divisions so that staff on specific wards have a named member of the IPCT to contact. For example, one IPCP may cover surgery, another medicine, another critical care settings and so on. In other organisations, nurses may take on specific roles so that one IPCN undertakes all the audit, another all the surveillance and so on. Within each of your clinical placements it is worth identifying your point of contact for IPC advice within that area. It has been identified that the presence of an IPCN/P can both improve practice and reduce rates of infection (Venberghe et al., 2002; Ward, 2012).

As can be seen from this scenario, one of the important roles of the IPCP is in providing advice and information, to staff, patients and their relatives. They are a vital point of contact for all staff, and it is therefore important to be aware of who the IPCN is for your placement area and how this person can be contacted.

The consultant microbiologist

This member of staff will provide advice related to the medical aspects of patient management. This might include advice about the prescribing of antibiotics, translating laboratory reports, advising doctors on treatment and so on and medically reviewing patients with infections. This consultant may or may not also be the infection control doctor, but will generally be a member of the IPCT and sit on the IPC committee. Outside of the NHS acute hospital Trust setting, the IPC team may function differently. Previously there was the Health Protection Agency which had a nurse and doctor who worked locally, taking responsibility for IPC matters outside the NHS such as in nursing and residential homes. Primary Care Trusts also often employed their own IPC practitioner to cover services such as community nursing, podiatry and dentistry. However, primary and community care provision has changed with the creation of Clinical Commissioning Groups. Community IPC practitioners may now be employed by a variety of organisations such as the CCGs themselves, local councils and acute Trusts who provide IPC services to primary care. This can cause confusion about who to contact for staff working in primary care so good communication within and between services is important to ensure that all staff know who their first point of contact is for IPC. In some areas, health protection or public health nurses may provide IPC input alongside other health protection related responsibilities. Mental Health and Care Trusts function very much like acute Trusts in most cases in relation to IPC provision, employing their own IPC practitioners.

The director of infection prevention and control

This role is required under the Health and Social Care Act 2008 (Department of Health, 2015) and should be in place in all registered NHS care providers. The person undertaking this role is generally not in a full-time or unique role, but it is undertaken alongside another role. However, time should be allocated for the person to fulfil the requirements of this role. The DIPC needs to be an effective leader who is highly visible, senior and authoritative. The DIPC in particular provides assurance to the Trust Board that systems are in place within the organisation to ensure safe and effective healthcare, though they do not need to be a member of the Trust Board. They should, however, report directly to the chief executive.

Considering recent changes within the NHS, the role of the DIPC will differ when working for either commissioning (such as Clinical Commissioning Groups) or provider (such as an NHS hospital) organisations. Provider organisations are expected to have their own DIPC to provide information and assurance to the board. In commissioning organisations, the role will involve providing advice on service specifications and performance indicators related to provider contracts. While there is no single model for how the role of the DIPC is provided within each organisation, the commitment to patient safety and quality care should be paramount. The DIPC role can be undertaken by microbiologists, directors of public health, infection prevention and control practitioners, directors of nursing, medical directors and so on – each organisation will be different.

The infection prevention control link nurse/practitioner

Link nurses/practitioners are used frequently in healthcare settings to support many areas of specialist practice in the UK, including diabetes, pain management and tissue viability. The link nurse role was introduced into infection prevention in 1988 by Rozila Horton; these are practising nurses who have an interest in a specific area of nursing and act as a formal link to the specialist team for that area within the organisation. The role is used in different ways within organisations, with activities and responsibility varying. Titles can be different, requirements to undertake the role can vary and how effective the role is can be dependent on many issues such as the person undertaking the role, how they are perceived by their colleagues and how well they are supported by the IPCT.

Not all link staff are nurses. For example, in departments where nurses are not employed, such as podiatry, the link person might be referred to as a link practitioner. In a basic sense, the role of the link person is to act as a bridge between the IPCT and clinical staff, sharing knowledge and good practice, and sometimes being involved in clinical audits, surveillance and the education of staff in their work area. Four key themes for the role have been identified by the RCN (2012a): acting as a role model for IPC; enabling others to learn and develop their IPC practice; communication and networking around IPC practice; and supporting others in local audit and surveillance, though the last theme is considered optional due to the differing nature of healthcare organisations. Though there is a lack of evidence about the efficacy of link staff, some studies have highlighted benefits to having link systems in place in infection prevention and control (Miyachi et al., 2007; Seto et al., 2013; Lloyd Smith et al., 2014).

In some areas you may be able to clearly identify the person in this role and in others not. You may have also been to practice areas which have no designated IPCLN – this is not a mandatory role and some organisations have taken the decision not to utilise it due to a lack of efficacy in their areas. However, in some areas the use of link nurses can mean that problems are identified and addressed more quickly.

As can be seen from the above case study, having a link practitioner in place can lead to a quicker resolution to problematic issues such as outbreaks of infection. Having staff with a greater level of knowledge in these areas who have a link and direct relationship with the local IPCP can be of benefit to both patients and staff in such situations.

The infection prevention and control committee

As previously mentioned, NHS organisations generally have an infection prevention and control committee (IPCC) which meets on a regular basis and reports to the Trust Board. Its members vary between organisations but will include the members of the IPC team and other people such as the Chief Nurse, Medical Director, Occupational Health Lead, Health and Safety and Clinical Governance representatives and other people in senior roles within the organisation. The role of the IPCC is multi-faceted and will include planning, monitoring, evaluating, updating and educating in relation to IPC. It sets general IPC policy and provides input into specific IPC issues. Simply stated, its function is to prevent and control healthcare-associated infections. That is accomplished in a variety of ways, some of which include: surveillance of infections, product evaluation, investigation of infection outbreaks and development of IPC procedures.

In the United States in 2010 there were approximately 51.4 million inpatient surgical procedures and an even larger number of invasive medical procedures. In 2009, there were more than 6.9 million gastrointestinal (GI) upper, 11.5 million GI lower, and 228,000 biliary endoscopies performed. Each of these procedures involves contact by a medical device or surgical instrument with patients’ sterile tissue or mucous membranes. A major risk of all such procedures is the introduction of pathogenic microbes, which can lead to infection. Failure to properly disinfect or sterilize equipment may lead to transmission via contaminated medical and surgical devices (e.g., carbapenem-resistant Enterobacteriaceae [CRE]).

Achieving disinfection and sterilization through the use of disinfectants and sterilization practices is essential for ensuring that medical and surgical instruments do not transmit infectious pathogens to patients. Because it is not necessary to sterilize all patient-care items, health care policies must identify whether cleaning, disinfection, or sterilization is indicated based primarily on each item’s intended use, manufacturers recommendations, and guidelines. Multiple studies in many countries have documented lack of compliance with established guidelines for disinfection and sterilization.

Failure to comply with scientifically based guidelines has led to numerous outbreaks and patient exposures. Because of noncompliance with recommended reprocessing procedures, the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) issued a health advisory alerting health care providers and facilities about the public health need to properly maintain, clean, and disinfect and sterilize reusable medical devices in September 2015. In this article, which is an updated and modified version of earlier articles, a pragmatic approach to the judicious selection and proper use of disinfection and sterilization processes is presented, based on well-designed studies assessing the efficacy (via laboratory investigations) and effectiveness (via clinical studies) of disinfection and sterilization procedures.

A rational approach to disinfection and sterilisation

Almost 50 years ago, Earle H. Spaulding devised a rational approach to disinfection and sterilization of patient-care items or equipment. This classification scheme is so clear and logical that it has been retained, refined, and successfully used by infection control professionals and others when planning methods for disinfection or sterilisation.

Spaulding thought that the nature of disinfection could be understood more readily if instruments and items for patient care were divided into 3 categories based on the degree of risk of infection involved in the use of the items. The 3 categories he described were critical, semi critical, and noncritical. This terminology is used by the CDC’s “Guidelines for Environmental Infection Control in Healthcare Facilities” and the CDC’s “Guideline for Disinfection and Sterilization in Healthcare Facilities.”

Critical items

Critical items are so called because of the high risk of infection if such an item is contaminated with any microorganism, including bacterial spores. Thus, it is critical that objects that enter sterile tissue or the vascular system be sterile because any microbial contamination could result in disease transmission. This category includes surgical instruments, cardiac and urinary catheters, and implants used in sterile body cavities. The items in this category should be purchased as sterile or be sterilized by steam sterilization if possible. If heat sensitive, the object may be treated with ethylene oxide (ETO), hydrogen peroxide (HP) gas plasma, vaporized HP, HP vapor (HPV) plus ozone, or by liquid chemical sterilant if other methods are unsuitable.

Liquid chemical sterilant can be relied on to produce sterility only if cleaning, which eliminates organic and inorganic material, precedes treatment and if proper guidelines as to concentration, contact time, temperature, and pH are met. Another limitation to sterilization of devices with liquid chemical sterilant is that the devices cannot be wrapped during processing in a liquid chemical sterilant; thus, it is impossible to maintain sterility following processing and during storage. Furthermore, devices may require rinsing following exposure to the liquid chemical sterilant with water that, in general, is not sterile. Therefore, because of the inherent limitations of using liquid chemical sterilant in a nonautomated (or automated) reprocessor, their use should be restricted to reprocessing critical devices that are heat sensitive and incompatible with other sterilization methods.

Summary of advantages and disadvantages of commonly used sterilisation techniques

Semi-critical items

Semi critical items are those that come in contact with mucous membranes or nonintact skin. Respiratory therapy and anaesthesia equipment, gastrointestinal endoscopes, bronchoscopes, laryngoscopes, Endo cavitary probes, prostate biopsy probes,28 cystoscopes, hysteroscopes, infrared coagulation devices, and diaphragm fitting rings are included in this category. These medical devices should be free of all microorganisms (i.e., mycobacteria, fungi, viruses, bacteria), although small numbers of bacterial spores may be present. Intact mucous membranes, such as those of the lungs or the gastrointestinal tract, are generally resistant to infection by common bacterial spores but susceptible to other organisms, such as bacteria, mycobacteria, and viruses.

Because semi critical equipment has been associated with reprocessing errors that result in patient lookback and patient notifications, it is essential that control measures be instituted to prevent patient exposures. Before new equipment (especially semi critical equipment as the margin of safety is less than that for sterilization) is used for patient care on more than one patient, reprocessing procedures for that equipment should be developed. Staff should receive training on the safe use and reprocessing of the equipment and be competency tested. At the University of North Carolina (UNC) Hospitals, to ensure patient-safe instruments, all staff that reprocess semi critical instruments (e.g., instruments which contact a mucous membrane such as vaginal probes, endoscopes, prostate probes) are required to attend a 3-hour class on HLD of semi critical instruments. The class includes the rationale for and importance of high-level disinfection, discussion of high-level disinfectants and exposure times, reprocessing steps, monitoring minimum effective concentration, personal protective equipment, and the reprocessing environment (establish dirty-to-clean flow). Infection control rounds or audits should be conducted annually in all clinical areas that reprocess critical and semi critical devices to ensure adherence to the reprocessing standards and policies. Results of infection control rounds should be provided to the unit managers, and deficiencies in reprocessing should be corrected and the corrective measures documented to infection control within 2 weeks (immediately correct patient safety issues, such as exposure time to high-level disinfectant).

Non-critical items

Noncritical items are those that come in contact with intact skin but not mucous membranes. Intact skin acts as an effective barrier to most microorganisms; therefore, the sterility of items coming in contact with intact skin is “not critical.” Examples of noncritical items are bedpans, blood pressure cuffs, crutches, bed rails, linens, bedside tables, patient furniture, and floors. In contrast to critical and some semi critical items, most noncritical reusable items may be decontaminated where they are used and do not need to be transported to a central processing area. There is virtually no documented risk of transmitting infectious agents to patients via noncritical items when they are used as noncritical items and do not contact nonintact skin and/or mucous membranes. However, these items (e.g., bedside tables, bed rails) could potentially contribute to secondary transmission by contaminating hands of healthcare personnel or by contact with medical equipment that will subsequently come in contact with patients. The table below list several low-level disinfectants that may be used for noncritical items. The exposure time for low-level disinfection of noncritical items is at least 1 minute.

Summary

When properly used, disinfection and sterilization can ensure the safe use of invasive and non-invasive medical devices. The method of disinfection and sterilization depends on the intended use of the medical device: critical items (contact sterile tissue) must be sterilized before use; semi critical items (contact mucous membranes or nonintact skin) must be high-level disinfected; and noncritical items (contact intact skin) should receive low-level disinfection. Cleaning should always precede HLD and sterilization. Current disinfection and sterilization guidelines must be strictly followed.

The following information assists you to implement the NHMRC guidelines in practice and to develop your local practice policies.

Hand Hygiene

• Effective hand hygiene is the single most important strategy in preventing healthcare associated infections.

Implementation

• Wash hands with soap and water if visibly soiled, use soap and water or an alcohol-based hand rub if hands are visibly clean
• Ensure alcohol-based hand rub meets the Therapeutic Goods Administration (TGA) requirements
• Know the correct technique:
• Hand washing (40–60 sec): wet hands and apply soap; rub all surfaces; rinse hands and dry thoroughly with a single use item; use item to turn off faucet if required
• Hand rubbing (20–30 sec): apply enough product to cover all areas of the hands; rub hands until dry
• Conduct hand hygiene as often as required dependent upon tasks conducted (see Table 2 below)
• Performing routine hand hygiene in view of a client before and after any client contact is a demonstration of good infection prevention management
• Educate and encourage your clients to conduct hand hygiene too.
• Ensure the following are considered and practiced in line with your practice policy to facilitate effective hand hygiene:
• Hand cream
• Clothes
• Jewelry
• Artificial nails and/or nail polish
• Any cuts and abrasions present (see NHMRC Guidelines page 33-35 for more information on these areas).
• When to conduct hand hygiene?
• The 5 Moments of Hand Hygiene
• Before touching a client
• Before a procedure
• After a procedure or body substance exposure risk
• After touching a client
• After touching a client’s surroundings.

^{Table 2. Additional situations when Allied Health clinicians should conduct hand hygiene}

Allied Health Practice Points and Considerations

• Optometry Australia recommend that all areas where contact lenses may be inserted or removed should be fitted with hand basins as alcohol-based hand rubs are unsuitable for use in contact lens practice due to the risk of transferring undesirable aspects from the hands to the lens prior to eye insertion.
• Where possible hand basins should be fitted with elbow, foot or sensor-controlled taps to reduce the need for touching.
• A designated hand washing sink that is not used for cleaning and/or reprocessing is required.
• Hand washing facilities separate to client treatment areas for practice areas such as offices, workshops and storage areas should also be provided.
• Podiatrists who perform any procedure that involves penetration of normally sterile tissues must perform surgical scrubbing techniques prior to doing so.

Checklist

• Does your practice have a hand hygiene policy and procedure in line with NHMRC Guidelines?
• Do you make hand hygiene products readily accessible to increase compliance?
• Are all staff trained in correct hand hygiene practices
• Are the hand hygiene facilities in your clinic adequate for the tasks being undertaken?
• Do you demonstrate hand hygiene in front of clients?
• Do you promote and facilitate hand hygiene among your clients?
• Do the hand hygiene products you’re using meet requirements; are they compatible with one another?
• Are all staff compliant with policies in place?
• Is there a designated hand-washing sink in client communal areas?
• Avoid wearing lanyards and neck ties, as these can facilitate infection transmission
• If working in your own clothes, keep in mind that it should be laundered daily
• Follow the “bare below the elbows” strategy to allow for proper hand hygiene practices:
• You should wear clothing with short sleeves (or long sleeves that easily roll up)
• Avoid wearing jewelry and watches. Rings increase hand contamination, therefore if you choose to wear a ring it should be a plain band that you can easily move around your finger while performing hand hygiene
• If you are provided with a uniform for work areas at higher risk of exposure:
• Wear a clean uniform for each shift
• Wash your uniform separately from your other clothing
• Do not take a contaminated uniform home
• If your uniform becomes contaminated with blood or body substances, use workplace laundry facilities where possible
• Choose footwear which helps protect you from dropped sharps or other objects and the risk of contamination with potentially infectious material.

Coughing and Sneezing

• Respiratory hygiene and cough etiquette must be conducted as standard infection prevention and control at all times.

Implementation

• Cover the nose/mouth with disposable single-use tissues when coughing, sneezing, wiping and blowing noses
• Dispose of tissues in the nearest waste receptacle or bin after use
• If no tissues, cough or sneeze into inner elbow
• Practice hand hygiene afterwards
• Keep contaminated hands away from the face (mucous membranes of the mouth, eyes and nose)

Clients with symptoms of respiratory infections if treatment cannot be delayed or delivered by alternate means:

• Sit as far away from others as possible
• Separate in waiting area where possible
• Staff with suspected or confirmed viral respiratory tract infections should stay home while they have symptoms.

Client Education

An organisational approach to client-centred care is associated with both safer and higher quality care. Educating clients and encouraging their participation is essential to successful infection prevention and control.

Implementation

Make sure clients can clean their hands when needed, for example:

• When entering or leaving your workplace
• After using the bathrooms
• After contact with communal surfaces/shared client care equipment
• Encourage clients to question your hand hygiene and use of PPE
• Discuss the specific risks (e.g. infection) associated with procedures you are conducting
• Help clients feel comfortable disclosing their health or risk status
• Encourage them to identify and communicate risks via feedback channels
• Provide educational material through a variety of written and visual media.

Allied Health Practice Points and Considerations

Client education should be provided on the following:

• Appropriate use, storage, disposal and/or cleaning of any assistive technology provided for personal.
• use, for example:
• Prescribed eye drops and ointments.
• Contact lenses and contact lens cases
• Orthoses and prostheses
• Communication and hearing devices
• Wheelchairs
• Kitchen utensil adaptive equipment
• Precautions to minimise spreading any infections on themselves or to others, for example:
• From one eye to the other or to other people by not sharing eye drops, contact lenses, towels
• Not sharing eye make-up and disposing of it if contaminated past expire
• Suitable management and disposal of wound care products at home.

Blood and Body Spills

Infection prevention and control requires prompt removal of blood and body substance spills, followed by cleaning and disinfection of the contaminated area.

Implementation

Appropriate processes for managing spills depends on:

• The setting
• Your practice policies
• The volume of the spill
• Be familiar with the location of your workplace’s spill kit
• Dispose of all the used parts of the spill kit after use to avoid cross-contamination
• Clean up spills immediately in line with the table below and your practice policy.
• If spills occur on soft furnishings:
• Use a detergent solution to thoroughly clean the area
• Do not use a disinfectant such as sodium hypochlorite
• Soft furnishings can be wet vacuumed
• Furnishings must dry before reuse.

Good hygiene

An effective way to protect workers and others from the risk of exposure to COVID-19 is by requiring workers and others to practice good hygiene.

Employers must direct workers, visitors, and others to the workplace to practice good hygiene – washing hands regularly with soap and water for at least 20 seconds and drying them with clean paper towel:

• before and after eating
• after coughing or sneezing
• after going to the toilet
• when changing tasks and after touching potentially contaminated surfaces.

An alcohol-based hand sanitiser with at least 60% ethanol or 70% isopropanol as the active ingredient must be used per the manufacturer’s instructions when it is not possible to wash hands.

Good hygiene requires everyone at the workplace to:

• cover their coughs and sneezes with their elbow or a clean tissue (and no spitting)
• avoid touching their face, eyes, nose and mouth
• dispose of tissues and cigarette butts hygienically, for example in closed bins
• wash their hands before and after smoking a cigarette
• clean and disinfect shared equipment and plant after use
• wash body, hair (including facial hair) and clothes thoroughly every day
• have no intentional physical contact, for example, shaking hands and patting back.

Employers must also ensure adequate and accessible hygiene facilities are provided. For more information, including providing facilities for temporary, mobile or remote workplaces, see Work Health and Safety (Managing the Work Environment and Facilities) Code of Practice 2015. Workers also have a responsibility to take reasonable care of themselves and to not do anything that would affect the health and safety of others at work (for example, coming to work when unwell). Workers must follow any reasonable health and safety instructions from their employer.

To prevent the spread of COVID-19 in the workplace, it is important that workers:

• work safely and observe any new requirements for physical distancing (even if it means performing tasks in a different way to what they are used to)
• follow instructions (such as about how to wash hands thoroughly)
• if unsure, ask how to perform the work safely and within the restrictions
• use personal protective equipment such as gloves in the way they were trained and instructed to use it
• report any unsafe or unhealthy situations (such as a lack of soap in the bathroom) to a supervisor, manager or health and safety representative (HSR).

Visit Safe Work Australia for more hygiene guidance.

Maintaining a cleaning regime

COVID-19 spreads through respiratory droplets produced when an infected person coughs or sneezes. A person can acquire the virus by touching a surface or object that has the virus on it and then touching their own mouth, nose or eyes. A combination of cleaning and disinfecting will be most effective in removing the COVID-19 virus and protecting workers and others from the risk of exposure.

It is highly recommended that workplaces are cleaned at least daily, and more frequent cleaning may be required in some circumstances. For example:

• if the workplace operates in shifts, workspaces should be cleaned between shifts
• if equipment has been shared between workers, it should be cleaned between uses, where practicable.

Cleaning with detergent and water is sufficient. Once clean, surfaces can be disinfected. When and how often your workplace, or certain surfaces, should be disinfected will depend on the likelihood of contaminated material being present. This would include:

• when there has been a case or suspected case of COVID-19 at the workplace, or
• at workplaces with a high volume of workers, customers or visitors that are likely to touch surfaces.

Organisations that do not have control over the ongoing cleaning regime of the workplace should consult and work closely with property managers or building landlords to ensure regular cleaning and disinfecting takes place, especially in communal areas and high touch points. Employers should also provide workers with cleaning products including disposable wipes to regularly clean and disinfect workstations and equipment. Rubbish bins should also be provided to enable workers to dispose of the wipes and tissues in an appropriate manner.

Introduction

Effective communication is key to patient safety to ensure no harm occurs in the delivery of patient care. Nurses constitute the largest workforce in the NHS and play a vital role in ensuring patient safety, spending the most time with patients and performing many roles. These include providing effective and safe care, ongoing patient monitoring and coordination of care. Protecting patients from harm can be seen as fundamental in all nursing activities. Generally, the vast majority of patients accessing healthcare services will have a positive experience due to the high-quality, safe care delivered by dedicated healthcare professionals. However, errors and omissions in their care result in harm to some patients and most of these incidents are preventable. In a review of root cause analyses, communication was found to be an important causal factor (World Health Organization, 2008) and is one of the most common causes of dissatisfaction within healthcare services (Royal College of Nursing, 2017). Communication strategies are indicated in varying forms, as policies and procedures, performance statistics, incident reports, workplace inductions, learning from errors, education and training. These strategies are essential to engage healthcare professionals in patient safety activities that promote a positive safety culture. This chapter will provide an overview of patient safety and safety culture, and how human factor principles are applied to patient safety. The importance of learning from errors cannot be underestimated as this is key to promoting a positive safety culture. This relies, however, on effective incident reporting structures and strategies to support this process.

Concept of patient safety

At its simplest, patient safety is defined as the “prevention of patient harm” (Kohn et al ., 2000). The World Health Organization (2009, p. 15) offers a similar but broader definition and states that: “Patient safety is the reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum.”

The use of the word ‘unnecessary’ in this definition recognises that errors, violation, patient abuse and deliberate unsafe acts (termed ‘incidents’) occur in healthcare. To standardise the terms used relating to incidents, the World Health Organization (2009) has published an International Classification for Patient Safety (ICPS). This conceptual framework was developed to enable categorisation of patient safety information by using a standardised set of concepts and agreed definitions. The table below illustrates some examples of the key concepts and definitions commonly used in clinical practice.

While healthcare brings enormous benefits to those using the health service, errors are common, and patients are frequently harmed. It is important to recognise that healthcare and healthcare delivery is a multifaceted phenomenon reflected by the complexities of health, social, political and organisational context (Curry and Nunez-Smith, 2015). Individual beliefs, values and motivations that underlie individual behaviours are also complex, and therefore keeping patients safe from harm is a significant issue and one of the most prominent healthcare challenges worldwide.

Safety culture

‘Safety culture’ is integral to the overall culture of an organisation. The following definition of safety culture was originally cited in the UK Health and Safety Commission report in 1993 and is quoted widely in the healthcare literature and many governments report:

Safety culture as a concept is usually described in terms of perceptions relating to trust, values and attitudes that focus upon preventing errors and maintaining patient safety. It also refers to the way in which patient safety is thought about, how this is implemented within an organisation, and the structures and processes in place to support this. All these factors have a huge positive or negative influence on patient safety outcomes. The effect of a healthcare organisation’s safety culture on patient clinical outcomes has been studied extensively, with communication identified as an important organisational aspect affecting patient safety (Wang et al ., 2014). A positive safety culture is therefore characterised by effective communication founded on mutual trust to keep patients safe from actual and potential harm. In comparison, a negative safety culture can cause harm and injury and can be characterised by poor communication of patient safety issues within clinical environments and across the organisations. The table below provides further characteristics that you may experience in your clinical practice areas.

In general, the overall concept of safety culture focuses on preventing errors and maintaining patient safety, which may seem straightforward. However, promoting a positive safety culture is multifaceted due to the different dimensions that are associated with it. The Agency for Healthcare Research and Quality (AHRQ) identified 12 dimensions when it developed the Hospital Survey on Patient Safety Culture (HSOPSC). This is a pre-validated questionnaire that is widely used internationally to study and evaluate individual perceptions of safety culture in hospital settings (AHRQ, 2012). Other pre-validated questionnaires such as the Safety Attitude Questionnaire (SAQ) (developed by Sexton et al ., 2006) also identify similar dimensions. It is beyond the remit of this chapter to discuss safety culture questionnaires in detail. Further information can be found on The Health Foundation website (www.health.org.uk/sites/default/files/MeasuringSafetyCulture.pdf). This document provides a summary of the surveys, together with their strengths and weaknesses.

Incident reporting

Since the publication of An Organisation with a Memory (Department of Health, 2000), healthcare organisations have made significant efforts to reduce patient safety incidents and subsequent harm. It is now recognised that an organisation’s safety culture and approach to patient safety incidents are key factors influencing safety and quality. As a form of communication, incident reporting is an established mechanism for improving patient safety. Organisations with a positive safety culture (as illustrated in Table 8.3 ) report a large number of patient safety incidents and acknowledge healthcare professionals for their candour and commitment to learning. In comparison, those organisations with a negative safety culture will blame individuals and consider reporting those incidents ‘out of line’ (Taylor, 2012). It is important to note that an increased number of reported patient safety incidents reflects an improved reporting culture and should not be interpreted as a decrease in the safety of the NHS. Equally, a decrease cannot be interpreted as an increase in the safety of the NHS. Evidence suggests that there is a positive correlation between safety incident reporting data and a high Hospital Mortality Ratio Score (HMRS) for those organisations that report large numbers of incidents (Keogh, 2013). Conversely, it is recognised that only a relatively small percentage of incidents that occur are actually reported. In addition, those incidents that are considered ‘near misses’ were not reported. In nursing, the reasons for failure to report incidents have been extensively researched (for example, Alahmadi, 2010; El-Jardali et al ., 2014) and findings reveal a number of barriers to reporting, for example:

• time constraints
• failure to recognise an incident.
• feeling threatened
• fear of blame
• failure to receive feedback.

Any patient safety incident is a reportable circumstance where there is significant potential for harm, near miss or no harm (adverse event) for one or more patients receiving healthcare. Another key challenge when reporting a patient safety incident is the terminology that is used within the reporting systems. As a student, you will encounter unintended or unexpected patient safety incidents in your placement experiences and it is fundamental that you “demonstrate an understanding of how to identify, report and critically reflect on near misses, critical incidents, major incidents and serious adverse events in order to learn from them and influence their future practice” (NMC, 2018b, p. 22). The cycle image demonstrates the process that should be followed when patient safety incidents occur.

Summary

Nurses constitute the largest workforce in healthcare. They spend most time with patients and therefore play a vital role in patient safety. To improve patient safety, a positive safety culture must exist to protect patients from unnecessary harm. Safety culture is a multifaceted concept that incorporates many dimensions, but the fundamental element is communication, which has been discussed in this chapter. Understanding how harm does occur to patients, and reporting of errors so that lessons can be learnt, are vital to improving patient safety. A number of strategies and tools can be used to encourage learning from errors and more than one approach can be used. This chapter has focused on the use of patient stories as a method of learning from ‘real life’ clinical incidents and it is hoped that you can adopt this method to share with colleagues, peers and the wider healthcare team.