Infection Control from a Nursing perspective

Author: Ann M. Macey. Paediatric Specialist Nurse

Based in Worthing & Southlands Hospital Trust, UK

INTRODUCTION

The following is a personal observational report from a nursing perspective.  Comparisons between UK and India (Sanjiban, Kolkata)

are inevitable but not necessarily negative.  The writer has endeavoured to be candid in all aspects of the report.

As this is a personal view, the following will be written in the first person.

KEY WORDS

ACOUNTABILITY/RESPONSIBILITY

What does it mean? blameworthyness, liability, acceptance of responsibilty, answerable

There does not appear to be a suitable translation into Bangla.

Analogies may help to clarify the meaning.

Everyone in a professional nursing position is accountable for their actions.

If you are a Dr, a nurse in charge of a ward or a senior nurse, if you ask somebody not qualified to carry out a procedure they are not trained to do you are also  accountable for their actions.

For example: A nurse asks a cleaner to clear up after administation of IV medication and the cleaner gets a needlestick injury.  The nurse is responsible and accountable for that needlestick injury, not the cleaner.

CONSEQUENCES

Definition: Result or effect of an action good or bad

Every action we carry out has a consequence.

For example:

If we comb our hair (action) we have untangled hair (result) good

If we get up late and miss the bus (action) we may be late for work (result)bad

On the ward if we forget to sign that we have given a drug (action) the consequence of your action is that the drug may be given again and the patient overdose.

If you do not carry out the correct a-septic procedure when preparing an IV site for medication that patient may get an infection.  That is the consequence of your actions.

It has been an observation that Nursing Practice and expertise in Sanjiban is excellent and on the whole the nursing staff are excellent clinicians and carry out their jobs well.  BUT the consequences of their actions - thinking ahead of what could or might happen seems to be lacking.

If a patient develops phlebitis around a cannula site.  The nursing staff will know visually what is wrong but may not why it has happened, it may not have been kept clean, but they do not appear to know why or actually what is happening to the vein resulting in the redness.

The knowledge of the physiology and pathophysiology of the body, the actual function of the systems and what is happening when something goes wrong appears to be lacking in their training.

The underpinning knowledge of nursing actions are key to understanding what can go wrong if infection control procedures are not carried out correctly.

GOOD HANDWASHING

Correct handwashing as per handwashing procedure should take at least 2 minutes.  Use antiseptic soap and dry with clean paper, not a towel. 

I am pleased to say the latter has now been replaced in Sanjiban with paper.

Hands should be washed by ALL staff on entering a ward area, especially from outside.  Outside clothing should be removed including cardigans.  Unfortunately I still see nurses in the Winter with long sleeved cardigans under their uniforms with the cardigan sleeves down.

Short sleeved clothes not visible under uniforms should be compulsory. 

Outside clothes, and that includes Drs jackets, have dust and dirt on them.

What is the use of good handwashing

 and removing your shoes if you are bringing contamination on your clothes?

HOSPITAL ACQUIRED INFECTIONS  (HAI'S)

COMMUNITY ACQUIRED INFECTIONS (CAI'S)

10% of all patients will acquire a nosocomsial infection

How do we know what is an HAI and what is a CAI?

In Sanjiban they have a very good system.  On admission all patients have a blood sample and a urine sample taken for analysis.

If they have a catheter a sample can be taken from the neck of the catheter tube between the patient and the bag.  The urine in the bag may have been in there for several hours.  A sterile catch is essential for a correct result.

If an organism is found in either within 48 hours we can assume that it is a Community acquired infection.  Any samples taken after 48 hours that contain micro organisms we can assume it is a Hospital acquired infection.

CROSS INFECTION

Good handwashing is the best preventative measure against Hospital acquired infections.  GLOVES ARE NO SUBSTITUTE FOR HANDWASHING.

Although I am sure some nurses think they are.

Cross infection is avoidable:

Not washing hands between patients, and that includes Doctors.

BAD CATHETER CARE

  This starts with the insertion of the catheter in the first place.  If the genital area is not cleaned sufficiently infection can be transmitted.  This is an aseptic procedure and should be treated as such.     

Catheters should not be on the floor.  When moving a patient the tubing should be clamped off to stop back-flow.  Catheters should be regularly emptied and charted correctly if on a fluid chart.

A urinary tract infection is unpleasant and not only needs antibiotic medication but delays discharge.

VENTILATOR ASSOCIATED INFECTIONS:

The wrong or careless suction procedure could cause pneumonia (Ventilator Associated Pneumonia) of pseudomonas which thrives well in damp warm conditions.

A closed circuit ventilation systems  reduces the incidents of cross infection.

SURGICAL SITE INFECTION (SSI)

A surgical patient post-op should arrive on the ward free of infection.

If the patient develops a  site infection it could have been an infection contracted in theatre.

We must assume that the hospital staff are well, fit and healthly with excellent immune systems. Unfortunately  the patients are not.  Their immune system is low, maybe immunocompromised, maybe with open wounds. They are susceptible to infections.

MRSA (Methicillin resistant Staphylococcus)

This is a huge problem in UK.  The probable cause being over prescribing antibiotics, thus causing resistance to many bacteria.

India does not appear to have the same problem and in Sanjiban I have been assured this is a rare occurence.

Infection control obviously starts with the nursing staff but also asking visitors to wash their hands before visiting relatives.

No visitor should be allowed in a ward who has a cold, cough or an open wound.  Remember the consequences.

ASEPTIC NON TOUCH TECHNIQUE (A.N.T.T)

Using this procedure will go a long way in protecting a patient from cross infection.  A sterile procedure is not possible in a ward situation. Dead skin cells and dust are always in the air whatever you do: a sterile field may be attainable and certainly an aseptic area is.

IF SOMETHING GOES WRONG

Reflection is a wonderful tool for any situation.  Gibbs Reflective Cycle helps anyone to think about a situation and try and improve next time.

HANDS

Look after them, do not let them get dry and cracked.  Hospital Gel is freely available and should have hand moisturiser to keep your hands in good condition.

CONCLUSION

Although Infection Control procedures are not perfect, and not many systems are, In the past 3 years of observation the improvements have been very positive and noticeable.

HAI's have been reduced, beds removed to allow more space  beween patients, cleaner uniforms and A.N.T.T. procedures carried out to a high standard and clean paper to dry hands on the wards.

In UK we have an infection control nurse allocated in each ward.  There is no extra payment for this but it is his/her job to make sure all new nurses and students are taught good hand hygeine and A.N.T.T procedures.

They might also meet other nurses once a month to discuss improvements. The system seems to work, maybe it is worth a try in Sanjiban.

References:

W.H.O. Prevention of Hospital Acquired Infection WHO/CDS/CSR/2002.12

Oxford Journal (Medicine and Health) Vol 5 Iss 1 (Feb 2014)

Wikipedia - HAI

Gibbs Reflective Cycle (1988) Cumbria University, UK