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Prevention and control of healthcare-associated infections
This pathway covers the prevention and control of healthcare-associated infections in primary, community and secondary care.
Healthcare-associated infections can develop either as a direct result of healthcare interventions such as medical or surgical treatment, or from being in contact with a healthcare setting. Healthcare-associated infections can exacerbate existing or underlying conditions, delay recovery and adversely affect quality of life.
Healthcare-associated infections are caused by a wide range of microorganisms. The most well known include those caused by meticillin-resistant Staphylococcus aureus (MRSA), meticillin-sensitive Staphylococcus aureus (MSSA), Clostridium difficile (C. diff) and Escherichia coli (E. coli).
Patient safety has become a cornerstone of care in the NHS, and preventing healthcare-associated infections remains a priority. Healthcare-associated infections are estimated to cost the NHS approximately £1 billion a year, £56 million of which is estimated to be incurred after patients are discharged from hospital. In addition to increased costs, each one of these infections means additional use of NHS resources, greater patient discomfort and a decrease in patient safety. A 'no tolerance' attitude is now prevalent in relation to avoidable healthcare-associated infections.
Surgical site infections
Surgical site (wound) infection occurs when pathogenic organisms multiply in a surgical wound, giving rise to local signs and symptoms, such as heat, redness, pain and swelling, and (in more serious cases) with systemic signs of fever or a raised white blood cell count. Infection in the surgical wound may prevent healing taking place so that the wound edges separate, or it may cause an abscess to form in the deeper tissues.
Surgical site infections comprise up to 20% of all healthcare-associated infections. At least 5% of patients undergoing surgery develop a surgical site infection. Surgical site infections can have a significant effect on quality of life for the patient, and are associated with considerable morbidity and extended hospital stay. Surgical site infections also result in a considerable financial burden to healthcare providers. The majority of surgical site infections are preventable and measures can be taken in the preoperative, intraoperative and postoperative phases of care to reduce risk of infection.
Use of 'must' in recommendations
There is a legal duty to implement some of the recommendations in this pathway in order to comply with legislation. The word 'must' is used in these recommendations and details of the relevant legislation are given in footnotes. In addition, 'must' is used in some other recommendations on patient safety where the consequences of not implementing them would be very serious – that is, there would be a greatly increased risk of adverse events, including death.
The NICE guidance that was used to create the pathway.
Infection control. NICE clinical guideline 139 (2012)
Surgical site infection. NICE clinical guideline 74 (2008)
Prevention and control of healthcare-associated infections. NICE public health guidance 36 (2011)
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Information for the public
NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.
Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent, the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.
If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children. If a young person is moving between paediatric and adult services their care should be planned and managed according to the best practice guidance described in the Department of Health's Transition: getting it right for young people.
Updates to this pathway
12 February 2013 Minor maintenance updates.
September 2012 Links to Prevention and control of healthcare-associated infections (NICE public health guidance 36) updated. Implementation tools added.
An aseptic technique ensures that only uncontaminated equipment and fluids come into contact with susceptible body sites. It should be used during any clinical procedure that bypasses the body's natural defences. Using the principles of asepsis minimises the spread of organisms from one person to another.
Surgery involving an incision in which no inflammation is encountered, without a break in sterile technique, and during which the respiratory tract, alimentary or genitourinary tracts are not entered.
Surgery involving an incision through which the respiratory, alimentary, or genitourinary tract is entered under controlled conditions but with no contamination encountered.
Surgery involving an incision in which there is a major break in sterile technique or gross spillage from the gastrointestinal tract, or an incision in which acute, non-purulent inflammation is encountered. Open traumatic wounds that are more than 12–24 hours old also fall into this category.
The excision or wide removal of all dead (necrotic) and damaged tissue, that may develop in a surgical wound.
'Hands on' or face-to-face contact with patients. Any physical aspect of the healthcare of a patient, including treatments, self-care and administration of medication.
An incision undertaken during an operation in which the viscera are perforated or when acute inflammation with pus is encountered (for example, emergency surgery for faecal peritonitis), and for traumatic wounds where treatment is delayed, there is faecal contamination, or devitalised tissue is present.
The use of handrub or handwashing to reduce the number of bacteria on the hands. In this pathway this term is interchangeable with 'hand hygiene'.
A preparation applied to the hands to reduce the number of viable microorganisms. This guidance refers to handrubs compliant with British standards (BS EN1500; standard for efficacy of hygienic handrubs using a reference of 60% isopropyl alcohol).
Occurs when a wound has been sutured after an operation and heals to leave a minimal, cosmetically acceptable scar.
Occurs when a wound is deliberately left open at the end of an operation because of excessive bacterial contamination, particularly by anaerobes or when there is a risk of devitalised tissue, which leads to infection and delayed healing. It may be sutured within a few days (delayed primary closure), or much later when the wound is clean and granulating (secondary closure), or left to complete healing naturally without the intervention of suturing.
People employed by the health service, social services, a local authority or an agency to provide care for a sick, disabled or elderly person.
Any waste produced by, and as a consequence of, healthcare activities.
Modern (post-1980) dressing materials. Designed to promote the wound healing process through the creation and maintenance of a local, warm, moist environment underneath the chosen dressing, when left in place for a period indicated through a continuous assessment process.
Blood flow through tissues or organs. If not optimal, it can increase the risk of infectious complications (particularly surgical site infections).
Equipment that is intended to be worn or held by a person to protect them from risks to their health and safety while at work. Examples include gloves, aprons, and eye and face protection.
Patient receiving healthcare in primary or community care
Patient receiving healthcare in primary or community care
Everyone involved in providing care should be:
- educated about the standard principles of infection prevention and control and
- trained in hand decontamination, the use of personal protective equipment, and the safe use and disposal of sharps.
Wherever care is delivered, healthcare workers mustIn accordance with current health and safety legislation (at the time of publication of the pathway [March 2012]): Health and Safety at Work Act 1974, Management of Health and Safety at Work Regulations 1999, Health and Safety Regulations 2002, Control of Substances Hazardous to Health Regulations 2002, Personal Protective Equipment Regulations 2002 and Health and Social Care Act 2008. have available appropriate supplies of:
- materials for hand decontamination
- sharps containers
- personal protective equipment.
Educate patients and carers about:
- the benefits of effective hand decontamination
- the correct techniques and timing of hand decontamination
- when it is appropriate to use liquid soap and water or handrub
- the availability of hand decontamination facilities
- their role in maintaining standards of healthcare workers' hand decontamination.
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Hands must be decontaminated in all of the following circumstances:
- immediately before every episode of direct patient contact or care, including aseptic procedures
- immediately after every episode of direct patient contact or care
- immediately after any exposure to body fluids
- immediately after any other activity or contact with a patient's surroundings that could potentially result in hands becoming contaminated
- immediately after removal of gloves.
Decontaminate hands preferably with a handrub (conforming to current British standardsAt the time of publication of the pathway (March 2012): BS EN 1500:1997.), except in the following circumstances, when liquid soap and water must be used:
- when hands are visibly soiled or potentially contaminated with body fluids or
- in clinical situations where there is potential for the spread of alcohol-resistant organisms (such as Clostridium difficile or other organisms that cause diarrhoeal illness).
Healthcare workers should ensure that their hands can be decontaminated throughout the duration of clinical work by:
- being bare below the elbow when delivering direct patient care (the Guideline Development Group considered bare below the elbow to mean: not wearing false nails or nail polish; not wearing a wrist-watch or stoned rings; wearing short-sleeved garments or being able to roll or push up sleeves)
- removing wrist and hand jewellery
- making sure that fingernails are short, clean and free of nail polish
- covering cuts and abrasions with waterproof dressings.
An effective handwashing technique involves three stages: preparation, washing and rinsing, and drying. For preparation, wet hands under tepid running water before applying liquid soap or an antimicrobial preparation. The handwash solution must come into contact with all of the surfaces of the hand. The hands must be rubbed together vigorously for a minimum of 10–15 seconds, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers. Rinse hands thoroughly before drying with good quality paper towels.
When decontaminating hands using an alcohol handrub, ensure that hands are free from dirt and organic material. The handrub solution must come into contact with all surfaces of the hand. The hands must be rubbed together vigorously, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers, until the solution has evaporated and the hands are dry.
Apply an emollient hand cream regularly to protect skin from the drying effects of regular hand decontamination. If a particular soap, antimicrobial hand wash or alcohol product causes skin irritation, consult an occupational health team.
Use of personal protective equipment
Use of personal protective equipment
Selection of protective equipment mustIn accordance with current health and safety legislation (at the time of publication of the pathway [March 2012]): Health and Safety at Work Act 1974, Management of Health and Safety at Work Regulations 1999, Health and Safety Regulations 2002, Control of Substances Hazardous to Health Regulations 2002, Personal Protective Equipment Regulations 2002 and Health and Social Care Act 2008. be based on an assessment of the risk of transmission of microorganisms to the patient, and the risk of contamination of the healthcare worker's clothing and skin by patients' blood, body fluids, secretions or excretions.
Gloves used for direct patient care:
- must conform to current EU legislation (CE marked as medical gloves for single use)At the time of publication of the pathway (March 2012): BS EN 455 Parts 1-4 Medical gloves for single use. and
- should be appropriate for the task.
Gloves must be worn for invasive procedures, contact with sterile sites and non-intact skin or mucous membranes, and all activities that have been assessed as carrying a risk of exposure to blood, body fluids, secretions or excretions, or to sharp or contaminated instruments.
Gloves must be worn as single-use items. They must be put on immediately before an episode of patient contact or treatment and removed as soon as the activity is completed. Gloves must be changed between caring for different patients, and between different care or treatment activities for the same patient.
Ensure that gloves used for direct patient care that have been exposed to body fluids are disposed of correctly, in accordance with current national legislationFor guidance see (at the time of publication of the pathway [March 2012]): Safe management of healthcare waste (2011). or local policies (see the guidance on waste disposal in this pathway).
Alternatives to natural rubber latex gloves must be available for patients, carers and healthcare workers who have a documented sensitivity to natural rubber latex.
Do not use polythene gloves for clinical interventions.
Other protective equipment
When delivering direct patient care:
- wear a disposable plastic apron if there is a risk that clothing may be exposed to blood, body fluids, secretions or excretions or
- wear a long-sleeved fluid-repellent gown if there is a risk of extensive splashing of blood, body fluids, secretions or excretions onto skin or clothing.
When using disposable plastic aprons or gowns:
- use them as single-use items, for one procedure or one episode of direct patient care and
- ensure they are disposed of correctly (see the guidance on waste disposal in this pathway).
Face masks and eye protection must be worn where there is a risk of blood, body fluids, secretions or excretions splashing into the face and eyes.
Respiratory protective equipment, for example a particulate filter mask, must be used when clinically indicated.
Safe use and disposal of sharps
Safe use and disposal of sharps
Safe use and disposal of sharps
Do not pass sharps directly from hand to hand, and keep handling to a minimum.
- must not be bent or broken before disposal
- must not be recapped.
In dentistry, if recapping or disassembly is unavoidable, a risk assessment must be undertaken and appropriate safety devices should be used.
Used sharps must be discarded immediately by the person generating the sharps waste into a sharps container conforming to current standardsAt the time of publication of the pathway (March 2012): UN3291 and BS 7320..
- mustFor guidance see (at the time of publication of the pathway [March 2012]): Safe management of healthcare waste (2011). be located in a safe position that avoids spillage, is at a height that allows the safe disposal of sharps, is away from public access areas and is out of the reach of children
- must not be used for any other purpose than the disposal of sharps
- must not be filled above the fill line
- must be disposed of when the fill line is reached
- should be temporarily closed when not in use
- should be disposed of every 3 months even if not full, by the licensed route in accordance with local policy.
Use sharps safety devices if a risk assessment has indicated that they will provide safer systems of working for healthcare workers, carers and patients.
Train and assess all users in the correct use and disposal of sharps and sharps safety devices.
Healthcare waste must be segregated immediately by the person generating the waste into appropriate colour-coded storage or waste disposal bags or containers defined as being compliant with current national legislationFor guidance see (at the time publication of the pathway [March 2012]): Safe management of healthcare waste (2011). and local policies.
Healthcare waste must be labelled, stored, transported and disposed of in accordance with current national legislation and local policies.
Educate patients and carers about the correct handling, storage and disposal of healthcare waste.
Patients who have a long-term urinary catheterView the 'Long-term urinary catheters: prevention and control of healthcare-associated infections in primary and community care' path
Patients who have enteral feedingView the 'Enteral feeding: prevention and control of healthcare-associated infections in primary and community care' path
Patients who have a vascular access deviceView the 'Vascular access devices: prevention and control of healthcare-associated infections in primary and community care' path
Paths in this pathway
- Prevention and control of healthcare-associated infections in primary and community care
- Standard principles of prevention and control of healthcare-associated infections in primary and community care
- Long-term urinary catheters: prevention and control of healthcare-associated infections in primary and community care
- Enteral feeding: prevention and control of healthcare-associated infections in primary and community care
- Vascular access devices: prevention and control of healthcare-associated infections in primary and community care
- Prevention and control of healthcare-associated infections in secondary care
- Surgical site infection: prevention and treatment
Pathway created: March 2012 Last updated: February 2013
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