Health Protection Scotland (HPS)
In 2007 Health Protection Scotland (HPS) carried out a healthcare acquired infection (HAI) prevalence survey to establish a baseline of the issue for future action. This survey found that one of the highest rates of HAI was prevalent in surgery departments (11.2%). Dougherty& Lister (2008: 51) suggest that HAI's are defined as infection occurring in patients after admission to any health care facility that was neither present nor incubating at the time of the admission. HAI is a patient safety issue and can be a significant occurrence that can impact unfavourably on patients while they receive care. This essay will consider how HAI's could be reduced and prevented in a post surgery environment in Scotland. Further, references will be provided to highlight and support the points made in this essay. Finally, this essay will consider the initiatives and actions raised to summarise in its conclusion.
An area of recognition when endeavouring to reduce, prevent and control HAI's is surveillance. The Scottish Surveillance of Healthcare Associated Infection Programme (SSHAIP) issued its surgical site infection surveillance protocol and resources pack, SSHAIP (2006:9). They indicate that surveillance is required to provide information on incidence, occurrence and trends over periods of time, this in turn can be used to decrease and help control incidents of infection and alert the establishment concerned to these when they occur. This suggests that continuous collection, subsequent analysis, understanding and feedback of this information are vital for planning and implementation of healthcare practise. This results in early warning systems, intervention, trend analysis, resource allocation and quality of care provided. NHS Scotland boards are required to implement surveillance of in-patient surgical site infection (SSI) for at least two operative procedures; this provides comparable indicators across Scotland. SSHAIP (2006). One example would be to carry out surveillance on aseptic techniques being utilised post surgery. Dougherty& Lister (2008: 51) comment that aseptic technique is the practise, procedures and equipment used under sterile conditions to prevent the risk of infection. This suggests that this could be utilised to keep a patient free from HAIs. An example being to prevent infection of surgical wounds by infectious organisms.
NHS Education for Scotland (NES) develop educational and training resources aimed at tackling HAI and reducing the impact of HAI's in healthcare. There are various programmes, examples being the Cleanliness Champions programme which promotes safe practice and safe environment. This programme includes healthcare workers and undergraduate nursing. A framework for mandatory induction training in HAI for NHS Scotland has also been introduced, NES (2004). This suggests that giving people this information helps them carry out infection control methods properly; a good understanding is beneficial to reducing the problem. An example being education on barrier nursing, Dougherty& Lister (2008: 71) define barrier nursing as utilising infection control procedures to help control the spread and purge of pathogenic organisms. This could be utilised in a post surgical ward after invasive procedures have been carried out. This would be particularly useful in source isolation for example a patient with MRSA who could be placed in a single room or provide protective isolation to patients with impaired immunity due to surgery. In barrier nursing, healthcare staff attending the patient needs to wear protective clothing and carry out the required hand hygiene protocols.
Reducing or controlling HAI's also concerns the environment within the establishment of healthcare they are in. The Healthcare Environment Inspectorate (HEI) state these areas as environment, facilities, handling and disposal of linen, waste handling and disposal, sharp handling and disposal, patient equipment, hand hygiene and clinical practise, HEI (2009:5). This suggests the focus is on the promotion and implementation of cleanliness and procedures that will break the chain of infection. One audit tools highlighted is hand hygiene. Gould et al, (2008 cited by Gould D 2009:110) comments that hand hygiene is commonly described as the most effectual method of preventing and controlling the spread of infection. This suggests that many infections in healthcare settings are transmitted to patients directly via the hands. Most models of hand hygiene are based on the World Health Organisations (WHO) concept of the "My five moments of hand hygiene" WHO (2009:123).These are before touching a patient, before clean/aseptic procedures, after body fluid exposure/risk, after touching a patient, and after touching patient surroundings. It should be noted that appropriate equipment should be used such as sinks with elbow controlled taps and pedal bins for example. Examples in a post surgical environment would be to use hand hygiene protocols as part of an aseptic non-touch technique used for dressings and care and utilisation of devices.
Many guidelines, standards and policies are in place for NHS Scotland. These cover many topics relating to reducing HAI's in a post surgery environment. Samples of this are the Scottish Intercollegiate Guideline Network (SIGN), Post Operative Management in Adults Document 77, SIGN (2004). In section six of this document it outlines guidance on hand washing, antimicrobial therapy and observations which are pivotal in identifying early signs of infection. This guidance is in the form of posters, leaflets and written text. This suggests that this information should be placed readily around the healthcare environment and also be available for the patient. The Scottish Management of Antimicrobial Resistance Action Plan 2008, Scottish Government (2008) comments that resistance to antibiotics and other antimicrobials is a key threat and is increasing. In this publication they published the steps to be implemented to improve the quality of antimicrobial prescribing and reduce the risk of resistance in an acute hospital. This suggests that as the use of antibiotic in treating HAI's becomes more prevalent, the organism builds up resistance thus leaving the antibiotic ineffective. Other examples are NHS Forth Valleys Single Room Guidelines for Isolation Purposes, NHS Forth Valley (2005) and Single Room Guidelines for Isolation Purposes, NHS Forth Valley (2010). This guideline could be used in a post surgical environment if the patient for example had MRSA or C-Diff where it would be necessary to minimise and prevent the spread of infection.
In conclusion, the consequences of poor cleanliness, education, knowledge and standards regarding HAI, should promote the importance of prevention and reduction of HAI in a post surgical environment. Helping to achieve this requires surveillance, feedback and, if necessary, implementation of changes brought about as a consequence of the feedback. Regular audits and re-audits should be carried out using the various tools and models available. Hygiene should be a priority as cleanliness is a basic measure for the maintenance of hygiene,WHO (undated). Hygiene not just for the people involved but the environment setting also. Many things prevent infection, examples being good hand hygiene, personal protective clothing, environment, waste handling and disposal, good observation of the patient. One of the objectives of NHS Forth Valley is to ensure the appliance of its standard infection control policy (SICP) to all patients and healthcare workers, in all healthcare establishments at all times, NHS Forth Valley (2010:4). This highlights the importance of breaking the chain of infection in any healthcare setting.
Information is readily available via the internet, publications, literature and advertisement to both patient and staff alike, and should be followed to the level that they are intended. According to the Nursing and Midwifery Council (NMC), a Nurse has to keep their knowledge current NMC (2008), not just practical skills but also theories, including infection control and the paths it may take. Two basic principles govern the main measures that should be taken in order to prevent the spread of nosocomial infections in health-care facilities. These are to separate the infection source from the rest of the hospital and cut off any route of transmission. WHO (2009). This suggests good underlying principles that should be applied appropriately, depending on the circumstances and environment. Patients and their friends, family or carers can also be encouraged to report any abnormalities or issues that may cause concern. Having the information and knowledge of how to reduce and control the route of transmission is vital in a post surgical setting. There should be no excuse for a lack this knowledge and skill in reducing HAI as the mechanisms are in place to provide information to all healthcare workers. The most important aspect is patient and worker safety and this should be forefront in any healthcare workers thoughts.