Infection control issues clarified

The risk of transmission of blood-borne viruses such as hepatitis C cannot be eliminated through immunisation of healthcare staff or treatment following exposure. It is essential all perioperative staff understand the transmission routes of blood-borne viruses and the measures required to prevent cross-infection.

This article outlines the basic principles of infection control in the perioperative setting. It aims to clarify the concept of standard precautions to ensure perioperative staff manage all patients’ blood and body fluids in the same way. It also explains the legal consequences when healthcare organisations fail to reasonably manage the risk.

The perioperative setting is a high risk area in which the exposure to blood-borne pathogens is particularly high. Inherent within perioperative nursing care is the requirement to assess and manage the risk of infection. The perioperative practitioner therefore plays a pivotal role in promoting infection control procedures within the perioperative setting and is accountable for promoting evidence-based practice infection control measures.

However, common infection control rituals have been documented (Parker 1999, Redfern 2001, Hospital Infection Society 2002). Many perioperative practitioners fail to question, test and, if necessary, abandon outdated practices in favour of evidence-based practice.

Tanner et al (2007) highlighted noncompliance with recommended guidelines for hand antisepsis. Though guidelines have been available in the UK compliance among practitioners remains patchy. The guidelines from AfPP (2005) and the Hospital Infection Society (2002) recommend a two minute scrub for all scrubs. Tanner et al research indicated the majority of initial scrubs lasted for between three and five minutes with shorter durations for repeated and subsequent scrubs.

It is essential registered professional practitioners continually reflect and examine the clinical effectiveness of their practice. The question they should ask themselves is whether they are culpable of practising ritually rather than basing infection control procedures on evidencebased practice? This critical thinking will need to be benchmarked by the fact that when it comes to managing the risk of infection, all perioperative staff have a duty of care to administer care in the best interests of the patient and registered professionals are also accountable to their regulatory body to:

“Deliver care based on current evidence, best practice and, where applicable, validated research when it is available.” (NMC 2004).

REAL RISK

The risk of being infected with blood-borne pathogens during clinical invasive procedures is real. The emergence of increasing incidences of human immunodeficiency virus (HIV), hepatitis B (HBV) and C (HCV), tuberculosis (TB), Multi-resistant staphylococcus aureus (MRSA) and Transmissible Spongiform Encephalopathy (CJD) demonstrate the need for perioperative staff to be vigilant and ensure adequate safeguards are in place against potential contamination from blood-borne disease and “superbug” infection. There are 63,500 adults living with HIV/AIDS in the UK, over a third of whom remain unaware of their infection (Health Protection Agency 2006).

Hospitals that infect patients have been widely reported by the media and such reports cause patients and the public much concern. Patients put their mutual trust and confidence in perioperative carers to ensure infection control policy is adhered to and they come to no harm during their perioperative stay. Within the NHS in Scotland it is estimated approximately 9% of patients entering Scottish hospitals acquire an infection, equating to at least 100,000 infections costing £180 million per year (Scottish Executive 2002). Similarly 9% of hospital patients who require hospital treatment within the UK may pick up a healthcare associated infection (HAI) while in hospital (National Audit Office 2004), costing the NHS budget £1 billion a year. For a patient acquiring a HAI this could mean 11 extra days in hospital. Surgical site infections also account for 11% of all healthcare associated infections.

These statistics are reliable evidence of why stringent infection control measures are required and monitored for effectiveness within perioperative settings to ensure the perioperative facility is managing the risk of infection as far as is reasonably practicable.

In recent years the Government has increased its efforts to combat the high incidence of healthcare acquired infection culminating with the publication of the Healthcare Act (October 2006). The Act introduced a new Code of Practice for the prevention and control of health care associated infections. The Government wants infection rates substantially reduced over the next two years and the new code is an example of a proactive measure to help reduce infection rates. The purpose is to help NHS and Independent healthcare hospitals within England and Wales to plan and implement effective infection prevention and control measures.

Organisations which fail to comply with the code will be investigated by the Healthcare Commission and could be sanctioned with an improvement notice, special measures or reported to the Health and Safety Executive. The Health and Safety Executive has sufficient authority to prosecute healthcare organisations where it is evident there have been failures with infection control measures. Such prosecutions may occur under the Health and Safety at Work Act 1974 Section 3 alleging a breach of duty of care owed by an employer to the general public. Healthcare associated infection covers any infection by any infectious agent acquired as a consequence of treatment for a medical condition or acquired by a healthcare worker in the course of duties (DH Code of Practice 2006).

CAUSES OF CROSS-INFECTION

Perioperative staff should understand the cause of cross-infection in order to assess the risk. Occupational exposure to infected blood and body fluids can occur where there is:

• Cutaneous contamination where the healthcare worker has cuts or breaks in the skin and has not covered with a waterproof dressing.

• Mucous membrane contamination. Blood contact with broken skin or mucous membranes provides a route of transmission whenever contact with blood or other body fluids is anticipated. There have been at least four documented cases of US workers who sero-converted after being exposed to HIV infected blood through contact with mucous membranes (Stringer et al 2001).

• Percutaneous contamination. These injuries are caused by sharp objects such as medical devices, needles and blades which cause inoculation of infected blood.

LITIGATION

The possibility that patients, or the relatives of deceased patients, would sue an NHS Trust on the basis that an infectious disease had been contracted during a hospital stay is growing in likelihood (Dimond 2006).

The mention of MRSA or any other healthcare acquired infection on a death certificate may be grounds for a litigation claim.

The National Audit Office (2004) suggested clinical negligence claims in respect of healthcare associated infections, in particular MRSA, are increasing. A patient suffering a surgical site infection would have to establish whether a system failure in infection control procedures occurred which caused the infection.

According to civil law and the law of negligence a patient, or relatives of a deceased patient with cause of death established as a HAI, would have to prove on the balance of probabilities:

• A duty of care was owed to the patient.

• There was a breach of the duty of care because a reasonable standard of care was not followed.

• The breach of the duty of care led to foreseeable harm.

• The law recognises the harm caused as being subject to compensation.

The healthcare facility owes a duty of care to the patient as well as its employees to ensure infection control systems are in place to prevent the patient acquiring an infection as a result of a clinical intervention or clinically invasive procedure. Safe systems would include whether an infection control policy existed and whether such a system is regularly reviewed and updated in accordance with best practice. A safe system of working also includes assurance staff were appropriately trained and competent in administering infection control practice.

The law requires reasonable care is taken to prevent the risk of cross-infection. Within perioperative practice the law would require registered staff to follow a reasonable standard of evidence-based practice. This is known as the Bolam Test which is currently the standard by which the courts assess clinical practice.

“The test is the standard of the ordinary skilled man exercising and professing to have that special skill. A man need not possess the highest expert skill at the risk of being found negligent… it is sufficient if he exercises the skill of an ordinary competent man exercising that particular art.”

Therefore the healthcare worker would have to justify his/her actions for not complying with local infection control policy and whether this would be supported by competent professional opinion. A registered perioperative practitioner who was identified as spreading MRSA due to not complying with local hand washing protocols would be as culpable as a practitioner who administered the wrong drug to a patient.

HOW IS RISK MANAGED?

An independent multi-disciplinary working group (2005) identified while protecting patients from the risk of contracting an infection or infections is of vital importance in the operating theatre, protecting theatre personnel from the risk of acquiring infections from patients is equally as important. The most widely used strategy to reduce the risk of infection is a system of standard precautions, previously referred to as universal precautions. This system requires that all patients’ body fluids be treated as potentially infectious.

Universal precautions (UP)

The term “universal precautions” (UP) was introduced in 1987 by the Centers for Disease Control in Atlanta, US. This was in response to the need to establish a set of guidelines for healthcare workers that would define ways of minimising the transmission of blood-borne pathogens and increase awareness of dangerous practices.

The concept of UP suggests that all patients should be assumed to be infectious and therefore be treated with full infection control precautions. This universal approach also aimed to protect healthcare staff with the introduction of mandatory personal protective equipment consisting of gloves, gowns, aprons, face masks and eye protection.

However, the reality of the introduction of universal precautions within perioperative practice in the UK was that they often were only applied to patients known to be of high risk or infected with a blood-borne virus. Whether a lower standard of care with regard to precautions for individuals not suspected of being at risk was occurring is debatable but such a situation left an inherent danger of leaving a false sense of security as any patient requiring surgery could potentially be a high risk.

There is no system in use which can detect 100% of infected patients (Wicker 1991). Therefore a new approach to managing the risk was required. With increasing numbers of patients being treated, best practice recommended that all patients are treated as potentially infected. The Centers for Disease Control 1998 (US) therefore recommended that universal precautions were replaced with standard precautions. Additional precautions can be taken when judged when it is known a patient is of high risk.

Standard precautions (SP)

All patients have the right to be treated with dignity and respect, and the use of standard precautions eliminates the risk of random inappropriate practice which was often inherent with the application of universal precautions previously. The aim of standard precautions is to reduce the risk of staff contact with blood and body fluids. In essence they assess the activity to be completed and not the individual who is to receive the care. The Hospital Infection Society 2002 and the Association for Perioperative Practice, formerly known as the National Association of Theatre Nurses, 2005 recommend:

“That a standard set of precautions be established for every invasive procedure, with additional risk assessment of each patient to determine extra and specific precautions that may be appropriate.”

Principles of standard precautions

Hand washing: This is the most effective method of management of cross-infection especially in the battle against MRSA and should occur (ICNA 1997)

• If hands are visibly contaminated.

• After the removal of protective clothing.

• Between patient contacts.

• After contact with blood and body fluids.

• Before invasive procedures.

• Before handling food.

Skin: Cuts and abrasions in any area of exposed skin should be covered with a dressing which is waterproof, breathable and is an effective viral and bacterial barrier (RCN 2002).

Gloves: A local glove protocol should exist and establish which gloves are appropriate for the clinical procedure or aspect of care. Gloves should be worn wherever there is potential contact with blood or body fluids.

• Gloves must be worn only once for one aspect of patient care.

• Gloves must be of good quality and provide adequate protection and must be changed and discarded after each patient episode or if visibly contaminated.

• Double gloving is required if there is a risk of penetration such as when handling surgical instrumentation.

Impervious gowns/plastic aprons:

• Disposable plastic aprons or water impermeable gowns should be worn whenever splashing with body fluids is anticipated. A standard, re-enforced surgical gown offers greater protection from blood/body fluids than an apron as more of the body is covered.

• Impervious gowns/plastic aprons should be worn during decontamination of theatres.

• Aprons should be single patient use only and changed immediately if contaminated.

Eye and face protection: Water repellent visor masks or goggles should be worn when there is a risk of body fluid splashes to the face. Perioperative staff should be aware of aerosol or splash contamination especially if power tools are being used such as drills and saws. Sharma et al (1997) found blood splashes on 23% of masks and 16% of goggles worn by scrub nurses during 100 Caesarean sections. The incidence of splashes for surgeons was even higher with blood found on 40% of masks and 50% on their goggles. As a result of the high incidence of blood splashes staff are urged to wear protective masks and eyewear for all operations and reduce the risk of acquiring viral disease. For care of patients with smear positive respiratory TB, high efficiency filter masks should be worn during cough induction, bronchoscopy and for prolonged contact.

Sharps: Special precautions are required for the management of sharps.

• Sharps bins should be free from protruding sharps and stored off the floor.

• The temporary closure mechanism should be utilised when the bin is not in use.

• Needles and syringes must not be disassembled prior to disposal and should be discarded as one unit

• Surgical blade removers are recommended.

• Sealed bins should be stored in a locked holding area away from public access.

Accidental exposure. In the event of a sharps or needlestick injury:

A Encourage bleeding.

B Wash area thoroughly with soap and water.

C Cover with a waterproof dressing.

DNote the name of the patient, if known.

E Report to line manager and document the incident

F Report to occupational health.

GIf the patient is thought to be HIV positive, post-exposure prophylaxis (PEP) may be required. This should be given as soon as possible after injury. The DH 2004 reviewed prophylaxis policy for HIV and recommends administering an anti-HIV drug such as Zidovudine in combination with other anti-HIV drugs soon after exposure to blood/body fluids can reduce the transmission of the HIV virus.

HIf the conjunctivae or mucous membrane is splashed with blood or body fluid irrigate with copious amounts of saline and follow steps D to G.

Spillage: When managing blood or body fluid spillage, local infection control policy should be adhered to. The principles include:

• Wear apron and gloves for personal protection.

• Absorb liquid using paper towels, mop or spillage boom depending on amount of spillage.

• For blood spills apply 1% hypochlorite solution and leave for 2 minutes according to manufacturers’ instructions.

• Clean area with detergent and water and dry.

• Discard cleaning equipment into designated yellow clinical waste bags.

• If there is a risk of excessive blood/body fluid loss occurring, use collecting drapes where practicable to reduce risk of spillage.

• The operating table should be protected and covered with a non-permeable sheet.

• Floor suction devices should be considered.

THEATRE ENVIRONMENT

The designs of modern operating theatres are based on Health Building Note 26: Facilities for surgical procedures published by NHS Estates 2004. The guidance provides scientific principles of asepsis to the physical layout of perioperative settings. The promotion of asepsis and compliant theatre design reduce the risk of infection by controlling the working environment. Fox 1997 refers to the movement of staff, surgical instruments and patients as “circuits of hygiene” in theatre and says they are constant reminders of the need to adhere to aseptic techniques.

Staff working in the operating theatre are the main source of airborne bacteria especially when walking around the operating theatre (Hambraeus 1988).

Therefore, the number of staff within the theatre and their movement should be restricted. The type of ventilation system used in the operating theatre is one of the main factors which will determine the number of organisms in the air. The ventilation system is designed to control the temperature and humidity of the operating theatre and to dilute microbial contamination and expired anaesthetic gases by affecting at least 20 air changes per hour without recirculation and by moving air from clean to less clean areas (Gilmour 2004). Laminar flow ventilation results in less air contamination compared to conventional plenum ventilation. The aim of an ultra clean ventilation system is to provide clean filtered air in the zone in which the operation is to be performed and sterile medical devices are exposed. A multicentre study of 8,052 joint replacement operations demonstrated ultra clean ventilated theatres reduced the incidence of deep joint sepsis substantially compared with operations carried out in conventional plenum ventilated theatres (Lidwell O.M. et al 1987). A temperature maintained at 37°C and high humidity is optimal for bacteria. Therefore keeping the temperature lower at 20-24°C and maintaining humidity at 50%-55% may inhibit bacterial growth (NATN 2000). Professional standards for perioperative practice define the benchmark for clinical practice which must be achieved in any perioperative setting. The Association for Perioperative Practice, formerly the National Association of Theatre Nurses, published Standards and Recommendations for Safe Perioperative Practice (2005) and included national guidelines for decontamination and infection control to help formulate local policies. Healthcare facilities with perioperative settings are advised to use the guidance when formulating and reviewing local infection control policies.

Infection control is everyone’s responsibility. It is not possible to irradiate infection totally but there is a need to ensure the current incidence of infection is reduced. This will be a challenge for us all due to emerging new pathogens and the evolution of antibiotic resistant organisms. Link this with a sicker, older patient population more susceptible to infection than ever before, and it becomes evident there has never been such a need for perioperative practitioners to be safe with their practice, to be sure of their local infection control policy and to never forget their duty of care to the patient.

REFERENCES

1 Bolam v Friern Hospital Management Committee (1957) 1 WLR 582.

2 Centers for Disease Control 1987. Recommendations for prevention of HIV transmission in health care settings. Morbidity and Mortality Weekly Report 36,3: 3-18.

3 Centers for Disease Control 1998 USPHS/IDSA. Guidelines for the Prevention of Opportunistic Infections in Persons Infected with Human Immunodeficiency Virus. Morbidity and Mortality Weekly Report 46 ,1-46 http://wonder.cdc.gov/wonder/prevguid/ m0048226/m0048226.asp

4 Department of Health 2006. Code of Practice for the prevention and control of healthcare associated infections. DH London. http://www.dh.gov.uk/assetRoot/ 04/13/93/37/04139337.pdf

5 Department of Health 2004. HBN 26 Facilities for Surgical Procedures Volume 1. NHS Estates Leeds ISBN 10: 0113224958.

6 Department of Health 2004. HIV post-exposure prophylaxis: guidance from the UK chief medical officers. Expert Advisory Group. DH London.

7 Dimond B. 2006. Infection control: the rights of the patient. British Journal of Nursing Vol 15 No12 5-6.

8 Fox N. 1997. Space, sterility and surgery: circuits of hygiene in the operating theatre. Social Science of Medicine 45: 5, 649-657.

9 Gilmour D. 2004. Infection control principles, Chapter 7 p87 in A Textbook of Perioperative Care. Elsevier Churchill Livingstone ISBN 0-443-07285-X.

10 Hambraeus A. 1988. Aerobiology in the operating room – a review. Journal of Hospital Infection 119 Supplement A 68-76.

11Health Protection Agency 2006. http://www.hpa.org.uk/infections/ topics_az/hiv_and_sti/hiv/epidemiology/ introduction.htm

12 Hospital Infection Society Report. April 2002. Behaviours and rituals in the operating theatre. Journal of Hospital Infection. http://www.his.org.uk/_db/ _documents/Rituals-02.doc

13 Infection Control Nurses Association. 1997. Guidelines for Hand Hygiene. ICNA.

14 Lidwell O.M. et al 1987. Ultraclean air and antibiotics for the prevention of post operative infection. A multicentre study of 8052 joint replacement operations. Acta Orthop Scand 58:1-13.

15 National Association of Theatre Nurses. 2005. Standards and Recommendations for Safe Perioperative Practice. AfPP, Harrogate.

16 National Association of Theatre Nurses. 2000. Safeguards for invasive procedures. AfPP, Harrogate.

17 National Audit Office. 2004. Improving patient care by reducing the risk of hospital acquired infection. Report by the Controller and Auditor General. http://www.nao.org.uk/pn/03-04/ 0304876.htm

18 Nursing Midwifery Council. 2004. Code of professional conduct: standards of conduct, performance and ethics. NMC London. http://www.nmc-uk.org/aDisplay Document.aspx?DocumentID=201

19 Parker L. 1999. Ritual or Reason? Nursing Times Vol 95 May 19, No20 60-63.

20 Redfern S. 2001. Does perineal fallout exist? Myths and rituals in the operating room. Australian College of Operating Room Nurses. Spring 2001 19-23.

21 Report from an Independent Multidisciplinary Working Group 2005. Trust and Protection: Protecting Operating Theatre Staff from the risk of infection. HSD Communications, Rickmansworth.

22Royal College of Nursing. 2002. Universal Precautions for the control of infection. RCN London. Publication code 000 264.

23 Scottish Executive. 2002. Preventing infections acquired while receiving healthcare: The Scottish Executives Action Plan to Reduce the Risk to Patients, Staff and Visitors. Scottish Executive, Edinburgh. http://www.scotland.gov.uk/ Publications/2002/10/15677/12344

24 Sharma J. et al. 1997. Blood splashes to the masks and goggles during Caesarean section. British Journal of Obstetrics and Gynaecology 104:12, 1405-1406.

25 Stringer et al. 2001. Quantifying and Reducing the Risk of Blood borne Pathogen Exposure AORN Journal Vol 73 No6 1135-1146.

26Tanner J. et al. 2007. National survey of hand antisepsis practices. Journal of Perioperative Practice Vol 17 No1 27-37.

27Wicker P. 1991. Universal Precautions- Infection Control in a High Risk Environment. British Journal of Theatre Nursing Vol 1 No9 16-18.

John Beesley
John Beesley, RGN, LLM Healthcare Law, BA (Hons) NEBOSH, is and RCN Officer, Yorkshire and Humberside.