Infection Control
Questions Received:
Responses:
What is meant by the term Universal Precautions?
20th February 2000
These are the precautions taken by clinical staff to limit the risk of spread of infectious diseases. Such precautions mainly apply to blood and other body fluids and are widely accepted and practiced both nationally and internationally. In the UK the Department of Health regularly sets down guidelines for the Health Authorities in turn to follow. Precautions have long been established for limiting the risks associated with hepatitis B and more recently hepatitis C, and similar precautions are now taken for the control of human immunodeficiency virus (HIV). In essence the guidelines centre around safeguards aimed at reducing the risk of transferring infections from patient to practitioner, patient to patient, or practitioner to patient. The main safeguards are:
Regular hand washing using the appropriate technique
Wearing gloves when handling blood or body fluids or when in contact with soiled surfaces
Wearing plastic aprons
Wearing a mask and protective eyewear when there is a risk from irrigations, splashes or aerosols
Not resheathing needles after use
Taking care to ensure that all soiled materials or waste is disposed of correctly
The term ‘Universal Precautions’ includes those policies and procedures that govern isolation and aseptic practice.
References
Centre for Disease Control (1998) Update: Universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health settings. MMWR, 37(24), 377.
Guidance for clinical health care workers: protection against infection with HIV and hepatitis viruses. London: Smith & Nephew Medical, 1990).
Royal College of Nursing (1994) Universal precautions against hepatitis and AIDS. London: Royal College of Nursing.
Why is infection control so important in hospitals?
This is because pathogenic organisms and the various forms of illness they produce can easily spread in an environment such as a hospital. First of all many people enter a hospital with an infectious condition. Secondly patients admitted into a hospital, although they themselves may not be infected, are at risk of developing an infectious condition due to their exposure and because their illness, and in some cases the treatment they are receiving, compromises their ability to resist infection. Hospital-acquired infections (nosocomial infections) are a major problem, particularly those caused by micro-organisms such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE), and last year cost the UK National Health Service an estimated one billion pounds (Heath, 1995). The infection-control team works in close collaboration with the microbiology department, the wards, and other hospital units with the aim of limiting the risks which arise as a result of many people living and working in the close-knit hospital environment. The five fundamental infection-control measures are surveillance, isolation, hand washing, disinfection, and sterilization (Whitehouse, Sexton, and Kirkland, 1998). The education of patients, their relatives and staff is a major part of the work undertaken by the infection-control team.
References
Heath, H.B.M. (editor) (1995) Potter and Perry's Foundations in nursing theory and practice. London: Mosby, Times Mirror International Publishers Ltd (Chapter 28: Controlling Infection, pp 567-591).
Whitehouse, J.D., Sexton, D.J., and Kirkland, K.B. (1998) Infection control: past, present, and future issues. Comprehensive Therapy, 24(2), 71-77 (Feb).
There are two aspects which need to be taken into account with this question:
The rights of the of the individual who has to undergo the procedure
The duties of those who are going to carry it out.
The person undergoing the procedure has a right to know what is going to be carried out, the risks involved and what the alternatives are. And also a right to have this explained in a meaningful way.
The person performing the procedure, or someone appointed to deputise for them, has a duty to explain the procedure, the risks and the alternative forms of treatment that are available. At the same time the person providing the information would be expected to reasonably satisfy herself/himself that the person receiving this information had understood what had been imparted.
I am a staff nurse in orthopaedic theatres and require information regarding transmission of hepatitis C during surgery, i.e air borne droplets of wash and bone.
22nd March 2000
Hepatitis C is transmitted in a similar way to hepatitis B, mainly by blood or body fluids (Burkitt et al, 1996; Berger, 1998). It has a lower rate of transmission than hepatitis B following needle stick injury, the risk of infection from one percutaneous exposure being 2.7-10% (Patz and Jodrey, 1995; Fry, 2000). Since there is no vaccine for hepatitis C, the best option is to prevent exposure (Davis, 1996). The short answer therefore to this question is that "universal precautions" - undoubtedly already in place in orthopaedic theatres - apply.
In view of the risk of infection with hepatitis C associated with orthopaedic procedures, protective devices such as self-capping needles, needle-free intravenous systems and improved barrier materials have an important part to play in the prevention of infection (Patz and Jodrey, 1995).
Anything that has come into contact with blood or body fluids should be regarded as potentially infectious. Such a substance may constitute tissue handled directly or indirectly during the time of the operation or contact with instruments drapes etc that have been exposed to blood or body fluids.
The risks of contamination are clearly increased if the external body defences, particularly the skin, is breached. Theatre staff therefore should take care to cover any skin abrasions and wear gloves when handling blood or body fluids. The wearing of face masks coupled with the special airflow systems that exists in operating theatres should minimise any risks that may result from airborne droplets.
References
Berger, A. (1998) Behaviour of hepatitis C virus. British Medical Journal, 317(7156), 437 (Aug 15)
Burkitt, H., Quick, C., and Gatt, D. (1996) Principles of asepsis and infection control. In: Essential surgery problems, diagnosis and management (2nd edition). Edinburgh: Churchill Livingstone (pp 65-72).
Davis, M.S. (1996) Occupational hazards of operating: opportunities for improvement. Infection Control Hospital Epidemiology, 17(10), 691-693 (Oct).
Fry, D.E. (2000) Hepatitis: risks for the surgeon. American Surgery, 66(2), 178-183 (Feb).
Patz, J.A., and Jodrey, D. (1995) Occupational health in surgery: risks extend beyond the operating room. Australia and New Zealand Journal of Surgery, 65(9), 627-629 (Sep).
Online Resource
Department of Health - Guidance for Clinical Health Care Workers: Protection against infection with blood-borne viruses; Recommendations of the Expert Advisory Group on AIDS and the Advisory Group on hepatitis
http://www.open.gov.uk/doh/chcguid1.htm
What are the four responsibilities of an infection control nurse?
25th August 2000
The role of the infection control nurse will differ slightly from location to location, but generally the role is likely to encompass the following areas of responsibility:
Implementing and reviewing policies relating to the control of infection
Collating and reviewing data on the incidence of infection
Auditing practice and the facilities utilised to achieve and maintain infection control standards
Acting as an educational resource both to untrained and trained members of staff
Additional responsibilities might include: participating in or conducting research projects, liaising with outside agencies such as schools, colleges, and voluntary organisations, and fostering links with professional groups involved with healthcare.
We should like to thank Mrs. Penny Criddle, Clinical Nurse Specialist in Infection Control at the RD&E Hospital, Exeter, for her contribution to this answer.
I work in a nursing home and have had a client admitted with hepatitis C. Some staff are getting upset and state that he cannot have C without B. I say the we should treat him as all other clients (he is basically self care but confused) and take the usual precautions with any blood products.
28th September 2000
First of all it should not be assumed that because your client is a carrier of hepatitis C he must therefore also carry the hepatitis B virus.
Secondly, providing that universal precautions are adopted the risk of becoming contaminated is really quite small. As you are probably aware, universal precautions apply whenever handling or coming into contact with body fluids: washing hands and wearing gloves when in contact with body fluids such as urine, saliva, faeces, and particularly when in contact with the person's blood. Contact with blood and blood products is the most common mode of transmission. "Although body secretions may transmit the virus, this form of transmission is less of a risk than with HBV" (Porth 1998; HBV = hepatitis B virus). At the same time wearing a plastic apron is a wise precaution. Similarly care should be taken when disposing of materials that may have become contaminated. Here again the precautions already described should be employed.
Details of these precautions should be obtainable by contacting the Infection Control nurse at your nearest hospital. Information can also be obtained by consulting the Department of Health’s website:
www.open.gov.uk/doh/chcguid1.htm
(Guidance for clinical health workers: protection against infection with blood-borne viruses. Recommendations of the Expert Advisory Group on AIDS and the Advisory Group on hepatitis.)
Vaccination against hepatitis C is available. To pursue this you should contact your General Practitioner and your employer.
We would like to touch on the importance of sensitivity when caring for any person harbouring the hepatitis C virus. When attending to their needs, it is important to avoid conveying anything that may be construed by them as suggesting that they are different, or in some way "contaminated".
Reference
Porth, C.M. (1998) Alterations in function of the hepatobiliary system and exocrine pancreas. In: Pathophysiology: concepts of altered health states, edited by T. Gibbons. Philadelphia: Lippincott-Raven (Chapter 33, p 757).
See also
Department of Health (1990) Guidance for clinical health care workers: protection against infection with HIV and hepatitis viruses. London: Smith & Nephew.
We should like to thank Miss Heather Cann, Infection Control nurse at the Royal Devon & Exeter Hospital, Wonford, for her help with this response.
I have been told that surgical masks are only effective in preventing possible infection for 5 minutes. I have been trying to locate research to verify this. Could anyone help in identifying this research article?
24th April 2001
We have not been able to trace the exact article that you are looking for, but we are aware of other studies showing that surgical masks become less effective over time. For example, Philips et al (1992) found that a fresh face mask almost completely prevented bacterial contamination of an agar plate 30 cms from the mouth, but after 15 minutes there was a measurable increase in the level of contamination. McLure et al (1998) concluded that for procedures lasting less than 15 minutes, the operator should wear a face mask, particularly when the face is in close proximity to the operative field and the need for speaking is anticipated.
Nursing and medicine both have long traditions, and ways of doing things tend to be passed on from generation to generation of nurses and doctors. In recent years, however, there has been a questioning of some aspects of practice, and an increasing desire to move towards evidence-based interventions. This approach is also evident with regard to the use of surgical masks (Romney, 2001). Many of the practices that occur in the operating theatre and other locations where sterile procedures are being carried out are derived from the elaborate principles of antisepsis and asepsis set down by Lister. The surgical face mask has become a familiar part of the uniform worn by theatre personnel and the aims are presumably twofold - to reduce the risk of wound contamination by transfers of nasal, oral and pharyngeal micro-organisms from clinical staff to patient, and to reduce the risk of the transfer of infection from patient to clinical staff. In most modern hospitals, the wearing of a mask is compulsory within the operating theatre. Anecdotal evidence suggests that surgeons and other theatre personnel consider wearing face masks a nuisance but feel it is the "thing to do" (McCluskey, 1996). It has become such a deeply ingrained tradition that it will take a great deal of evidence to bring about a change in this practice should one be required.
Although there have been many studies into the effectiveness or otherwise of surgical masks, the evidence so far is equivocal. For example, an earlier study found that operating theatre masks made of synthetic materials appeared to protect the patient well but the wearer slightly less well (Rogers, 1980). The same study found that the cheaper paper masks worn for ward duties were less effective. A later "masked" versus "unmasked" controlled study by Tunevall (1991) concluded that although masks may be used to protect the operating team from drops of infected blood and from airborne infections, they do not appear to protect the patient operated on by a healthy operating team. A subsequent review of the literature found that the present generation of masks does not protect staff either from airborne bacteria or Hepatitis B virus (McCluskey, 1996). The use of tracer materials applied to the interior of face masks has demonstrated that contaminating materials can escape around the mask edges (Ha'eri and Wiley, 1980). There have been suggestions that face masks may be unnecessary - for example, it has been proposed that non-scrubbed staff do not need to wear face masks in operating theatres with forced ventilation (Mitchell and Hunt, 1991).
References
Ha'eri, G.B., and Wiley, A.M. (1980) The efficacy of standard surgical face masks: an investigation using "tracer particles". Clinical Orthopaedics and Related Research, 148, 160-162 (May).
McLure, H.A., Talboys, C.A., Yentis, S.M., and Azadian, B.S. (1998) Surgical face masks and downward dispersal of bacteria. Anaesthesia, 53(7), 624-626 (Jul).
McCluskey, F. (1996) Does wearing a face mask reduce bacterial wound infection? A literature review. British Journal of Theatre Nursing, 6(5), 18-20, 29 (Aug).
Mitchell, N.J., and Hunt, S. (1991) Surgical face masks in modern operating rooms--a costly and unnecessary ritual? Journal of Hospital Infection, 18(3), 239-242 (Jul).
Philips, B.J., Fergusson, S., Armstrong, P., Anderson, F.M., and Wildsmith, J.A. (1992) Surgical face masks are effective in reducing bacterial contamination caused by dispersal from the upper airway. British Journal of Anaesthesia, 69(4), 407-408 (Oct).
Rogers, K.B. (1980) An investigation into the efficiency of disposable face masks. Journal of Clinical Pathology, 33(11), 1086-1091 (Nov).
Romney, M.G. (2001) Surgical face masks in the operating theatre: re-examining the evidence. Journal of Hospital Infection, 47(4), 251-256 (Apr).
Tunevall, T.G. (1991) Postoperative wound infections and surgical face masks: a controlled study. World Journal of Surgery, 15(3), 383-387; discussion 387-388 (May-Jun).
I am currently an RN working on a Medical Surgical unit at a community hospital. I have recently found out I was pregnant and am wondering about the risks of taking care of our "isolation" patients. We frequently have cases of MRSA and VRE on our unit and my question is about the safety of healthcare workers caring for these types of contagious patients.
29th November 2004
Thank you for your enquiry into a commonly asked question. I think first of all it is worth remembering that the skin and mucous membranes (the external body defences) - provided that they are intact - are an effective barrier against invasion by micro-organisms when nursing people who are harbouring infectious organisms, or indeed organisms that have acquired specific resistance. When nursing people who require isolation you adopt the policy laid down by your local Infection Control Team, and other than this Universal Precautions are practiced. These measures, in my view, contribute significantly towards your own safety and that of your unborn child.
You may wish to make further enquiries. If you do I suggest you first check with your own Infection Control Team.
Additionally you may wish to visit the web sites of the Infection Control Nurses Association http://www.icna.co.uk/default.asp and/or the Health Protection Agency http://www.hpa.org.uk/