utbreaks of penicillin resistant Staphylococcus aureus infections were reported in the 1940s and it soon became apparent that this organism was spreading in hospitals around the world. The introduction of phage typing enabled the different epidemic strains to be characterised and a particularly virulent strain, type 80/81, was identifi ed that often infected neonates and caused furunculosis in the nursing staff. Other strains of different phage types were common causes of postoperative sepsis. In 1955, Leonard Colebrook, who had previously worked on burns infections in Birmingham, proposed that hospitals should appoint a full-time control of infection offi cer to review information on sepsis and to coordinate preventive measures. Although the idea was widely accepted, no full-time offi cers were appointed in the UK. Meanwhile, about the same time, a severe outbreak of postoperative wound sepsis occurred in the Royal Devon and Exeter Hospital where Brendan Moore was Director of the Public Health Laboratory. He was a good research worker which was infl uenced by his early mathematical training, and his organising ability was aided by his considerable Irish charm. His main interests were in the bacteriology of the environment and water and he was well known for developing a special swab for detecting enteric pathogens in sewage. However, he immediately turned his attention to the problem of staphylococcal infections and helped to implement the recommendations later published in Staphylococcal Infections in Hospitals (Ministry of Health, 1959). These included the setting up of an Infection Control Committee and a ward record of infections fi lled in by the medical staff. These records were often inaccurate and although improved if completed by ward sisters, the information obtained was often too late to introduce useful preventive measures. He also observed in a study of sutures in infected wounds that the staphylococci isolated from them were mercury resistant and were often epidemic strains. This enabled him to develop a laboratory test for early recognition of epidemic strains in advance of phage typing results. Another major staphylococcal outbreak in Torbay hospital, which was some distance from Exeter, attracted Brendan Moore's attention. An Infection Control Committee had also been set up and a surgeon, Mr AM Gardner, was appointed as the Infection Control Offi cer, but although interested, he had limited time available for epidemiological studies. The local laboratory facilities were also unable to deal with all the swabs required. The Matron, Mrs Stamm, on Brendan Moore's suggestion and with the agreement of the hospital secretary and the consultants, offered the full-time services of a hospital sister to help in the ascertainment and prevention of infection in patients and to collect clearance swabs from staff. Miss E Cottrell was the fi rst Infection Control Sister (ICS) to be appointed in the country in 1959. She had been a theatre superintendent, which provided suitable background experience, and she was senior enough to be able to discuss problems with all staff, ranging from surgeons to ward cleaners. She played a major part in developing the role of Infection Control Nurse (ICN) today ( Moore, 1961 ; Gardner et al, 1962 ). The success of the ICS in Torbay led to the appointment of Sister Forman in Exeter in 1960. At that time, ward sisters were asked to keep a diary containing details of infection. The diary was inspected by the ICS on her daily rounds and further information added as necessary. A daily visit to the laboratory was also made listing the isolations of epidemic staphylococci, providing evidence of potential outbreaks. Sister Forman recognised the importance of microbiology in this new post and since no formal training was available she joined the laboratory technicians in their lectures. As well as surveillance, she also helped in assessing the adequacy of ward techniques in relation to teaching practices. The daily identifi cation of clinical infections enabled the incidence of infection to be calculated in the hospital or ward, but it was early recognised by Brendan Moore that the number of infections was usually too small for statistical comparisons to be made between hospitals as originally shown by Owen Lidwell, and infections arising after discharge of a patient from hospital were often missed. He described these diffi culties at the fi rst International Conference on Nosocomial Infections at the Centers for Disease Control (CDC), Atlanta in 1970 and explained how in Exeter the presence of an ICS visiting the wards every day enabled infected patients to be identifi ed more rapidly and where appropriate sent to the local isolation hospital ( Moore, 1971 ). A number of other hospitals with problems of infection were interested in the appointment of an ICS but were often uncertain of their duties. The newly appointed nurses often spent most of the day at their desks recording data on infection or collecting nasal swabs from staff, but useful action was often not followed. Others visited wards reprimanding staff for hygienic errors without the necessary knowledge to assess risks. A few ICSs were able to visit Exeter to discuss their role with Brendan Moore and Sister Forman. It was therefore decided by Brendan Moore, assisted by Rodney Cartwright, to organise an educational residential conference in Lyngford House, Taunton, in 1966. A small group of us, mainly interested bacteriologists and ICSs attended and heard talks by the Torbay and Exeter teams and discussed the problems found by the newly appointed ICSs. Further annual meetings were held in Taunton in 1967 and 1968 and with the increasing numbers of ICSs, a larger meeting was held in Birmingham in 1969 organised locally by Kathy Brightwell, the Infection Research Nurse, and her colleagues in the Hospital Infection Research Laboratory (HIRL). The only society at the time with a primary interest in hospital infection was the Central Sterilizing Club, which did not fulfi l the nurses’ requirements, and in 1970 at the Annual Conference in Bristol the Infection Control Nurses Association (ICNA) was formed. Dr Brendan Moore was the fi rst President, Henry Street from Torbay was the fi rst Chairman, Annette Seekers (previously Viant) from Bristol was appointed Secretary and Kathy Brightwell the Treasurer. One of the problems discussed was the membership and it was decided that only Infection Control Nurses should be full voting members.Whether this was the best decision remained uncertain because many Infection Control Offi cers (ICO) – later changed to Infection Control Doctors (ICD) – did not join as they were unwilling to be associate members (non-voting). This also applied to some Infection Control Technicians, particularly those from Holland, O
Data is an essential tool for convincing healthcare workers to accept that problems exist, inspire them to better performance, or demonstrate that their performance is improving. Infection control professionals have access to a wealth of data on healthcare associated infections. Using simple graphical examples this paper illustrates how data can be analysed and presented in accessible ways that will help infection control practitioners to better understand infection problems and to use the information to influence practice.
To investigate the environmental contamination of rooms of patients colonised with meticillin resistant Staphylococcus aureus (MRSA), we conducted a prospective study during a five month period in a French university hospital. Environmental samples were taken once per week for each MRSA included patient, until the patient was discharged. The surfaces swabbed were the covers, the lifting pole, the bed bars, the table and the trolley. A 500-litre air sample was collected with an impactor air sampler, and a Petri dish was left open in the room for two hours. The aims of the study were to assess the impact of nasal decolonisation and dressing changes on the day of sampling on environmental contamination of the room. Thirty patients were included in this study. In total, 37.5% of the rooms tested positive: surface samples were positive in 11.8% of cases (39/320), and air samples were positive in 17.9% of cases (23/128). Much higher levels of contamination were observed on days on which dressings were changed, in the absence of nasal decolonisation with mupirocin. This study shows that the environment is often contaminated in the rooms of patients with MRSA. Our results are consistent with the findings of other studies suggesting that the environment may play an important role in the persistence of hospital epidemics, and that this contamination should be taken into account in the organisation and delivery of care and in evaluations of preventive measures.
Many features of the NHS conspire to make workforce planning different and difficult. It is often integrated with other planning processes. There are few available guidelines for workforce configurations of infection control (IC) teams or evidence that assesses the effectiveness of different staffing configurations. A telephone survey of IC practice in four NHS trusts in England was undertaken to assist an NHS foundation trust to evaluate the workforce options for reconfiguring their IC team. The calls were semi-structured, recorded qualitative data and lasted 30-40 minutes. The thematic analysis revealed three IC themes: working practices, workforce profiles and governance issues, and suggested that multi-disciplinary, hospital-based IC teams have a strategic approach to engagement with clinical areas. The background, purpose and findings of the survey are reported and the implications for the future evidence base of IC practice.
SAGE Publications, Los Angeles, London, New Delhi and Singapore 10.1177/1469044607085545 4 British Journal of Infection Control JANUARY 2008 VOL. 9 NO. 1 ecently a colleague asked me, ‘So, what do you do in the HPA?’ This question took me back to a time when working in a profession dedicated to the prevention of healthcare associated infections (HCAI) was not at all in vogue. When I used to tell people I worked in infection control, always, without fail, I got the same response: raised eyebrows, followed by a frown and a blank look combined with a ‘what’s that?’ This was the response from friends, family and surprisingly from many healthcare workers both in and out of the hospital setting. Now we have a different picture. Infection control in hospitals is challenging healthcare professionals, confounding politicians and providing headlines for the media. At social occasions, everyone has an opinion on why hospitals have ‘super bugs’ and how the cleanliness of the hospital is the solution to everything. The media have of course blurred the boundaries between fact and fiction with some exaggerated headlines. However, rather than see these recent developments as negative, they could be viewed in a positive light because ultimately the increased exposure has led to an increased awareness that there is a problem with healthcare associated infections. Political interest in driving down healthcare associated infections has added to this and resulted in the generation of a number of policy documents and directives.
Effective hand hygiene practice within health care is widely recognised as being one of the single most important interventions to control and prevent the spread of healthcare associated infection (HCAI). This study aimed to explore nurses' and patients' perceptions towards patient hand hygiene and determine whether patients who required assistance with their hand hygiene were encouraged and offered appropriate facilities at appropriate times. In January 2007, within an acute teaching hospital in Scotland, six observational sessions, each lasting 4 hours were undertaken, 33 nurses completed a survey questionnaire, and interviews were carried out with 22 patients who required hand hygiene assistance. 100% of nurses and 95% of patients believed that patient hand hygiene was an important part of controlling and preventing HCAI. 64% of nurses reported having offered patients facilities to decontaminate their hands during the observational period, but only 14% of patients agreed with this. Out of 75 patient hand hygiene opportunities identified, facilities were provided on only one occasion. Despite nurses believing patient hand hygiene is an important part of preventing and controlling HCAI, unless patients are able to undertake this task independently, they are rarely encouraged or offered facilities to do so.
A variety of infection prevention and control precautions are used to minimise the risk of infection spread from person to person, both patients and staff. Standard Precautions (SPs), including hand hygiene and use of personal protective equipment (PPE), are applied routinely to all patients, whereas transmission-based precautions (TBPs) are used when a patient is known or suspected to have an epidemiologically important infectious disease or condition, in order to further reduce the risk of spread of infection. The use of single room isolation is part of TBPs and is a cornerstone of hospital infection prevention and control practice. However, successfully implementing TBPs, including single room isolation, continues to be a challenge in the UK for a number of reasons. Effective approaches to increasing the quality and safety of patient care are increasingly based on utilising simple tools that increase the likelihood that care will be provided in a reliable way. The tool presented is intended to facilitate both learning and practice in relation to TBPs and to promote the delivery of safe patient care in relation to single room isolation. It is designed for use in those situations when a single room is available for patient isolation. It also highlights the other important TBPs to be taken to prevent the spread of infection, whether or not a single room is available. It can be adapted for use with any organism or disease for which TBPs are recommended. At a time when healthcare associated infections (HCAI) such as Clostridium difficile and meticillin resistant Staphylococcus aureus (MRSA) continue to have an impact on both acute and community care settings, and their reduction is embedded within national targets for NHS healthcare providers, tools that make it easy for healthcare workers to apply safe practices within their daily routines are essential. Initial testing suggests that this tool is acceptable to healthcare workers and further study will identify its potential contribution to healthcare workers' knowledge and practice in this area.
A pilot research study was undertaken on two tertiary care wards to examine factors influencing hand hygiene compliance. This comprised environmental audit and observation of individual staff for two hour periods. Although it was labour intensive, observation proved a valuable tool in highlighting problems in risk assessment. The results show that hand hygiene was performed following a high proportion (59%) of hand hygiene opportunities, but not in accordance with local guidelines, due predominately to choice of inappropriate hand decontamination agent and/or unnecessary use of gloves. These errors in individual decision-making processes about the choice of hand hygiene measures may be the reason why motivational interventions can be ineffective, and they need to be addressed before audit of compliance can be meaningful.
Annually about 45,000 European Muslims attend the Hajj pilgrimage in Mecca, Saudi Arabia. One in seven pilgrims with respiratory symptoms suffers from proven influenza and upwards of one in 25 from respiratory syncytial virus (RSV) (Rashid et al, 2008). To investigate whether travellers bring these infections back home we conducted a pilot survey on pilgrims with flulike illness who returned home after the Hajj 2005 by setting up clinics at two UK mosques. The East London and the Aylesbury mosques situated in London and in Buckinghamshire were chosen to represent dense and moderately dense Muslim populations respectively.
The aim of this audit was to establish the knowledge of different healthcare workers regarding meticillin resistant Staphylococcus aureus (MRSA) infection control precautions within the clinical environment. Data was interpreted to identify how education could be appropriately targeted to enhance the knowledge of all staff. A cross-sectional audit tool was developed from existing policies and national guidelines. Stratified random sampling was undertaken and 961 audits were distributed proportionately to differing groups of healthcare workers from within one UK NHS hospital; 411 audits were returned giving a 43% response rate. The majority of staff (71%) felt that MRSA is a very serious issue. The amount of staff that had read the trust's MRSA policy or received any formal MRSA education varied considerably, depending on the healthcare worker's occupation, and it was predominantly the nursing staff who had read the MRSA policy. It was unexpected, but encouraging, to find that unregistered nurses (healthcare assistants) and doctors had received the most education regarding MRSA. Of concern was that the majority of hotel services staff (69%) had not read the policy or received any MRSA education (79%). Only medical staff felt they had received adequate amounts of education on MRSA.
Aims: This paper aims to provide a better understanding of divisions between the espoused and actual infection control practice of staff working within a renal unit and to investigate the sources of knowledge used to underpin practice. Background: Healthcare associated infection continues to be a major problem for health services. It has been claimed that healthcare associated infections may be reduced by around a third through the use of effective infection control measures. The effectiveness of these measures will rely upon the learning and skills of those implementing them. Methods: The study employed a primarily qualitative approach using participant observation and semi structured interviews over a six month period on a renal unit within a district general hospital. Results: Results gained provided some indication of a gap between espoused and actual compliance with infection control policy in practice while also indicating that tacit knowledge and learning in practice may offer an effective means of gaining and implementing infection control knowledge. Conclusions: This study highlights divisions between espoused and actual infection control practice, it also emphasises the role of tacit learning and how tacit knowledge may be gained and employed in practice.
Every NHS trust is expected to have a Director of Infection Prevention and Control (DIPC). What might work well for organisations directly providing clinical services is increasingly inappropriate for primary care trusts (PCTs) as they lose their provider functions. This paper discusses the potential role for the PCT DIPC in the future, with increasing emphasis on the role in commissioning.
Since July 2007 the Department of Health (DH) in England and the NHS Purchasing and Supply Agency (NHS PASA) have been working jointly and have developed the HCAI Technology Innovation Programme, which has been formally acknowledged in the DH HCAI strategy for 2008 — Clean Safe Care (DH, 2008). Funding has been made available to support the programme as part of the Comprehensive Spending Review for 2008-09. This paper provides an overview of the programme including the predicted benefits and outcomes. The actual outcomes from the programme will be published as academic papers in a range of journals, including the journal of the Infection Prevention Society.
Hospital acquired infection severely affects patients, prolongs hospital stays and presents a major challenge for quality of patients' care (Emmerson et al, 1996; Hand washing Liaison Group, 1999). Improvement in hand hygiene can help in reduction of hospital acquired infection (Hand washing Liaison Group, 1999; Kilpatrick et al, 2007; Whitby et al, 2007; Duerink et al, 2006; Sohn et al, 2005; Jumaa 2005; Randle et al, 2006). Three observational audits were carried out to ascertain existing hand hygiene practice. In the first audit, prescribed standards were achieved in only 29% of cases. After appropriate educational interventions, a repeat study after three months showed significant improvement in up to 84% of cases. The final audit, eight months after the second study, showed that although consultants and registrars had maintained high standards (90%), senior house officers' (SHOs) practice deteriorated (46%). Although both SHOs and registrars changed during this period, only SHO performance deteriorated. Possible reasons may be either that SHOs need more education, or that because they have a busier workload, omission is more common among them, but, this requires more exploration. Conclusion: Hand hygiene is a simple but important practice. Repeat audits plus education appears to drive up standards. Recommendations: To achieve desirable and sustained behaviour change, there is a need to present information on hand hygiene to all doctors at regular intervals. Regular but random covert surveillance observation of practice with a professionals' prior consent appeared to assist in improving practice in this study.
A pilot study using an integrated care pathway (ICP) when caring for patients suffering from Clostridium difficile associated disease (CDAD) was undertaken over a six-month period within six wards in two hospitals. The aim was to standardise practice and improve communications for this group of patients. There was increased staff knowledge and understanding with 91% of nursing staff reporting that the use of a CDAD ICP had improved patient care and treatment. Seventy-seven per cent of staff expressed that communications had improved since using the ICP and 77% felt that accessibility of patient information had improved. Lastly 86% of the staff felt better equipped to nurse patients with CDAD. A literature review yielded no other documented evidence of the use of an ICP for this patient group.
