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INFECTION CONTROL

Infection prevention and controlis an enormous challenge in UKhealthcare settings. The National

Institute for Health and CareExcellence [NICE] (2012) reported thatabout 300,000 people a year in Englandacquire an infection associated withtheir care as an NHS patient. Theseinfections take on greater significancein the context of increasing antibioticresistance, as healthcare-associatedinfections (HCAIs) are not always

easy to treat and can result in seriouscomplications (NICE, 2012). Meticillin-resistant Staphylococcus aureus[MRSA]and Clostridium difficilewere reportedlyresponsible for approximately 9,000deaths in hospitals and the communityin England in 2007 (NICE, 2012). Theseso-called super-bugs bacterialspecies that are able to survive exposureto antibiotics are often multidrugresistant and put a tremendousstrain on NHS resources, as well ascompromising patients recovery,quality of life and wellbeing. Crucially,

How to ensure better infection controlin the patients home

they are increasingly being seen in thecommunity (Institute for HealthcareImprovement [IHI], 2014). As well asinvestigating infection prevention andcontrol in patients homes, the authorsalso look at a range of infection controlmeasures specifically designed for usein immobile patients.

COMMUNITY CARE

Infection prevention and control can

be hard to maintain within a hospitalenvironment, but with the changingface of the NHS meaning that morecomplex care is being provided inthe community and within patientshomes (Department of Health [DH],2009), the goal of zero tolerance ofpreventable HCAIs is even more ofa challenge.

As the focus of care graduallymoves from hospitals to the

community and because the UKspopulation is ageing (Royal Collegeof Nursing [RCN], 2012) due inpart to medical improvements anincreasing amount of people withcomplex needs require healthcare

input, both in nursing and residentialcare, and also in their own homes.The amount of people with long-term complex care needs, such asthose with diabetes, is also rising(RCN, 2012), and these people arealso at greater risk of infection.

INFECTION PREVENTIONAND CONTROL

It is imperative that meticulousinfection control measures arepromoted both in hospital and bycommunity nurses overseeing care inthe community. It is also important toguard against the transfer of infectionfrom one setting to another. Infectioncontrol involves removing sources ofinfection as well as preventing thespread of infection.

The main sources of infectionare bacteria and viruses, fungi, andyeasts, and these microorganismscan live on people and animals,in the environment, and in foodand water. In the patients home,cleaning utensils such as mops,personal hygiene equipment suchas toothbrushes, and householdappliances such as fridges can allcollect harmful microorganisms

(Health Protection Agency [nowPublic Health England] [HPA], 2007).

This is also true of healthcare-related devices, such as catheters, oreven equipment that the patient mayhave been discharged with, such ascrutches or wheelchairs, as wellas surgical site infections (SSIs)(IHI, 2014).

MRSA infections used to be the

preserve of hospital patients, but areincreasingly being found in patientshomes and nursing homes (knownas community-associated MRSA orCA-MRSA), often presenting as skininfections (David and Daum, 2010).

Jackie Stephen-Haynes, professor and consultantnurse in tissue viability, Birmingham CityUniversity and Worcestershire Health and CareNHS Trust

Infection prevention and control is an enormous challenge withinthe hospital environment, but with the changing face of theNHS meaning that more complex care is being provided in thecommunity and within patients homes, the goal of zero toleranceof preventable healthcare-associated infections (HCAIs) is evenmore of a challenge. So-called super-bugs put a tremendousstrain on NHS resources, as well as compromising patients

recovery, quality of life and wellbeing, and are increasinglybeing seen in the community. This article looks at the provisionof infection control in the community and how nurses need toorganise services that involve patients in their own care. It alsoinvestigates the use of a range of infection control products,including a wash cap (octenisanwash cap [schlke]), specifcallydesigned for use in immobile patients.

KEYWORDS:Infection controlPersonal hygieneWash capsAntiseptics

Jackie Stephen-Haynes

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Other harmful microorganisms canbe airborne (such as the flu virus) ortransmitted through contact by poorhand hygiene such as C. difficile,which causes diarrhoea.

Microorganisms that can cause

infection abound in non-sterileenvironments and cuts, abrasionsand areas that are subject to invasiveprocedures all become vectorsof infection a way for harmfulmicroorganisms to enter the bodyand infect a patient (IHI, 2014).

Ulcers and wound sites areobvious areas that will be susceptibleto microorganisms such as MRSA,and care must be taken when treating

wounds that contamination does notoccur good hygiene and asepticdressing techniques for wound care,including not re-using single-useitems are essential (NICE, 2008).

WHO IS AT RISK?

Some people are more at risk ofinfection. The very old and veryyoung may have compromisedimmune systems, as will peoplewith underlying conditions (Vasto

et al, 2007).

Similarly, people who haveunderlying conditions such asdiabetes require meticulous skincare, as the peripheral neuropathythat often accompanies the diseasecan mean that injuries to thefoot go unnoticed and cuts andabrasions in that area can becomeportals of infection (as well as therebeing an increased risk of foot

ulceration) (Mousley, 2003).

NICE guidelines highlight howimportant hand-washing is forpreventing HCAIs in the community(NICE, 2012). Healthcare staffmust guard against transferringmicroorganisms from one patientto another in the community byscrupulous hand-washing particularly when dressing wounds,handling cannulas or feeding tubes, allprime areas of infection transmission.

NICE guidance cites improvedhand-washing regimens as resultingin between 30 and 45% reductionsin infection rates (Ryan et al, 2001;

The patients personal hygienealso plays a crucial role ininterrupting the spread of microbes.

Personal hygieneAs well as focusing on the nursesactions and the patients environment

when seeking to interrupt thespread of microorganisms, it is alsoimportant to look at the patientthemselves. The HPA (2007) offersthe following guidance on patientspersonal hygiene: They should regularly bathe,

shower, or undergo a full bodywash to avoid the accumulationof bacteria on the skin. This isparticularly important for thosewho are incontinent of faeces

or urine Patients should have their ownpersonal hygiene items such astowels, toothbrushes, razors,flannels, etc

Separate flannels/cloths mustbe used to wash the patientsface/body and genital/anal areas(having different-coloured flannelscan help here). Disposable clothscan be used instead

In nursing homes in particular,patients should have their own

wash bowls.

When community nurses arecommissioning or delegating carethey need to ensure that all of thestaff involved pay special attentionto patients who are immobile andunable to wash themselves orthose who may have cognitiveimpairment or perhaps do not wantto be washed.

Also, unlike in hospital where staffare on-hand 24 hours a day to ensurethat infection control protocols arebeing followed, in the community particularly in patients homes thisis not possible.

Therefore, it is necessary forcommunity nurses to researchinfection control products thatcan be used by carers and/orpatients themselves as part of aneveryday routine to help protectagainst infection. This is wheredecontaminating cleansing rangeshave a useful application, as theuse of disinfectant body lotions,shampoos and mitts can aid the

INFECTION CONTROL

Fendler et al, 2002;). Hand-washingis essential to stopping the spread ofinfection and should be performedafter every patient contact.

HOW DOES INFECTION TAKEHOLD IN THE COMMUNITY?

The patients home and, indeed,the patient themselves, can actas a reservoir for microorganisms(HPA, 2007). There are places wheremicroorganisms can take hold andthrive, including pets, furniture,food and water, as well as personalhygiene items including towels, washbowls, sponges and flannels

Patients who live alone, are

immobile, have cognitive impairment,or who are not able to look after

There are places wheremicroorganisms can take holdand thrive, including pets,furniture, food and water

their personal hygiene (in particularunwashed clothes, skin folds, hair,and nails), risk providing even more

portals for infection. It is vital that,as well as thinking about infectioncontrol with regard to their own handhygiene and clinical practices, nursestake account of the patients hygieneand physical state (HPA, 2007).

HOW CAN COMMUNITYNURSES PREVENT INFECTION?

Breaking the chain of infection in thepatients home involves targeting one

or more portals to halt the spread ofmicroorganisms (HPA, 2007). This caninclude: Using antimicrobial therapy

with careful stewardship todestroy the source of infection

Promoting good personal hygiene Protecting the patient through

immunisation Preventing microbes from

entering the body through the useof protective clothing

Use of correct aseptic techniqueby community nurses whenhandling invasive devices, andcovering wounds and catheterinsertion sites, for example, withsterile dressings, etc.

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INFECTION CONTROL

be used alongside octenisan washmitts in bedbound patients, or thosewith limited mobility who are unableto shower or bathe. The wash capsare impregnated with octenidine,a broad spectrum antimicrobial(Figure 1) (Dettenkofer et al, 2002;

Rigopoulos et al, 2009). octenisan hasa skin-friendly formulation, whichmeans that it can be used regularly bynurses, both for cleansing and to helpprotect the patient from infection.

The range is free from artificialcolours and perfumes and issuitable for all skin types evenpatients who are sensitive to soap orhypoallergenic allergies.

The octenidine-impregnated washcaps have the following benefits: Single-use reduces risk of

cross-contamination Convenient and easy for

community nurses and carersto use

They can be heated to bodytemperature to enhancepatient acceptability.

ApplicationBefore use, the patients hair should

clinician in breaking the chain ofinfection, particularly as these can beused by carers.

WHAT IS CURRENTLY BEINGUSED TO FIGHT INFECTION?

Chlorhexidine has been used for hand-washing and is good for combatingS. aureusbut it can be an irritant,

especially with repeated use (Weitzet al, 2013). Hand-washing with soapand water and using alcohol handrubs and gels is also recommended,although alcohol-based gels carrythe risk of irritation. Also, alcohol-based gels are not effective against allmicroorganisms, for example, they havebeen found to be ineffective againstnorovirus (Zimmerman, 2011).

Octenidine didhydrochloride

is a well-known antiseptic with aproven action against bacteria. In onestudy, Dettenkofer et al (2010) testedthe effect of skin disinfection withoctenidine around central venouscatheter sites, demonstrating that itwas effective in preventing infection.In 2009, Rigopoulos et al lookedat the effects of octenidine in nailinfections, concluding that it providedsafe and efficient therapeutic actionagainstPseudomonas.

THE OCTENISANRANGE

octenisan (schlke) is a rangeof wash products, which haveoctenidine didhydrochloride as an

active ingredient and are aimed atdecontamination and cleansing of thepatients whole body to aid infectioncontrol. The range includes: octenisan wash lotion: designed

for ambulant patients whocan wash themselves, this is a

complete body wash that can beused on the hair, face and delicatebody areas

octenisan wash mitts: designedfor use in patients with limitedmobility, who are unable toshower or bathe.

Nurses also need to payspecial attention to patientswho are immobile and unable

to wash themselves

In addition to octenisan washmitts and octenisan wash lotion,a new product the octenisanwash cap is also now available,providing community nurses with arange of infection control applicationsfor use in the patients home.

octenisan wash capsoctenisan wash caps are designed to

Figure 1.octenisan wash caps are impregnatedwith octenidine, a broad-spectrum

antimicrobial, and are designed toprovide optimum patient comfort.

Mr A was 75 years old andlived in a care home

with nursing support.After many years of cigarettesmoking, Mr A managed to stop,but as a consequence gained a

significant amount of weight. Hehad a body mass index (BMI) of 35and was clinically obese. He alsohad hypertension and congestivecardiac failure, which led to markedlimitations in his physical activityand an increase in breathlessnessand fluid retention.

Because of his deterioratingcondition, Mr A was booked intohospital for a full medical assessment.

However, before being admittedhe had to be screened for bacterialcolonisation and was prescribed afive-day decolonisation protocol.

The care home staff alreadyused octenisan antimicrobial washlotion for hair and whole-body

washing, but as Mr A had limitedmobility, it was agreed to useoctenisan wash mitts and octenisan

wash caps at his bedside.

One of the care home nursescommented: It was very quick andeasy to use the wash mitts and caps.The octenisan wash cap was placedon Mr As head, completely coveringhis hair, then massaged thoroughlyand left for five minutes.

While the cap was working,we used a pack of wash mitts,

which were heated, to wash MrAs body. Using only one pack foreach resident also helped reducethe risk of cross-contamination.

Case studyCare home resident requiring hospital admission for bacterial colonisation screening

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INFECTION CONTROL

be dry and untreated (no hair gel,mousse or hairspray). The cap isplaced on the patients head thenmassaged thoroughly and left for fiveminutes to completely saturate thehair. After use, the hair can be rinsedwith water and dried if preferred

by the patient, although this is notabsolutely necessary, enabling easiercare for bed-bound patients.

The single-use wash caps canbe heated to body temperaturein a microwave before use (for amaximum of 20 seconds at 600W),helping to make the experience ofhair washing more comfortable forthe patient. It is not necessary touse the wash cap in conjunction

with any additional agent. Duringa full treatment period, the nurseshould stress to the patient and/or carers that the hair should becombed as little as possible betweenwash cap applications.

Precautionsoctenisan wash caps should notbe applied in cases of known orsuspected allergy to any of theingredients (community nursesshould crosscheck ingredients withpatient notes). The caps should alsobe avoided in combination withanionic surfactants (compoundsthat act as detergents) as they canimpair the cleansing action. Otherprecautions include: Do not use octenisan wash caps

in combination with PVP iodineproducts

Do not use the octenisan washcap with other soaps, ointments,oils, enzymes or similar agents

Use only for a limited periodof time

When using octenisan wash capsbe careful not to allow eye contactwith the solution. If the solutiondoes get into the patients eyes,rinse them thoroughly with water.

CONCLUSION

It is common practice now toprovide infection control measures

in the hospital environment, butwith more care being providedin patients homes, infectioncontrol prevention measures alsoneed to be more accessible in thecommunity setting.

octenisan wash caps can form aninvaluable infection control tool fornurses caring for people in their ownhomes as well as in hospital. They aresafe to use, highly effective and lesscorrosive than many disinfectants,thereby deserving a place in the

nurses infection control armoury. Thewash caps are also designed to beused on fragile, sensitive skin.

With care moving closer tohome and an increase in long-termconditions, there is likely to be a rise inimmobility and problems with personalhygiene. Against this background, anyrange of products that makes infectioncontrol easier for nurses, carers andpatients alike is to be welcomed.

REFERENCES

David MZ, Daum RS (2010) Community-

associated methicillin-resistant

staphylococcus aureus: epidemiology

and clinical consequences of an

emerging epidemic. Clin Microbiol Rev

23(3):61687

Dettenkofer M1, Wilson C, Gratwohl

A, et al (2010) Skin disinfection with

octenidine dihydrochloride for central

venous catheter site care: a double-

blind, randomized, controlled trial. Clin

Microbiol Infect16(6):6006

DH (2009) Transforming Community Services:

ambition, action, achievement. Transforming

services for acute care closer to home. DH,

London

Fendler EJ, Ali Y, Hammond BS, Lyons MK,

Kelley MB, Vowell NA (2002) The impact

of alcohol hand sanitizer use on infection

rates in an extended care facility.Am J

Infect Contr30(4):22633

HPA (2007)HPA South-West Community

Infection Control Guidelines for CommunitySettings. HPA, London

IHI (2014)Reducing MRSA Infections:

staying one step ahead. Available

at: www.ihi.org/resources/Pages/

ImprovementStories/ReducingMRSA

InfectionsStayingOneStepAhead.aspx

(accessed 9 April, 2014)

Mousley M (2003) Diabetes and its effect

on wound healing and patient care.Nurs

Times99(42):70

NICE (2008) Surgical Site Infection: prevention

and treatment of surgical site infection.

NICE, London

NICE (2012)Infection: prevention and control of

healthcare-associated infections in primary and

community care. NICE, London

RCN (2012) Going Upstream: nursings

JCN

contribution to public health: prevent,

promote and protect. RCN, London

Rigopoulos D, Rallis E, Gregoriou S, et

al (2009) Treatment of Pseudomonas

nail infections with 0.1% octenidine

dihydrochloride solution. Dermatology

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Ryan MA, Christian RS, Wohlrabe J (2001)

Handwashing and respiratory illness

among young adults in military training.

Am J Preventive Med 21(2):7983

Vasto S, Colonna-Romano G, Larbi A,Wikby A, Caruso C, Pawelec G (2007)

Role of persistent CMV infection in

configuring T cell immunity in the elderly.

Immunity & AgeingAvailable at: http://

www.immunityageing.com/content/4/1/2

(accessed 22 May, 2014)

Weitz NA, Lauren CT, Weiser JA, et al (2013)

Chlorhexidine gluconateimpregnated

central access catheter dressings as a

cause of erosive contact dermatitis: a

report of 7 cases.JAMA Dermatol149(2):

1959

Zimmerman R (2011) Alcohol-based hand

sanitizers associated with norovirus

outbreaks.MedscapeAvailable at: http://

www.medscape.com/viewarticle/737884

(accessed 21 May, 2014)

KEY POINTS

Infection prevention and controlis a daily challenge in many UKhealthcare settings.

Approximately 300,000 people

a year in England acquire aninfection associated with theircare as an NHS patient.

Super-bugs put a tremendousstrain on NHS resources aswell as compromising patientsrecovery, quality of life andwellbeing and are increasinglybeing seen in the community.

Infection control is difficultenough for nurses within

hospitals, but with the changingface of the NHS meaning thatmore complex care is beingprovided in the community, thegoal of zero tolerance is evenmore of a challenge.

The article also investigatesthe use of a range of infectioncontrol products, including awash cap (octenisanwash cap[schlke]), specifically designedfor use in immobile patients.

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