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Since The Scottish Office guidance on the control of hospital infection was last updated in 1998 the world of infection control has undergone substantial change. Although basic principles - such as the primacy of handwashing and universal precautions remain unchallenged, the field of conflict between health care services and an increasingly fickle population of micro-organisms becomes ever more diverse and reaches into the community with growing frequency as the duration of hospital stay shortens. Hospital acquired infection (HAI), e.g. multi-resistant Klebsiella (MRK), is becoming a problem in patients discharged to Nursing Homes, while chronic carriage of methicillin resistant Staphylococcus aureus (MRSA) creates problems when these patients are admitted to hospital. A chapter relating to infection control in the community and addressing the hospital/community interface therefore seemed both necessary and desirable in this new document, although its major thrust relates to modern hospital infection control.
Against the background of the need for infection control standards and routine surveillance of HAI are contractual agreements with patient care deliverers. It is clearly important to clarify the roles and responsibilities of Health Boards, General Practitioners (GPs), and other deliverers of care regarding infection control provision and function - and Chapter 1 endeavours to set these in context.
During the preparation of this guidance document a major outbreak of Escherichia coli (E. coli) 0157 infection arose in Lanarkshire - with implications for both hospitals and the community. In Chapter 3 the guidance on the arrangements for the management and control of major outbreaks -and in particular the need for hospitals to have a contingency plan which can be speedily activated in the event of such community outbreaks, is pertinent and addressed.
The Sub - Committee feels strongly that such a plan must clearly identify the importance of an adequate provision of appropriate isolation rooms in District General and Teaching Hospitals in order to deal with such events. The group also commends the development of the concept of having a fully staffed integrated Infection Unit facility with isolation capacity and modern ventilation in all major Scottish hospitals1 (see Chapter 5 and Chapter 6).
The recent changes in the delivery of healthcare have highlighted the close interface now existent between the hospital and its community. Infection control problems are not the exclusive prerogative of hospitals. Indeed, with shortening of in-patient stays today's hospital problem may be tomorrow's primary care dilemma (see Chapter 2). The impact of the community care programme - and the clear trend towards both early discharge and increased day case surgery is therefore highlighted. The expansion of minor surgery in primary care also places a responsibility on GPs to comply with a myriad of regulations relating to all aspects of infection control practice, e.g. use of sterilisers, disposal of waste and the procedures for protection of both staff and patients. GPs, as with their hospital counterparts, now need to embrace fully the principles of modern infection control. General guidance as to how this may best be achieved is presented in Chapter 2. A local Infection Control Policy is required - with regular audit and review of practice in order to ensure that the risk of infection is minimised and the quality of individualised care improved.
The interface between hospital and primary care is increasingly the subject of scrutiny, and the need to carry the infection control message right into the patient's home is clearly mandatory. Community or Practice Nurses may therefore find themselves both advising and caring for a growing number of "at-risk" patients on home dialysis or parenteral therapy delivered through long indwelling catheters. Ideally there should be a "seamless" infection control service which pervades all disciplines, Without barriers, but this is yet to be fully achieved.
The emergence of multiple antibiotic resistant bacteria such as MRSA, MRK and vancomycinresistant enterococci has challenged existing infection control arrangements, posing searching questions of existent policies for the prevention of cross infection and the provision and use of hospital isolation facilities. Equally important is the need to address the problem of inappropriate or excessive antibiotic use, by ensuring that effective antibiotic policies are in place and that compliance with recommendations is audited (see Chapter 4).
Contemporary medical practice is the victim of its own success. The growing numbers of elderly and immuno-compromised patients seen, and the increasing sophistication of medical biotechnology engenders enormous infection control challenges to available resources and expertise. It is essential that Infection Control Teams (ICTs) have access to expert guidance on technical matters such as hospital (including Theatre and Intensive Care Unit) design and ventilation, the use of autoclaves, sterilisation and disinfection of equipment, e.g. endoscopes, and safe disposal of clinical waste. In this document reference is made to current guidance where it exists - but it is important that expert advice should always be sought, as appropriate. Technical queries may be referred to the NHS in Scotland, Healthcare Engineering and Environment Unit (HEEU) at the University of Strathclyde (address in Appendix 5), where such expert advice is readily available (see Chapter 5).
The safe disposal of clinical waste - whether produced in the hospital or the community - is a matter of concern to infection control professionals, managers and the general public. In particular, the safe handling and disposal of "sharps" remains a major challenge in all healthcare sectors. The failure of many existing incinerators to comply with the new emission standards and the development of alternative treatment technologies has created an urgent need for a clear statement of good practice, the guidance redefining wherever possible the obligations and responsibilities of those engaged in waste management (see Chapter 7).
The growing list of identified bloodborne viruses has focused attention on the potential for transmission of infection from health care worker to patient, patient to healthcare worker and from patient to patient. The importance of universal precautions remains unchallenged - but there is a need to have an understanding of the complex ethical issues and the legal obligations now placed on both healthcare workers and employers. Here the co-operation of the ICT and Occupational Health Service (OHS) is paramount (see Chapter 8).
The control of infectious disease remains one of the great ongoing challenges in medicine. Improved vaccines will eventually influence the number of infected patients, but in the meantime the problem can only be controlled by the education of all healthcare personnel in the principles of good infection control practice. This updated guidance document attempts to achieve this.
The spectre of litigation casts a long shadow over all aspects of current healthcare practice - and the field of infection control is no exception. Competing resource demands should not be allowed to compromise the core elements of good infection control practice, which should pervade the daily professional lives of everyone involved in the delivery of high quality modern healthcare.
C Christopher Smith
Chairman
Hospital Infection Sub-Committee of the Scottish Office Department of Health's
Advisory Group on Infection
July 1998
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