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2.1. INTRODUCTION
2.1.1 Communicable diseases and endogenous or opportunistic infection still present a formidable challenge to health and health care delivery in the community. Infection control in the primary care setting has obvious relevance for healthcare professionals, patients and their carers - such as relatives and home helps. Mindful of the UKCC Code of Professional Conduct, which requires all nurses to protect patients and colleagues from cross infection, the Royal College of Nursing has produced Guidelines for nurses in general practice6.
Infections treated or acquired in hospital are potential problems when patients are discharged back into the community, either to their own homes or to nursing or residential homes. This is particularly true of multiresistant organisms such as MRSA for which specific DoH guidance is available7,8. Infection control issues need to be borne in mind, therefore, whenever patients are discharged from hospital and should be the concern of senior and junior doctors as well as nursing staff. There should be good communication and liaison between the hospital staff discharging the patient and the primary care team who will take over responsibility for the patient's care. Written information should be passed timeously from hospital units to primary care. Support and advice is also available from the Public Health Medicine Department of Health Boards and from CMM and CICN.
2.1.2 New infections - and the resurgence of old infections, continue to engender public concern. Human Immunodeficiency Virus (HIV) infection and other bloodborne viruses, notably Hepatitis B and C, have placed an additional burden on health care teams relating to counselling, infection control, individualised treatment, management of the family and contacts and education relating to these issues. Concern is frequently expressed about transmission of these bloodborne viruses in the Community. Universal precautions should be observed at all times, with the major elements reinforced in ongoing staff education and incorporated in posters/charts clearly displayed at strategic locations e.g. surgeries and clinic side rooms. Protection of healthcare workers and patients from bloodborne virus infection is particularly important and detailed guidance is available 9, 10. (See also Chapter 8 and Appendix 3)
Meningococcal infection in the community also gives rise to much anxiety. Guidance on appropriate measures for control has been produced by the CPHM(CI)/EH) Working Group in Scotland11. This guidance is regularly reviewed and updated.
2.1.3 There are important legal responsibilities associated with infection control and these are embodied in The Health and Safety at Work Act, COSHH Regulations, Management of Health and Safety at Work Regulations and The Environmental Protection Act (see Appendix 2). These are as applicable in the primary care setting as in the secondary/tertiary care sector. Indeed, as contractors, GPs are responsible as employers for the Health and Safety of their staff as well as their patients.
It is advisable for all GPs to prepare a written safety policy which will cover the use of specialised equipment such as autoclaves and the handling of substances hazardous to health e.g. chemical disinfectants, pathogenic organisms, used sharps and other clinical waste. There is also a statutory obligation to keep a detailed record of all accidents on the premises, including needlestick injuries.
2.1.4 Resistant bacteria such as MRSA and MRK are an increasing problem in healthcare and social care settings while outbreaks of food poisoning with Salmonella spp, Campylobacter spp and E.coli 0157 continue to cause problems with a not inconsiderable incidence in Scotland. On the positive side, however, there is now general recognition that investment in disease prevention is a worthwhile and important use of available resources. Emphasis on infectious disease eradication by the use of new or improved vaccines, and a better understanding of the processes relating to infection and immunity will contribute to a positive outcome in this area as will legislation relating to the handling, sale and commercial preparation of food.
Primary prevention of infection by immunisation/vaccination and advice on behaviour modification takes place to a great extent in a primary care setting. The "green book" 12 gives the detailed recommendations of the Joint Committee on Vaccination and Immunisation both for primary immunisation of children and for adults.
2.1.5 Patients now spend significantly less time in hospital, with early discharge and increased day case management. Caring for individuals at home has many advantages for the patient -including a reduced risk of cross infection, but does pose other problems relating to infection control. Patients may, for example, require treatment that involves the use of specialised equipment - such as dialysis machines, long term central venous lines and nebulisers. Specific information is needed on the decontamination and care of this equipment in order to prevent infection in the individual and reduce the propensity for problems within the environment in which they are cared for. Infection control also has relevance for the use and handling of equipment in the community - including beds, commodes and mattresses, and systems should exist to deal with varying situations arising in different settings, e.g. in Homes for the Elderly.
Provision must also be made in the community for the safe handling and disposal of contaminated clinical waste (see Chapter 7).
2.2. COMMUNICATIONS AND NETWORKS
2.2.1 The responsibility for infection control in primary care lies with the Primary Health Care Team. Advice and guidance on infection control is available from the CPHM(CI)/EH) who co-ordinates infection control programmes on behalf of the Health Board, LA and the community as a whole. A number of CPHMs(CI)/EH) have experienced ICNs working with them.
Expert advice is available from CMMs. GPs are encouraged to make use of their expertise and experience. Specimens for microbiological examination often provide additional, more precise, information which informs clinical decision making - including antibiotic choice when prescribing, and helps in the epidemiological investigation of any outbreak. Any trend away from this practice is to be discouraged. CMMs are always available to discuss reports and to advise on more general issues related to infection and infection control. Antibiotic prescribing policies need to be regularly reviewed (see Chapter 4).
A list of statutorily notifiable diseases is shown at Appendix 4. GPs play an important part, not only in infectious disease surveillance, but also in infection control by notifying to the Department of Public Health Medicine all occurrences, or suspected occurrences, of these diseases.
2.3. THE ICN IN THE COMMUNITY
2.3.1 The role of the community infection control nurse (CICN) is a developing one. Key areas of the role include developing communication networks, advising, supporting and educating professionals, voluntary organisations and the general public and pivotal involvement in prevention and treatment of infection generally.
The ICN provides specialist nursing input within Public Health Medicine Departments, Trusts, primary care settings and the wider community on the surveillance, prevention, investigation and control of communicable disease in the community, assisting the CPHM(CI)/EH) in these functions. The following services are provided by the CICN:
• information, advice and training relevant to communicable disease
and infection control;
• access to relevant guidelines and policies;
• assistance in monitoring and auditing infection control standards
and practice;
• support to carers in the management and control of infection;
• providing communicable disease advice to the general public.
2.4. POLICIES, PROCEDURES AND GUIDELINES
2.4.1 Infection control in the primary care setting has necessarily attracted less attention than in hospitals. However, the large number of patients treated, and changes in the organisation of primary care services resulting in an increase in screening procedures and minor operations gives substantial opportunity for transmission or acquisition of infection. Doctors, dentists and nurses need to be aware of current good practice including the need for effective infection control policies and appropriate decontamination of surgical instruments. Instrument sterilisation can either be by means of an autoclave or by formal agreement with the local Sterile Service Department. In either case thorough precleaning is essential prior to sterilisation. GPs should ensure that benchtop sterilisers, which should only be used for UNWRAPPED instruments, are regularly serviced and that staff responsible for decontamination procedures are adequately trained - particularly in the use of microbicidal disinfectants and the time needed for them to work. Guidance on all aspects of the use of small benchtop steam sterilisers is contained in a MDA Device Bulletin13 and further advice is given in a Health Technical Memorandum (HTM)14. Studies have shown a lack of knowledge in primary care of the concept of sterilisation, the correct use of chemical disinfectants and the requirements for maintenance of sterilisers15.
2.4.2 All Health Centres and health care premises and the Primary Care Teams working there, should have an Infection Control Policy which includes current copies of relevant approved policies and standard operating procedures pertinent to the activities being undertaken in that area16
For example:
Handling of Used Instruments
Handwashing Techniques
Needlestick Injury Policy
Spillages (Blood and Body Fluid)
Management of an Outbreak (Copy of local outbreak plan)
Universal Precautions
Disinfection and Sterilisation
Disposal of Clinical Waste
Laundry Management
Food Hygiene (Environmental Health Department)
Handling and Transportation of Specimens
Hotel Services
Equipment and Purchasing
High Risk and Communicable Diseases
Guidance on Minor Surgery in General Practice17
This list is not exhaustive and specific local needs should be addressed.
Handwashing/Hygienic Hand Disinfection is the single most important factor in preventing the spread of infection in healthcare facilities in the community - including day care centres, nurseries and nursing homes.
All staff should be instructed in the correct technique for achieving thorough hand disinfection and compliance should be carefully monitored.
There is a requirement to ensure that appropriate protective clothing is available18 and that healthcare workers/employees are informed and instructed as to the use and purpose of these items, and their care and disposal. In the Community disposable plastic aprons and gloves (non sterile) are commonly used. Where there is any doubt as to the need for protective clothing, advice can be sought from the local ICT who will carry out a risk assessment and issue guidance.
2.5. RESIDENTIAL CARE
2.5.1 The move to care in the community and increasing longevity has resulted in a need for more residential and nursing homes. Within these settings the risks of acquiring and spreading infection are high. Elderly people are compromised by their age and frailty. Some may be catheterised. While it is important to remember that the environment is the resident's "home" and not an extension of a hospital, good basic standards of infection control are essential and should be regularly "policed". DoH advice already exists which is relevant7,8.
2.5.2 It is the responsibility of the medical practitioner and facility manager to "flag up" those residents who, if they are admitted to hospital, are carriers, for example of MRSA, MRK or other potentially infectious disease(s).
2.6. AUDIT
2.6.1 Infection Control issues and standards lend themselves to audit, and their inclusion in the programme of audit in the primary care setting should be enhanced, for example:
a) environmental audit;
b) handwashing audit;
c) antibiotic prescribing policy;
d) care of long term catheters;
e) prevention of infection spread in Nursing Homes, e.g. MRSA, E.coli 0157.
2.6.2 As a result of the increase in day-case surgery and the current emphasis on early post operative discharge, surgical wound infection presents more often to the primary care team. It is important that appropriate swabs are taken and referred for microbiological examination. Combined surveillance and audit by the primary care team and their hospital counterparts and the ICT will yield invaluable data on the true incidence of post operative wound infection. Health Boards may consider the need for surveillance as part, of the quality standards agreed with healthcare facilities.
2.6.3. All policies and procedures should be reviewed regularly by the appropriate Health Board Officer. Systems should be in place to feed back audit results to those who need to know so that appropriate action can be taken.
2.7. TRAINING
2.7.1 Opportunities should be sought to include issues relevant to infection control in undergraduate and postgraduate medical, dental and nursing education. The increasing presence of undergraduate students from many health care disciplines in the community provides scope to encourage good practice in this respect at an early stage in their careers.
2.7.2 Continuing postgraduate training should include maintaining an awareness of the changing patterns of infectious disease and developing practices relating to the prevention and control of infection in the community as well as the hospital setting.
2.7.3. Those in higher specialist training for a career in the specialty should be introduced to infection control and become associate members of the Infection Control Committee and its sub-groups.
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