6.1. INTRODUCTION
6.1.1 The prevalence of infectious disease has decreased in the population - but its variety has altered with the emergence of new or antibiotic-resistant pathogens. Demographic and social changes have also been reflected in increased prevalence of infection in the disabled elderly, e.g. soft tissue infection and in otherwise healthy young people, e.g. HIV.
6.1.2 In hospital practice - and also increasingly in the community, infections occur with multi-resistant bacteria, often a reflection of inappropriate or excessive antibiotic use49. The importation of infectious diseases has also increased with burgeoning overseas travel (for business and holidays), to countries where there is an increase in the prevalence of endemic disease due to breakdown in social structures, vector control and resistance to insecticides of disease carrying insects.
6.1.3 The last decade has also seen the re-emergence of tuberculosis, diphtheria, Group A streptococcal infections and verocytotoxin producing E.coli as problems. Relaxation in immunisation practices also results in the resurgence of disease, e.g. diphtheria in the Russian Federation. At risk groups such as overseas workers, holiday makers, immigrants, political refugees and aid workers, now enter the UK while incubating disease - and highly infectious patients are presenting to hospital Accident and Emergency Departments (either directly or via their GP), Infectious Disease Units, or General Medical Wards with a pyrexial illness shortly after returning from abroad. This may be due to malaria or invasive salmonellosis, for example.
6.1.4 All hospitals receiving acutely ill patients must have infection control policies in place. The procedures should be known to all relevant staff for the safe management of these exogenous infections and to avoid exposing staff (and other patients) to the risk of contracting infection. The movement of many classical nosocomial infections into the community, e.g. MRSA also needs consideration, as does other antibiotic-resistant bacteria, notably MRK.
6.1.5 Increasing problems are being encountered with immunocompromised patients and those with prosthetic devices in situ. These patients are susceptible to endogenous, e.g. Staph. epidermidis as well as community- acquired and opportunistic infection, and frequently require expert hospital based management, to address the problem.
6.1.6 Problems are now encountered daily with IV drug abusers who may be HIV, Hepatitis B or Hepatitis C sero positive. These patients represent a major potential hazard for all who care for them.
6.2. FUNCTION OF THE INFECTIOUS DISEASE SPECIALIST AND THE SPECIALISED UNIT
6.2.1 Clinicians in General Practice and Accident and Emergency (and other) departments often need to seek the advice of a specialist in infectious diseases. The function of these specialists combines a consultation role50,51 and provision of in-patient care in units with isolation and non-isolation beds managed by the medical and nursing team trained in the specialty.
6.2.2 The function of Infectious Disease units is two fold:
including the seriously ill patient suspected of having infection. A dedicated ward with isolation and other rooms with appropriately trained staff is more effective in managing infection than a scattering of isolation rooms widely dispersed across the hospital 52 . A recent report recommends that "Health Boards should ensure that individual rooms, preferably with en suite toilet facilities, be made available for patients with communicable disease under treatment in hospitals"1. Moreover, patients identified as colonised or infected with multiresistant pathogens, e.g. MRSA, should be managed in these units if appropriate isolation facilities cannot be guaranteed elsewhere.
(2) A part of the Infectious Disease Unit should be set aside to manage patients who do not need isolation once the nature of their illness has been clarified - but who do require specialist care, for example a patient suspected of malaria or with a pyrexia of unknown origin (PUO), especially after foreign travel.
6.3. UTILISATION OF EXISTING INFECTIOUS DISEASE/INFECTION UNITS
6.3.1 These are primarily based in teaching hospitals and were originally developed to manage infection arising in the community by isolating those patients with infection. Two recent reports1, 53 concluded that poor use was currently being made of existing facilities, available expertise was often ignored and that facilities which were in place were in danger of being lost by default. Clearly the position needs to be urgently addressed.
6.3.2 It is recommended that these specialist services be preserved and enhanced by embedding Infection Units in District General or major teaching hospitals. The trend in the USA, Scandinavia, Australia and Canada is to support the expansion of such facilities. It is hoped that the impetus to remove these infectious disease units from isolated positions, and integrate them into large multi-faceted hospitals with all necessary diagnostic and high dependency facilities, will both improve utilisation of these units and increase their role in managing patients with HAI, opportunistic, endogenous and tropical infection.
6.3.3 A more flexible approach which permits the occasional use of these beds by noninfected patients can help in periods of low occupancy and a clear understanding of the function of these units will allow their more cost-effective use in the future.
6.3.4 The importance of these units is also recognised as a base for teaching the next generation of doctors and nurses to diagnose and appropriately manage infection and for research in the specialty.
6.4. AIMS OF CURRENT RECOMMENDATIONS:
The aim of this chapter is to:
6.4.1 Identify the key areas of referral to these units.
6.4.2 Outline issues relevant to care of the infected patients and health care workers and highlight the importance of close liaison with public health personnel.
6.4.3 Highlight the essential building and staffing requirements for such a unit.
6.4.4 Identify their role in education, training, appropriate utilisation of expertise and in research.
6.5. ADMISSION PROCEDURE
6.5.1 Admission to an Infectious Disease Unit can be from:
General Practice
An Accident and Emergency Department
A ward in the same hospital
Another hospital
Port or Airport Medical Staff
or via self-referral, e.g. HIV positive patients known to the Unit.
Most units will have direct and open 24 hour access.
6.5.2 Ambulance Transport
A patient with a known or suspected infectious disease should be transferred by ambulance staff who have been made aware of the potential for infection. Use of protective clothing and subsequent equipment cleaning and ambulance disinfection will be determined by local policy and national guidelines (see also 1.4.62).
6.5.3 Accident & Ememency Department
Many non-elective admissions occur through the Accident and Emergency Department following GP or self referral. Measures to protect staff and other patients there will be according to local Trust infection control policies. If in doubt, the ICT should be immediately contacted.
6.6. CONTACT TRACING
6.6.1 This is the responsibility of the CPHM(CI)/EH) and his Team working with the involved clinicians and HICC and liaising with SCIEH, S0DoH or other CPHMs(CI)/EH) as necessary for the identification and follow up of contacts locally and in other areas.
6.7. CARING FOR THE INFECTED OR POTENTIALLY INFECTED PATIENT
6.7.1 Infectious Disease Units should provide facilities for both source and protective isolation (see 5.5 for definitions).
6.8. ACCOMMODATION /ISOLATION PROVISION
6.8.1 In special circumstances such as bone marrow transplant or severely neutropenic patients (neutrophil count <500/mmI) single room isolation facilities are desirable, existing either within the Haematology Unit or Infectious Disease Unit. Air exchange may be required and should be managed by HEPA filtration and positive ventilation51.
6.8.2 The minimum requirement for hospital management of an HIV infected patient with proven or suspected pulmonary tuberculosis which may be multi-resistant (MDRTB) is single room accommodation, preferably air vented to the outside until sputum smears are negative or the diagnosis of smear positive TB is excluded or treatment established55 . Procedures such as induced sputum, physiotherapy, nebulised therapy and bronchoscopy should be undertaken in such rooms while treatment of patients with MDRTB should be carried out only in hospitals with adequate isolation facilities56 . Ideally these should be in an Infectious Diseases Unit.
6.8.3 Patients with suspected Viral Haemorrhagic Fevers (VHF) will initially be cared for in a specialist infectious disease unit with staff fully trained in the use of containment isolation 57 . The transfer of these patients would involve close co-operation with the local CPHM(CI)/EH). No such unit exists in Scotland and the current procedure involves transferring the patient to the Royal Victoria Infirmary and Associated Hospitals Trust in Newcastle (contact address and telephone number at Appendix 5). Transfer is arranged by the involved consultant telephoning the consultant physician there if a VHF patient is suspected clinically. This should be undertaken by the Infection Disease Specialist who has placed the patient in a category of high probability. Transfer of the patient would require close collaboration with the local CPHMs(CI)/EH). See also S0DoH guidance on the arrangements for the management of patients with VHF58
6.9. INFECTION CONTROL POLICIES
Infection Control Policies should be produced by each HICC/TICC (see 1.4.9 These recommendations must be readily available to all staff and cover the following areas of activity:
6.9.1 Cleaning, Disinfection and Sterilisation policies should include a recommended list of disinfectant solutions and procedure for disinfecting/sterilising instruments28 (see 4.3.2.6). This document28 reinforces the importance/primacy of hand/forearm washing in reducing the incidence of HAI and the correct procedure for this and surgical scrub procedures.
6.9.2 A policy for domestic cleaning and the need for specially trained staff should be accepted.
6.9.3 Isolation of Patients including guidance on the indications for source or protection isolation and associated procedures e.g. the need to wear protective clothing - plastic aprons, gloves, masks and in certain circumstances goggles and the need for restricted visiting.
6.9.4 Laundry - linen should be separated into infected/non- infected articles and disposed of in the appropriately colour coded bag (see Chapter 7).
6.9.5 Clinical Waste Policy including guidance on the segregation, handling, treatment and disposal of all health care waste (see Chapter 7).
6.9.6 Bloodborne Virus Policy
Policies on the Prevention of Needlestick Injuries and guidance on the procedures to be followed in the event of exposure (e.g. needlestick or eye splashing) to bloodborne viruses are available10 (see also 8.6.2).
6.9.7 Last Offices - Handling of a body after death, including later disposal and post mortem examination should be according to the HSAC document40 and local Trust policy. If an infection hazard exists, the body should be placed in a cadaver bag with the top-end of the zip at the head and a Biohazard or Danger of Infection label should be attached to the outside of the bag. While maintaining confidentiality, hospital porters, mortuary attendants and funeral directors must be warned of possible infection risk59.
6.9.8 Patient Identification of Carrier Status
Where known, the patient's notes should be flagged and relevant personnel informed of the carrier status of the patient, e.g. MRSA.
6.9.9 Immunisation of Staff should be undertaken before they are permitted to work in an Infectious Disease Unit. Reimmunisation/vaccination would be a responsibility of the OHS. The immunisation status of bank, agency or locum staff should also be checked before they start work.
6.9.10 There is contentious evidence that regular microbiological screening of healthcare workers may be helpful in investigating outbreaks or case clusters e.g. of MRSA. Screening should be carried out when advised by the ICT.
6.9.11 Policies and procedures should be reviewed regularly. Trends in infection, referral patterns and the effectiveness of cross-infection control should be audited.
6.10. STAFF EDUCATION AND TRAINING
6. 10.1 Medical, dental and nursing students should be exposed to core knowledge of infection control and management. Specialist Grade Registrars training in the specialty, should be trained in Infection Control and encouraged to attend Infection Control Meetings. Regular training of nursing staff in infection control should be standard in Infectious Disease Units.