76 JCN 2014, Vol 28, No 3

INFECTION CONTROL

Infection prevention and control is an enormous challenge in UK healthcare settings. The National

Institute for Health and Care Excellence [NICE] (2012) reported that about 300,000 people a year in England acquire an infection associated with their care as an NHS patient. These infections take on greater significance in the context of increasing antibiotic resistance, as healthcare-associated infections (HCAIs) are not always easy to treat and can result in serious complications (NICE, 2012). Meticillin-resistant Staphylococcus aureus [MRSA] and Clostridium difficile were reportedly responsible for approximately 9,000 deaths in hospitals and the community in England in 2007 (NICE, 2012). These so-called ‘super-bugs’ — bacterial species that are able to survive exposure to antibiotics — are often multidrug resistant and put a tremendous strain on NHS resources, as well as compromising patients’ recovery, quality of life and wellbeing. Crucially,

How to ensure better infection control in the patient’s home

they are increasingly being seen in the community (Institute for Healthcare Improvement [IHI], 2014). As well as investigating infection prevention and control in patients’ homes, the authors also look at a range of infection control measures specifically designed for use in immobile patients.

COMMUNITY CARE

Infection prevention and control can be hard to maintain within a hospital environment, but with the changing face of the NHS meaning that more complex care is being provided in the community and within patients’ homes (Department of Health [DH], 2009), the goal of zero tolerance of preventable HCAIs is even more of a challenge.

As the focus of care gradually moves from hospitals to the community and because the UK’s population is ageing (Royal College of Nursing [RCN], 2012) — due in part to medical improvements — an increasing amount of people with complex needs require healthcare

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

INFECTION PREVENTION AND CONTROL

It is imperative that meticulous infection control measures are promoted both in hospital and by community nurses overseeing care in the community. It is also important to guard against the transfer of infection from one setting to another. Infection control involves removing sources of infection as well as preventing the spread of infection.

The main sources of infection are bacteria and viruses, fungi, and yeasts, and these microorganisms can live on people and animals, in the environment, and in food and water. In the patient’s home, cleaning utensils such as mops, personal hygiene equipment such as toothbrushes, and household appliances such as fridges can all collect harmful microorganisms (Health Protection Agency [now Public Health England] [HPA], 2007).

This is also true of healthcare-related devices, such as catheters, or even equipment that the patient may have been discharged with, such as crutches or wheelchairs, as well as surgical site infections (SSIs) (IHI, 2014).

MRSA infections used to be the preserve of hospital patients, but are increasingly being found in patients’ homes and nursing homes (known as community-associated MRSA or CA-MRSA), often presenting as skin infections (David and Daum, 2010).

Jackie Stephen-Haynes, professor and consultant nurse in tissue viability, Birmingham City University and Worcestershire Health and Care NHS Trust

Infection prevention and control is an enormous challenge within the hospital environment, but with the changing face of the NHS meaning that more complex care is being provided in the community and within patients’ homes, the goal of zero tolerance of preventable healthcare-associated infections (HCAIs) is even more of a challenge. So-called ‘super-bugs’ put a tremendous strain on NHS resources, as well as compromising patients’ recovery, quality of life and wellbeing, and are increasingly being seen in the community. This article looks at the provision of infection control in the community and how nurses need to organise services that involve patients in their own care. It also investigates the use of a range of infection control products, including a wash cap (octenisan® wash cap [schülke]), specifically designed for use in immobile patients.

KEYWORDS:Infection control Personal hygiene Wash caps Antiseptics

Jackie Stephen-Haynes

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78 JCN 2014, Vol 28, No 3

Other harmful microorganisms can be airborne (such as the flu virus) or transmitted through contact by poor hand hygiene — such as C. difficile, which causes diarrhoea.

Microorganisms that can cause infection abound in non-sterile environments and cuts, abrasions and areas that are subject to invasive procedures all become vectors of infection — a way for harmful microorganisms to enter the body and infect a patient (IHI, 2014).

Ulcers and wound sites are obvious areas that will be susceptible to microorganisms such as MRSA, and care must be taken when treating wounds that contamination does not occur — good hygiene and aseptic dressing techniques for wound care, including not re-using single-use items are essential (NICE, 2008).

WHO IS AT RISK?

Some people are more at risk of infection. The very old and very young may have compromised immune systems, as will people with underlying conditions (Vasto et al, 2007).

Similarly, people who have underlying conditions such as diabetes require meticulous skin care, as the peripheral neuropathy that often accompanies the disease can mean that injuries to the foot go unnoticed and cuts and abrasions in that area can become portals of infection (as well as there being an increased risk of foot ulceration) (Mousley, 2003).

NICE guidelines highlight how important hand-washing is for preventing HCAIs in the community (NICE, 2012). Healthcare staff must guard against transferring microorganisms from one patient to another in the community by scrupulous hand-washing — particularly when dressing wounds, handling cannulas or feeding tubes, all prime areas of infection transmission.

NICE guidance cites improved hand-washing regimens as resulting in between 30 and 45% reductions in infection rates (Ryan et al, 2001;

The patient’s personal hygiene also plays a crucial role in interrupting the spread of microbes.

Personal hygieneAs well as focusing on the nurse’s actions and the patient’s environment when seeking to interrupt the spread of microorganisms, it is also important to look at the patient themselves. The HPA (2007) offers the following guidance on patient’s personal hygiene: They should regularly bathe,

shower, or undergo a full body wash to avoid the accumulation of bacteria on the skin. This is particularly important for those who are incontinent of faeces or urine

Patients should have their own personal hygiene items such as towels, toothbrushes, razors, flannels, etc

Separate flannels/cloths must be used to wash the patient’s face/body and genital/anal areas (having different-coloured flannels can help here). Disposable cloths can be used instead

In nursing homes in particular, patients should have their own wash bowls.

When community nurses are commissioning or delegating care they need to ensure that all of the staff involved pay special attention to patients who are immobile and unable to wash themselves — or those who may have cognitive impairment or perhaps do not want to be washed.

Also, unlike in hospital where staff are on-hand 24 hours a day to ensure that infection control protocols are being followed, in the community — particularly in patients’ homes — this is not possible.

Therefore, it is necessary for community nurses to research infection control products that can be used by carers and/or patients themselves as part of an everyday routine to help protect against infection. This is where decontaminating cleansing ranges have a useful application, as the use of disinfectant body lotions, shampoos and mitts can aid the

INFECTION CONTROL

Fendler et al, 2002;). Hand-washing is essential to stopping the spread of infection and should be performed after every patient contact.

HOW DOES INFECTION TAKE HOLD IN THE COMMUNITY?

The patient’s home and, indeed, the patient themselves, can act as a reservoir for microorganisms (HPA, 2007). There are places where microorganisms can take hold and thrive, including pets, furniture, food and water, as well as personal hygiene items including towels, wash bowls, sponges and flannels

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

‘There are places where microorganisms can take hold and thrive, including pets, furniture, food and water’

their personal hygiene (in particular unwashed clothes, skin folds, hair, and nails), risk providing even more portals for infection. It is vital that, as well as thinking about infection control with regard to their own hand hygiene and clinical practices, nurses take account of the patient’s hygiene and physical state (HPA, 2007).

HOW CAN COMMUNITY NURSES PREVENT INFECTION?

Breaking the chain of infection in the patient’s home involves targeting one or more portals to halt the spread of microorganisms (HPA, 2007). This can include: Using antimicrobial therapy —

with careful stewardship — to destroy the source of infection

Promoting good personal hygiene Protecting the patient through

immunisation Preventing microbes from

entering the body through the use of protective clothing

Use of correct aseptic technique by community nurses when handling invasive devices, and covering wounds and catheter insertion sites, for example, with sterile dressings, etc.

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INFECTION CONTROL

be used alongside octenisan wash mitts in bedbound patients, or those with limited mobility who are unable to shower or bathe. The wash caps are impregnated with octenidine, a broad spectrum antimicrobial (Figure 1) (Dettenkofer et al, 2002; Rigopoulos et al, 2009). octenisan has a skin-friendly formulation, which means that it can be used regularly by nurses, both for cleansing and to help protect the patient from infection.

The range is free from artificial colours and perfumes and is suitable for all skin types — even patients who are sensitive to soap or hypoallergenic allergies.

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

cross-contamination Convenient and easy for

community nurses and carers to use

They can be heated to body temperature to enhance patient acceptability.

ApplicationBefore use, the patient’s hair should

clinician in breaking the chain of infection, particularly as these can be used by carers.

WHAT IS CURRENTLY BEING USED TO FIGHT INFECTION?

Chlorhexidine has been used for hand-washing and is good for combating S. aureus but it can be an irritant, especially with repeated use (Weitz et al, 2013). Hand-washing with soap and water and using alcohol hand rubs and gels is also recommended, although alcohol-based gels carry the risk of irritation. Also, alcohol-based gels are not effective against all microorganisms, for example, they have been found to be ineffective against norovirus (Zimmerman, 2011).

Octenidine didhydrochloride is a well-known antiseptic with a proven action against bacteria. In one study, Dettenkofer et al (2010) tested the effect of skin disinfection with octenidine around central venous catheter sites, demonstrating that it was effective in preventing infection. In 2009, Rigopoulos et al looked at the effects of octenidine in nail infections, concluding that it provided safe and efficient therapeutic action against Pseudomonas.

THE OCTENISAN® RANGE

octenisan (schülke) is a range of wash products, which have octenidine didhydrochloride as an

active ingredient and are aimed at decontamination and cleansing of the patient’s whole body to aid infection control. The range includes: octenisan wash lotion: designed

for ambulant patients who can wash themselves, this is a complete body wash that can be used on the hair, face and delicate body areas

octenisan wash mitts: designed for use in patients with limited mobility, who are unable to shower or bathe.

‘Nurses also need to pay special attention to patients who are immobile and unable to wash themselves’

In addition to octenisan wash mitts and octenisan wash lotion, a new product — the octenisan wash cap — is also now available, providing community nurses with a range of infection control applications for use in the patient’s home.

octenisan wash capsoctenisan wash caps are designed to

Figure 1.octenisan wash caps are impregnated with octenidine, a broad-spectrum antimicrobial, and are designed to provide optimum patient comfort.

M r A was 75 years old and lived in a care home with nursing support.

After many years of cigarette smoking, Mr A managed to stop, but as a consequence gained a significant amount of weight. He had a body mass index (BMI) of 35 and was clinically obese. He also had hypertension and congestive cardiac failure, which led to marked limitations in his physical activity and an increase in breathlessness and fluid retention.

Because of his deteriorating condition, Mr A was booked into hospital for a full medical assessment. However, before being admitted he had to be screened for bacterial colonisation and was prescribed a five-day decolonisation protocol.

The care home staff already used octenisan antimicrobial wash lotion for hair and whole-body washing, but as Mr A had limited mobility, it was agreed to use octenisan wash mitts and octenisan wash caps at his bedside.

One of the care home nurses commented: ‘It was very quick and easy to use the wash mitts and caps. The octenisan wash cap was placed on Mr A’s head, completely covering his hair, then massaged thoroughly and left for five minutes.

‘While the cap was working, we used a pack of wash mitts, which were heated, to wash Mr A’s body. Using only one pack for each resident also helped reduce the 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 is placed on the patient’s head then massaged thoroughly and left for five minutes to completely saturate the hair. After use, the hair can be rinsed with water and dried if preferred by the patient, although this is not absolutely necessary, enabling easier care for bed-bound patients.

The single-use wash caps can be heated to body temperature in a microwave before use (for a maximum of 20 seconds at 600W), helping to make the experience of hair washing more comfortable for the patient. It is not necessary to use the wash cap in conjunction with any additional agent. During a full treatment period, the nurse should stress to the patient and/or carers that the hair should be combed as little as possible between wash cap applications.

Precautionsoctenisan wash caps should not be applied in cases of known or suspected allergy to any of the ingredients (community nurses should crosscheck ingredients with patient notes). The caps should also be avoided in combination with anionic surfactants (compounds that act as detergents) as they can impair the cleansing action. Other precautions include: Do not use octenisan wash caps

in combination with PVP iodine products

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

Use only for a limited period of time

When using octenisan wash caps be careful not to allow eye contact with the solution. If the solution does get into the patient’s eyes, rinse them thoroughly with water.

CONCLUSION

It is common practice now to provide infection control measures in the hospital environment, but with more care being provided in patients’ homes, infection control prevention measures also need to be more accessible in the community setting.

octenisan wash caps can form an invaluable infection control tool for nurses caring for people in their own homes as well as in hospital. They are safe to use, highly effective and less corrosive than many disinfectants, thereby deserving a place in the nurse’s infection control armoury. The wash caps are also designed to be used on fragile, sensitive skin.

With care moving closer to home and an increase in long-term conditions, there is likely to be a rise in immobility and problems with personal hygiene. Against this background, any range of products that makes infection control easier for nurses, carers and patients 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): 616–87

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 Infect 16(6): 600–6

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 Contr 30(4): 226–33

HPA (2007) HPA South-West Community Infection Control Guidelines for Community Settings. 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 Times 99(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: nursing’s

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 218: 67–8

Ryan MA, Christian RS, Wohlrabe J (2001) Handwashing and respiratory illness among young adults in military training. Am J Preventive Med 21(2):79–83

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 & Ageing Available at: http://www.immunityageing.com/content/4/1/2 (accessed 22 May, 2014)

Weitz NA, Lauren CT, Weiser JA, et al (2013) Chlorhexidine gluconate–impregnated central access catheter dressings as a cause of erosive contact dermatitis: a report of 7 cases. JAMA Dermatol 149(2): 195–9

Zimmerman R (2011) Alcohol-based hand sanitizers associated with norovirus outbreaks. Medscape Available at: http://www.medscape.com/viewarticle/737884 (accessed 21 May, 2014)

KEY POINTS Infection prevention and control

is a daily challenge in many UK healthcare settings.

Approximately 300,000 people a year in England acquire an infection associated with their care as an NHS patient.

Super-bugs put a tremendous strain on NHS resources as well as compromising patients’ recovery, quality of life and wellbeing and are increasingly being seen in the community.

Infection control is difficult enough for nurses within hospitals, but with the changing face of the NHS meaning that more complex care is being provided in the community, the goal of zero tolerance is even more of a challenge.

The article also investigates the use of a range of infection control products, including a wash cap (octenisan® wash cap [schülke]), specifically designed for use in immobile patients.

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