Health Business

Don’t break the Code

Diane Gilmour of The Association for Perioperative Practice explains the Code of Practice for infection prevention

Healthcare-associated infections (HCAIs) such as Meticillin resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C. diff) are never far from the media headlines.

This article focuses on key components of the Code of Practice on Health Care Associated Infections to show how legislation has provided the framework to ensure that not only do NHS bodies have a duty to comply with the Health Act 2006 but so do practitioners.

Documents published
Over the years various documents have been published by the government – Getting Ahead of the Curve (DH 2002); Winning Ways: Working Together to Reduce Health Care Associated Infection in England (DH 2003); Saving Lives: A Delivery Programme to Reduce Health Care Associated Infection (DH 2005); Essential Steps to Safe, CleanCare: Reducing Health Care Associated Infection (DH 2006c) – in an effort to introduce preventative measures to reduce HCAIs.

The publication of the Health Act 2006 (DH 2006b), introducing the Code of Practice for the Prevention and Control of Health Care Associated Infections (DH 2006a), is to support the reduction of HCAIs but more importantly ensures that all NHS bodies are held to account for HCAIs.

The Code of Practice is intended to help NHS bodies plan and implement strategies to prevent and control infection and sets out criteria to ensure that patients are cared for in a clean environment. The Code ensures that the risk of HCAIs is kept as low as possible.

What is an HCAI?
The Code defines an HCAI as: “Any infectious agent acquired as a consequence of a person’s treatment by the NHS or which is acquired by a Health Care Worker (HCW) in the course of their duties” (DH 2006a, p1).

NHS bodies must ensure that when commissioning services from contractors, they to have appropriate systems to protect patients, staff and visitors as “far as reasonably practicable” from HCAIs (DH 2006a).

The Code has three headings and outlines systems within each that are required to be in place to ensure that evidence-based protocols comply with the provisions within the Act to protect patients, visitors and staff:

Management, organisation and the environment.
Clinical Care Protocols.
Health Care Workers.

Under each heading are duties against which the trust (acute or other) will monitor its compliance. Each of the provisions of the basic Code applies to all acute trusts in England and Wales. Other NHS bodies such as Primary Care Trusts, Ambulance or Mental Health Trusts may be exempt from some of the other provisions.

Within the Code of Practice the duties, as listed in Table 1, are further broken down to provide additional detail to ensure application of the Code. Key aspects within the provisions impact on clinical practice.

Duty 2 part d: The NHS body must ensure that all staff whose normal duties are directly or indirectly concerned with patient care receives suitable and sufficient training, information and supervision on the measures to enable them to carry out their duties taking all necessary measures to prevent and control risks of infection (DH 2006a).

Duty 4 parts b–f: The Code designates lead managers for decontamination and requires NHS bodies to ensure that there are effective arrangements for the decontamination of instruments and other equipment.

Duty 4 Part e: There is adequate provision of suitable handwashing facilities and anti-bacterial hand rubs (DH2006a).

Duty 4 part h: Clothing worn by staff when carrying out their duties is clean and fit for purpose (DH 2006a).

Duty 10: NHS bodies must have in place core clinical care protocols for the prevention and control of infection. These include:

Standard (Universal) Precautions. This should form part of induction programmes, the policy based on evidence that includes hand hygiene and personal protective equipment and the policy audited for compliance.
Aseptic technique. The technique should be standardised, clinical procedures should be carried out in such a way that promotes and maintains the principles asepsis.
Safe handling and disposal of sharps. Protocols should include risk management and training in the management of needle-stick injuries and the provision of medical devices, which incorporate sharps protection mechanisms.
Prevention of occupational exposure to blood borne viruses (BBV) including prevention of sharps injuries.
Disinfection policy.
Control of infections with specific alert organisms such as MRSA and C. dif.

The Code of Practice reinforces the crucial need among all healthcare workers, including perioperative practitioners, to adhere to policies and procedures aimed at the prevention and control of HCAIs. We all have a legal duty to promote our codes of conduct where we do the patient no harm. Review your own policies; be involved in revising them if necessary; take the lead in auditing them; and ensure that your own practice is compliant. As part of the annual heath check the Healthcare Commission will ensure that your organisation is fit for purpose.

Know your enemy - MRSA
Meticillin-resistant Staphylococcus aureus (MRSA) is a bacterium responsible for difficult to treat infections in humans. Over the years, it has evolved an ability to survive treatment with beta-lactam antibiotics including penicillin, meticillin and cephalosporins. MRSA is especially troublesome in hospital-associated infections. In hospitals, patients with open wounds are susceptible to acquiring infections which is contracted through direct contact e.g. with hands.

Know your enemy - C diff
Clostridium difficile is a species of bacteria of the genus Clostridium. C difficile is resistant to most anti-biotics and is transmitted from person to person by the fecal-oral route. Because the organisms form heat-resistant spores it can remain in the hospital environment for long periods of time. Once spores are ingested they pass through the stomach unscathed because of their acid-resistance. They change to their active form in the colon and multiply.

About the Association for Perioperative Practice
The Association for Perioperative Practice (AfPP) was established as the National Association of Theatre Nurses, known as NATN, in 1964. It is a registered charity working to enhance skills and knowledge within operating departments, associated areas and sterile services departments. It aims to enhance the quality of care in the NHS and the independent sector throughout the UK.

AfPP also works to encourage the exchange of professional information between members and co-operation with other professional bodies. These include the Departments of Health, the Perioperative Care Collaborative, the Nursing, Midwifery and Health Visiting Advisory Committee (Scotland), the medical Royal Colleges, CNOs of all four member countries, Skills for Health and many of the British Safety Institution Committees and other groups set up to discuss specific issues.

Table 1

Systems within code	Duties required to monitor compliance: evidence-based protocols
Management, organisation and the environment	1. Duty to protect patients, staff and others from HCAIs. 2. Duty to have in place appropriate management systems for infection prevention and control. 3. Duty to assess risks of acquiring HCAIs and to take action to reduce or control such risks. 4. Duty to provide and maintain a clean and appropriate environment for health care. 5. Duty to provide information on HCAIs to patients and public. 6. Duty to provide information when a patient moves from the care of one health body to another. 7. Duty to ensure cooperation. 8. Duty to provide isolation facilities. 9. Duty to ensure adequate laboratory support.
Clinical Care protocols	10. Duty to adhere to policies and protocols applicable to infection prevention and control.
Health care workers	11. Duty to ensure, as far as is reasonably practicable, that health care workers are free of or are protected from exposure to communicable infections during the course of their work, and that staff are suitably educated in the prevention and control of HCAIs.