1 Infection prevention and control (IP&C)

A healthcare associated infection (HCAI) can be defined as 'an infection occurring in a patient during the process of care in a hospital or other healthcare facility, which was not present or incubating at the time of admission. This includes infections acquired in the hospital but appearing after discharge and also occupational infections among staff of the facility' (WHO, 2011). Figure 1.1, Boxes 1 and 2, describes individual patient and other risk factors for the development of HCAIs; Box 3 lists the top six HCAIs.

HCAIs are significant harm events and healthcare staff have to be aware of their implications, not just from an individual patient perspective (patients can, and do, die from infections that they did not come into hospital with, or contracted as a result of hospital or other healthcare intervention), but also in the wider context. It is important to have a high awareness of the possibility of HCAI in both patients and healthcare staff to ensure early and rapid diagnosis resulting in effective treatment and containment of infection.

The introduction of national reduction, and local 'stretch', targets for MRSA bloodstream infections (see Chapter 43) and Clostridium difficile (see Chapter 31) , has kept these organisms at the top of the Department of Health agenda and in the media spotlight since 2004. These targets have largely been successful.

The focus has been on the implementation of evidence-based best practice and adherence to sound infection prevention and control practice, supported by a large number of Department of Health / NHS England / Public Health England drives, initiatives and legislation. MRSA and C. difficile, however, are just the tip of the iceberg, as the nature of infections and infectious diseases is constantly evolving. At the time of writing, the greatest 'infection control' threat that the NHS is facing is not from pandemic influenza (see Chapter 41) or another outbreak of Ebola virus disease (see Chapter 33) but from multi-drug resistant Gram-negative bacteria (see Chapter 29), which presents a global public health threat and, perhaps, the beginning of a world without antibiotics. The application of, and compliance with, infection prevention and control as part of everyday practice is going to become more crucial to patient care than ever, given the risk of patients dying from infections that previously could have been treated.

Organisms causing HCAIs

Figure 1.1, Box 4, lists the 'alert organisms' that are commonly implicated in HCAIs, as they can cause cross-infection and outbreaks in healthcare settings. There are also a number of 'alert conditions' that have wider public healthcare implications (see Figure 1.1, Box 5).

While HCAIs are, on the majority of occasions, acquired as a result of cross-infection arising from exposure to other colonised or infected patients or staff, they can arise endogenously from the patient's own resident microbial population, particularly where invasive devices (see Chapters 20 and 30) are inappropriately managed. Communicable diseases (see Chapter 2) acquired in healthcare settings through exposure to other patients, relatives or healthcare staff, can also be considered to be healthcare associated.

The Health and Social Care Act (Code of Practice)

The Code of Practice on the prevention and control of infections and related guidance (DH, 2015) came into being in 2008 as part of the Health and Social Care Act, which established the Care Quality Commission (CQC) (http://cqc.org.uk).The Health and Social Care Act 2008 and its regulations are law, and must be complied with.

Since April 2009, NHS Trusts have been legally required to register with the Care Quality Commission (CQC) under the Health and Social Care Act, 2008, and as a legal requirement of their registration must protect patients, workers and others who may be at risk of a healthcare associated infection. This has since extended to encompass other NHS bodies, independent healthcare and social care providers, primary dental care and independent sector ambulance providers and primary medical care providers.

In relation to HCAI, the CQC will monitor compliance with the statutory requirements of registration and will judge whether the requirement is met with reference to the Code of Practice. In cases of failure to comply with the registration requirements, the CQC has a range of enforcement powers that it can use to respond to breaches and which are proportionate to the risk of infection. It may draw the breach to the registered provider's attention and give the provider an opportunity to put it right within a reasonable period of time. In extreme cases the CQC has the power to cancel registration.

Table 1.1 lists the 10 Compliance Criteria of the Code of Practice.

IP&C - everybody's business

Infection prevention and control is an integral part of an effective risk management and patient safety programme and as such must be embedded in every aspect of patient care in every conceivable patient / healthcare setting by all healthcare staff. It is important to note that Registered Nurses and Midwives are bound by the Nursing and Midwifery Council (NMC) Professional Standards of practice and behaviour for Nurses and Midwives (The Code) (NMC, 2015), and medical staff registered with the General Medical Council (GMC) and licensed to practise medicine have to abide by the GMC's Good Practice Guidance (2013) (http://www.gmc-uk.org/guidance/good_medical_practice.asp).

Good management and organisation are crucial to establishing high standards of infection control. All healthcare providers must ensure that they have systems in place that address:

• leadership
• management arrangements
• design and maintenance of the environment and devices
• application of evidence-based protocols and practices for both users and staff
• education, training, information and communication.

All staff are responsible for the care that they give, and are accountable or answerable to someone for their actions. They also have a duty of care, which is a legal obligation to ensure that patients in their care come to no harm as a consequence of any act or omission by the healthcare worker. The Infection Prevention and Control Team (IP&CT) are required to hold staff to account and to challenge poor practice and non-compliance (compliance essentially means acting in accordance with agreed standards or guidelines). Therefore it is essential that staff understand that they are responsible for their practice in relation to IP&C, and for protecting the patients in their care as far it is practically and reasonably possible from HCAIs, and that they are answerable to someone if they are non-compliant. For example, failure to record the visual infusion phlebitis (VIP) scores for two days on a patient with a peripheral cannula in situ (see Chapter 20) leading to a bloodstream infection (BSI - bacteraemia or septicaemia; see Chapter 25) could be viewed as negligent, meaning that harm has been caused to the patient through careless omission (as opposed to a deliberate act), and that the duty of care has been breached.

Holding staff to account however is not about apportioning blame. It is about encouraging responsibility, ownership and engagement, and the IP&CT and healthcare staff working together to reduce, prevent, control and manage HCAIs and the risk to patients. IP&C is an integral component of patient centred care, and all aspects of IP&C clinical practice must be viewed as being as important as all other aspects of patient care, not as add-ons.

Staff must have the competency or ability to undertake tasks or clinical interventions; part of this ability means possessing the necessary knowledge and skills. To undertake clinical activities / interventions without the appropriate knowledge or skills or training places patients and healthcare workers at risk. Staff must also be aware that if there are omissions or gaps in a patient's paperwork in relation to the documentation of IP&C interventions, the legal interpretation is that care was not given.

Avoidable versus unavoidable infections

Avoidable HCAIs are essentially those where poor clinical practice and non-compliance with IP&C can be evidenced / demonstrated. Any successful reduction in HCAIs requires a zero tolerance approach by all healthcare staff with regard to poor infection control practice, non-compliance with policies, protocols and evidence-based best practice recommendations, and avoidable infections.

HCAIs and the Duty of Candour

All NHS provider bodies registered with the Care Quality Commission (CQC) have to comply with the new Statutory Duty of Candour as a requirement of their registration.

The Duty of Candour is legal duty on hospital, community and mental health Trusts to inform and apologise to patients if there have been mistakes in their care that have led to significant harm. It is therefore applicable to all healthcare professionals in all settings who have a professional responsibility to be honest with patients when things go wrong. This includes reporting incidents and near misses, being open and honest with patients / clients and their carers, and apologising. With regard to applying the Duty of Candour in relation to HCAIs, the onus is on the medical team...