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Clinical governance

Hygiene Code

Infection prevention and control in England is underpinned by the Health and Social Care Act ([53]), which has been summarized in a separate code of practice (DH [30]). Known as the Hygiene Code, this mandates a set of responsibilities to healthcare providers including hospitals, general practitioners, dentists and care homes. This legislation is monitored and enforced by the Care Quality Commission (CQC), which assesses care providers against the requirements of the Code during periodic inspections. Each provider must be registered with the CQC and declare compliance with the 10 criteria of the Hygiene Code. These criteria are summarized in Table 4.5.
Table 4.5  The Hygiene Code
  1. Systems to manage and monitor the prevention and control of infection. These systems use risk assessments and consider the susceptibility of service users and any risks that their environment and other users may pose to them.
  2. Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections.
  3. Ensure appropriate antimicrobial use to optimize patient outcomes and to reduce the risk of adverse events and antimicrobial resistance.
  4. Provide suitable accurate information on infections to service users, their visitors and any person concerned with providing further support or nursing/medical care in a timely fashion.
  5. Ensure prompt identification of people who have or are at risk of developing an infection so that they receive timely and appropriate treatment to reduce the risk of transmitting infection to other people.
  6. Systems to ensure that all care workers (including contractors and volunteers) are aware of and discharge their responsibilities in the process of preventing and controlling infection.
  7. Provide or secure adequate isolation facilities.
  8. Secure adequate access to laboratory support as appropriate.
  9. Have and adhere to policies, designed for the individual's care and provider organizations that will help to prevent and control infections.
  10. Providers have a system in place to manage the occupational health needs and obligations of staff in relation to infection.
Source: DH ([30]). © Crown copyright.
All healthcare organizations are required to appoint a senior manager to the role of ‘director of infection prevention and control’, or DIPC (DH [20]). This person must have the seniority to be able to influence the board of directors to ensure that infection prevention is accorded the highest priority.
All but the smallest healthcare providers should have (or have access to) an infection prevention and control team, who will advise on day‐to‐day aspects of infection prevention. The team will usually consist of one or more nurses trained in infection prevention along with a consultant microbiologist or infection control doctor and an antimicrobial pharmacist. Some teams will have additional staff working in audit, surveillance, or data collection and analysis. The role of the infection prevention and control team is varied but principally involves providing advice, education and support to healthcare professionals, caregivers and the wider organization to ensure patient and staff safety is maintained and risks are minimized.

Professional responsibility

In England, nurses must be aware of the measures that are in place in their workplace to ensure compliance with the Hygiene Code. For example, many hospital trusts have a programme of regular visits to clinical areas by senior staff, who carry out inspections against the criteria of the Code as if they were external assessors. This programme ensures that senior staff are familiar with the Code and that everyone is familiar with the inspection process. In addition, nurses may need to carry out activities to promote compliance and provide evidence of assurance, such as audits of hand hygiene performance or compliance with aseptic technique. One such set of audits in place in many hospitals in England is the aforementioned Saving Lives (Infection Prevention Society [63]). Audits are discussed in more detail in the section below on environmental hygiene and the management of waste in the healthcare environment.

Other legal and professional issues

In England, the Health and Safety at Work etc. Act ([52]) is the primary piece of legislation relating to the safety of people in the workplace. It applies to all employees and employers, and requires them to do everything that is reasonable and practicable to prevent harm coming to anyone in the workplace. It requires employers to provide training and appropriate protective equipment, and it requires employees to follow the training that they have received, use the protective equipment provided, and report any situations where they believe inadequate precautions are putting anyone's health and safety at serious risk.
The Nursing and Midwifery Council's Code (NMC [86]) states that all nurses must work within the limits of their competence. This means, for example, not carrying out aseptic procedures without being competent and confident that this can be done without increasing the risk of introducing infection through lack of knowledge or technique.
In addition to healthcare‐specific requirements, items of legislation and regulation have been devised with the objective of reducing the risk of infection; these apply to healthcare as much as they do to any other business or workplace. These include legislation and regulation relating to food hygiene (Food Safety Act [40]), water quality (Water Supply (Water Quality) Regulations [122]), waste management (Waste (England and Wales) Regulations [121]) and other issues that are peripheral to healthcare but must be taken into account when developing policies and procedures for an NHS trust or other healthcare provider. The relevant regulations are summarized in Table 4.6.
Table 4.6  Legislation significant to healthcare infection control policy
LegislationCoverage
Control of Substances Hazardous to Health (COSHH) (HSE [57])Introduced to prevent or reduce healthcare worker exposure to potentially harmful substances. The guidance includes the need to identify hazards, risk assess the potential for harm, if possible remove the harm, and where needed provide measures to reduce the level of harm. This includes the need to provide suitable equipment, training and where necessary health surveillance. The COSHH regulations have forced changes in areas such as endoscopy, where previously harmful chemicals (such as gluteraldehyde) were used with little control. Modern endoscopy units use safer chemicals in special automated processors to significantly reduce the potential for harm to users.
Health Building Note 00‐09: Infection Control in the Built Environment (DH [26])Provides guidance on infection prevention measures for new buildings and refurbishments. Includes guidance on finishes, layout and fittings. Should be read in conjunction with other health building notes (HBNs) for specific facilities, such as Health Building Note 04‐01 Supplement 1: Isolation Facilities for Infectious Patients in Acute Settings (DH [27]).
Legionnaires' Disease: The Control of Legionella Bacteria in Water Systems – Approved Code of Practice and Guidance (HSE [58])Sets out the requirements of employers to control legionella, including identifying and assessing sources of risk; preparing a scheme to prevent or control risk; implementing, managing and monitoring precautions; keeping records of precautions; and appointing a responsible manager.
Water Systems: Health Technical Memorandum 04‐01 Addendum – Pseudomonas aeruginosa – Advice for Augmented Care Units (DH [24])Concerned with controlling or minimizing the risk of morbidity and mortality due to Pseudomonas aeruginosa associated with contaminated water outlets. Guidance is provided on assessing the risk to patients, and the document offers remedial actions to take when a water system becomes contaminated with P. aeruginosa, including protocols for sampling, testing and monitoring water. It also offers advice on forming a water safety group and developing water safety plans. This guidance came about in response to an outbreak in Belfast where three babies died and several others were infected via water contamination with P. aeruginosa (Wise [130]).
Health Technical Memorandum 07‐01: Safe Management of Healthcare Waste (DH [25])Sets out the necessary handling of waste to reduce harm to people and the environment.
Food Safety Act ([40])Sets out regulations for the safe handling and preparation of food.
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