Chapter 4: Infection prevention and control
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Nursing care of patients with suspected or known infection: managing safe care
Related theory
The principle of infection prevention and control is preventing the transmission of infectious agents. However, measures taken to reduce the risk of transmission must be reasonable, practicable and proportionate to the transmission risk. They must not lose sight of the need to provide safe and efficient healthcare and keep services running efficiently for the benefit of all patients. For example, while S. aureus can cause severe infections, it is carried by around a third of the population and so isolating every patient who carries it would not be practicable or possible. On the other hand, its antibiotic‐resistant version (known as MRSA) can cause equally serious infections and is resistant to common first‐line antibiotics that would normally be used to treat these infections. It is carried by far fewer people, and it is therefore reasonable and practical to take additional precautions to prevent its spread in healthcare (Coia et al. [13]).
The management of any individual who is infected or colonized with an organism that may pose a risk to other individuals must be based on a risk assessment that takes into account the following factors (Jones [65]):
- What is the organism responsible for the infection?
- What are the possible routes of transmission and how easily can it be spread?
- How susceptible to infection are any other people being cared for in the same area and what would be the likely consequences if they were to become infected?
- How practical would it be to implement specific infection prevention and control precautions within the relevant area or institution (e.g. bearing in mind the number of single rooms available and staffing levels)?
- What are the individual's other nursing needs?
The infection prevention and control policies of health and social care providers are based on generic risk assessments of their usual client or patient group and should be adhered to unless there are strong reasons to alter procedures for a particular individual's care. In such circumstances, the advice of the infection prevention and control team (IPCT) should be sought first. Nurses working in organizations without an IPCT should identify the most appropriate source from which to seek advice, preferably before it is needed. The local public health unit will be able to signpost appropriate advice providers.
All patients should have an assessment for infection risk on arrival and where possible beforehand if admission is planned. This assessment may need to be repeated at intervals depending on the changing condition of the patient. Based on this assessment, additional transmission‐based precautions may be required for patients known or strongly suspected to be infected or colonized with organisms that pose a significant risk to other patients.
The precautions will vary depending on the route by which the organism can travel from one individual to another, but there will be common elements (Box 4.3).
Box 4.3
Transmission routes
Transmission routes can be divided into the following:
- Direct contact: person‐to‐person spread of infectious agents through physical contact.
- Indirect contact: where someone comes into contact with a contaminated object.
- Enteric: organisms carried in faeces.
- Parenteral transmission: where blood or body fluids containing infectious agents come into contact with mucous membranes or exposed tissue. In healthcare, this can occur through transplantation or infusion (which is why blood and organs for transplantation are screened for blood‐borne viruses such as HIV) or through an inoculation injury where blood splashes into the eyes or a used item of sharp equipment penetrates the skin.
- Faecal–oral transmission: where an infectious agent present in the faeces of an infected person is subsequently ingested by someone else and enters their gastrointestinal tract. This is the route of most gastrointestinal illness as well as water‐ and foodborne diseases (salmonella, norovirus and C. difficile infections are also spread in this manner).
- Droplets: large respiratory particles.
- Airborne: smaller airborne particles, usually respiratory.
Evidence‐based approaches
Transmission precautions can be grouped as follows.
Contact precautions
Patients known or strongly suspected to be infected or colonized with pathogenic micro‐organisms that spread via direct contact with the patient or indirectly from the patient's immediate care environment (including care equipment) should be managed with contact precautions.
Contact precautions normally consist of standard precautions enhanced with isolation of the patient in a single room and use of gloves and apron for any procedure involving contact with the patient or their immediate environment.
Enhanced contact precautions
Enhanced contact precautions are used for patients known or strongly suspected to be infected or colonized with highly resistant organisms. This involves the addition of a long‐sleeved gown to the normal contact precautions above.
Enteric precautions
Patients suffering symptoms of diarrhoea or vomiting that do not have an obvious mechanical or non‐infectious cause should be cared for using enteric precautions. These should be used from the first instance of diarrhoea or vomiting, regardless of whether a causative organism has been identified, until there is a definitive diagnosis that the symptoms do not have an infectious cause (prompt collection of a stool sample is important). Enteric viruses are highly transmissible and outbreaks occur rapidly if precautions are not speedily implemented.
Enteric precautions consist of prompt isolation of the patient in a single room, ideally with an en suite toilet facility. The door of the room should be closed, and gloves and apron should be used for any procedure involving contact with the patient or their immediate environment (Health Protection Agency [54]).
Droplet precautions
Patients known or strongly suspected to be infected or colonized with pathogenic micro‐organisms that are mainly transmitted via droplets of body fluids should be cared for with additional infection control precautions. The infectious agents are most often respiratory secretions expelled during coughing and sneezing but can include droplets from other sources, such as projectile vomiting or explosive diarrhoea.
Droplet precautions consist of isolation of the patient in a single room with the door closed and use of gloves and apron for any procedure involving contact with the patient or their immediate environment. Droplets are heavy and will usually travel no more than a metre from the person before settling on surfaces, so good hand hygiene and frequently touched surface environmental hygiene are essential. The patient should where possible be encouraged to practice good respiratory etiquette. For some infections (high‐risk respiratory viruses, e.g. tuberculosis), staff entering the room may be required to wear a mask for close and prolonged contact and during aerosol‐generating procedures.
Airborne precautions
Patients known or strongly suspected to be infected or colonized with pathogenic micro‐organisms that are transmitted through the airborne route are cared for with airborne precautions. Airborne transmission involves droplets or particles containing infectious agents that are so tiny that the particles can remain suspended in the air for long periods of time. Infections spread via this route include measles and chickenpox.
Airborne precautions consist of isolation of the patient in a single room, if possible with negative pressure ventilation or a positive pressure ventilated lobby, with the door closed. Gloves and apron should be used for any procedure involving contact with the patient or their immediate environment. Staff entering the room should wear a properly fitted respirator (FFP3) mask (Siegel et al. [110]) (Figure 4.52).
Figure 4.52 A correctly fitted FFP3 mask may be required for aerosol‐generating procedures on patients with infections such as tuberculosis or influenza.
Some guidelines merge droplet and airborne precautions in order to provide a single set of instructions for staff caring for patients with any respiratory or airborne infection. A risk assessment should be carried out to determine the most appropriate PPE on a case‐by‐case basis.
Vector transmission
Many diseases are spread through the action of a vector, most often an insect that travels from one person to another to feed. This route is not currently a concern in healthcare in the UK; however, in some areas of the world, for example where malaria or dengue are endemic, protecting patients from vectors such as mosquitoes is an important element of nursing care. Diseases spread by vector do not generally spread from person to person.
