Healthcare-associated infections (HCAIs) cost the health service millions of pounds per year, as well as causing women and their families unnecessary suffering and concern.
In the mid 1800s, Semmelweis established that hospital-acquired diseases were transmitted via the hands of healthcare workers. He observed that maternal mortality rates, predominantly attributed to puerperal fever, were higher in one clinic than another. As a consequence, Semmelweis recommended that hands be scrubbed using chlorinated lime solution before every contact.
An HCAI is described by the 2006 Health Care Act as any infection to which a person may be exposed or is made susceptible (or more susceptible) in circumstances where healthcare is being, or has been delivered, to that or any other individual, and the risk of exposure to the infection, or susceptibility (or increased susceptibility) to it, is directly or indirectly attributable to the provision of healthcare.
HCAIs are the most common complication affecting those in hospital; the problem does not just affect people in hospital and hospital workers. HCAIs occur in any healthcare setting, including the general practice setting, clinics and long-term care facilities. HCAI is a potentially preventable adverse event, as opposed to unpredictable complications. Anybody working in or entering any healthcare facility can transmit infection or become infected. This risk can be significantly reduced when effective infection prevention and control procedures are implemented.
It is acknowledged that not all infections are preventable. Managing infection control and ensuring best practice can improve care outcomes and service user safety significantly.
Transmission of infections can occur through contaminated hands of a healthcare worker, equipment and medical devices used.
All healthcare workers will come into contact with people who have infections and/or contagious diseases; they must know how to prevent or reduce the transmission of infection.
The National Institute for Health and Care Excellence has produced evidence-based guidelines regarding management and how to prevent and control HCAIs.
Hand hygiene is seen as the single most important activity for minimising the likelihood of infection. Pathogens on the hands of midwives can be removed by hand washing if transmission is to be prevented. Infection involves a cycle of events that permits the spread (transmission) of infection occurring (Figure 2.1).
Healthcare workers, including midwives, have the greatest potential to spread micro-organisms that can result in infection; this is related to the number of times that they have contact with people in the care environment. Hands, therefore, are very efficient vehicles for the transmission of micro-organisms.
Hands should be decontaminated before direct contact with women and after any activity or contact that contaminates the hands; this includes after gloves have been removed. Alcohol hand gels and rubs are a practical alternative to soap and water; however, alcohol is not a cleaning agent. Hands that are visibly dirty or potentially grossly contaminated must be washed with soap and water and dried thoroughly. Hand preparation increases the effectiveness of decontamination. Whenever feasible, staff should have access to the means to clean their hands at the point of care; where possible soap and water should be used. However, this is not always possible with the placement of sinks or access to sinks in the home. The ability to clean the hands is possible when the midwife uses alternative methods.
Detergent wipes should be used if soap and water is not available and this should be followed by drying the hands thoroughly with paper towels or air drying; then alcohol gel can be used. Only use alcohol gel if the hands are visibly clean; using alcohol gel on contaminated hands renders the solution ineffective. Detergent wipes and hand rubs should be readily available at the point of care; if not, the chance of using them will be lost and hands will retain potentially dangerous microbes. Alcohol gel should be used between different care activities with the woman or baby.
The midwife should keep nails short, clean and polish free and should avoid wearing wristwatches and jewellery, particularly rings with ridges or stones. Artificial nails must not be worn and any cuts and abrasions must be covered with a waterproof dressing.
Wristwatches and any bracelets should be removed and long sleeves rolled up before washing the hands and wrists. The NHS has implemented a ‘naked below the elbows’ rule that has banned healthcare workers from wearing long sleeves, wrist watches and jewelry to promote effective hand and wrist washing; this includes the avoidance of wearing ties when carrying out clinical activity.
Hospitals are unique places that differ considerably in terms of the risk of potential infection spread when compared to a ‘normal’ home environment. While risks occur wherever direct contact between people or equipment happens, inpatient hospitals have a large number of people who are living in a small physical area. Moreover, those being cared for may have direct contact with a large number of people as a result of their on going care needs, allowing for many more opportunities for micro-organisms to be spread from one person to another than would normally occur at home. Some of these micro-organisms may be resistant to antibiotics.
Figure 2.2 demonstrates the correct technique for hand washing.
The five moments of hand hygiene (Figure 2.3, which can be found in the Appendices at the end of the book) define the key times, providing a standardised approach to hand washing that is simple and straightforward.
Along with an understanding of hand hygiene, the midwife must also understand how infection is transmitted. Knowing how and when to apply the fundamental principles of infection prevention is key to controlling infection.