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UPDATE

The control and prevention of

hospital-acquired infections
AUTHOR Jason Beckford-Ball, BA, RMN, is assistant
clinical editor, Nursing Times, Terry Hainsworth, BSc,
RGN, is clinical editor, Nursing Times.
ABSTRACT Beckford-Ball, J,. Hainsworth, T. (2004) The
control and prevention of hospital-acquired infections,
Nursing Times; 100: 29, 2829.
Recently the publics attention has been focused on the
issue of hospital-acquired infections. The latest Audit
Commission report (National Audit Office, 2004) reveals
an increase in MRSA cases from 7,250 in 20012002 to
7,647 in 2003-2004. This has resulted in new action plans
for prevention and control of infection.

Modern health care has brought many benefits, but one

unfortunate side-effect of treating large numbers of people in close proximity has been the growth of hospitalacquired infections (HAI).

What are hospital-acquired infections?

HAI is a term used to describe all infections that do not
stem from the patients original diagnosis on admission.
HAIs are caused by bacteria, viruses or parasites that
originate from the hospital environment, contaminated
equipment, staff, or other patients. The most common
types are urinary tract infections, chest infections, and
surgical wound infections (National Audit Office, 2004).
Recently, the publics attention has been focused
on the issue of HAIs due to the publicity surrounding
so-called superbugs such as methicillinresistant
Staphylococcus aureus (MRSA), which, in part due to
overprescribing, have developed immunity to antibiotics.
MRSA is carried in the nose or on the skin. In the community it is relatively harmless, but in hospitals it can be
dangerous due to the concentration of people with disease
and open wounds, and to the virulence of the organism.
Strict infection control procedures are the best defence
against MRSA, but one study found that less than half of
health care staff complied with them (Girou et al, 2002).

The surveillance of HAIs in England

Surveillance involving data collection, analysis and feedback to clinicians is vital when attempting to detect
HAIs. However, the latest National Audit Office report
(NAO, 2004) states that there has been little improvement in the information available on the incidence and
cost of HAIs since the NAOs original report on hospital
infection rates in 2000 (NAO, 2000).
This is partly due to inconsistency in policy. The
original NAO report recommended that the voluntary
Nosocomial Infection National Surveillance Scheme
(NINSS), instigated in 1996, be made mandatory.

However, instead of this, a new approach was introduced

in April 2001 with mandatory laboratory-based MRSA
bloodstream infection surveillance.
In 2002 responsibility for HAI surveillance transferred
to the Health Protection Agency, which continued mandatory trust-wide surveillance of MRSA bacteraemias, other
specific organisms, and orthopaedic surgical site infections. However, had it developed the system to include
specific areas such as bloodstream, surgical site, and
urinary tract infections, this information could have
been fed back to clinicians to influence practice. Instead,
as the data is collected across whole hospital sites clinical staff cannot relate it to their particular specialties.
This mandatory laboratory-based MRSA surveillance
has helped identify increases in the frequency of
infections resistant to common antibiotics, albeit with
wide regional variations. To supplement this figures are
supplied by the Public Health Laboratory Services
Communicable Disease Centres voluntary reporting system, which show increases in infections (Fig 1).
The latest Audit Commission report concludes that
there has been limited progress in the implementation
of comprehensive mandatory surveillance. For example,
the only kind of MRSA hospitals have to report is bloodstream infections, which have increased from 7,250 in
2001-2002 to 7,647 in 2003-2004. As a result accurate
data, other than that on rates of hospital-wide MRSA, is
unavailable for the NHS in England. It is therefore impossible to accurately quantify any changes in NHS trusts
infection rates.

Prevention and control

The basic principles of infection control are (Ayliffe
et al, 2000):
Remove sources of infection by treating infections and
decontamination procedures;
Prevent transfer with good hand hygiene, aseptic procedures, and appropriate isolation;
Enhance resistance with good nutrition, and appropriate antibiotic prophylaxis or vaccination.
These should underpin all nursing practice and are
fundamental in the prevention of HAIs. Every hospital
must have policies in place to ensure the control and
prevention of infection. Nurses are likely to be aware of
policies regarding hand hygiene, use of protective clothing, and safe disposal of sharps (NAO, 2004).
There are other key policies important in the control of
infection including policies that will reduce the infection
risk from use of catheters, tubes, cannulas, and those
regarding the prudent use of antibiotics. However, infection control is a complex problem. For example, HAI risks

NT 20 July 2004 Vol 100 No 29 www.nursingtimes.net

KEYWORDS

Infection control Public health MRSA

BOX 1. NUMBER OF STAPHYLOCOCCUS AUREUS BACTERAEMIAS REPORTED UNDER THE VOLUNTARY

AND MANDATORY SURVEILLANCE SCHEMES ADAPTED FROM NAO (2004)
20
18

Ayliffe, G et al (2000) Control of

Infection: A Practical Handbook.
London: Arnold
Department of Health (2003) Winning
Ways: Working Together to Reduce
Healthcare Associated Infection in
England. London: DoH

16
14
Number of reports (x1,000)

REFERENCES

Dentith, M., Shelmerdine, T. (2004)

Organising an awareness week to target
hand hygiene practice. Nursing Times
100:17, 36-38

12
10
8

Girou, E. et al (2002) Efficacy of hand

rubbing with alcohol based solution
versus standard hand washing with
antiseptic soap: randomised clinical
trial. British Medical Journal. 325:
7360, 362

6
4
2

Financial Year (Apr-Mar)

MRSA (methicillin resistant)

MSSA (methicillin sensitive)

are greatly increased by extensive movement of patients

in the hospital, by high bed occupancy, and by an absence
of facilities to isolate infected patients.
New plans have been unveiled this week including
giving nurses more power to keep wards clean, enabling
patients to speed dial cleaners (p2), MRSA and cleanliness targets (p5), and bringing in foreign experts (p4).

Nursing implications
It is easy to blame the increase in HAIs on falling standards
but it should be remembered that medical advances have
resulted in more patients surviving, such as those with
cancer or the critically ill. During treatment these patients
are more vulnerable to infection.
Plans to allow patients to request cleaners have no
evidence base. In fact, despite the attention given to
hospital cleanliness and sections of the media and public
being convinced that dirty hospitals cause infections,
research evidence does not sustain this view (Patel,
2004). Instead the control of HAI depends on a number
of issues.
Over the last few years many trusts have implemented
hand hygiene initiatives to raise awareness of the issues
and improve compliance. Good infection control
measures are often simple practical interventions, many
of which are nurse led, such as putting alcohol hand gels
at every bedside, holding awareness days, and organis-

NT 20 July 2004 Vol 100 No 29 www.nursingtimes.net

v=voluntary

20032004 v

20022003

20022003 v

20012002 v

20012002 v

20002001 v

19992000 v

19981999 v

19971998 v

19961997 v

19951996 v

19941995 v

19931994 v

19921993 v

m=mandatory

No susceptibility data

ing educational activities (Dentith and Shelmerdine,2004).

Hand hygiene is a crucial factor in the control of HAI
because hands can easily transfer micro-organisms from
one area or patient to another. Despite strategies promoting hand hygiene there still seems to be difficulty persuading staff to adopt good practice (Shuttleworth, 2004).
However, failure to comply with measures such as
good hand hygiene, is rarely due to laziness or lack of
care, but due to barriers preventing effective practice:
Poor knowledge of the guidelines;
A lack of education;
Inadequate facilities;
Time pressures;
Lack of access to hand hygiene agents.
Schemes to improve handwashing compliance by
staff wearing badges saying ask me if my hands are
clean have been considered successful (Dentith and
Shelmerdine, 2004) although investigation into the
effect on infection rates have not been undertaken.

National Audit Office (2000) The

Management and Control of Hospital
Acquired Infection in Acute NHS Trusts
in England. London: The Stationery
Office
National Audit Office (2004) Improving
Patient Care by Reducing the Risk of
Hospital Acquired Infection: A Progress
Report. London: The Stationery Office
Patel, S. (2004) The impact of
environmental cleanliness on infection
rates. Nursing Times 100: 01, 32-34
Shuttleworth, A. (2004) A new role to
reduce the incidence of health careassociated infection. Nursing Times
99:8,44-45

Conclusion
Good infection control is essential but the complex nature
of infection means that it is not always easy to achieve.
Accurate surveillance that provides information to clinicians about where improvements can be made, comprehensive education, regular updates, and good hospital
policies are all necessary to control the spread of HAIs.

This article has been double-blind

peer-reviewed.
For related articles on this subject
and links to relevant websites see www.
nursingtimes.net

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