According to the latest LaingBuisson survey (2018), there are 416 000 people over the age of 65 years living in care homes in the UK. As part of their registration requirements, care homes have to meet the standards set down by the Care Quality Commission, including those relating to infection prevention and control. Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations (2014) relates to people not receiving unsafe care and treatment and the prevention of avoidable harm and risk of harm. These standards also apply to community nurses who visit residents in care homes for clinical purposes, for example, for wound dressing, catheterisation and syringe driver management. A subsection of this regulation states that care providers are responsible for ‘assessing the risk of, and preventing, detecting and controlling the spread of, infections, including those that are healthcare associated’. It points people to the Code of Practice relating to the prevention and control of infection, which comes from the earlier mentioned Act (Department of Health (DH), 2015). This article aims to discuss the specific risks for infection in the care home setting and highlights the responsibilities of community nurses in assessing and minimising these risks in their interactions with this patient group.
Risk factors for infection
While anyone can acquire an infection, there are some people who are at higher risk, either because of factors specific to the patients or because of the setting within which they find themselves being cared for.
Patient-specific factors include the following (Ward, 2016):
| Type | Method of action | Discussion |
|---|---|---|
| Alcohol-based handrub solution | The majority of alcohol-based hand antiseptics contain either isopropanol, ethanol, n-propanol, or a combination of two of these products. Studies have found that sanitizers with an alcohol concentration between 60 and 95% are more effective in killing bacteria than those with a lower alcohol concentration or non-alcohol-based sanitizers. | Fast acting and useful where additional, rapid hand cleansing is required. The presence of alcohol offers additional protection against contamination when compared to alcohol-free solutions. Alcohol hand gel products can come in a gel form or a more liquid form. Placed onto dry hands, where hands are not visibly contaminated, they provide an additional method for ensuring hands are clean before proceeding with clinical care. |
| Antimicrobial foam solutions | Alcohol free, antimicrobial foam solutions often contain Benzalkonium Chloride 0.1%: Didecyl Dimethyl Ammonium Chloride 0.25% and are effective against bacteria and viruses. | Foam solutions include moisturising agents for the skin's protection. In addition, the advantage of foam hand sanitizer is that the product clings to hands during the application and does not easily slide off the hands like gel hand sanitizers can. |
| Alcohol-free handrub solutions | Alcohol-free preparations use agents other than alcohol to kill microorganisms, such as povidone-iodine, benzalkonium chloride or triclosan. Because these are alcohol-free they may be susceptible to contamination, although this is controversial. Some evidence claims that although susceptible to contamination they offer longer protection against certain bacteria once applied. | Used when alcohol based solutions aren't available or contraindicated—such as when the skin is dry or inflamed. |
| Chlorhexidine solutions | Chlorhexidine has a bacteriostatic and bactericidal activity and acts more slowly on the hands than alcohol solutions. It has a wide antimicrobial activity. | Alcohol-based hand hygiene product containing chlorhexidine gluconate are superior to other solely alcohol-based hand sanitisers in effective hand disinfection. |
| Iodine solutions | Iodine solutions have a long history of effectiveness against bacterial contamination. | Iodine's use is limited due to staining of the skin and skin irritation. Its use has been superseded by Chlorhexidine and alcohol-based solutions. |
Source: (Pellowe et al, 2003; NICE, 2012; Loveday et al, 2014; Department of Health, 2013; Cousins, 2014; Aziz, 2016; NICE, 2018a; NICE, 2018b; Higginson, 2018)
There are several sources of infections in care homes (Ward, 2016), including:
Standard and transmission-based precautions
Standard principles for infection prevention and control apply in all cases when dealing with blood, other body fluids and mucous membranes. These include appropriate and timely hand hygiene, the use of protective clothing such as gloves and aprons, appropriate sharps management and management of blood and body fluid spillages. In addition, the use of an aseptic non-touch technique is required for some clinical procedures carried out by community nurses in care homes, such as urinary catheterisation and wound management. Transmission-based precautions are those based on the route of transmission of the infection that a patient has or is suspected to have. These routes are categorised as contact, airborne or droplet. This would mean, for example, that if a resident has a wound with an MRSA infection, contact precautions should be applied, since this organism spreads through contact. Community nurses can assist with precautions both by applying them in their own work with care home residents and by encouraging other staff to comply through education and role modelling.
The role of the community nurse
One element referred to in the Code of Practice (DH, 2015) is that all patients should be assessed for their infection risk. In terms of the community nurse, this encompasses risks to the patient from themselves and others and risks to staff from the patient and environment. Staff members can reduce risks to themselves through the use of standard and transmission-based precautions during clinical procedures with the residents for whom they are caring. When providing care to care home residents, community nurses are, in effect, visitors who are not employed by the specific care home but provide certain nursing services to them, either because it is residential in nature and there is no nurse on site, or because the nurses on site have not been trained to carry out the procedures. In addition, in homes that provide both nursing and residential services, on-site nurses may not be in a position to provide the service needed, because of issues related to registration, insurance etc. Thus community nursing input would be required. This places community nurses in a precarious position at times, as there may be a conflict between their standards and those applied by the staff in the care home. In 2008, research by the Joseph Rowntree Foundation showed that there was an opportunity for a more strategic approach to the provision of nursing support to residential homes. This can be sporadic, and interactions may occur more by default than by design and appropriate planning. There is reliance on both sides on staff applying all required infection prevention precautions to minimise risk of infection and cross-infection. Community nurses may need to provide appropriate education to care staff about minimising risks to specific patients, such as those with invasive devices and wound dressings managed by the nurses, and about aspects such as infection risks, ensuring optimum nutritional status and improving compliance with infection precautions. However, care staff are the ones responsible for the overall care of the residents. These situations need partnership working in order to ensure that infection and cross-infection do not occur in residents being seen by the community nurse. Such nurses have a busy workload, but the time dedicated toward communicating with and teaching care staff is well spent if it prevents infections, particularly considering the higher risk of sepsis in older patients and those with urinary tract infections (Nasa et al, 2012). Community nurses can provide a good quality service to care homes by adopting strategies to minimise infection risk. In addition, funding and management support as well as a positive collaborative link between community nurses and the staff working in care homes are vital for infection control.