It is shocking that approximately three-quarters of Escherichia coli bloodstream infections develop before people are admitted to hospital (Public Health England (PHE) and NHS Improvement (NHSI), 2017). Additionally, gram-negative infections are thought to have contributed to about 5500 deaths in 2015 (PHE and NHSI, 2017), which highlights the imperative of reducing gram-negative bloodstream infections at every opportunity across all health and social care settings, including clients' homes visited by district nursing teams.
The PHE and NHSI (2017) emphasised the importance of essential practice standards to prevent sepsis, antimicrobial stewardship, a focus on infection prevention and management, and education, including of patients, so that antibiotic prescribing is limited to the treatment of diagnosed bacterial infections. Not all homes are clean and safe environments for nursing care but, increasingly, it is recognised that hospitals are sometimes contaminated environments, with Shek et al (2018) finding that 87.5% of freshly laundered curtains tested positive for methicillin-resistant Staphylococcus aureus (MRSA) by day 14 in their longitudinal study in a Canadian regional plastics/burns unit. Strangely, none of the rooms where the curtains were hung had been occupied by patients with MRSA, which confirmed that nurses and others are transmitters, despite being expected to adhere to professional practice standards, including exemplary hand hygiene. By day 21, the MRSA count on almost all curtains exceeded 2.5 CFU/cm, which is the requirement for food processing equipment cleanliness in the UK.
The imperative of addressing healthcare-associated infections was the subject of a parliamentary debate in May 2018 (House of Commons, 2018a), which after an evidence review, concluded that standards of infection prevention and control in the NHS should be raised. The National Institute for Health and Care Excellence (NICE) (2014) estimated that 300 000 patients a year in England acquire a healthcare-associated infection as a result of care, costing the NHS in excess of £1 billion annually. Since then, hospital data for England have suggested downward trends for Clostridioides difficile and MRSA but upward trends for E. coli and methicillin-susceptible S. aureus, although the data for Northern Ireland, Scotland and Wales have been more promising (House of Commons, 2018b).
Nonetheless, it appears that hand hygiene and other preventive measures are not always adhered to, and antimicrobial resistance continues to grow and pose ever-greater threats to treatment regimes. Recognising the particular challenges of out-of-hospital care, NICE (2017) updated its guidelines for infection control and prevention in primary and community care. The guidelines prioritise hand hygiene while also recommending the appropriate use of personal protective equipment, safe use and disposal of sharps, correct waste disposal, as well as judicious use of devices such as indwelling catheters, enteral feeding devices and venous access devices, with the necessary education of patients, families and carers, as well as healthcare workers.
While recognising that homes visited by district nursing teams are not always ideal environments for the maintenance of the highest standards of infection control and prevention, the growing need to overcome any barriers to the delivery of the best possible healthcare practices regarding infection control and prevention requires district nurses and other staff visiting homes to ensure that they ‘do no harm’ to their clients.
‘Hospital data for England have suggested downward trends for Clostridioides difficile and MRSA but upward trends for E. coli and methicillin-susceptible S. aureus.’
