Infection prevention and control (IPC) has been my passion for more than 20 years now, ever since I became fascinated by an outbreak of meticillin-resistant Staphylococcus aureus (MRSA) within the intensive care unit at the hospital where I was a junior ward sister. It sparked an interest in IPC and led me down a new career path, and I am now a director of infection prevention and control (DIPC) in an NHS trust.
The post is a requirement under the Health and Social Care Act 2008 Code of Practice on the Prevention and Control of Infections and Related Guidance (Department of Health, 2015). As a full time DIPC who also happens to be an experienced and senior IPC specialist nurse, I am in a fairly unique position and I am proud to have been appointed. My extensive job description states that, as DIPC, I have corporate responsibility for infection prevention and control throughout the trust as delegated by the chief executive, reporting directly to the chief executive and the trust board. It's a position of significant, and sometimes overwhelming, responsibility and now that I have been in post for 2 years, this seems a good point at which to pause and reflect on what has changed in IPC since I first decided to specialise 20 years ago, and what the challenges currently are in terms of preventing and controlling healthcare-associated infections (HCAIs) within the NHS today.
Last year I was asked what it was as DIPC that kept me awake at night, and my immediate response was the global public health threat posed by antimicrobial resistance, which quite frankly scares me, and new pathogens such as carbapenem-resistant Enterobacteriaceae (CRE) and Candida auris, but there are also many other things that frequently disturb my sleep. The biggest of these is keeping the profile of IPC and HCAI reduction high on everyone's agenda and engaging with staff across the board within the NHS. This is at a time when there are so many competing priorities, including a workforce that is under constant and ever-increasing pressure, ever-increasing financial constraints and limited resources (including within IPC), a population with increasingly complex health needs, increasing demands on people's time, and an antimicrobial world that is constantly evolving and posing new threats.
Staff are overwhelmed and I am very much aware that while IPC is my immediate priority, and generally the first thing on my mind when I wake up and often the last thing on my mind when I fall asleep, it is not necessarily the first priority for our healthcare staff, who have everything coming at them from all directions and are told everything is a priority.
Everyday practice
There have been many national reports, recommendations and guidance documents, innovations and campaigns, HCAI reduction targets for MRSA bacteraemia and Clostridium difficile infection, and new Acts and legislation (Box 1). However, we are still trying to get the basics right and embed IPC into everyday practice.
The biggest problem with trying to ‘sell’ IPC to staff is that you can't see what you are dealing with in terms of the microbial world, and so it is difficult for staff to fully appreciate the potential implications of a single, simple, non-compliance or omission, such as not decontaminating their hands after ‘moment 5’ (after contact with the patient's surroundings) of the ‘5 moments for hand hygiene’ (World Health Organization, 2009) when they are rushing from one patient or task to another, or not removing their apron and/or gloves when leaving a bay or side room.
The basic principles or cardinal rules of IPC in relation to hand hygiene and personal protective equipment seem so clear and simple to IPC teams (how hard is it to remember that there are ‘5 moments’ for hand hygiene, and that non-sterile gloves and aprons are only ‘clean’ at the point at which they are put on?). However, when talking to colleagues in hospital and community settings, it is clear that these two aspects of IPC practice in particular remain complicated for so many healthcare workers, and our incessant reminders about, and focus on, such simple things can actually make them seem trite.
There are lots of day-to-day components to IPC (Box 2). Without a doubt, certain aspects of IPC are complicated, and it has a scientific basis that staff are not necessarily aware of.
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I have always been fascinated by the pathogenesis of infection, and the interaction between microorganisms and the human host. Understanding the nature of microorganisms and the havoc that they can cause, and how easy it can be to break the chain of infection through the application of standard precautions, is what has always driven me and gets me out of bed in the morning.
Simple messages
We need to give staff clear, simple and consistent messages about what to do, whether it's hand hygiene, cleaning or screening for CRE. But in doing so, are we too focused on instructing staff, and making the basics of IPC sound boring and dry? I think that we need to be more innovative and really make IPC come alive by incorporating the background and the science behind it and relating it to patient stories and, crucially, we really need access to nursing and medical staff and allied health professionals very early on in their training so that they get a sound understanding of the theory behind the practice.