Basic hygiene lies at the heart of infection control in the community: a pioneering role in community infection control at Capital and Coast District Health Board is removing fear from health care workers and helping break the chain of infection.

Infection control is just good basic hygiene, according to Capital and Coast District Health Board's (DHB) community-based infection control facilitator Suzanne Miller. She believes it's no coincidence that the Greek goddess of health was named Hygieia, from which our word hygiene comes. In ancient Greek understanding, however, health was only understood in relation to a life lived without indulgence or excess. It wasn't until the early 1800s that scientists realty understood the links between micro-organisms and disease, and the importance of prevention through hygiene.

Miller's community-based role is a year old now and remains a unique position among DHBs. In the United Kingdom, this role is much more common. The position at Capital and Coast was first proposed by a locum infection control nurse at the hospital, Viv Murray. A business plan was prepared by the infection control team, which had been receiving an increasing number of requests for infection control support and advice from the primary sector. Other changes occurring at that time were shorter patient stays, a reduction in the number of hospital beds, and the consequent increase in care being delegated to health care workers in the community. The challenge for the team was to ensure that both caregivers and clients in the community stayed healthy.

Over the past year, Miller has developed the role and discovered that her previous four-year experience as an HIV nurse specialist has stood her in good stead. "In my previous role at the DHB I had to teach infection control and I was often working alongside families and other health services in both the secondary and primary sectors, eg mental health providers, women's health and general practice. I tried to make people feel safer by teaching them to use standard precautions. People fear infection and they need to know how to protect themselves and their patients. To remain healthy and to keep their patients healthy, caregivers need to understand the relationship between human beings, bugs and the environment. If people understand how diseases are transmitted from one person to another, they then know how to stop that happening. This is what is known as the chain of infection. Breaking that chain involves a number of factors including immunisation against vaccine-preventable diseases, good hand-washing techniques, the appropriate use of gloves, the immediate covering of wounds and broken skin, appropriate use of antibiotics, not sharing towels or utensils with other patients, and care with the storage of food and fluids."

Anyone in the community providing primary health care is able to call Miller for help with infection control. Her major clients include long-term care facilities, the regional public health service, primary health organisations and a range of non governmental health services. "The job is huge, ranging from assisting providers with infection control policy development, to anti-microbial use, surveillance and staff education. My work has three arms: prevention, on-the-spot advice and education. I see myself in almost an ambassadorial role. I have a message to give which is about helping people stay well by avoiding infection. I need to make these messages as simple as possible, in order to reach everyone. One of those messages is about the importance of hand washing, which is the single most important activity to prevent infection. Our hands remain the biggest transmitters of germs."

When health workers' hands are not visibly soiled or when hand washing facilities are not readily available, Miller recommends an alcohol-based handrub for routinely decontaminating hands. They require less time and are more effective for standard hand washing than soap, improve skin condition and increase compliance.

Decreasing public awareness

Education about how infection happens and how to prevent it is an ongoing task, says Miller. In the 1940s and 50s, public health education about preventing infection may have been more common. Along with greater use and availability of antibiotics and other treatments, public awareness appears to have decreased. With increasing resistance to antibiotics and new emerging infectious diseases, the basics of infection control must be remembered. Following the international theme promoted by the Centers for Disease Control in the United States that prevention is primary, Miller has been developing some educational resources for the community. These include a number of posters with simple and eye-catching messages (see opposite). The latest deals with preventing the spread of influenza and the common cold and respiratory hygiene. The posters can be used in a range of health facilities, as their messages are generic. Recent research has shown that not only does influenza vaccination of elderly people in long-term care decrease their risks of pneumonia and death, but there is a strong link between the vaccination of health care workers and decreases in mortality among these residents. (1)

Another of Miller's tasks is helping staff deal with patients with multiple resistant organisms or other complicated conditions like tuberculosis, especially those living in long-term facilities. There is now increased recognition of the risks associated with institutionalised care. Cultural issues can also play their part--with staff whose English is their second language and with patients for whom there are cultural barriers or stigmas around certain diseases. "Often I am used as a liaison person as staff work out how to manage such patients. My role is to facilitate a good outcome for clients and staff. My message remains the same: basic requirements are good hygiene, a clean environment, clean linen and dressings, and clean equipment.

"I have also worked with long-term facilities seeking certification. Much of this requires helping staff understand how infection control and other health care standards apply in the sector and then making sure that policies and procedures are in place that reflect this. I work alongside the facility's own infection control facilitator who is responsible for ensuring standards are adhered to."

Nurse manager at Wellington's Churtonleigh Medical Hospital, Leonie Pedersen, speaks highly of Miller's work with her nurses and health care assistants. As well as delivering in-service education sessions, Miller has provided the hospital with educational material, and specialist advice and support, when staff have had patients with complicating conditions to manage. Miller has also been instrumental in setting up a group for residential care staff in the Wellington region who are responsible for infection control. "This group is largely made up of nurse managers like myself who don't often have the opportunity to network and share information in such a supportive way," said Pedersen. "We have all appreciated the way that Suzanne has made the effort to meet us and visit our facilitities prior to an infection control issue arising. She makes herself available and keeps us up to date with the latest information and research as it comes to hand."

Although Miller misses her contact with patients, she is stimulated by the ongoing challenges her new role presents. One of these is contributing to Capital and Coast DHB's new website, which will include a section on community-based infection control; another working with regional public health on a project to assess the feasibility of establishing community assessment centres in the event of a pandemic, eg the Avian 'flu or severe acute respiratory syndrome (SARS). "A project team set up last year identified infection control as the area of greatest need in the primary sector should a pandemic arise. Good infection control practices should be integrated into the everyday practice of all health practitioners," said Miller.

(1) Carman, W.F., Elder, A.G. et al (2000) Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial The Lancet; 355, 93-97.