General practice infection control and meeting the 5th edition

Consistent and correct management of infection in general practice is imperative to preventing and controlling the spread of healthcare-associated infections including COVID-19, Coronaviruses, influenza flu and hepatitis. Correct and ongoing infection control measures are essential for the health of your patients and staff. Additionally, they’re a requirement under the RACGP Standards 5th edition.

This article, first published in AGPAL Quality News magazine Summer 2019 edition, is designed to provide your team with information and techniques to assist in basic infection control strategies. It helps to identify the relevant 5th edition accreditation requirements and has some advice for COVID-19, added in March 2021.

Prevention

With an understanding of how infectious diseases are spread, we can better understand preventing their transmission. This ultimately creates a safer, more hygienic practice environment for staff and patients. It may seem like common knowledge, but correct hand washing is the most effective way to prevent the spread of infections in general practice.3 If washing your hands with soap and hot water is not available, an alcohol-based hand rub to the surface of the hands is the recommended alternative.⁴

Evidence from both the SARS and COVID-19 epidemics show that hand hygiene is very important to protect health care workers from getting infected. Hand washing removes germs through mechanical action (WHO Guidelines on Hand Hygiene in Health Care 2009). The World Health Organization (WHO) has indicated that:

• Alcohol-based hand rub products should contain at least 60% alcohol and, should be certified. Where supplies are limited or cost-prohibitive they can be made locally by carefully following the WHO Guide
• It has been shown that plain soap is effective at inactivating enveloped viruses such as the COVID-virus due to the oily surface membrane that is dissolved by soap, killing the virus. 
• Chlorinated water at 0.05% is not recommended for routine hand hygiene because it has skin and other toxic effects, however, soap is (usually) easy to find and can be used effectively.

When handwashing, the WHO ‘5 Moments for Hand Hygiene’ outlines the following five times  people should be practicing hand hygiene in a health care setting:

1. Before touching a patient
2. Before a procedure
3. After a procedure or body fluid exposure risk
4. After touching a patient’s surroundings.

There are also other instances where hand hygiene is crucial:⁶

• After using the toilet or being in a bathroom
• Before and after eating, and
• Before examining neonates and those who are immunocompromised.

The method in which you wash and dry your hands has a significant impact on your hand hygiene. It’s recommended that posters or instructions on correct hand washing and hand rubbing techniques be displayed around the practice for both team members and patients to see.

Gloves are also practical and can be an effective tool for managing the spread of infection within general practices across Australia. Gloves can help reduce the risk of contamination by your team by placing a barrier between exposure to blood or other body fluids, and therefore transmission of infectious agents to other areas of the practice, patients or team members.⁸

Gloves are not a fool-proof solution because if used incorrectly, wearing gloves can be worse than wearing no gloves at all. 

In addition to the spread of infection by direct contact, other common forms of infectious disease transmissions are caused by droplet and airborne transmissions6 which are passed through coughing, sneezing and even talking.

If not contained, the droplets and vapour from a cough, sneeze or breath become airborne and the chances of the spread of disease to another carrier significantly increase. To minimise droplet transmission through coughing and sneezing it’s recommended that you:

• Cover the mouth and nose, preferably with a disposable tissue, while coughing or sneezing
• Dispose of tissue in general waste, and
• Wash hands or use hand disinfectants.

RACGP Standards and recommendations

We strongly encourage you to familiarise yourself with the Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019 Guidelines), the Australian Commission on Safety and Quality in Healthcare has recently released COVID-19 specific resources and the specific RACGP Standards 5th edition requirements linked to Criterion GP4.1 Infection prevention and control, including sterilisation.

These Guidelines and the RACGP’s Infection prevention and control standards work in conjunction with the RACGP Standards 5th edition support practices to manage infection control.

Criterion GP4.1 Infection prevention and control, including sterilisation outlines what is necessary of your practice team when undergoing accreditation, with content related to the responsibility of clinical team members, infection control processes and policies, managing infection, informing patients and more.

Due to the importance of minimising healthcare-associated infections in general practices, medical centres and medical clinic settings, teams must document and specify clear lines of accountability and responsibility. This is also while ensuring infection prevention and control policies and processes are in place. All members of the practice team are required to be educated around infection control processes and be confident in implementing effective management techniques to appropriately manage the risk of infection across all areas of the practice.

As part of accreditation requirements, Criterion GP4.1 Infection prevention and control, including sterilisation requires practice teams to meet the following Indicators:

• GP4.1 > A Our practice has at least one clinical team member who has primary responsibility for:
  • Coordinating prevention and control of infection
  • Coordinating the provision of an adequate range of sterile equipment (reprocessed or disposable)
  • Where relevant, having procedures for reprocessing (sterilising) instruments onsite or offsite, and ensuring there is documented evidence that this reprocessing is monitored and has been validated
  • Safe storage and stock rotation of sterile products, and
  • Waste management.
• GP4.1 > B Our practice has a written, practice-specific policy that outlines our infection control processes. 
• GP4.1 > C Our practice has a clinical team member who has primary responsibility for educating the practice team about infection prevention and control.

At a minimum, all members of your practice team must have easy access to personal protective equipment (PPE), such as masks, gloves, gowns and protective eyewear. They must also receive education about the proper use of PPE and have a clear understanding of the purpose of PPE and how to apply, remove and dispose of it appropriately.

GP4.1 > D All members of our practice team manage risks of potential cross-infection in our practice by methods that include:

• Ggood hand hygiene practices
• Tthe use of PPE
• Ttriage of patients with potentially communicable diseases 
• Ssafe storage and disposal of clinical waste including sharps
• Ssafe management of blood and body fluid spills.

Specific details are outlined in the RACGP’s Infection prevention and control standards and must be followed at all times by staff. To ensure knowledge is retained, you could undertake pop quizzes to seek areas for improvement, identifying where additional training or reminders may be required for your staff.

In addition to Criterion GP4.1, the RACGP Standards 5th edition detail actions for practice staff to help minimise the risk of healthcare-associated infections. As a quick reference, the RACGP Standards recommend that members of your practice team:

• Receive appropriate immunisation for vaccine-preventable diseases
• Use fluid repellent surgical masks to cover mouth and nose wherever possible (if not immune)
• Clean hands immediately after seeing a patient with a known infectious disease.
• Provide segregated waiting room areas for patients with known infectious diseases such as influenza
• Ask patients to apply correct respiratory etiquette – offer some assistance if the patient is unaware of correct etiquette
• Make other health practitioners and staff in the practice aware of the infected patient’s condition.
• Clean any areas promptly that may have been infected.

For more information, fact sheets and helpful posters, see the resources outlined below or contact your AGPAL Client Liaison Officer for personalised accreditation support.

Resources

• AGPAL resources – Available to all AGPAL clients in their AGPAL accreditation hub at no additional cost
  • Help us limit the spread of infection poster
  • Infection control policy template
  • Business continuity plan
• The ‘Hand Sanitiser Australia Project’, formed from the Practice Managers Network Facebook group, has teamed with Manildra Group, WaterTest Systems and Mera Chemicals to manufacture, supply and distribute medical-grade hand sanitiser, particularly for general practices and health care services.

Education and Training

• Department of Health
  • COVID-19 online 30-minute training for all healthcare workers in all settings
  • COVID-19 Infection Control Training
• ACSQHC
• Infection Prevention and Control
• ACSQHC Infection prevention orientation eLearning module (free)
• ACSQHC Infection Prevention and Control eLearning Modules
• WHO – Infection Prevention and Control eLearning Modules
• Hand Hygiene Australia 5 moments for hand hygiene
• Hand Hygiene Australia – online training modules

References

1. Centres for Disease Control and Prevention (2014). Diseases and Organisms in Healthcare Settings.
2. Australian Commission on Safety and Quality in Healthcare. (2010). Australian Guidelines for the Prevention and Control of Infection in Healthcare. http://bit.ly/AGPALQN183IC2 
3. Medline Plus (2018). Infection Control. http://bit.ly/AGPALQN183IC3 
4. Hand Hygiene Australia. (2009). What is Hand Hygiene? http://bit.ly/AGPALQN183IC4 
5. World Health Organization (2006). Five moments of hand hygiene. http://bit.ly/AGPALQN183IC5 
6. Royal Australian College of General Practitioners. (2014). Infection prevention and control standards: For general practices and other office-based and community-based practices (5 ed.). http://bit.ly/AGPALQN183IC6
7. Tierno, P. M. Jr. (2003). Preventing the spread of germs.Scholastic Parent & Child 11(2) 44. http://bit.ly/AGPALQN183IC7
8. South Australia Health. (n.d.). Appropriate Glove Use in Health Care. http://bit.ly/AGPALQN183IC8 
9. Hand Hygiene Australia. (2011). Appropriate Glove Use? http://bit.ly/AGPALQN183IC9 
10. Maine Centre for Disease Control & Prevention. (n.d.). Disease Surveillance Epidemiology Program: Airborne and Contact Diseases, COVID-19. https://www.maine.gov/dhhs/mecdc/infectious-disease/epi/airborne/coronavirus/index.shtml