Introduction

There are certain protocols and standards of behaviour that you must be aware of before accessing an acute care area. Ignoring these will not only make you an unwelcome visitor but could affect the wellbeing of patients and disrupt the working environment of the unit.

You need to understand the appropriate dress, infection control measures and how to act in the presence of patients before entering. You may encounter patients who are critically ill and may be unconscious – this can be upsetting.

Respect the privacy and dignity of patients, other visitors and healthcare professionals. If you are meeting a patient wait to be introduced, ask permission to ask questions and be mindful of boundaries. Follow the advice and guidance of the medical team at all times.

If you can, attend your first visit to an acute care area with an experienced colleague.

Health and Safety

Ensure that you familiarise yourself with and follow local health and safety policies for the site you are visiting.

The main health and safety rules for sites are often printed on the back of visitor passes. Before entering a clinical area for the first time, check with staff if there are any particular conditions that you need to be aware of, such as:

  • Fire and evacuation routes.
  • Accident/incident reporting processes.
  • Dress code or protective clothing requirements.
  • Infection prevention measures.
  • X-ray protection and controls.

It is important to report any accidents or incidents that you may be involved with while working in acute care. Follow your company procedures for reporting, but also ensure that you inform the unit manager of the area where you are working.

Always follow the unit manager’s advice as to what is required. You may be asked to complete an accident report form describing the details of the incident. This will document the date, time, location, who was involved, details of any injuries sustained, treatment received, any actions taken and any further actions required.

Infection Prevention and Control

One of the most common complications for patients are healthcare associated infections (HAIs). Patients in ICUs (adult intensive care units) are at an increased risk of developing infections – the worldwide median rate is nine infections per 100 discharged patients (or 23.7 infections per 1,000 patient days).

The increased risk of infection is associated with the severity of the patient's illness and underlying conditions, length of exposure to invasive devices and procedures, increased patient contact with healthcare personnel and length of stay in the ICU.

Common ICU infections are ventilator-associated pneumonia (VAP), bacteraemia, urinary tract infection and wound infections.

Infection prevention focuses on reducing opportunities for patients to acquire infections as a consequence of their hospital stay. Reducing infections and unintentional harm to patients is high on the political agenda.

Standard Precautions

Standard precautions (formerly known as universal precautions) are a set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin (including rashes), and mucous membranes.

As a result of standard precautions, opportunities for cross contamination are reduced between patients, staff to patients, patients to staff and to you. You need to be aware of what you touch and ensure thorough hand washing and drying at every chance. Standard precautions include:

  • Hand hygiene
  • Personal protective equipment
  • Prevention of needle stick/sharp instrument injuries
  • Respiratory hygiene/cough etiquette
  • Waste disposal and decontamination/sterilisation

Hand Hygiene

Hand hygiene is one of the most effective methods to prevent the transmission of pathogens. Removing many transient microorganisms will reduce the opportunity of them being passed to vulnerable patients.

There are few reasons why you might need to touch a patient or their immediate environment, however there is no harm in knowing when the World Health Organization (WHO) suggests that healthcare staff should wash their hands.

Hand Hygiene

Alcohol gels and hand rubs
Alcohol gels are usually found at hospital and department entrances and should be used on clean hands. They do not remove soiling, which relates to heavy duty dirt and anything else you may have picked up by contact.

Alcohol gels are a highly effective way of cleaning your hands but if used repeatedly can build up and impact your skin. After every five or so applications the build-up of gel should be washed off using soap and water. 

Most washbasins will have a liquid or solid soap for general use. Effective hand cleansing and care should be performed in a correct manner to remove dirt and microorganisms and to maintain the integrity of your skin. Fingernails should be short and clean before every hospital visit.

Jewellery
Jewellery should be removed when working in clinical care settings to prevent the spread of microorganisms. Most staff providing healthcare will remove jewellery at the start of the working day.

Hand Hygiene

There are six steps to that should be used to wash hands effectively with soap and water:

  1. Wet your hands first with lukewarm water as soap is concentrated and should not be applied to dry skin as it can damage the tissues. The water helps soap to create lather and spread over the whole hand.
  2. Use about 5ml of liquid soap in one hand and rub the hands together to get a good lather.
  3. Make sure that both hands are thoroughly covered and rubbed, especially between the web spaces between the fingers, and the creases of the wrist as these are the areas which are frequently missed.
  4. Rinse under running lukewarm water while rubbing hands together to remove all the soap as it dries the skin if left and can lead to damaged skin, especially in cold weather.
  5. Gently and thoroughly dry the hands, web spaces and creases.
  6. Use a water-based, not oil-based hand cream if there is one available. This will keep your hands in better health.

Personal Protective Equipment (PPE)

The appropriate level of PPE should be available for you to access, in the area you are working or visiting. PPE includes facemasks, eye protection, gloves and gowns. 

It is unlikely that you would be involved in any procedure on a patient with a known infection, as the number of personnel involved is reduced to prevent any possible transmission.

If it is necessary for you to be present ask for specific guidance on the additional infection prevention methods being employed and what equipment you need to wear, for your own safety.

The risk of exposure to body substances or contaminated surfaces must always be assessed before any healthcare activity.

Respiratory hygiene/cough etiquette
Be aware of covering mouth and nose when coughing or sneezing and performing hand hygiene after contact with respiratory secretions.

You should avoid entering acute care areas if you have an infection. If unsure, ask the staff for advice before entering.

Common Microorganisms in Hospitals

There are many types of bacteria which may impact on the patient during their stay in hospital. When they are ill, they are far more vulnerable to attack by organisms and have fewer means of fighting the infection. In addition, many of the organisms found in hospitals are resistant to treatment and this is known as antibiotic resistance.

MRSA (methicillin resistant Staphylococcus aureus)
MRSA is a bacterium which is regularly found on human skin which is known as “carrying”. No harm occurs to the carrier but it can easily be passed to others where it may become embedded deeper and cause a wide range of potentially fatal infections. Bacteria enter the body when patients have catheters, maybe urinary or into a blood vessel, via feeding tubes or when they have a drip into a vein. 

MRSA is a multi-resistant strain of the bacteria and is resistant to many antibiotics. Rigorous attention to handwashing will help prevent passing it on to others.

Pseudomonas aeruginosa
P.aeruginosa is found widely in the environment with the species aeruginosa being responsible for the majority of human infections by this bacterium. P.aeruginosa is one of the more common causes of HAI and is increasingly resistant to many antibiotics.

It is an opportunistic pathogen, and more often affects those patients who are already sick as opposed to healthy people. Many of them will be immunocompromised patients who may already have HIV, catastrophic burns or cancer. Infections which may be severe or possibly fatal such as pneumonia, surgical site infections and bloodstream infections are caused by this bacteria.

Clostridium difficile
The people at highest risk of catching C diff are those who take antibiotics and who also seek medical care. It is a species of bacteria that causes severe diarrhoea when competing bacteria in the gut flora have been treated with antibiotics. It often affects elderly patients and is very debilitating. 

It is difficult to treat as in around 20% of patients it returns and may return many times. It is also quite commonly transmitted to others, when this is described as an outbreak – and wards closed for deep cleaning.

Glycopeptide/vancomycin resistant enterococcus (GRE or VRE)
Enterococcus is a bacteria which is carried harmlessly in the gut. GRE or VRE is referred to when the bacterium has become resistant to glycopeptides or vancomycin antibiotics. They can cause a range of different illnesses, including urinary tract infections, bacteraemia (bloodstream infections) and wound infections.

Infections caused by GRE/VRE mainly occur in hospital patients, particularly those who:

  • Are immuno-compromised.
  • Have had previous treatment with certain other antibiotics (particularly cephalosporins and glycopeptides).
  • Are on a prolonged hospital stay.
  • Are in specialist units such as intensive care or renal units.

However, GRE are sometimes found in the faeces of people who have never been in hospital or have not recently been given antibiotics. Transmission is mainly on hands contaminated by contact with colonised or infected patients, contaminated surfaces or equipment.

Waste Management

Hospitals produce vast quantities of waste which may be a hazard to anyone handling it. It is therefore carefully segregated at source, identified to the source and handled with great care. It may be infectious, contaminated with blood or other dangerous tissues, or be contaminated with drugs or chemicals.

Waste will be separated at source in the hospital. In general, yellow or orange bags contain clinical waste and black bags uncontaminated domestic waste (including clean paper).

Clinical waste is anything which may be contaminated by body fluids from the patient and is disposed of in a high temperature incineration facility away from the hospital site.

Sharps should be disposed of in special protective waste bins that are clearly marked.

Laundry arrangements are different from hospital to hospital and discarded linen will be placed in different types of bags dependant on its classification. Linen is generally classified as used, infected or soiled and will be disposed of according to this classification.

Access to Acute Care Units – Entering

An appointment should have been made in advance of your visit, in most cases through the procurement/supplies department.

Access is restricted in acute care areas with a bell at the door with an intercom and possibly a camera. A member of staff will ask you to identify yourself and the reason for your visit before allowing access.

You must wear your ID badge and a visitor badge if you were given one, and comply with any local policy for dress code and infection control. Once inside the unit it may be necessary to sign in with a receptionist. Under no circumstances enter clinical areas unaccompanied or without permission.

Access to Acute Care Units – Dress Code

In order to reduce the risk of infection most acute care units have a “bare below the elbows” dress code. This means that jackets, etc, are removed with sleeves folded back to the elbow. There should be no dangling elements such as scarves or ties and all jewellery except stud earring and wedding bands removed.

Some units may ask you to change into their indoor clothing, including footwear. However even if you do not have to change your shoes, your own should not be open-toed.

Hair should be worn off the collar and put up if necessary.

Access to Acute Care Units – By the Patient’s Bed

Following the “bare below the elbows” code you must always wash your hands according to unit policy before approaching or moving between beds.

If the bed is screened off, do not enter as the screens/curtains are in-situ to preserve the patient's privacy possibly whilst a procedure is being done or if the patient is performing other personal needs.

Permission from the staff must be gained before approaching the patient's bed area and the patient must also give their verbal consent if they are awake. You must introduce yourself and explain the purpose of your visit.

The patient may be in a single room because of risk of infection to or from the patient. If the patient is being “barrier nursed” there will be notices posted outside the room and instructions regarding what precautions need to be taken before entering. These precautions will often include the wearing of protective clothing such as gloves and an apron or gown. Always seek assistance from the staff to ensure that you comply with the policy before entering a room.

When exiting the room and before moving away all protective clothing should be disposed of in the bins provided outside the door (according to local policy) and you should wash and dry your hands.

Access to Acute Care Units – By the Patient’s Bed

You should only need to work at the bedside if you need to demonstrate your product in use with a patient. This is quite unusual, and a less intrusive method could be to show your products to people in their offices or in a canteen.

If you are privileged enough to be able to be by the bedside, ensure that the clinical staff are able to advise on what activities are possible and how you should approach the patient. You are only there to manage, effect appropriate use of and possibly educate either the staff or the patient on the use of your equipment. You have no other reason for being there and the hospital and company provides no vicarious liability for any other activity.

If you are asked inappropriately by a clinician how to use your equipment, you must remind them, however difficult that this is, that you are there solely to support your product and not to suggest clinical uses for it or make decisions that are not yours to make.

It is suggested you make a detailed note of the situation, should this action have any consequences and keep a copy. Inform your line manager of the circumstances.

Critical incidents do occur when patients are acutely ill and should you be a witness to a developing scenario, it is best to remove yourself from the scene and only return after permission has been given. If you have seen anything which you think may be useful make a file note.

If you judge that a unit is too busy to give their attention to your presence, make sure they know this and plan to return on another day. 

Access to Acute Care Units – By the Patient’s Bed

Remember in an acute care unit, especially intensive care or recovery area, patients may appear to be unconscious, however, they may still be able to hear, as it is the last of the senses to go. Be respectful in the patient’s immediate environment at all times. If relatives are present, be sure to address them and ensure they know who you are and the reason for your attendance.

The area around a patient’s bed is full of equipment and monitors, and there are many trailing cables. Lines connected to the patient make this a hazardous environment – be wary of what you are touching and how they are connected. Seek advice if there is any doubt in your mind.

Confidentiality and Patient Data

Confidentiality of patient information is a legal requirement under the Data Protection Act 1984 (updated to Data Protection Directive 95/46/EC). No patient information should be subject to any discussion outside of the appropriate environment, in this case, the hospital.

In hospital public places, mentioning a patient's name or details of their illness may overheard by others. Exercise care to maintain confidentiality.

In 1999, Dame Fiona Caldicott chaired a national committee which developed and subsequently introduced and mandated Caldicott guardians in all hospitals in the UK with the purpose of safeguarding any use of confidential NHS information.

There is therefore a responsible individual at each of your sites who could intervene should you or your company keep any identifiable patient information without competent authority.

Any patient record should be held confidentially and securely. All people who come into contact with personal health information in their work should have training in confidentiality and security issues. This includes the need to ensure that specific identifiers are given to patient records, which you and the company may keep, so that the individual cannot be identified.

Any data stored on medical devices must be erased from the device before it is removed from the hospital, so that there is no chance of inadvertent loss of confidentiality for patients.

Whilst most of us have cameras on our phones, you must not take or agree to take any photographs in theatres or other clinical areas, even on someone else’s phone or camera. In most hospitals, there are professional medical photographers who have the skills to take clinical photographs.

The clinician must have asked for patient consent to take clinical photographs and there are rules and ethical guidelines for the clinician from the General Medical Council on the use of images.

Acute Care Settings

In many areas of the acute hospital it has become the norm to wear scrub suits, and people forget to use their ID badge. This makes it very difficult for you to find out who they are and what their role is. You will have to ask.

Team members change regularly with shift working. Time which you spend getting to know the key influencers and personnel will repay your time investment. Teams are often multi-disciplinary and everyone practices together for the patient but with their own roles and responsibilities. It is helpful for you to find out who holds the budget and how purchasing decisions are made, as this varies tremendously from hospital to hospital.

Without exception, the main focus of the staff is on the patient and not anything else.

An acute hospital, and particularly larger teaching hospitals, have many different areas where patients may be very ill or unconscious requiring intensive treatment, which may be planned (elective) or emergency. They are not always the easiest environments in which to sell products and support the increasingly complex devices. However, medical and nursing care is ever more dependent on technology.

Any visitor to the environment needs to be fully mindful of the hazards, seen and unseen in the area, so that they can protect themselves from any harm which may befall them and still maintain the role that they are there to fulfill.  

Adult Intensive Care Units (ICU)

Intensive care units (ICUs) are specialist hospital wards that provide treatment and monitoring for people who are very ill.

They are staffed with specially-trained healthcare professionals and contain sophisticated monitoring equipment. ICUs are also sometimes called CCUs (critical care units) or ITUs (intensive therapy units).

ICUs are often open care areas with few walls other than for isolation rooms for patients with specific infections, such as TB or other highly infectious diseases. It is also possible to protect the patient by isolating them, so that they do not catch an infection if they are vulnerable.

The units are well staffed, with 1:1 care and a higher percentage of senior medical staff due to the complexity of the care being delivered. It is likely that many of the patients will be unconscious and relatives will be alongside their beds.

It is useful to remember that these patients are very sick and their relatives may be tense and worried.

Adult Intensive Care Units (ICU)

Equipment
Depending on the condition of the patient, there will be a large amount of equipment at each bedside, many of which have bleeps and alarms to alert carers to a change of situation. 

A vast range of monitors will be found in an average ICU patient, to monitor all their physiological activity, so that the staff can alter the action according to how the patient is responding. These lies and tubes enable fluid to be balanced, in and out, liquid food to be given directly and any number of other normal bodily functions to be managed.  

Most patients will be connected to a ventilator which takes over the process of breathing for the patient. The patient will be connected to the ventilator via a tube in their throat or via a small cut in their neck (a tracheostomy).

Data management systems are usually in use, which automatically create a full and frequent picture of the patient with all their physiological activity as well as responses to medications and other support being provided. 

High Dependency Units (HDU)

Patients are often transferred to high dependency units (HDUs) from the ICU when they no longer have such a high level of dependency.

Post-operative patients require close observation or monitoring for more than a few hours.

High dependency is a step-down unit, in that there is more scrutiny and support to the individual patient than possible in an ordinary ward, so that there is usually a minimum nurse to patient ratio of 1:2 and not usually any medical staff present.

Equipment
As the patients still require close observation there will be a chart table or data management system at the bedside.

Patients will normally be conscious and able to communicate, however they will still be being carefully monitored and supported.

The area around their bed will still be full of bleeping monitors and supportive equipment but they are not usually being ventilated.

Coronary Care Units (CCU)

The coronary care unit is a specialised ward area separated from others, although close to the cardiology wards, with specialist care and monitoring following an acute cardiac event or intervention such as angiography. It is often a closed unit, as patients need to rest and recuperate, with relatives present.

Patients will often be admitted following or prior to invasive procedures in the cardiac catheterisation laboratory such as stent insertion. CCU patients are generally conscious and do not require ventilation.

Equipment
The bedside of the CCU patient is less cluttered than those in ICU, but will still have many monitors present. Patients are acutely ill and are closely scrutinised by the staff, 24 hours a day.

Emergency Departments (A&E)

The emergency department of the hospital essentially is where patients are assessed and treated for any medical emergency or trauma which has happened to them. They may have arrived by ambulance or helicopter, recognising that rapid assessment and treatment should occur in the “golden hour” following injury.

Resuscitation and diagnosis is the specialised field of the emergency support team, in order to treat and support the immediate needs of a sick patient or to treat initially and return them home as soon as possible.

It is for this reason that the inappropriate use of emergency departments by people who should have attended a minor injury unit, or their general practitioner, manage to block access to A&E departments causing long hours of waiting.

Neonatal Intensive Care Units (NICUs)

The term neonate refers to an infant in the first 28 days after birth and applies to premature, post-mature and full-term infants. Criteria for admission vary in specific neonatal units, but examples of where intensive care is required include unstable babies requiring 1:1 nursing and those needing complex clinical procedures.

Neonatal units are generally full of incubators where the environment for the baby can be totally controlled. The infant will be attached to any number of monitors to manage and support their tiny bodies. They are often also wrapped in cotton wool with hats on to reduce loss of heat. Anxious parents are almost always present.

When working in close proximity to babies bear in mind that NICUs are temperature-controlled between 22 and 26°C. Light and noise control is also important.

Special Care Baby Units (SCBUs)

Babies that are less acutely ill than those in the NICU may be admitted to special care baby units. SCBUs are often attached to the NICU and share the same medical and nursing staff.

Babies admitted to special care units are in the step-down phase of their care from an intensive support environment to one where parents usually deliver much of the care required. However the unit is able to monitor the baby more closely than in a normal ward. 

Clinical Trials and Product Support

Before new products are introduced, clinical trials usually take place and you may need to take part, so you will need to understand the process.

Loans and trials
Most hospitals manage the purchase of products for clinical use via the procurement or purchasing department. It is worth asking how this is managed at your hospitals as this may differ, but individuals are almost never permitted to make purchases based on their own wishes. You will be signposted to the individual who will be your link to the process and they should help you to enable any trials or new product introductions go according to plan. If you get things wrong at this stage it could jeopardise future plans and also damage relationships with you as an individual and also your company. 

Staff training
Many modern products require the staff to be trained in their use and with good planning and a suitable timescale, all training must have been done prior to blanket introduction of the product. Provide visual guides and written instructions as well as personal support where required throughout the trial process. You must assure that staff are safe and confident in the use of the product before leaving them unsupervised. Contact details to ask you for assistance must be provided in case of need for support.

Clinical Trials and Product Support

Trial product supplies
When planning the trial it is vital that enough product is provided for the length of the project. You must also make sure that there is clear understanding as to who is paying for the products as some trusts might believe that the cost is the company’s and not theirs.

It will be important to have a large enough trial sample to make the trial acceptable, therefore the number of people involved, there availability during the trial period and the length of the trial must be determined early on. In addition, it may be that approval needs to be sought from the hospital ethics committee.

Master indemnity will need to be placed with the procurement department.

Evaluation of the product
Evaluation forms should come from the hospital and must have been developed between the company and the clinical and procurement staff to remove any risk of bias in the questions. At the end of the trial, you may be asked to help with the collation and reporting of the trial responses. 

During the trial, you will need to ensure that a sufficient supply of evaluation forms is available in all trial areas. 

Clinical Trials and Product Support

Trials involving electronic equipment
All powered products must undergo an electrical safety check with EBME or the medical engineers prior to introduction, so you will need to liaise with the department to ensure that they have the time allocated before the trial is due to start. Electrical safety stickers will be printed and attached to your equipment when they are deemed to be safe for use. 

Product trials for clinical use: unsterile products
All items which are lent to the hospital during a trial will need to be checked before they are sent off site – usually to the SSD (sterile service department) – for sterilising. If the staff do not know the equipment, it would be very helpful for you to be present. The decontamination certificate will accompany the equipment to ensure that the kit was sterilised since it was used. 

This whole process need to take account of the fact that it can take as long as 48 hours for the equipment to be processed at SSD

Product trials for clinical use: sterile products
Trial products must be found a safe and appropriate space in a store room. Each item will need to be checked to ensure it is in date and there are no defects in the packaging. Manufacturer’s instructions for use must be available. It is helpful to have one member of staff who keeps an eye on the stock and knows to contact you, should there be any issues with supply.

Adverse Incidents

An adverse incident is one that causes, or has the potential to cause, unexpected or unwanted effects involving the safety of device users (including patients) or other persons.

The MHRA (Medicines and Healthcare products Regulatory Authority) operates the yellow card reporting system. Should a product fail for any reason or appear to have been tampered with, the first line of action is for staff to report this to the MHRA within 24 hours of the event. The device should be removed and kept on site until a response is received from the MHRA.

You must not remove the product from the site but may be made aware of the event by staff. You should note the product details and batch number. It is likely that the MHRA will contact your company and ask for the product to be inspected and the outcome reported back to them.

Sometimes, you will know about an issue with one of your products before the staff do at the hospitals. They frequently rely on you to contact them and let them know if stock should be taken off their shelves and when new stock will be available.

Adverse Incidents

The MHRA manages issues with medical devices, so that the market and their customers are aware of issues and problems with devices which may follow an adverse incident. 

Their system of reporting incidents by users, is completed by notification to all users of any changes that have been made to the design of the device or it’s preparation for use. These notifications are called FSNs (field safety notices) which the MHRA defines as below.

A field safety notice is an important communication about the safety of a medical device that is sent to customers by a device manufacturer, or their representative. FSNs tell users what they need to do to reduce the specified risks of using the medical device. The actions are referred to as FSCAs (field safety corrective actions).

Products can be removed or replaced in the market under a FSCA. All field safety notices are sent to the MHRA and the customer by the responsible manufacturer. It is the company's legal duty to report any corrective actions taken on devices.

The MHRA site lists all alerts and recalls for drugs and medical devices.

Decontamination and Sterilisation

Strict regulations affect decontamination and sterilisation in the EU. As part of ensuring that each instrument or device is appropriately cleaned and sterilised, manufacturers' instructions must be provided by the company.

These instructions should ensure that information is provided for cleaning methods and dis-assembly (if required for cleaning) as well as re-assembly for safe use.

Medical device companies that frequently lend instruments to hospitals may have a loans department that manages the entire dispatch process.

Loans management by companies with highly specialised sets of instruments are subject to localised policy and company procedures. Reps involved in the process of lending instrument sets to hospitals should learn the processes involved and if possible assist the customers (users and sterile service departments) to understand the kit which is lent. Checks to ensure everything is present after delivery are an essential part of customer service and may help you when you support the surgery. 

Loan kits often have to be ordered to arrive at least 48 hours in advance of use, in order for all the content checking and decontamination processes to be completed.

Decontamination and Sterilisation

Cleaning is usually undertaken by machine at high temperatures for reusable items, prior to the sterilisation process. Once items are checked for cleanliness they are packed and autoclaved. The most common form of sterilisation is achieved by autoclaving, using steam. This is a process which subjects the pack to pressure at high temperatures (134 degrees centigrade) for a number of minutes (usually three or more). This achieves sterilisation which is the process that eliminates, removes or kills all forms of microbiological life.   

The specialists who undertake this action may be sited away from the hospital site in the sterile service unit. 

Other methods of sterilisation or high-level disinfection may be via an irradiation process which is undertaken by industrial processes or locally, cold chemicals may provide the means to kill or reduce harmful organisms.

Exam

This ends the course. You can now continue to the exam. 

 

Take Exam

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