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Infection Control Practices

This coursework contains the full 6,000-word summative essay on the Literature review on the infection control practices in the Nursing Homes most particularly in the United Kingdom. It is well known that the elderly population has a substantially increased incidence and severity of many infectious diseases (Hampton, 2003). The student will focus on the infection control and prevention issues most specifically to person- to-person transmission and a little regarding food –borne transmission. In fact, the Centres for Disease Control and Prevention (CDC) estimates that 1.5 million nosocomial infections occur in long-term care residents per year, which translates to an average of one infection per resident per year (Williams, 2008). Between February and May 2006 infection control staff across the United Kingdom and Ireland completed the third national survey into health care associated infection. A prevalence rate of 7.6% broadly supports the results that were reported in the first and second national surveys (Cole, 2007).

According to Knoll and Lautenschlaeger (2010), the rate of healthcare-associated infections (HCAIs) is listed for the United Kingdom at approximately 50 thousand cases in every year. Among these are the elderly people, which are the most vulnerable hosts (Aitkenhead, 2009). According to Nazarko (2007b), infection control in UK care homes does not yet receive the same level of scrutiny as in hospitals. People requiring care in nursing homes may have infections, or may be at risk of picking up infection from other people. Staff and visitors may also be at risk since they are the ones who are in direct contact with the clients. As being observed by the student, infections spread rapidly between the residents in the Nursing homes. Standard precautions aim to eliminate sources of infection whenever possible and to prevent the spread of infection (Nazarko, 2007). Controlling the spread of the infection may be difficult for some workers due to lack of education on infection control and prevention. This is the main reason why the student came up with several sources that may sum up the problems and makes solutions that may be helpful to health personnel.

The number of people in care homes will continue to expand as the population ages. Today, according to Hampton (2003), residents in care homes have more complicated medical conditions than they did 5 years ago, as they become even more elderly and the trend continues towards shorter and shorter hospital stays in acute care facilities.

This literature review was made by the student to emphasize the importance of compliance of infection control procedures in the care home. The student’s experiences and knowledge gained from work based studies and broad sources of reading materials greatly contribute in making the substance of this paper. This paper may help readers to gain knowledge on the ideal infection control procedures that applies mainly in the healthcare setting.

Common mode of transmission in a nursing home facility

Infection control is described by the National Health Service Executive as a managed environment, which minimises the risk of infection to patients, staff and visitors (Health Protection Agency, 2006). Standard precautions are directed towards breaking the chain of infection by preventing the transmission of infection (Cole, 2010). According to El-Kadiki and Sutton (2005), compliance of infection control may provide high quality and safe services among individuals. It may also prevent cross contamination among staff member and may lower the costs of health care services since prevention is more economical than treatment (Eriksen et al, 2007).

From the article by Nazarko (2005), the spread of infection within health care requires three elements: 1. a source of infecting organism (bacteria, viruses, and fungi), 2. a susceptible host and, 3.a route of transmission of the organism from one person or site to another. In relation to the nursing home environment, the source may be a resident, a staff member or a visitor. That certain individual may have signs of infection, or may be colonized and does not show any symptoms (Knoll, 2010). The source may also be inanimate objects within the environment that have become contaminated such as equipments. The host is the resident or client that is on the nursing home facility. According to Williams (2008), resistance to pathogenic microorganisms may vary greatly from each individual. Microorganisms can be transmitted by variety of routes and the same organism can be transmitted by more than one routes. According to Cole and Lai (2009), there are common modes of transmission of infection in the nursing homes that every staff can prevent by just executing correct infection control procedures. However, the student has chosen the most common types that were being noticed in the workplace. These are 1. Person-to person, 2. Food-borne, and 3. Hospital Acquired Infections (HAIs).

Cole and Lain (2009) briefly describe person-to person spread as a conveyance of a certain disease condition to another individual. Person-to-person spread of infections may be airborne, faecal-oral, blood-blood or skin-to-skin. The most common infectious diseases the student noticed over the past few months were colds and flu. The spread of the infection to each person was so massive despite flu vaccination several months before the onset. The residents that were affected with the viral infection were treated with several courses of antiviral medications and antibiotics. Aitkenhead (2009) indicated that anti-viral medication is currently under-used for older people in care homes in the UK. Isolation was also done to severely affected residents. According to Cole and Lai (2009), isolation may be done to residents if they acquired infectious or communicable disease; they may also be place on isolation if a certain individual has been suspected of any infectious disease. Despite doing procedure, flu virus was able to spread on few of the residents and staff. False handing or poor infection control procedures must have caused the break in isolating the resident with infection.

Food borne infection had also been very common among care homes. With this, according to Ashurst (2007a) on her article, nursing homes and hospitals in the United Kingdom are now subject to strict environmental health inspections to monitor the premises, and making sure that foods that are served are safe for consumption. As being observed by the student in the workplace, all kitchen staffs are handlers of basic food hygiene certificate as part of their induction programme. Kitchen staffs were taught about the principles of food hygiene with emphasis being placed on high standards of personal hygiene, including hand washing.

As stated in Ashurst (2007b) in her second article, food safety should never be taken for granted, as people may lost their lives as direct result of the staff failure to follow agreed policies and procedures. This matter is to protect both the residents and staffs from potential harm. Food poisoning, according to Ashurst (2007a), is caused by poor hygiene and, in particular, is caused by the contamination of ready-to-eat food with food poisoning bacteria. From the student’s basic knowledge, poor temperature control of ready-to-eat food may also cause of bacteria to multiply in large numbers. The best environment for most bacteria to grow and increase in number is a moist environment between 5°C and 60°C. This range of temperatures is known as the ‘growth’ or ‘danger’ zone (Fisher and Hartshorn, 2005). Undercooking may also cause poisoning since this enables food poisoning bacteria to survive.

Hospital acquired infections, according to Gaspard et al (2008), is an infection acquired during hospital care which was not present or incubating prior to admission. Among reported case of nosocomial infections on the student’s work place, MRSA or Methicillin-resistant Staphylococcus Aureus is the most common.

Common types of person to person infection in Nursing Homes in the UK

There have been a number of outbreaks on infection in the Nursing Homes in the UK, according to Nararco (2005). Few of these infective diseases are Flu, gastrointestinal conditions, pneumonia, urinary tract infection, and scabies. Wound infections had also been very common in residents, especially those who developed decubitus ulcers or bed sores. Each of these infectious conditions will be discussed by the students.

Influenza is defined by Daniell (2004) in his journal article as an acute viral, respiratory infection causing the temperature to rise quickly, with profound malaise, headache, myalgia, congested nose, cough and breathing difficulties. For otherwise healthy individuals, influenza is an unpleasant but usually self-limiting disease; this normally resolves in 7–14 days. Flu continues to cause outbreaks in care homes and in the community (Benison, 2006). The student was able to observe that influenza outbreaks occur readily in elderly care homes. They strike rapidly and are frequently associated with widespread severe illness and deaths. Eleven years ago, According to Nguyen-Van-Tam (2000), in Britain, outbreaks are frequently detected too late in their course when the options for effective intervention are few. Flu vaccinations are being given to staffs and clients during outbreaks. Vaccination against flu must also be given to staffs considering they are exposed in both setting – inside and outside the care home. Whilst this cannot be applied to all situations it is advisable in some circumstances. It should always be combined with other infection control efforts however to ensure complete protection. In conjunction with vaccination is post exposure prophylaxis, this is used where vaccines do not exist after contact with infection has occurred (Booker, 2004). Staff spend a lot often time with residents, and can infect vulnerable residents inadvertently. If staff have flu vaccinations they are very unlikely to bring the flu virus into the home, therefore reducing the risk of older people getting flu (Daniell, 2004). The flu immunization season, which is the beginning of winter season, is a busy time for the nurses but its preventive value cannot be overestimated. If an outbreak of flu does occur, anti-viral medication can be used (Eriksen et al 2007). According to Benison (2006), the combined use of immunization and targeted treatment with antiviral agents can effectively control the serious impact of seasonal influenza on vulnerable communities of residents in care. Scottish researchers found that giving flu vaccinations to nursing staff working in nursing homes reduced death rates (Booker, 2004). Flu Vaccination can highly reduce death rates and prevents vulnerable older people who develop flu from becoming increasingly disabled.

Second condition that had been known to be very common is gastroenteritis or diarrhoeal problems. According to Ashurst (2007a), this condition is very common and extremely infectious and affects approximately 1 in 5 people are affected by the condition in England every year. In which at least 50% of cases of gastroenteritis are due to foodborne illness are caused by norovirus. This can be acquired from contaminated foods and water. However, this can easily be prevented by frequent and correct execution of hand hygiene since bacteria can be transferred this way through poor hygiene. For example, if someone does not wash their hands after going to the toilet. For this reason, staffs and residents are encouraged to perform hand hygiene after using the bathroom or changing incontinence pads.

Any viruses or bacteria on their hands will be transferred to whatever they touch, such as a glass, kitchen utensil or food. As per Doctor’s recommendation every time a resident experiences this kind of condition, nurses in the workplace, including the manager, must assure that food be properly cooked and stored to prevent gastroenteritis. It has also been encouraged to thoroughly wash both hands before eating and after. Bleaching soiled laundry and household surfaces may also help prevent spreading bacteria caused by gastroenteritis (Parker, 2004).

Based on the student’s observation, Pneumonia has also been common to the clients in the nursing home. According to Booker (2004), pneumonia in nursing and residential care homes may be different from that found in the general population. Mortality is also higher this group. According to Metha (2009), pneumonia vaccine is important since there had been reported outbreaks of pneumonia in unvaccinated clients in some nursing homes within the UK and even in United States of America for people who are aged 65 years and above. According to Roberts (2004), the bacteria that cause pneumonia can become extremely resistant to any types of antibiotics in nursing homes, and when the disease occurs, it can be difficult to treat. As being observed in the workplace, nurses determine new resident’s vaccination records to determine the need of the vaccine and the risks. As the student involves himself in the caring of residents with Pneumonia, good, general nursing care is vital. Adequate rest had been encouraged and smoking- discouraged. The patient may well be agitated and fearful and will need plenty of reassurance.

Urinary incontinence is one of the most common and disabling conditions affecting a frail elderly individual (Hampton, 2004); this can also lead to the use of indwelling catheters for some. According to Nazarko (2009), urinary tract infection (UTI) is the most common healthcare-acquired infection in the UK. So far, based on the student’s observation in the workplace, UTI due to long term indwelling catheterization has the highest rate of prevalence and reoccurrence. With the general knowledge the student has, patients should be monitored at regular intervals; communication between carers and relatives should be effective to promote understanding how and why long-term catheters should be maintained. Catheter care is a nursing procedure and its importance is sometimes overlooked. According to Harvey (2007), it should be addressed by education and self-directed learning. Practices such as routine catheter irrigation should be avoided and the NICE guidelines recommend that bladder instillations or washouts must not be used to prevent catheter associated infection (Brown, 2006). However, if necessary, perform appropriate catheter care and consistently use appropriate infection control guidelines while maintaining a closed drainage system. In the workplace, the use of bubble bath/oils, perfumed soaps and talc around the genitals should be avoided as they break down the body’s natural protective flora. Also, common tradition on the workplace to prevent or treat UTI is to offer cranberry juice to the residents. However, frustratingly, a study of Hampton (2004) concluded that there was no good quality or reliable evidence for the effectiveness of cranberry juice in prevention and treatment of UTI and that more research is needed. It was also confirmed in the study by Harvey (2007) that claims that Cranberry juice, on a daily basis, will not have any effect greater than that water in preventing UTI.

If an older person becomes suddenly confused, it’s not an indication that the elder must be developing Alzheimer’s Disease (Brown, 2006). It has also been observed by the student in the workplace that some staffs may mistakenly assume that confusion is normal for all older people. Staff seeking advice from a healthcare provider regarding a quick onset of confusion may be surprised if the doctor orders a urine specimen. Actually, a urine specimen is not a bad idea since urinary tract infections are a common cause of delirium in the elderly (Goldrick, 2005).

Scabies had also been one of the causes for outbreaks in the UK nursing homes (Nazarko, 2005). This can easily be spread by staffs, relatives, visitors, and residents since close prolonged contact causes the transmission. In this case, the student ensures all staffs must wear gloves and aprons upon dealing with infected individual. The infected individual must also be taken for a bath or shower everyday with the aid of medicated soaps and shampoos. Bed bathing is still a nursing skill that is greatly appreciated by patients but it can be associated with cross-infection. According to Parker (2004), bowls used to bath patients are often stacked inside each other in the sluice and poorly cleaned. Infection control nurses have tried to have this practice changed so that individual bowls are kept at each bed space and cleaned after use.

Wound infection had also been one of the most common infections found in the nursing homes. However, as the student able to perceive, it the less common among all of those infective diseases mentioned earlier. There is little information on the development of wound infection within the nursing and residential care settings. Wound infection can be a huge burden on the patient and relatives in terms of pain and suffering, with the added threat of a resultant systemic illness (Russell, 2006). Skin had been considered as the first line of defence. In healthy people it is intact and even if a person has contact with microorganisms, they can be removed by washing. The treatment of wound infection has been and still is a subject which is debated within literature (Timmons, 2003). Based on the student’s basic understanding, in order to help prevent wound infection in any care setting, it is vital that basic infection control protocols are followed. Correct hand-washing technique is essential to avoid the transfer of bacteria from staff to a resident.

As a protocol on the nursing home where the student works, residents with infected wounds should be isolated if possible, and wounds should be reassessed regularly to avoid further complications. The principles of aseptic technique should be followed in order to avoid cross-contamination among residents. Preventing pressure sores in the vulnerable elderly is complex. The literature written by Russel (2006) clearly highlights the importance of early and continual assessment of the individual’s risk of pressure sore development and implementation of preventive strategies. As being observed by the student, senior nurses and managers of the home regularly inspect and ensure proper training of the staffs since lack of knowledge is a contributing factor that should be addressed by the provision of education and training so that all staff possess and implement evidence-based practice. This should be supported by strategies to provide guidance on the prevention of pressure sores. Skin care had been part of the daily routine for nurses and carers in the nursing home. The skin should be kept clean and dry, perfumed soaps and cleansing agents must be avoided because they cause excessive dryness and irritation (Timmons, 2003). In cases of incontinence or if the area is contaminated with urine or faeces, it is best to wash the area with warm water and pat dry with towels or soft tissues.

Impact of poor infection control practice

Having robust policies and procedures in place for infection control is fundamentally important. However, each organization has to go a step beyond this (Flanagan, 2009). As care homes fill with increasingly vulnerable elderly, control of infection within long-term care facilities becomes a daunting problem (Cole, 2007), with residents developing similar infections to acute care facility. Elderly patients are at particularly high risk of contracting infection because of reduced innate immunity, malnutrition, and the presence of chronic medical conditions (Roberts, 2004). According to Maudsley (2004), poor infection control practices may lead to common infections such as urinary infection, respiratory infection, and skin and soft tissue infections, resulting in increased costs to the health service, extended durations of care and substantial morbidity. Aside from that, infections acquired by infected residents or individuals may spread to other, which cause a serious problem on controlling and containing. People requiring care in hospitals, care home clinics, doctors’ surgeries and their own homes may have an infection or may be at risk of picking up infection from other people (Cole, 2007). Staff and visitors are also at risk of infection. Staffs in a healthcare facility may also be considered as the main transporter of the disease itself. According to Hampton (2003), education in infection control and attention to employee health is essential to enable staff to care appropriately and prevent the spread of infection for today’s care home population.

Antimicrobial Resistance

According to Brown (2006), overuse of antimicrobials may lead to increase resistance in many pathogenic bacteria of viruses. As observed by the student during every consultation, General practitioners usually prescribe oral broad-spectrum agents such as cephalosporins. Although many antibiotics initially prescribed are broad-spectrum, which is capable of killing a wide range of bacterial types, each antibiotic has limited effectiveness against certain types of bacteria (Goldrick, 2005). If an infection does not resolve, the antibiotic being taken may not be compatible with the bacteria causing the infection. Antimicrobials are specific as to the type of organism they work for and they should not be used for a purpose that is different from that for which they were prescribed (Nazarko, 2005). In line with El-kadiki’s (2005) article, unwarranted use of antimicrobials can partially mask symptoms and delay the exact diagnosis and recovery. Unless directed by the prescriber, antimicrobials should not be administered before the service user has symptoms (prophylactic treatment) because that increases the risk of resistance developing. According to the General Health Protection-Department of Health (2006), nurses must ensure that General practitioners (GP) do not prescribe antibiotics unnecessarily for the residents. It is important that antimicrobials are administered appropriately to ensure successful treatment and reduce the development of resistance.

Policies and Procedures

According to Nazarko (2007b), there are several policies that the National Health board formulated to implement healthy practice within the care home setting. These policies are implemented in every Nursing Home; as observed, the manager also ensures that these policies and procedures are made available to the staffs for all the time. This may ensure that written policies, procedures and guidance for the prevention and control of infection are implemented. The manager also engages staff throughout the care home to promote and secure the implementation of best practice in the prevention and control of infection.

In the nursing homes, there are several infection control procedures. On where the student works, hand hygiene, disinfecting, personal protective equipment, and safe use and disposal of sharps are the very common practices. These practices are beneficial to both the residents and the staff. The practice of these procedures can also be found in the Infection control manuals that are located in all units in the nursing home. As mention on the previous section, the manuals are placed in a certain area of the institution to make it accessible to all the staffs. From the manual, aseptic techniques based from the UK standards were identified. There are 3 aseptic techniques that are commonly identified by the UK healthcare system. These are 1. Hand hygiene, 2. Personal Protective equipment and 3. Safe use and disposal of sharps. The student will discuss briefly on the later part of this essay.

Hand Hygiene

The most basic aseptic technique found to be the most common is Hand hygiene. On the study made by Knoll and Lautenschlaeger (2010), demonstrates compliance of the staffs in the nursing home with regard to hand hygiene guidelines can be significantly influenced by a number of factors. According to the research article by Rickard (2006), the link between hand hygiene and the infection rate in healthcare establishments is not in doubt. Research articles and reviews have demonstrated the evidence that increased hand-hygiene performance reduces the infection rate. Careful infection-control practice, including frequent hand washing, will remain critical for limiting the spread of infection. Also, very importantly, is the availability of soap, hand towels, disinfectant and disposable cleaning cloths. Infection control is an extremely important aspect of health care. Based on the research by Gould (2001), cold and flu may also be acquired by failing to perform hand hygiene. The cause of the increase of incidence of flu in the nursing homes must be from noncompliance of basic hand hygiene. It was also reported that improper or failure to perform hand washing can cause pneumonia in older people and in people who are diagnosed with chronic illnesses (Stanwell-Smith, 2008). Based on what the student found out, several journals that discuss about the cause infections in the health care setting were mostly from the staff’s poor hygiene practices. Although these measures are all important in the prevention of cross-infection, they are not likely to be used appropriately without education and monitoring of hand washing and cleaning practices of all staff.

Personal Protective Equipment

Infection control is also concerned with personal protective equipment or PPE. Personal protective equipments in the workplace are also used such as disposable gloves and plastic aprons. By definition by Williams (2008), Personal protective equipment or PPE is a specialized protective covering worn by an employee for protection against infectious materials. The use of PPE is essential when working in a healthcare setting. The purpose of PPE is to prevent the worker from coming into contact with infection. Usage of PPE promotes health and safety upon working with clients (Brown and Nay, 2006). From the student’s basic experience, the most basic principle of infection control based from the infection control manual is to work from clean to dirty. In this instance, this refers to getting in contact with clean body sites or surfaces before touching dirty or heavily contaminated areas. This method prevents any debris from spreading toward the cleaner surface. This principle had been competently practiced by the staffs on where the student works.

Safe Disposal of Sharps

Safe disposal of sharps is the third most practiced infection control procedure in the healthcare setting. Ideally, the contaminated syringe needles, scalpel blades, and other sharp devices should be thrown away in a sharps bin (Aitkenhead, 2009). As being observed by the student, sharps bin are located in a protected room in the nurse’s station where residents with mental incapacity, such as dementia, will not be able to gain access on the bin. Based on the article by Trim (2004), numerous staffs sustain sharps injury. In his definition, sharps injury is an injury where a sharp material contaminated with body fluids, penetrates the skin. Majority of the sharps injuries are avoidable and happen when they are handled or disposed in an unsafe manner.

Aside from these three main techniques to prevent spread of infection in the nursing home, there are some other protocols the student’s workplace implements. Among these are provision of yellow bins, plastic bags and red hampers.

Waste Segregation, Use of Bins, and Laundry

Waste segregation had also been part of infection control. According to Conrardy and Hillanbrand (2010), the safe and effective disposal of waste starts with the healthcare professionals or practitioners. Staff in the nursing homes had been instructed to dispose infectious waste such soiled dressings, catheter bags, incontinent bags, etc. in the yellow bin and domestic waste on the black bin. Nappies and incontinence pads however are thrown in black bins. The protocol of pads disposal on where the student works is being followed by staff. Soiled nappies and incontinence pads are being wrapped with plastic bags prior to disposal on the black bin. Aside from that, instructions are given to staffs to be familiar with the waste management policy and procedures for health care waste management. The policies and procedures manual for waste management is accessible to everybody as it is together with the infection control manual.

According to Ashurst (2010), it is part of the Care Quality Commission’s responsibilities to ensure that care homes meet the requirements of the national agenda for infection prevention and control; this includes monitoring laundry facilities. Based on the practice on where the student works, soiled linens are placed on a special kind of bag before placing in to red hampers. Dirty linens are being handled with extra care paid to the potential spread of infection. It is also stated on the manual that gloves and disposable plastic apron should be worn upon handling of soiled garments. It is impossible to avoid all contact with infected tissue or potentially contaminated body fluids, excreta, and secretions. Appropriate barriers such as gloves should be used when handling potentially contaminated linen followed by hand hygiene after removal of the gloves. If a certain material is reusable, transmission of infective agents is prevented by cleaning and by appropriate disinfection or sterilization. All staffs have a responsibility to prevent and control the spread of any infection that may threaten a care home with vulnerable older people in residence. Laundry services also have the potential to set a positive impression for visitors. Staffs working tirelessly behind the scenes in the laundry are sometimes in danger of being forgotten, so their major role in ensuring safety through infection control and securing the home’s reputation must be acknowledged. It is not just about utilising the most efficient chemicals and cleaning solutions in order to prevent infection. The training of staff can also be seen as an important preventative measure. If workers can understand and appreciate the issues concerned with infection control and management it is more likely they will follow procedures.

Application to Practice

It is not just prevention that makes up infection control, the process of surveillance and investigation can also be involved. Fundamentally this is the detection of infection origins and symptoms in order to develop efficient preventative measures. The student has gathered information regarding infection control and may also be helpful to some staffs, residents, and even relatives. On the recent learning that the student was able to gain upon the composition of this paper, he may be able to share the knowledge regarding infection control towards other staffs, especially those who involve in direct care to the clients. Ideal procedures and latest evidence-based practices may also be implemented when student’s knowledge will be shared. The basis of infection prevention and control is the attention to hygiene. Microorganisms can be found everywhere and the cleanliness of individuals, equipment and the environment is essential in reducing the risk of infection. Paying attention to the basics of nursing practice such as bed bathing, oral hygiene, nutrition and elimination is not only part of the ‘caring’ aspect of nursing, but also necessary for preventing cross-infection. The Infection Control Nurses Association devised a tool to determine of certain. According to the NHS Chief Medical director, Mr. Donalson (2005), this infection control audit tool for primary and community care settings builds on previous work for acute Trusts and provides a standardised method for monitoring both clinical practice and the environment. The feedback may enable the staff to know and systematically identify the points where improvement is greatly needed. Thus, enables them to give minimize infection and give quality care for the residents. However, this type of tool was never implemented by the manager on where the student works. Perhaps, knowing the existence of this tool may be very helpful to the company when introduced.


Based on the student’s perception, Nursing Homes should be required to demonstrate that all staffs receive training in infection control policies and procedures. Training must begin at induction, and be ongoing. It is also best to include domestic, laundry and kitchen staff in the training, and homes should be required to keep records of the training. It is also very important to ensure that the nursing home to formulate a programme of education and training for infection control. Through trainings and health educations, staff will be able to ensure that healthcare environment reflects the best practice designed for infection control; effective cleaning and decontamination procedures will also be made available. Infection control aims to help the staff, relatives, and clients to be aware of infection risks and to work in ways to reduce the risk of infection on a day-to-day basis. Educating staff will provide them with the knowledge needed to practice safely; reinforcing the role of all staff in the prevention of infection will help empower them to implement the knowledge they gained.

Although infection prevention and control is the responsibility of all staff who work within healthcare settings, an effective infection control team is essential to the success of an establishment’s infection control programme. When there is an outbreak of infection additional policies and procedures must be added to help everybody to work in preventing further infections and reduce the risk to staff, relatives, and clients. The implementation of strategies to address the issues discussed above should have an effect on infection control in general.

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