A nurse-led initiative to reduce levels of HCAIs in hospital

VOL: 103, ISSUE: 14, PAGE NO: 30-31

Heather Sud, RGN;Jane Gorman, RGN

Heather Sud and Jane Gorman have a job share as senior modern matrons at Mayday Healthcare NHS Trust, Croydon, Surrey

Abstract Sud, H., Gorman, J. (2007) A nurse-led initiative to reduce levels of HCAIs in hospitall. www.nursingtimes.net.

Abstract Sud, H., Gorman, J. (2007) A nurse-led initiative to reduce levels of HCAIs in hospitall. www.nursingtimes.net.
Acute trusts have been set the target of reducing healthcare-associated infections (HCAIs) by 60% by 2008. This article outlines work undertaken by the senior modern matrons in a four-tier approach, which resulted in a reduction of just over 50% in HCAIs

Healthcare-associated infections (HCAIs) are infections picked up as a consequence of contact with the healthcare system. The need to control HCAIs is enhanced by the emergence of anti-microbial resistant micro-organisms. An extensive number of micro-organisms can be spread in healthcare settings, so nurses have a key role to play in improving outcomes and experiences for patients. Patients rightly expect hospitals to be free from infectionand clean - it often makes a difference to how they feel they have been treated (John Reid, 2004). Infection control and cleanliness are linked in patients' minds. As methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile continue to receive much media and political attention, and with the emergence of extended-spectrum beta-lactamases (ESBLs), this is unlikely to change. All this means staff must ensure that the environment and reduction of hospital-acquired infections remain a high-profile goal. The Chief Nursing Officer has put infection control high on her agenda and enforced the principle of team working as central to delivering safer, cleaner environments (DH, 2004a). Incidences of HCAIs within each trust now contribute to the annual star ratings.

The Department of Health document Towards Cleaner Hospitals and Lower Rates of Infection (2004b) states that cleanliness contributes to infection control but preventing infections requires more than simple cleanliness.

With the advent of payment by results and increased patient choice, a robust system of HCAI prevention becomes increasingly important to each trust as infections have become more difficult and expensive to treat.

The National Audit Office (2003) reports that patients with hospital-acquired infections will spend on average an additional 11 days in hospital at a total cost of about £1billion per year - about £4-10,000 per person. Prevalence has been calculated at 9% of hospital patients. If we apply this to our trust, with 750 beds in Greater London, then this equates to 67 patients with unnecessary bed occupancy at any one time.

Aims

The study set out to investigate whether introducing a hospital-acquired infection risk assessment tool, coupled with soap surveillance, could reduce the levels of HCAIs - specifically MRSA and ESBLs - in three targeted areas within an acute district general hospital.

Interventions

As senior modern matrons within our trust, we have taken a clear role in monitoring standards of infection control and cleanliness. This was helped by the publication of A Matron's Charter (NHS Estates and DH, 2004), which focuses on ensuring the patients' environment is clean and safe. The role of the modern matron is considered to be a fundamental part of clinical governance, thus ensuring the quality of care is of the highest possible standard. We had a perception that the current level of care could be improved to better meet patient needs. We feel we have the high visibility and clinical credibility required to do this.

In April 2006 three wards were identified by the infection control team as having a higher rate of HCAIs than other similar wards. Bed occupancy during the study was 98-100% in all three wards and all inpatients in those areas were included in the study. They were anonymised unless they developed a hospital-acquired infection.

Three initiatives were introduced to reduce HCAIs:

• HCAI risk assessment tool;
• Geographical clinical ward plans;
• Covert soap surveillance.

Method

The study took place in a 750-bed district general hospital over a two-month period. The wards included were chosen because of their levels of hospital-acquired MRSA and ESBL in the previous three months and identified using the Pareto principle. This was developed by Vilfredo Pareto (1906) and states that for many situations, 80% of consequences stem from 20% of causes. In everyday life this means that we wear 20% of our clothes 80% of the time and 20% of our carpets get 80% of the wear. We were able to identify trends in three areas that had higher levels of HCAIs and lower cleaning scores and hand-washing rates. This means they have fallen below the agreed standard.

The initial study was carried out for a two-month period and quantitative data was collected related to HCAIs and hand-washing rates. Descriptive statistics were used to analyse risk scores against MRSA, ESBL and hand-washing rates.

Having identified these areas, the next step was to put a series of strategic plans in place to improve these scores, which were developed in conjunction with the infection control nurse:

• Active surveillance and investigation of HCAIs by modern matron and ward staff;
• Plans in place to reduce reservoirs of hospital acquired infections by 15% within 2 months;
• Application of high standards of cleanliness by ensuring nurses' cleaning scores are above benchmark 85%.

Weekly data was collected related to:

• Numbers of HCAIs in all clinical areas as identified by the infection control nurse;
• Hourly hand-washing rates. This refers to the number of times nurses wash their hands on a weekly basis and the figure is calculated by:

The beauty of this system is not only does it identify weekly overall hand-washing rates but also it is possible to monitor soap usage in specific areas, such as side rooms if patients require isolation.

This type of soap surveillance can be classed as a surrogate indicator of the quality of care provided.Indicators are used extensively as tools for assessing the efficiency, effectiveness and reliability of systems and measure performance against certain standards.

Risk factors associated with HCAIs have long been established (Rubinovitch and Pittet, 2001) but we could find no evidence of them having been used to develop a risk assessment tool, either within our trust or any other. It was felt there was a need to understand risk among hospital staff if we were going to improve patient confidence, decrease length of stay and wasted resources. It was also felt that risk assessment should be part of the overall assessment process. The Nursing and Midwifery Council code of professional conduct (2002) states that all nurses must work with other members of the team to promote healthcare environments that are conducive to safe, therapeutic and ethical practice, and the Health Bill (2006)states that healthcare professionals must:

1. Make a suitable and sufficient assessment of the risks to patients in receipt of healthcare with respect to HCAI;
2. Identify the steps that need to be taken to reduce or control these risks.

Therefore our first action was to develop a tool that amalgamated all the risk factors into one easy-to-use tool that can be used as an ongoing document throughout the patients' stay (fig 3). Nurses were required to complete the tool with each patient on admission and then weekly until discharged.

In conjunction with this, our targeted wards completed a weekly clinical ward diagram to highlight geographic high-risk areas on each ward and potential paths of cross-infection. It is also used to identify the overall risk scores for each six-bedded section. It provides a very visual tool that is discussed at each shift handover and allows better planning for placement of patients in the ward environment.

Relationships are everything and clinical engagement remains a vital component in the success of this project, as none of this would have been possible without the ward-based staff coming on board. Before beginning the project we met with as many of the ward nurses as possible to discuss the project. As it progressed, the nurses became more involved in benchmarking themselves against the other clinical areas. This has encouraged healthy competition, not only between individual wards but also across directorates.

No other variables were introduced in addition to those already in place, which included weekly ward rounds by the infection control nurse and isolation, whenever possible, of patients with infections.

Results

In a short period of time early results for this initiative have been very encouraging. Analysis of data has demonstrated that our interventions have had an impact on HCAIs. A total of 144 patients were included in the study. There was a decrease in the number of cases of MRSA and ESBL with only nine cases of HCAIs during the two-month period in all the three targeted areas combined, compared with 19 in the previous two months (Figs 1 and 2).

• HCAI rates in the targeted areas fell by just over 50%;
• Hand-washing rates increased by between 100% and 400%;
• Risk assessments were completed on 95% of inpatients;
• Nurses were able to discuss in detail where to place patients in the clinical area and their reasoning for making that decision.

Implications for practice

Analysis of the data showed that 85% of our clients fall into the high-risk group. Hospital-acquired infections can have a very serious effect on patient outcomes as well as increasing their length of stay and cost of treatment. Therefore identifying individual patients' risk factors can considerably reduce their risk of contracting any of these infections. The success of this project was due to multiple factors that include:

• Introduction of tools to monitor infection control practices;
• Close teamwork between matron and ward staff and commitment from all those involved;
• Collection of up-to-date information that allows anticipation of change and a proactive response;
• The authors maintaining a strong visible presence on the target wards and having clinical credibility to introduce change. Continuous monitoring processes should identify if nursing practice meets national and local standards. Initially there was some scepticism among ward nurses about the benefits of the risk tool and so constant monitoring was required to ensure the documentation was completed. Once ward staff began to see benefits in the tool then compliance improved and has been sustained.

Following the success of the initial study, another three areas were then targeted for a further two-month period. The initial results were replicated when MRSA and ESBL infections fell by 50%.

Conclusion

We are now planning how to take this strategy forward; originally it was intended to roll it out across the trust but a decision has now been made to combine this with nursing quality indicators, which are in the final stages of being produced. We conclude that rolling it out across the entire trust will dilute its effectiveness and reduce the matrons' ability to monitor progress. Two or three targeted areas are manageable but using the same principle in 22 clinical areas would probably adversely affect the results. The nursing indicators will allow us, through the continued collection of weekly and monthly data, to continue to target areas identified by the indicators. This means their impact can be more effectively monitored and the risk assessment tool can be used as an outcome indicator - this should allow us to link the risk indicator to the progress of the patient.

References

Department of Health (2006) The Health Bill 2006 .London: DH.

Department of Health (2004a) 'Hospital cleanliness a top priority for new top nurse', DH press release October 2004. London: DH.

Department of Health (2004b) TowardsCleanerHospitalsand Lower Rates of Infection programme. London: DH.

John Reid (2004) Foreword to Towards cleaner hospitals and lower rates of infection: A summary of action. London: DH.

National Audit Office (2000) The management and control of hospital acquired infection in acute NHS Trusts in England. London: The Stationery Office.

NHS Estates and Department of Health (2004) A Matron's Charter: An Action Plan for Cleaner Hospitals. London: DH.

Nursing and Midwifery Council (2002) Code of professional conduct.

Pareto, V (1906) Vilfredo Pareto's principle 80/20 rule.

Rubinovitch, B., Pittet, D. (2001) Screening for methicillin-resistant Staphylococcus aureus in the endemic hospital: what have we learned? Journal of Hospital Infection; 47: 1, 9-18.