Author:Martin Kiernan, MPH, ONC, DiPN, RGN, is nurse consultant, prevention and control of infection, Southport and Ormskirk Hospital NHS Trust; vice-president, Infection and Prevention Society (incorporating ICNA).
Martin Kiernan outlines why healthcare workers need to focus on high-impact interventions in the battle to reduce healthcare-associated infections. Another article in this supplement (p14) explains how these interventions fit into an overall strategy to improve performance.
Healthcare-associated infections (HCAIs) are rarely out of the media spotlight in the UK. The publication of the reports from the Stoke Mandeville Hospital in Buckinghamshire and Maidstone and Tunbridge Wells NHS Trust in Kent on the Clostridium difficile incidents has served to raise the level of public anxiety about the problems of infection.
In 2006 there were over 55,000 cases of C. difficile infections in people aged over 65 and, in England, 6,381 MRSA bacteraemia cases were reported under the mandatory surveillance scheme for the year April 2006–March 2007 (Health Protection Agency, 2007).
While HCAIs create a burden of morbidity and mortality, they also add financial costs to the health economy. Infection adds 3–10 days extra to length of stay (C. difficile infection adds an average of 21 days) (Wilcox et al, 1996) and can cost a trust an extra £4,000–10,000 per patient (Plowman et al, 2000).
Responsibility of each healthcare worker
The impetus now is to reduce all HCAIs. Although progress appears to be being made with, for example, MRSA bacteraemia where rates are now falling, avoidable infections still occur.
It is up to healthcare workers to reflect upon their own contribution to the burden of infection and to ensure that their practices do not add to the problem. Infection prevention and control specialists have for years championed the message that ‘infection control is everyone’s business’ and this is now starting to get through.
Poor practice is recognised as being unacceptable and peer-group pressure is being brought to bear on those reluctant to comply with accepted, evidence-based standards.
Changing practice with high-impact interventions (HII)
In June 2005 a set of tools and techniques entitled Saving Lives was launched as part of a programme to reduce HCAIs in England. These tools were a response to steadily increasing cases of MRSA bacteraemia.
Originally, the toolkit contained five high-impact interventions (HIIs), based on information obtained from the enhanced surveillance of MRSA bacteraemia and because of the increasing burden of C. difficile infection. The HIIs were reviewed and increased to seven in June 2007 (Department of Health, 2007).
What are the HIIs? The HIIs are an evidence-based bundle of procedures that are known to reduce the risks of infection from a given healthcare intervention.
The interventions include a method of measuring and demonstrating compliance with well-founded existing guidance. HIIs link evidence, measurement tools and a strategy for improving clinical care to ensure that the patient receives evidence-based care.
The theory behind care bundles is that, when several evidence-based interventions are grouped together in a single protocol, patient outcome will be improved.
Six of the HIIs are based on specific clinical interventions relating to the insertion of vascular access lines and urinary catheters, the creation of surgical wounds and assisting with artificial ventilation. The other remaining intervention is a bundle that is intended to reduce the risks of C. difficile infections (Box 1).
The use of these procedures is the root cause of most HCAIs. It is therefore vital that best practice is followed when patients are exposed to the risks associated with these treatments.
Why are HIIs important? These interventions are designed to increase the reliability of clinical practice. An emphasis is placed upon: consistent application by all practitioners every time an intervention is performed; and the reduction to a minimum of unjustifiable variations in clinical care (Box 2).
Observations of practice are made and recorded, and feedback is given to clinical teams. The process should not be confused with clinical audit as less detail is examined and the process is faster, allowing for almost immediate feedback.
Using HIIs HIIs are relatively easy to implement and audit, and provide a practical method for implementing evidence-based practice (see p14 ).
The HIIs work by using a mixture of education, administration and behaviour change to improve compliance with key elements of care. A short timescale for observation and analysis means that feedback of practice is reflective of current practice. This often results in staff becoming actively involved in the generation of ideas for improvement as the intervention is locally owned.
Importance of feedback and staff involvement Most staff believe their care is of a high quality and evidence-based, and their procedures are undertaken correctly. Without a review process, it is not possible to say if these opinions are correct.
Observation of clinical practice by peers with documentation of results and robust visual feedback of performance to staff is required to demonstrate compliance with best practice or to highlight areas for improvement. It is a check on the reliability of practice in the clinical setting for both teams and individual practitioners.
No member of staff should feel threatened by this process. Reliable, measurable and evidence-based care is something all healthcare professionals strive to achieve.
The HIIs provide an assurance mechanism for practitioners and are an opportunity for improvement when compliance is suboptimal. Patients have a right to expect that practitioners adopt best practice and the HIIs provide a valuable tool for demonstrating good practice.
Box 1. High-impact interventions
1. Central venous catheter care bundle;
2. Peripheral venous catheter care bundle;
3. Renal catheter care bundle;
4. Care bundle to prevent surgical site infection;
5. Care bundle for ventilated patients (or tracheostomy where appropriate);
6. Urinary catheter care bundle;
7. Care bundle to reduce the risk from Clostridium difficile.
Box 2. Why consistancy is important
The care bundle approach used in HIIs were originally developed in critical care settings (Fulbrook and Mooney, 2003).
For any planned clinical procedure, there are a number of critical components founded on a solid evidence base that must be undertaken correctly to reduce infection risk.
The adoption of some but not all of these components creates a situation where risk is not reduced to the optimal level, so clinical performance is suboptimal and inconsistent.
The critical components, if reliably applied, will increase compliance with the bundle and improve demonstrable consistency in practice.
Comment: Consistent high standards
It is easy to say that infection prevention and control is everybody’s business – but it is much harder to make this happen.
Good intentions can start in the boardroom but may have no impact on clinical practice. Conversely, the Healthcare Commission has found that a desire to implement good practice may be hampered as it is not seen to be a priority by senior management.
There are wide variations in standards between organisations, wards and even individual staff. The challenge is to ensure consistently high standards and to make infection prevention a priority at every level.
Doing this requires communication and shared values. Responsibilities have to be made clear at all levels so everyone is aware of individual and collective responsibilities.
Vital to this are effective infection prevention and control teams who establish and maintain channels of communication and influence strategy and practice across professional and organisational boundaries.
This supplement provides good practice examples that show it is possible to engage staff in reducing HCAI rates. It also highlights the tools, such as high-impact interventions, that we should all use to identify the cause of infections and to promote best practice.
All staff have to be aware of their role in preventing and controlling HCAIs. This requires critical appraisal of performance, recognition that improvement can be achieved and willingness and support to implement change.
Judy Potter, BSc, RGN is lead nurse/director of infection control, Royal Devon and Exeter NHS Foundation Trust, Exeter, and chairperson of the Infection Prevention Society.
Department of Health (2007) High Impact Interventions – Care Bundles. www.clean-safe-care.nhs.uk/public/default.aspx?level=2&load=Tools&NodeID=181#
Fulbrook, P., Mooney, S. (2003) Care bundles in critical care: a practical approach to evidence-based practice. Nursing in Critical Care; 8: 6, 249–255.
Health Protection Agency (2007) Annual Report on Healthcare-associated Infections. London: HPA.
Plowman, R. et al (2000) The Socio-economic Burden of Hospital-acquired Infection. London: Public Health Laboratory Service.
Wilcox, M.H. et al (1996) Financial burden of hospital-acquired Clostridium difficile infection. Journal of Hospital Infection; 34: 1, 23–30.