The Department of Health has published guidance that summarises good practice in infection prevention and ward cleanliness. Nerys Hairon highlights the main points
Hairon, N. (2008) Guidelines outline key actions to improve infection control. Nursing Times; 104: 36, 19–20.
The Department of Health has published a summary of the key interventions on infection prevention and control (DH, 2008a). The overall aim is to move towards the goal of zero tolerance of infection.
The DH says these interventions will enable trusts to prioritise efforts and maximise their impact to prevent healthcare-associated infections (HCAIs). The guide draws together the accumulated learning, evidence and good practice on the critical actions that trusts can take.
The DH wants to build on its recent success of tackling MRSA and aims to sustain the fall in rates to 2010–2011 (to less than 50% of the 2003–2004 figure). The DH also aims to cut Clostridium difficile infections by 30% nationally over the period from 2007–2008 to 2010–2011.
The guidance covers actions in four key areas: people; processes; practices; and performance. It also includes details of tools and resources to help practitioners, and examines specific areas such as fostering a ‘board-to-ward’ culture where interventions reach all levels of an organisation.
It follows a national campaign launched earlier this year to reduce inappropriate use of antibiotics. This reminded healthcare professionals about the problem of antibiotic resistance and to make clear to patients that antibiotics will not cure the common cold (DH, 2008b).
Recent NICE (2008) guidance on treating respiratory tract infections in primary care also aimed to address inappropriate use of antibiotics for these conditions (Hairon, 2008).
Nurses have a vital role in implementing effective infection control procedures and also in ensuring appropriate antibiotic use in both acute care and the community.
Four key areas
The DH guidance sets out four main areas where action can accelerate and sustain improvement. These are:
- People – the right trained staff, with appropriate skills and behaviours;
- Processes – systematic methods, procedures and ways of working;
- Practices – consistent individual, clinical and organisational practices;
- Performance – assurance of delivering on policies, procedures and standards.
Critical steps that trusts should take in each area are also outlined (see below).
The DH (2008a) emphasises that leadership to champion cleanliness at every level is vital to ensure continuous improvement.
This requires a ‘board-to-ward’ culture, with everyone understanding and playing their part. This culture should support staff to review, challenge and feed back on behaviours and practice. People in senior leadership roles play a key part in setting the strategy, culture and tone.
Training is also emphasised as essential to develop staff knowledge. Clearly, senior nurses are vital in promoting a ‘board to ward’ culture, ensuring staff review and challenge practice and ensuring staff have access to training.
The DH recommends trusts should carry out the following critical steps:
- Commit to building a ‘board-to-ward’ culture to ensure everyone understands their role in infection prevention and cleanliness;
- Ensure the director of infection prevention and control has the skills, responsibility and delegated authority to maximise their effectiveness;
- Provide comprehensive knowledge and skills assessment;
- Take a rigorous approach in setting personal HCAIs and cleanliness objectives then carry out individual appraisals;
- Assure compliance by empowering staff to ensure that good practice is followed and giving immediate feedback on results.
The guide refers practitioners to the DH’s ‘board-to-ward’ guidance, which aims to help create a culture of improving patient safety and care.
Processes should ensure that causes of infection are understood and that actions to prevent and control HCAIs and ensure cleanliness are reliably followed.
The DH recommends trusts should:
- Devise and implement an infection prevention and action/delivery plan;
- Use high-impact intervention care bundles to increase the reliability of clinical processes;
- Review the care pathway for patients with C. difficile;
- Ensure screening policies and procedures are consistently applied;
- Target environmental cleaning, with the aim of increasing public confidence and making other infection control actions easier.
The C. difficile care pathway and management toolkit brings together evidence and good-practice guidance on caring for patients with C. difficile infection.
In the area of environmental decontamination and cleaning, clinical staff – including matrons and infection control specialists – should be involved in setting and monitoring cleaning standards.
The DH emphasises the need for a consistent application of clinical and operational good practice to reduce HCAIs and improve cleanliness. It highlights training, systems to assure reliability of practice, the need for clinical leaders to act as role models and isolation practice as key elements.
- Introduce methods for assuring that clinical staff have the knowledge and skills to perform key clinical procedures, including aseptic technique and taking blood cultures;
- Assure prudent antimicrobial prescribing by implementing robust prescribing policies throughout the trust;
- Promote and enable the use of root cause analysis;
- Plan for isolation, including reviewing capacity and addressing any gaps;
- Set expectations for compliance with key policies.
The guidance says using broad-spectrum antibiotics can increase susceptibility to C. difficile infection. It adds there is some indication that carefully managing antibiotic use will help to reduce MRSA infection. Antibiotic prescribing guidance stresses the need for: a policy to limit the use of broad-spectrum antibiotics; a strategy for effective implementation; and tools and processes for measuring compliance. For a summary of key actions in practice, see box below.
Key actions in practice
The DH points out that trust boards have a responsibility to be sure they are delivering against HCAI targets and cleanliness requirements. Accurate monitoring is necessary to determine whether policies, processes and personal practices are being followed consistently.
- Routinely report on compliance;
- Link HCAI performance to clinical indicators – the impact of these infections on mortality rates and outcome measures must be clearly understood by all senior managers and practitioners;
- Communicate and present performance information in ways that change behaviour;
- Directly reinforce individual accountability – staff performance on HCAIs and cleanliness should be included in appraisals, performance objectives and reward and disciplinary processes;
- Assure capabilities through commissioning.
The DH guidance outlines the various toolkits, care pathways and resources that are available for trusts to use to improve practice in the areas covered above. For further information on all areas, see the www.clean-safe-care.nhs.uk website.
Nurses working in a variety of positions have a vital role in implementing infection control and prevention measures to ensure patient safety.
Department of Health (2008a) Going Further Faster II: Applying the Learning to Reduce HCAI and Improve Cleanliness. www.dh.gov.uk
Department of Health (2008b) Leaflet. Get Well Soon – Without Antibiotics. www.ctc.nhs.uk
Hairon, N. (2008) Guidance aims to cut antibiotic use in respiratory infections. Nursing Times; 104: 31, 23–24.
NICE (2008) Respiratory Tract Infections – Antibiotic Prescribing. Prescribing of Antibiotics for Self-Limiting Respiratory Tract Infections in Adults and Children in Primary Care. www.nice.org.uk