VOL: 103, ISSUE: 33, PAGE NO: 30-31
Heather P. Loveday, MA, PGCEA, PCDARM, RN, is (principal author).
Principal lecturer , ThamesValleyUniversity, London.Pellowe, C. et al (2007) Putting the epic2 infection control guidelines into practice. www.nursingtimes.net
Pellowe, C. et al (2007) Putting the epic2 infection control guidelines into practice. www.nursingtimes.net
The epic2 national evidence-based guidelines (Pratt et al, 2007) for preventing healthcare-associated infections offer principles of good infection prevention and control practice. They explain the role of healthcare providers and all healthcare staff in minimising the incidence of infection in hospital patients. The full guidelines have been published in the infection prevention and control section of nursingtimes.net. This article explains how they can be implemented in clinical practice.
This article focuses on the factors associated with the successful implementation of evidence-based practice in general and the epic2 guidelines in particular (Pratt et al, 2007). It also highlights the policy and strategy support available to ensure that these important recommendations for patient safety are implemented in everyday practice.
The first step in any implementation process involves gaining a real understanding of the task ahead. Successful implementation of evidence-based practice depends on:
Research on hand hygiene, isolation and standard precautions for preventing the transmission of blood-borne viruses has demonstrated that one factor contributing to the risk of patients acquiring an HCAI is the failure of some healthcare staff to adhere to guidelines (Pratt et al, 2001).
A number of barriers have been identified that prevent adherence to hand hygiene guidelines. Some of these apply equally to other aspects of infection prevention and control.
A systematic examination of the adherence issues associated with hand hygiene practice indicated that staff faced a range of barriers that needed to be overcome if they were to comply with guidelines (Boyce and Pittet, 2002).
Observational studies of hand hygiene practice show that the opportunities for hand decontamination vary between specialties and range from eight to 20 per hour and that actual hand decontamination events range from five to more than 100 per shift, with time taken to decontaminate hands in the 5-24 seconds range.
Factors contributing to poor adherence include: structural/organisational; personal well-being; human resources; knowledge deficits; and putting knowledge into practice. Each of these creates barriers to evidence-based practice and is discussed below.
Making things happen
The processes used for putting evidence into practice require a fine balance between task-focused roles and skills - such as technical and clinical know-how, project management skills and making use of external resources - and holistic roles and skills that require partnership working, interpersonal and communication skills, critical reflection and the ability to facilitate adult learning (Rycroft Malone et al, 2004).
The environment in which the change is proposed is also crucial. It is made up of three elements: culture; leadership; and evaluation. Implementation of evidence-based practice is more likely to succeed in learning organisations where:
Boundaries are clearly defined;
Values and beliefs are shared by all and staff;
Clients are valued.
Transformational leadership is key to getting knowledge put into practice. This emphasises promoting effective teamwork among a multidisciplinary group, democratic decision-making and an enabling approach to teaching/learning and managing. In addition, a commitment to evaluate and feed progress back to staff and clients throughout implementation maintains commitment and motivation (Rycroft Malone et al, 2004).
This can be described as the 'not enough of the right things' barrier. Researchers report that staff have to contend with a range of issues such as: insufficient or inadequately positioned sinks that are remote from patient care; a lack of soap dispensers; and poor supplies of alcohol handrub or liquid soap, or of good-quality paper towels with which to dry hands (Pratt et al, 2001).
At an organisational level, these barriers can be overcome by ensuring that infection control teams and clinicians are consulted when care facilities are being remodelled or built and that robust purchasing and supply processes are in place. At a ward and unit level, it requires personal responsibility for replenishing essential stocks and reporting faulty equipment.
Personal well-being factors
This can be described as the 'sore hands' barrier. Handwashing studies indicate that 25% of nurses report symptoms or signs of dermatitis involving their hands (Pratt et al, 2007). Multiple factors contribute to this, including the frequency of washing, the product used, water temperature, inadequate drying and shear forces associated with wearing and removing gloves. The use of alcohol handrub is less commonly associated with skin disorders (Boyce and Pitett, 2002; Pittet et al, 2000).
These barriers can be minimised at an organisational level by ensuring that products are properly evaluated before they are introduced across a trust or service and that alternative products are available to staff who develop skin problems. It is also essential that occupational health services and in-service education offer practical advice and emphasise the importance of maintaining skin integrity (Pratt et al, 2007).
Human resource factors
Human resource factors encompass the 'not enough staff or too many patients' barrier. High levels of patient dependency are likely to result in increased numbers of hand hygiene events and competing demands that reduce levels of adherence to hand hygiene guidelines (Hugonnet et al, 2007). Skill-mix and shift patterns have been shown to influence staff behaviour. Considerable emphasis is placed on the importance of providing clinical leadership and good clinical role models who cultivate an environment in which high-quality practice is expected, and who set an example to more junior staff. This is a key feature of many service/practice improvement strategies.
These barriers can be some of the most difficult to manage and overcome in a challenging healthcare environment where the needs of the service have a degree of unpredictability. At an organisational level, it is important that hand hygiene and other aspects of infection prevention and control are promoted as key components of high-quality care, with leadership from the trust board downwards. Addressing some of the other factors discussed here makes it more likely that staff will be able to comply with guidelines.
Understanding the evidence
A lack of awareness of guidelines or a poor knowledge and understanding of the principles of infection prevention and control may lead to minimal or inappropriate application of guidance. Staff may become confused about when to wash their hands and when to use an alcohol handrub, or lack the skills to assess risks and the need for hand decontamination in clinical situations.
The quality and breadth of the evidence base for change is important in terms of harnessing organisational and professional support. Successful implementation comes with well-designed research that is identified as cost-effective and relevant to practice and is reflected on by critical professionals. The recognition that patient experience and local information are important aspects of the evidence base is crucial and evidence needs to be used in the context of the patient experience and local circumstances. This requires the development of an in-depth understanding of both the health needs of the population and the expectations of consumers and other stakeholders involved in the provision of healthcare.
Continuing professional education and development is a cornerstone of guideline implementation. Winning Ways (Chief Medical Officer, 2003) highlighted education as a key element in the fight against HCAIs and introduced the practice of trusts making explicit provision for staff on induction to the organisation and as part of their annual continuing education programme.
Other triggers for specific education can arise from deficits highlighted in audits or 'near miss' events. The epic2 guidelines (Pratt et al, 2007) provide a list of suggested audit criteria at the end of each subject section, which can be adapted to suit local circumstances. In addition to providing new information, educational sessions can be used to motivate and inspire staff. Providing feedback on improved performance is a valuable motivator and enhances team cohesion.
Translating knowledge into action
Translation of knowledge and understanding can be described as the 'putting it into action' barrier, which encompasses a lack of skills and a range of non-adherent behaviours.
Everyday practice involves a range of skills from simple learned behaviours to complex situations that require the prioritisation of interventions and actions. In some situations, the combination of factors already discussed and the prevailing clinical situation may provide reasons for not performing hand hygiene that outweigh the reasons for adhering to guidance.
Other factors that affect the behaviour of individual practitioners are their attitude and motivation towards the desired behaviour, the social norms of their work environment - including good role models - and the perceived risk of infection arising from the activity. Audits of hand hygiene practice demonstrate that many healthcare staff decontaminate their hands following contact with a patient in order to protect themselves but that they fail to clean their hands before contact with a patient.
In order to overcome these barriers, interventions to implement guideline recommendations need to be selected and implemented in a systematic and planned way. In a systematic review of interventions to improve hand hygiene, Naikoba and Hayward (2001) concluded that:
The cleanyourhands campaign uses all the available evidence for improving hand hygiene practice and has focused on overcoming the barriers discussed above. Purchasing acceptable and effective alcohol handrub products, available at the bedside or carried by the healthcare professional, together with the use of reminders, role models and audit and feedback aim to significantly raise adherence to hand hygiene guidelines by making it easier for staff to clean their hands.
Strategies and tools to help implementation
There is a wide range of strategies for managing and influencing the adoption of innovation and change (Greenhalgh et al, 2004; Iles and Sutherland, 2001) with an increasing use of quality-improvement strategies in healthcare generally. Much of this work was developed systematically by the Institute for Health Improvement in the US and the Institute for Innovation and Improvement in England.
The past three years have seen an increased focus in using these approaches to reducing HCAI rates with the roll-out of the 100,000 Lives Campaign in the US, the World Health Organization's Global Safety Challenge and the Saving Lives Delivery Programme in England. These approaches all focus on implementing evidence-based practice in the interests of patient safety and quality of healthcare. They increasingly use internet technology to provide quality-improvement tools, support networks for sharing learning and performance-improvement methods, and deliver multidisciplinary and education programmes.
In addition, putting evidence into practice requires leadership, engagement of stakeholders from patients and staff through to chief executives, and a clear vision of the changes required.
There are many approaches to delivering change but essentially all require phases of assessment, planning, implementation and evaluation. Although a linear approach to change seems attractive and logical, often a number of activities and phases need to happen together if barriers are to be overcome and progress made (Rycroft Malone et al, 2004).
The context of the external environment for getting knowledge translated into practice is pivotal in change and improvement. Competing demands for resources in NHS trusts means this often involves prioritising changes and balancing external policy demands against the health needs of the local population and the resources available. In the case of HCAIs, the drivers for change and improvement are patient experience and expectations, the need to reduce the economic costs of HCAI at a local level and central government policy.
Using policy to drive implementation
The importance of all of the above issues have been taken into account by the DH in developing a range of policy initiatives to drive improvements in the provision of clean, safe care and assist in the implementation of evidence-based practice.
The publication of Winning Ways (CMO, 2003) set the agenda for making targeted improvements in the prevention of HCAIs that later developed into the MRSA/Cleaner Hospitals programme. The 2006 Health Act introduced a Code of Practice for the Prevention of Healthcare Associated Infection (DH, 2006) and underpins the linked initiatives in the MRSA/Cleaner Hospitals programme. The code sets out the obligations of NHS trusts in relation to management, organisation and environment, clinical care protocols and maintaining occupational health and safety. The extent to which a trust complies with the code is assessed as part of the annual health check conducted by the Healthcare Commission.
The MRSA/Cleaner Hospitals programme has been designed to ensure that staff are engaged at every level of the organisation and to shift the focus of responsibility for preventing HCAIs firmly in the direction of clinicians, with expert support and guidance being delivered by the infection control team. The overarching aim is to make infection prevention a personal priority for every healthcare professional's practice and support worker's role, from ward cleaner to consultant.
New guidelines for the prevention, screening and management of MRSA infection were introduced in 2006 and were followed by a strategy to implement targeted screening of high-risk patient groups. Guidelines for the prevention of Clostridium difficile are being developed and a sixth care bundle for reducing the risk of C. difficile infection has been developed and added to the Saving Lives Delivery Programme (DH, 2007).
The lack of appropriate educational material for all levels of staff stimulated the DH to commission a blended e-learning programme for all NHS staff. There are two versions of the programme, one for clinical and another for non-clinical staff. It covers the standard principles for infection prevention, which are expected to be adhered to in a Healthcare Commission assessment. Both versions are available free of charge at www.infectioncontrol.nhs.uk
Making use of information
The use of surveillance data is seen as an important tool to focus the attention of clinicians on rates of HCAI and help to identify where some NHS trusts face particular challenges. Mandatory surveillance of MRSA bacteraemia was introduced in 2001 and accompanied in 2005 by a target to reduce rates of MRSA bacteraemia by 50% by 2008. In 2004 the growing number of C. difficile infections led to a further mandatory surveillance scheme.
In order to provide clinicians with support in reducing rates of HCAI and achieving the MRSA target, the Saving Lives Delivery Programme was launched. Derived from the 100,000 Lives campaign in the US, it provides tools for use by clinical teams to benchmark practice and implement six care bundles known as high-impact interventions. These interventions are based on robust clinical and research evidence and are known to be effective in minimising the risk of HCAIs in vulnerable patients. Audit processes and the use of the Saving Lives tools also promote the direct feedback of information to clinical staff so that they can build on improvements or plan further action to address poor practice or performance.
Use of the Saving Lives tools requires trust chief executives to sign up to the programme and ensures board engagement and organisational commitment to supporting teams. Individual clinical teams then select the intervention most important for improving patient outcomes in their area of practice before embarking on cycles of reviewing and measuring levels of performance, agreeing benchmarks and planning their actions to improve practice. This is followed by an implementation phase in which they carry out their action plan and a demonstration phase in which improvements are evaluated and measured and fed back to the team.
The prevention of HCAIs and the attendant reduction in rates of MRSA, C. difficile and other antimicrobial-resistant bacteria is central to maintaining patient safety and public trust in the quality of healthcare. Patients and their relatives have a right to expect that evidence-based guidelines are implemented and adhered to by all healthcare staff. The key to implementation and quality improvement in infection prevention lies in combining the political will to create an environment that supports and challenges NHS trusts and individual practitioners cut HCAIs with the creation of an internal environment that focuses on learning, leadership and involvement to ensure that staff provide safe, clean care.
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