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Collaborative working to reduce HCAIs in Romania

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Two nurses from the North of England visited Zalau Emergency Hospital in May 2010 to share their knowledge of patient safety and infection prevention and control.

The nurses visited Zalau Emergency Hospital, in May 2010 as part of an on-going commitment to Medical Support in Romania (MSR), a UK registered charity

The hospital is a district general hospital serving a population of 240,000 and has around 800 beds. It has 26 clinical departments and 15 specialist units, including a separate Infectious Diseases Unit, Psychiatric Unit, Tuberculosis Unit and a Rehabilitation Unit. MSR was established in 1990 with its main aim to improve healthcare by working locally in Zalau providing aid but nationally with regard to training. Since 1990, over 200 medical and specialist personnel, mostly from the UK have made almost 400 visits to Romania, mainly to Zalau Emergency Hospital, but also to Bucharest.

Carole Hallam, a veteran of 4 visits to the hospital and Kath Higgins on her 2nd visit to Zalau used their experience of supporting and training nurses and other healthcare professionals across many NHS Trusts in the United Kingdom in patient safety and infection prevention and control. With their combined experience both from their respective UK roles and their previous visits to Zalau, Carole and Kath were clear that SMART (specific, measurable, achievable, realistic and time specific) objectives would be the best way to effect improvements to patient care within the hospital. These objectives were set up prior to the visit by negotiations with the Hospital Management and the Infection Prevention and Control Team. Included in the objectives were, to assess the opportunity to implement some of the best practice (National Institute for Health and Clinical Excellence 2008) guidelines to prevent surgical site infections and to participate in WHO (World Health Organisation) International Hand Hygiene Day

The timing of Carole and Kath’s visit coincided with a national concern in Romania with the outbreak of Staphylococcus aureus, amongst gynaecology patients in Bucharest; hence there was a keen interest in reducing risk of infection in surgical patients. As part of the facilitation package, Carole and Kath provided the Romanian staff with copies of the ‘Saving Lives’ (Department of Health 2007) High Impact Intervention tool, to prevent surgical site infections. With the Infection Prevention and Control nurses for the hospital this High Impact Intervention was reviewed and a post operative care bundle was developed using essential elements from the best practice (NICE) guidelines. The modified tool was translated with the assistance of other key staff at the hospital and a spreadsheet to collect the data was created. The essential elements for post operative care included:

  • An aseptic non touch technique is used for redressing wounds
  • Surgical wounds are not cleaned with antiseptics
  • Appropriate use of antibiotics
  • Wound swabs are taken when a wound infection is suspected

The next step was to train the Infection Prevention and Control Nurses and a Senior Nurse from Surgery on how to use the modified audit tool; Kath facilitated this through on-site instruction that incorporated testing the tool for ease of use and suitability with surgical patients in the hospital. The staff picked up the use of the tool very quickly and with their suggestion of a few minor amendments is now being used in helping to standardise best practice throughout the hospital. This achieved a number of the objectives agreed for the visit to Zalau Hospital.

Another of the objectives was to register Zalau Hospital on the WHO website to participate in the International ‘Save Lives- Clean your Hands’ Campaign. This was accomplished on 5th May prior to the visit; Carole had made sure that the hospital Director was in full support of this beforehand. This turned out to be a major achievement as Zalau Emergency Hospital was one of only three hospitals in Romania to participate in the campaign.

To ensure there was full exposure of ‘Save Lives – Clean your Hands’ the campaign was introduced to ward sisters and other nurses during the training session led by Carole for 60 nurses from the hospital and the World Health Organisation (WHO 2009) multimodal approach was followed:

Systems change

As part of the ongoing commitment to raise awareness at Management level and provide evidence of where improvements could be made a tool was developed to audit hand hygiene facilities in each clinical area. The tool covered an account of the number of beds, soap dispensers, soap dispensers broken, paper towel dispensers, paper towel dispensers empty, if alcohol hand rub used, and if so, how many dispensers/containers are available. Following the approval of Director of Nursing the audit was circulated to all ward and department areas with instructions for them to be returned within 48 hours. The return rate for these was surprisingly high with a 70% response rate.

Training and Education

Again, training was provided to the ward sisters on hand hygiene, the session covered correct technique and the ‘5 moments for hand hygiene’ (before patient care, before aseptic technique, after contact with blood and body fluids, after direct contact with the patient and after contact with the patient’s immediate environment.  Attendance at the session was high, some staff who had already finished their shifts stayed late in order to participate.

Observation and feedback

As part of this element, two clinical areas were chosen to undertake observations of care. This gave Carole and Kath the opportunity to provide general hand hygiene awareness in a fun and participative way that involved doctors and nurses in the clinical areas. The enthusiasm that was being generated because of this campaign inspired one of the Infection Prevention and Control Nurses to audit hand hygiene compliance using the WHO hand hygiene observation tool following some training in its use by Kath and Carole. With the ownership now taken by the Infection Prevention and Control team feedback for occasions when hand hygiene opportunities were missed, was given at the time of observation from staff within their own hospital rather than visitors through a translator.  As part of the drive to increase awareness Adenosine tri-phosphate (ATP) swabs were used to measure protein levels on hands, thus raising awareness of importance of a good hand hygiene practice and the infection risk of wearing stoned rings and wrist watches.

Raising Awareness

To maintain the level of awareness that had been promoted during the week an application was made on-line to the WHO to apply for permission to translate the posters for the ‘5 Moments for Hand Hygiene’. The initiative to translate and promote in clinical areas was taken up by the Infection Prevention and Control Nurses who agreed to translate the poster for use in the clinical area.

Culture Change

Hand hygiene was one of the key agenda items discussed at the inaugural Infection Control Committee.

This was a very positive visit with engagement with both the WHO multimodal approach to hand hygiene and participation in Saving Lives (Department of Health 2007) audits. What Carole and Kath sensed and experienced was there is a real sense of wanting to make improvements despite the limited resources.

Improvements have continued with the Infection Control Nurses in Zalau having other Saving Lives Care Bundles translated with plans to implement the High Impact Intervention for preventing ventilator associated pneumonia in the intensive care unit. Permission has been granted from the WHO for the Romanian staff to translate the ‘5 moments for hand hygiene’ posters to use in the hospital. On-going contact is maintained via email.

For Kath and Carole, the experience was one of a real sense of achievement and mutual respect for their Romanian colleagues, the hospitality and receptiveness they received throughout their stay stretched beyond the realms of professional courtesy. During the working day, staff were always willing to take time to talk with them, exchange professional knowledge, and participate in the training or audit and every evening they were invited into the homes of staff and their families and were made to feel so welcome. An invite to attend the International Nurse’s Day, celebrated on Thursday 6th May was a special occasion. The celebrations started with around 200 nurses attending the Town Hall where nurses shared innovative practice and chronic disease management. This was followed by dining, dancing and pălincă at a Restaurant nearby. The reward professionally and personally means that this is by no means the last time Carole and Kath hope to visit Zalau and once again share experience, knowledge and camaraderie with their Romanian contemporaries.

Further information on Medical Support in Romania can be found at


Kath Higgins, MSc, BSc, RGN, RNT, Senior Nurse.

Carole Hallam, MSc, BSc, RGN, RMN, Assistant Director of Infection Prevention and Control, Calderdale and Huddersfield NHS Foundation Trust

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