Healthcare-associated infections (HCAIs) have attracted the attention of the media and the public, and last month, Maidstone and Tunbridge Wells NHS Trust became the latest hospital trust to come under fire for poor infection control.
A report by the Healthcare Commission found ‘significant failings’ in the trust’s infection control practices, and said a ‘litany of errors’ in the poor handling of the HCAI Clostridium difficile had resulted in 90 deaths between April 2004 and September 2006.
The report highlighted the lack of strong leadership at the trust. The hospital board was heavily criticised by the commission, which said it had not put appropriate measures in place to prevent and manage infection, had not addressed problems raised by staff and that many of the infection control policies adopted were out of date or not easily available to ward staff.
‘Infection prevention and control is everybody’s responsibility, not just that of clinical staff,’ says Lesley Doherty, director of nursing and performance at the Royal Bolton Hospital in Greater Manchester. ‘But to clinically engage all health professionals in reducing rates of infection, you need to ensure good structures and policies are in place – it is about leading from the top.’
Ms Doherty has been in her role for three years, and has been instrumental in overhauling infection prevention and control at the trust. ‘Although we were providing a good level of care, it is only when we stopped and really took the time to look that we saw where improvements could be made,’ she says.
Having also been involved with the government’s national improvement teams,
Ms Doherty was able to observe infection control practices at other NHS trusts across the UK. ‘There are many examples of good clinical practice, and this was a great opportunity to see good works across the country that could be adapted by the trust,’ she says.
Infection control has become a major priority for the government and the Department of Health has introduced a raft of policies to help trusts reduce HCAI rates. In September the DH outlined new measures to tackle HCAIs including ‘bare below the elbows’ guidance on staff dress.
‘We have been bare below the elbows for two years now at the trust. A change in culture doesn’t happen overnight, and it has taken a long time for everyone to know we mean business. But bare below the elbows has been adopted across the board in clinical areas and at least 90% of our doctors no longer wear ties,’ she says.
As outlined in Saving Lives, the 2006 DH-MRSA/Cleaner Hospitals programme, the trust introduced a number of self-assessment tools – high-impact interventions that can be used to address specific areas of infection control.
‘This enabled us to assess practice and then structure any actions that needed to be taken,’ says Ms Doherty. ‘Although things were being done, there were no specific structures in place. The code of practice in the Health Act 2006 also gave us external standards to measure ourselves against.’
Using root cause analysis, Ms Doherty identified areas of practice that needed targeting to reduce infection rates. Daily ward checklists on peripheral line care, urinary catheter care and hand decontamination were then developed.
‘We also introduced a handwashing compliance chart,’ says Ms Doherty. ‘The standard was set at 95%: if wards were performing at 95% compliance or above, there would be a monthly audit; between 80% and 95%, it would be weekly; and below 80% they would be audited daily.’
A daily venous access checklist, incorporating a visual infusion phlebitis score policy, was also developed. Designed to ensure the effective daily management of peripheral cannulas, nurses use a chart to score the cannula from 0 (healthy) to 5 (advanced stage of phlebitis) and take the appropriate action.
As part of the overhaul of managerial and professional structures at Bolton Royal Hospital, the Bolton improving care system (BICS) was implemented, a specific approach to service improvement based on the lean technique, a management structure originally developed by car manufacturer Toyota.
In 2006 Ms Doherty introduced weekly ‘Go and see’ rounds in every ward and department. Matrons, ward sisters and team leaders were asked to identify three small things every week that could be changed to improve the environment. The changes were implemented the following week and improvements recorded.
‘The main aim is to create and maintain a clean, safe, bright and professional working area that gives patients confidence in the services that we provide,’ says Ms Doherty.
The trust also employed the 6s productivity tool – sort, straighten, scrub, safety, standardise and sustain – another lean principle with the emphasis on cleanliness, hygiene and safety.
The Health Act 2006 sets out a code of practice on infection control. To ensure the standards required at Bolton Royal Hospital are met, all staff have to sign a personal standards for infection control (PSI) document. Even visiting consultants and primary care staff have to sign the document, which clearly identifies the responsibilities of staff. And Ms Doherty says they do not have a problem getting staff to sign it.
‘Infection control underpins patient safety, and patient safety is what drives clinical staff,’ she says. ‘[Infection control] is in everybody’s job description – working to a code of practice underlines this.’
One of the most innovative approaches Bolton Royal Hospital has taken to improve infection control is the exemplar ward development programme. Nurses on exemplar wards work intensely with infection control staff for three months and are backed by a dedicated team, including a pharmacist, IT support and cleaners.
‘The idea came from asking ourselves “if a ward could do everything right, what
would it do?”,’ says Ms Doherty. ‘It is about taking a fresh look at infection control, dealing with the basics and incorporating policies into day-to-day practice.’
The exemplar wards employ all the trust’s infection control policies and Ms Doherty says the standard of care is expected to be very high, with at least 90% compliance with performance indicators.
The trust has three exemplar wards which are assessed regularly. So far, there have been no recorded HCAIs on any of these wards.
Rates of MRSA have significantly decreased at Bolton Royal Hospital over the past four years, but there is still a problem with the infection coming in from the community.
‘More than 30% of our cases of MRSA are pre-48 hours, which means the patient had the infection prior to admission to hospital,’ says Ms Doherty. ‘But we have a really good working relationship with the PCT, and have developed a joint root cause analysis tool to address this.’
The trust is also piloting a rapid screening tool for MRSA, where results of swabs could be obtained in two hours rather than two days.
A robust antibiotic policy has also seen rates of Clostridium difficile decrease. ‘In January this year we had 73 cases of C. difficile,’ says Ms Doherty. ‘In September, we had 14. This is directly due to antibiotic prescribing, and nurses are essential in enforcing this policy.’
While poor infection control practices continue to make headline news, hospitals like the Royal Bolton are proving that adopting a ‘board to ward’ approach to tackling infection can have a significant impact on patient safety, and ensure the rates of HCAIs continue to fall.
‘As long as we have infections that are avoidable, we have issues to address,’ says
Ms Doherty. ‘Changing culture is hard but, when you get it right, you can demonstrate a
Making policy a reality from board to ward
- Strong commitment and leadership are required from the trust board and senior managers – initiatives have to be led from
- Infection control teams act as facilitators
to guide staff on best practice. Initiatives may be nurse led but it is everybody’s responsibility to implement them.
- Ensure all policies are evidence based and up to date, and that all healthcare staff can access them easily.
- Use root cause analysis to identify problems and practical tools, such as self-assessment tools, to implement changes.
- Undertake regular audits to ensure compliance on issues such as hand hygiene are being met, and that best practice is being carried out.
- Look at implementing practices based on the lean technique, such as ‘go and see’ rounds and the ‘6s productivity tool’.
- Communication at all levels is paramount. Hospital boards must listen to the worries or concerns of ward staff and address issues as promptly as possible.