The commissioning arm of Eastern Kent and East Coast PCT, one of the biggest PCTs in the country, has set up a system for infection prevention and control which is now being replicated throughout the strategic health authority.
Sally Allum (pictured), assistant director of clinical performance at the PCT, explains the rationale: ‘The important issue for us at the PCT is ensuring that we fulfil our commissioning responsibility by making sure that every NHS pound is spent on providers who are working to the same infection prevention and control standards.’
The main building brick of the system is a committee that was set up with representatives from both commissioning and provider organisations. The Local Health Economy Infection Prevention and Control Committee was established eight months ago and includes representatives from the PCT, the acute providers, care homes, hospices, Kent County Council, GP practices and ambulance trusts.
The group meets once a month and, although some people were unsure of the purpose of the meetings to start with, they are very well attended. Ms Allum says: ‘Initially people were wary of it, perhaps seeing it as just another committee, another place to report to. If the room was empty then we would know that we had got it wrong. But it’s a full house, with some staff travelling 30 to 40 miles, which shows commitment.’
She adds: ‘Sharing of experience is a really important aspect of the committee, particularly if one of the organisations is having a problem.’
Root cause analysis
Part of the focus of the commissioning team is to ensure that root cause analysis (RCA) is carried out. The trust has worked with the Department of Health on a performance monitoring tool using RCA with the aim of reducing the number of cases of MRSA bacteraemia.
RCA is defined by the National Patient Safety Agency as a ‘retrospective review of a patient safety incident undertaken in order to identify what, how and why it happened’. The results of the analysis are used to identify areas for change in order to help minimise the reoccurrence of the incident type in the future.
Trusts are using RCA to find out where problems occur across an interlinking health system. A patient who is identified with MRSA bacteraemia within 48 hours of admittance is most likely to have come into hospital already with the infection. RCA traces the patient history, looking at any previous hospital admittance, treatment at a GP practice and whether, for example, the patient is looked after in a care home. If the root of the infection is from the community, this will need to be followed up in the community setting to see if the infection was avoidable and whether action needs to be taken.
Ms Allum explains: ‘Many patients have been an inpatient somewhere in the last three months. As part of the root cause analysis, we need to understand everything, from the care given by the GP to drugs prescribed and the treatment they have received.
‘What we have learnt is that clinical engagement is crucial and that staff need to be equipped with the skills and equipment to deal with RCA. Analysis must be timely. Otherwise you lose track of the history and what has happened. The response needs to be quick not just for that patient but of course for other patients.’
Ms Allum says that the trust was using its commissioning role to enforce the use of tools such as RCA. She adds: ‘RCA was developed by the NPSA and given out nationally but, as with any tool or initiative, the issue is whether it is actually being used to close that audit loop.’
The results of the RCA have already led to changes and refinements in the provider services. One example is the PCT working with the local ambulance trust to ensure staff no longer routinely insert a cannula for patients being admitted to A&E. They should be inserted as an exception rather than the rule. MRSA bacteraemia can be acquired from poor intravenous line management.
Working with the acute trust
One of the providers working with Eastern Kent and East Coast PCT is East Kent Hospitals NHS Trust. The trust has three acute sites with 40 miles between two of them. Sue Roberts is the deputy director for infection control and prevention at the trust and attends the monthly committee meetings set up by the PCT. She says that the development had ‘made us appreciate that the PCT is commissioning our services and we are therefore accountable to them’.
She adds that the provider trust had been comfortable with the intervention from the
PCT. She says: ‘We are well ahead with implementing the code of practice for infection prevention and control and have good systems set up. If we were not so far ahead, I think we would find the process more difficult and feel under pressure.’
Ms Roberts adds that the committee fosters an interactive reciprocal relationship between the commissioners and the providers. For example, the acute trust already has a body of experience in infection prevention and control which has proved helpful to the commissioning PCT.
RCA has proved a useful tool for East Kent Hospitals NHS Trust. It is well on its way to achieving its MRSA bacteraemia targets by March 2008. The target is to reduce this to 28 cases per year from 70, which has been a challenge as the trust saw a 30% reduction in cases over the three years prior to the target being set.
The trust is a pilot site for the DH. It is using a tailored version of the RCA tool produced by the NPSA to looking at MRSA bacteraemia identified in the first 48 hours after admittance.
Blood cultures that become contaminated during blood culture collection account for
about 10% of positive MRSA bacteraemias nationally. The use of 2% chlorhexidine in 70% isopropyl alcohol to clean the skin prior to blood culture collection should reduce this rate of contamination (see article, p6).
This skin preparation was introduced in the epic2 revised national evidence-based guidelines in 2007 for cleaning the skin prior to the insertion of central venous catheters and for cleaning between dressing changes. Its use is now being extended following a recommendation by the DH for blood culture collection.
Ms Roberts explains how this is expected to affect figures. ‘As people improve practice in conjunction with using the new 2% chlorhexidine/alcohol product, we should see the numbers of MRSA bacteraemias due to contamination at the time of blood culture collection fall. This will mean that the number of cases identified as being from the community, pre 48-hour cases, will decrease’.
Plans and funding
The PCT has plans to consolidate its work on infection prevention and control. The DH has recently allocated £50m of additional funding for reducing healthcare-associated infections. The strategic health authority – NHS South East Coast – has received £5m, of which £50,000 is being allocated to Eastern and Coastal Kent PCT.
The PCT is spending the money on a number of projects. Some is being spent on employing a staff member to look at antibiotic prescribing across the health economy. The aim is to develop a joined-up approach between the PCT and acute trusts and to reduce the incidence of Clostridium difficile.
A second project will see the development of local health economy policy on the transfer of patients with infection around the system. The project will look at key performance indicators that would be expected to be in place and the safety indicators that underpin the policy.
With regard to RCA, there will be a focus on ensuring that competence exists in care homes and in the county council.
Another project will look at cleaning standards using national best practice examples to develop a performance monitoring tool.
A communication strategy will be developed by bringing all local communication teams together to ensure that strong consistent media messages are released, such as those on hand hygiene and the ‘be seen to be clean’ message.
Ensuring public confidence
Ms Allum identifies that one of the biggest challenges is trying to ensure the public has confidence in infection control and prevention in healthcare settings. The committee has a lay member who gives the public perspective on how people are perceiving care in hospital.
Any new provider contractors who come into the market will have to adhere to the same stringent standards of infection prevention and control.
As Ms Allum confirms: ‘We do have the resources to provide support in the area of infection prevention and control. In our role of commissioners we can both challenge
and support providers in infection control and prevention.’