Author: Ingrid Torjesen, BSc, is freelance medical writer.
Ingrid Torjesen describes tools to help nurses review their clinical practice in infection control and identify how healthcare-associated infections can be avoided. These tools include high-impact interventions and root cause analysis.
Effective prevention and control of healthcare-associated infections (HCAIs) has to be embedded into everyday practice and applied consistently by all healthcare staff. Although it is not possible to prevent all HCAIs, most can be avoided if good infection control and hygiene practice is followed all the time by all staff (Box 1).
The code of practice for prevention and control of HCAIs (Health Act 2006) sets out criteria for ensuring patients are cared for in a clean environment to keep the risk of HCAI as low as possible. The code states: ‘Effective prevention and control of HCAI has to be embedded into everyday practice and applied consistently to everyone.’ It adds that NHS organisations must audit key policies and procedures for infection prevention and control.
Adhering to this code is a legal requirement for acute hospitals and other providers and the Healthcare Commission monitors compliance.
Key points – improving clinical practice
- Use infection data to identify ward/department and directorate with problems.
- Use HIIs to identify variations in clinical practice.
- Staff should have local ownership of processes and be actively involved in reviewing clinical practice.
- Results can be used to compare wards and departments.
- Good practice can be identified and shared.
- The impact of changes can be measured and fed back to staff.
- Success depends on staff understanding individual accountability and responsibility and authority.
Tools to prevent HCAIs
The Department of Health’s Saving Lives: Reducing Infection, Delivering Clean and Safe Care programme provides tools and resources to help trusts comply with the code. These include high-impact interventions (HII) and a root cause analysis tool.
High-impact interventions (HII) The Saving Lives programme now includes a revised assessment and action planning tool based on the duties in the code of practice (Health Act 2006). Seven HIIs, based on the concept of a care bundle, integrate the latest evidence-based guidelines and provide a means for staff, across an organisation or in a directorate or ward, to measure compliance to key clinical procedures.
The tools are designed for short-term use to identify where improvements can be made. A Pareto analysis or examination of infection data across a trust can be used to prioritise where the tools most need to be implemented (The Improvement Network, 2004). This could be where infection numbers are highest or there appears to be an identified risk with a particular procedure.
The benefit for staff is that they can receive almost immediate feedback from the observation tool (Fig 1).
The results of observation should be fed back to staff promptly so that ideas can be generated on how practice can be improved. Reobservation can be used to show the effectiveness of the actions agreed and create further opportunities for quality improvement (Fig 2).
Tool to investigate HCAI incident The root cause analysis tool can be applied by staff on the ward or the infection control team when an HCAI occurs to identify the potential cause. An action plan can then be developed to avoid infections occurring in this way in the future. The tool takes around 15 minutes to go through and is organised into three stages: react, record and respond.
The first reaction when a HCAI occurs should be to inform the multidisciplinary team caring for the patient, including the infection control team, and to log the incident. Next, the severity of the infection needs to be assessed, a management strategy determined and the patient informed. Treatment and monitoring should be in line with the organisation’s infection control policy. Immediate actions should be undertaken to manage risk to other patients and staff. All this must be recorded in the patient’s treatment plan.
The patient’s journey should then be recorded to determine how the infection occurred. It should specify how and where the patient was admitted, whether there were any transfers or movements after the admission and whether the patient was isolated. Details of the patient’s treatment, particularly whether they received any interventions such as an intravenous line or catheter insertions, should be included.
If the patient has been screened for any infections, the date and the results of these tests need to be documented, plus when positive results were confirmed. A record needs to be made of all treatments are given to the patient.
The patient’s journey can be analysed to identify any care elements missed out or not performed correctly. Reasons for non-compliance with these care elements should be listed. These may relate to the patient’s condition, the environment, staff knowledge and competency, treatment, contamination of equipment, procedures and compliance with hand hygiene.
By reviewing the record of this process the root causes that contributed to the problem can be ascertained. The chances of an infection occurring again in the same way can be reduced by responding to these issues.
A list of recommended solutions to address each root cause should be developed, written up in an action plan and implemented. This should be communicated to staff, the relevant local directorate or governance committees and the patient that was affected. Examples and areas of good practice should also be fed back to staff.
Box 1. Board to ward management of HCAIs
Organisations that had succeeded in reducing HCAIs have organisation-wide strategies to assure robust implementation of infection prevention and control policies. They have systems in place to monitor the effectiveness of clinical processes to prevent and reduce infection and understand the benefit of using compliance and infection data to focus their improvement work at high-risk areas. This has been reflected in the new Saving Lives tools.
To investigate an HCAI there are tools to break down the elements of a clinical procedure or patient journey into its key elements. In this way, compliance can be determined and areas where improvement is required targeted.
Nurses have a key role in generating ideas for improvement. Repeating the exercise at regular intervals will lead to reduced risk of HCAIs.
The Improvement Network (2004) How to Construct a Pareto Chart. Nottingham: The Improvement Network. www.tin.nhs.uk/index.asp?pgid=1135