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Using teamwork to fight infection

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Two teams’ joint working led to infection rates in renal dialysis patients plummeting 90%. Victoria Hoban talks to the nurses who won an NT Award for infection control

Back In 2005, hospital trusts were told they had three years in which to reduce MRSA infection rates by 50%. But with many trusts having failed to meet this target, the health service is once again being accused of losing the fight against infection.

This ongoing struggle highlights the achievements of the infection control and renal teams at Swansea NHS Trust, winners of the Johnson Diversy Infection Control category of the NT Awards 2007.

The success of the team’s three-year project to reduce the incidence of Staphylococcus aureus bacteraemia in haemodialysis patients has been dramatic. Between 2004 and 2007, quarterly rates of methicillin-sensitive Staphylococcus aureus (MSSA) and MRSA bacteraemia among patients in the renal dialysis unit fell by a staggering 90%.

Presenting the award last November, the judges summed up the immense value of this achievement, saying: ‘This nurse-led project started before targets to reduce healthcare-associated infections were set. The work has made a demonstrable difference and could easily be replicated in other critical care units.’

These results have not been achieved easily. Delyth Davies, lead nurse, infection control at the trust, insists it is a hard-fought and ongoing battle. ‘When you look at what causes infection, it is rarely one thing but is multifactorial,’ she explains.

She believes the key to the project’s success has been to focus on MRSA and MSSA in a specific clinical area – a brave decision that might not have taken place had the Welsh trust been under the same pressure as trusts in England.

‘The Welsh assembly didn’t feel a 50% decrease was realistic and so didn’t follow that path,’ she explains. ‘Instead, each trust has to set targets that are appropriate for that trust. For us, the rates of MRSA in the renal unit were a cause for concern, so we decided to tackle that. We were apprehensive but felt there was value in being more focused.’

This focus has definitely paid off. In collaboration with the renal unit staff and consultant microbiologist, Delyth and her team of four infection control nurses have implemented measures to reduce the incidence of MSSA and MRSA bacteraemia.

These include standardising procedures around the management of vascular access lines, introducing a vascular line management audit and MRSA screening, and opening a dedicated line insertion room.

Delyth stresses that the process has followed a steep learning curve, as new evidence-based interventions have been brought in and others changed. For example, early in the project, dressings for the vascular lines were changed from gauze to semi-permeable, which has a high moisture vapour transfer rate.

The appointment of a dedicated vascular access nurse ensured that procedures were standardised, with successful results.

‘There is national research into the value of having standardised practice. Before the appointment [of the vascular access nurse], lines were inserted predominantly by medical staff who rotated, which is not the same as having one specialist who is very practised at what they do,’ Delyth points out.

With space at a premium, securing a dedicated line insertion room was another issue. ‘We have a very dedicated renal team who knew the problems and knew there had to be changes, so they were able to adapt a room in the unit,’ says Delyth.

This collaborative attitude between the infection control and renal teams at Swansea NHS Trust has been a particular strength of the project. Delyth says that
the potential problems of uniting two departments in a common cause just never materialised.

‘It’s refreshing how well we have worked together,’ she says. ‘We have confidence in each other and a willingness to be challenged. People could have felt vulnerable but it has not been like that.’

To cement this teamwork, the NT Award cheque for £1,000 was split between the infection control and renal teams, and put towards CPD for staff.

As a result of all the measures, the quarterly rates of MSSA and MRSA fell dramatically from more than 400 and 350 respectively per 100,000 bed-days in 2004 to just 42 for both per 100,000 bed days by 2007 – a 90% decrease.

However, Delyth and her colleagues emphasise that progress has been a case of ‘two steps forward and one step back’, with figures fluctuating rather than falling steadily. The most recent figures show increases, particularly in MSSA rates. However, in the latter half of 2007, MSSA rates were still between 6% and 45% lower than in 2004, and rates of MRSA remained 80–90% lower.

These fluctuations have revealed vital information on a major cause of infection – they closely correlate to the number of patients awaiting permanent vascular access who have temporary lines only.

‘The number of patients in renal failure is on the increase. As they get referred, they have temporary lines,’ explains Delyth. ‘At times when there are waiting list initiatives in place, fewer patients have temporary line access and the rate of infection has gone down. Temporary access is probably the greatest risk of infection so, to maintain that decrease, we need to reduce the number of people waiting for permanent access. That is the next challenge we are looking at.’

This means working with another set of people – the vascular surgeons, who work closely with the renal teams – to present a strong business case for this. So Delyth and her colleagues are grateful for the clout and recognition that their NT Award has brought.

‘Winning has brought us national recognition, heightening awareness across the trust and raising enthusiasm. The awards are an excellent way of sharing good practice and really good for nursing,’ she says. ‘If dialysis patients get bacteraemia, it could be life-threatening, particularly with temporary lines. This
is because there is a risk of the line becoming dislodged or infected, which delays their access to dialysis until another means is established.

‘Being infection-free also means patients don’t have to have antibiotics, which can cause terrible kidney and hearing toxicity.Most importantly, it prevents patients being admitted to hospital so they can continue with their lives.’

Although the three-year project officially ended in April last year, the work continues and, with it, life-saving benefits.

‘We want to bring in other recommendations from the Department of Health’s Safer Practice in Renal Medicine, such as central-line care bundles,’ says Delyth. ‘Our aim is no avoidable infections, so we will continue looking, trying and evolving.’

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