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Keeping infection control in hand Improved levels of infection prevention and control within health care are getting a much needed push from new quality guidance, says Erin Dean

20 july 16 :: vol 28 no 46 :: 2014

prescribe antibiotics in accordance with local formularies. The National Institute for Health and Care Excellence (NICE) hopes its quality standard will reduce the 300,000 patients a year in England who acquire a healthcareassociated infection (HCAI) as a result of NHS care. In 2011 the prevalence of HCAIs fell to 6.4 per cent, compared with 8.2 per cent five years earlier, according to Health Protection Agency figures. Office for National Statistics figures show deaths from

SUMMARY

The control and prevention of healthcare-associated infections in the NHS has come a long way in the past decade – particularly in relation to clostridium difficile and meticillin-resistant Staphylococcus aureus bloodstream infections. But the publication in April of a new quality standard by the National Institute for Health and Care Excellence came with the warning that infection rates remain ‘unacceptable and avoidable’. The quality standard (Infection prevention and control QS61) comprises six statements (see box page 22) that are intended to focus attention on priority areas and drive improvement. They include reminders to healthcare staff to wash their hands before and after every episode of direct contact with a patient, to follow procedures to minimise the infection risks associated with catheters, and to

Despite huge progress in recent years, rates of healthcare-associated infections in the NHS remain ‘unacceptable and avoidable’, according to NICE. Its new quality standard addresses priority areas such as hand hygiene, antibiotics and catheters. In this article, front line nurses discuss attempts at infection prevention and control. Author Erin Dean is a freelance journalist

meticillin-resistant Staphylococcus aureus (MRSA) fell by 20 per cent from 364 in 2011 to 292 in 2012, and have fallen by 75 per cent since 2008. Despite the progress indicated by these figures, their publication by NICE with the quality standard led to headlines decrying that one in 16 patients are still catching an HCAI because of poor NHS care. Carol Pellowe, a senior lecturer at Guy’s and St Thomas’ NHS Foundation Trust, who was on the NICE advisory committee that drew up the quality standard, says that there is much to be celebrated when it comes to infection prevention and control. ‘We have made fantastic improvements, and although any HCAI is one too many, we have to put that in the context of where we were before. ‘These quality standards give people and organisations the goals that they should aspire to and make

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While huge improvements have been made, the war against infection is far from won, as shown by an outbreak of C. difficile in Glan Clwyd Hospital, Denbighshire, last year. Between January and May, there were 96 cases and 30 patients died. The RCN says that nurses who work in infection prevention and control (IPC) are worried that momentum could be lost if infection issues lose the high profile they have had for the past five years. A survey of IPC nurses by the Patients Association, published in October 2012, suggested that the focus on HCAIs could be waning. While 99 per cent of the almost 500 respondents said that infection prevention and patient

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ALAMY

it clear where improvements should be made, particularly around hand hygiene and devices, such as vascular access and urinary catheters.’ Some of the NICE standard’s statements may seem surprisingly basic, but Dr Pellowe says they are not easy to achieve. ‘You only need to go onto wards to see that people are just so busy they don’t even have time for a break. Also, some organisations don’t have sufficient monitors in place to observe what is happening.’ She adds that a system to survey patient harms, such as the NHS Safety Thermometer, ‘tells us how many urinary catheters are in situ at any one time, but not the reason why they were inserted or how long they have been in place’.

safety had improved compared with five years previously, more than three quarters reported that financial pressures and staffing problems posed a threat to further improvements. RCN infection control adviser Rose Gallagher says IPC nurses have told the college that 

Battlegrounds for infection control include (left to right) catheters, antibiotics, staff hygiene and clinical premises

THE CATHETER PASSPORT THAT TRAVELS WITH THE PATIENT Bringing down the rate of urinary tract infections (UTIs) is a significant challenge for the NHS. UTIs account for about 17 per cent of all healthcare acquired infections, according to Public Health England. One trust has developed a new approach to tackle UTIs by developing a ‘catheter passport’, which is intended to improve the management of indwelling urinary catheters that can cause these infections. Gill Abbott, head nurse for infection prevention control at the Heart of England NHS Foundation Trust, says the passport was introduced about two years ago.

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‘These patients are traditionally not in hospital all the time, and they tend to be accessing a range of services so there could be quite a gap in the communication between different professionals and services,’ she says. ‘Catheters could be used for longer than appropriate and left in when they were not needed, as healthcare staff didn’t really know the full story of the catheter journey.’ Details about the patient and the catheter are recorded when the device is first inserted, including the reason is it being used and when it should be reviewed. The document then stays with the patient, who can add to it (as can a carer or healthcare

professional) over time with relevant information, such as if the catheter gets blocked, so that it remains an up-to-date record. While the trust does not yet have evidence that the passport is reducing UTIs, the idea has been well received, particularly by district nurses who give the document to all patients with catheters. Ms Abbott says: ‘Catheter care is important because we know that these patients are more likely to get a UTI, and those with a UTI are more likely to get a bacteremia infection as well. The catheter passport has gained a lot of interest from other trusts around the country.’ july 16 :: vol 28 no 46 :: 2014 21

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Back to the patients

Kate Prevc, matron for IPC at the trust, says: ‘I realised that the traditional way of working in infection control was one that I was not happy with. There was still a lot of paper auditing going on, and a lot was done by distance, with IPC staff sitting in an office writing policies and going around ticking boxes. We wanted to take infection control back to the patients. ‘The first thing I did was stop delivering mandatory training face to face. I would tick my boxes about the IV lines and catheters, 22 july 16 :: vol 28 no 46 :: 2014

NICE quality standard 61 The six statements in the NICE quality standard on infection prevention and control are:  People are prescribed antibiotics in accordance with local antibiotic formularies as part of antimicrobial stewardship.  Organisations that provide health care have a strategy for continuous improvement in infection prevention and control, including accountable leadership, multi-agency working and the use of surveillance systems.  People receive health care from healthcare workers who decontaminate their hands immediately before and after every episode of direct contact or care.  People who need a vascular access device or urinary catheter have their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the device and its removal as soon as it is no longer needed.  People with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers, are educated about the safe management of the device or equipment, including techniques to prevent infection. Infection prevention and control is at: guidance.nice.org. uk/QS61

but the nurses and other staff weren’t listening. So we really changed what we did by using campaigns and we worked with staff on new algorithms.’ Campaigns at the trust have included Ban The Bacteraemia, for reducing blood infections, Houdini: Make that Urinary Catheter Disappear, on best practice for urinary catheters, and Get Stool Smart, on how to improve bowel management for patients. Ms Prevc says: ‘We focused on getting staff to recognise risks early on and doing something about it early on. With each of our campaigns we wanted to give staff the confidence to make safer risk assessments and use their clinical judgement. We now work

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 financial pressures mean that IPC teams are no longer expanding – indeed, in some cases they are shrinking – as NHS employers cut specialist nursing posts to save money. This concern touches on one of the NICE quality standard statements, which says that there should be continuous improvement in infection control. Nurses working in the area are worried about keeping infection prevention and control a priority for all nursing staff, says Ms Gallagher. ‘How do we maintain IPC’s position without having to detrimentally affect other quality improvement measures?’ she asks. ‘The focus on falls and pressure ulcer prevention is important, but it mustn’t mean we lose the focus on infection control. It is challenging for staff who are asked to measure many different things on a daily basis.’ Ms Gallagher adds that there is a tendency to overlook IPC ‘until it goes wrong’. One trust that has successfully kept IPC at the top of the agenda is University Hospitals Coventry and Warwickshire NHS Foundation Trust. In April this year the trust had just one case of C. difficile across all its wards – its lowest ever monthly total. A number of wards have been C. difficile-free for as many as 600 days. Back in 2006, the trust was recording up to 16 cases a day. MRSA rates at the trust have fallen from 17 in 2008/09 to two in 2013/14.

closely with our ward teams to achieve this.’ But a growing threat for IPC, which is addressed in the NICE quality standard, is the increasing number of infections that are resistant to treatment. The World Health Organization warns that antimicrobial resistance is an increasingly serious threat to global public health and that high proportions of antibiotic resistance have developed in bacteria that cause common infections, such as urinary tract infections, pneumonia and bloodstream infections.

UK strategy

The four UK governments have a joint five-year antimicrobial resistance strategy, which was published in 2013. Strategy pledges include improving infection prevention and control, and optimising the prescribing of available treatments. Better education for all healthcare staff to improve clinical practice has also been promised. David Tucker, deputy director for IPC at Guy’s and St Thomas’ NHS Foundation Trust, says that this is already an area being targeted by IPC teams. Each ward at the trust has a named pharmacist who monitors prescribing, and all patients using antibiotics have their charts highlighted with a coloured pen, and are reviewed after two days. ‘We should all be guardians of antibiotics,’ says Mr Tucker. ‘Nurses should have a knowledge of antibiotics and they can question clinicians as to whether an extended course of antibiotics is necessary, and whether it still needs to be received intravenously or can be oral. They should have a knowledge of the patients in their care and what they are on. ‘Anyone who is involved in patient care has a responsibility to ensure that antibiotics, which are a precious commodity, are used optimally’ NS

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Keeping infection control in hand.

Despite huge progress in recent years, rates of healthcare-associated infections in the NHS remain ‘unacceptable and avoidable’, according to NICE. It...
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