Research Proposal

 Infection Control→Surgical Site Infection

A Shared Vision

New hospital builds offer new HCAI challanges. The same is true for new work practices in health care. Whatever the pros and cons of PFI hospital constructions they certainly change the way a hospital works. The impact on HAIs may be beneficial but there will also be challenges.

Perhaps the most obvious threat relating to IPC is that PFI hospitals are said to be under-bedded by around 30%. This issue is often over simplified because staff to patient ratios are as important as the number of beds. Suffice to say there is ample evidence in the literature to show that HAIs increase dramatically when bed occupancy rises above 85%. So the challenge here is to change practice and innovate so that we can maximise bed occupancy whilst eliminating HAIs.

By far the most effective measure shown to reduce the transmission of infectious disease in any setting is hand washing so it is frustrating that the best compliance figures in studies in health care settings in the developed world is around 70%. This is both a threat and an opportunity. The opportunity is that it is a fair assumption that a 100% compliance would substantially reduce HAIs. The threat is that the 30% non compliance is probably a performance indicator for poor aseptic practice in every other area.

It has been shown that targeted and sustained interventions work. Having a CNS dedicated to training and audit in central and peripheral IV insertion reduces the incidence of septicaemia. The 'care bundle' approach advocated in the Saving Lives campaign also covers other risk areas such as CAUTIs and SSIs. So far these initiatives have been less successful.

A truly intensive and innovative approach to tackling HAI will rely on Education & Training, Data Collection, Audit, and Research. Only if all these areas are included will a true cultural transformation be possible. Obviously a major challenge will be the current financial situation in the NHS but the cost of not reducing HAIs will far outweigh the cost of implementing evidence based measures... including innovative technologies.

One of the first steps has to be the creation of a 'community of interest'. This has to include senior clinicians from all involved specialties. Currently many senior clinicians feel excluded not only from decision making and strategy but also feel isolated and kept out of the information loop. As in any national crisis such as war, all possible resources must be harnessed. Indeed the metaphor is completely apt because it is a war against HAI and a war-like strategy is required. That is why a small look at history is useful. For any war a national consensus and good level of morale are essential. Then there has to be good (perhaps even charismatic) leadership, good lines of communication, a basic level of equipment and training and finally persistence and resilience.

Most hospitals are like 'the curate's egg' when it comes to IPC.... good in places. Recognition of what is currently working is as important as what needs to be improved. This effectively requires a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis. This can be achieved fairly rapidly once an IPC board has been formed. The SWOT analysis has to be current and ongoing, a dynamic tool rather than a snapshot.

Changing behaviour requires an understanding of individual and group psychology, especially in a large hospital. A clinical psychology input to the ICP board would be helpful. So called 'Nudge Economics' is one model that lends itself to tackling HAIs. A raft of small, inexpensive measures can subtly and cumulatively change behaviour. (An example is a monthly graph prominently displayed in every ward to show the HAI situation.)

Other inexpensive measures can be used to give HCWs 'ownership' of a specific area. This might involve tasking one or more members of the ward staff to be responsible for that ward's own SSIs data gathering. Another member might be tasked with auditing cleaning practices using the ward's own immunofluorescent biosoil meter.

A further and more ambitious proposal is to run an in-house Smart Solutions programme. The NHS Smart Solutions programme had its faults and many thought that the 'Rapid Review Panel' was a misnomer. However the programme was unique and envied by health care systems. Unfortunately Smart Solutions no longer exists. ** as an organisation has stated full commitment in its aim to eradicating HAIs. The organisation also has a strategy to achieve global excellence in trauma care and to develop its brand. A fully fledged programme to evaluate ICP innovative technologies fits with the ** agenda. It also fits well with the aims of the **.

The expertise to run such a programme already exists within the Trust. One SS programme was outsourced from their core showcase hospitals and run in **, other and similar evaluations have been performed here.

A small number of surgical wards, ideally three, would be the focus of the SSP. One of the three wards would lead with a senior nurse specifically tasked with backfill for time required.A side room on that ward would be used as an IC laboratory. A research project specifically studying the egress of specific pathogens from patient into the environment would be supervised by the Microbiology department. This would include ethnographic studies using video monitering.

There would be a 6 monthly rolling-programme of training in aseptic practice. There would be a mandatory monthly half day for IC related teaching, audit and research updates.

This would be interactive rather than didactic with HCWs, nurses and doctors taking part.

The obvious choice for lead surgical ward would be **. This is a mixed plastic surgery and orthopaedic ward. It contains many joint care patients with mangled lower limbs who have been through ITU and carry multi-resistant bugs such as Acinetobacter. Even with adequate barrier nursing and isolation procedures this ward remains a high risk environment for transfer of HAIs.

Patients and their relatives increasingly worry about these risks and the threat of medico-legal action is increasing at the same time. Furthermore new multi-resistant pathogens such as NDM1 are on the increase. A robust, innovative approach to IC where a culture of best practice is expected will mitigate much of the risk. There are also opportunities for positive PR.

WARD BASED MEASURES

1. Culture & Behaviour

By designating 3 surgical wards as 'IPC zero tolerance' zones, it might be expected that the "Hawthorne Effect" would be a strong driver for the cultural paradigm that is needed. Part of the available skill set is a Clinical Psychologist. Individual as well as group psychology is a key part of motivating people to change behaviour. The 'Nudge' principal recently popularised in economics would be employed.

A raft of small measures aimed at improving behaviour would be introduced. These can be as simple as a large graphic display of monthly SSI and HAI rates. Encouragement would be given to every HCW to challenge any other, whatever their seniority, on aseptic practice. Discussion of these 'challenge' incidents would be held at weekly ward IPC meetings.

2. Uniforms

As in ITU and A&E, nurses and HCWs on the three zero tolerance wards would wear theatre scrubs instead of standard nursing uniforms. These would be laundered through the hospital estate.

3. Ward Based SSIS

A lead HCW would be tasked with updating a database of all SSIs and other microbiological test results. This would be reviewed at daily ward meetings involving both doctors and nurses. The database would be integrated with the upgraded hospital IT system. The Microbiology IT system would also be integrated into the main hospital system and its epidemiological functionality upgraded.

The early warning function that currently flags up MRSA, CDI, and multi-resistant Coliforms will be extended to include the ten organisms most frequently implicated in HAIs. A 'search and destroy' approach to early outbreaks would be implemented.

4. Cleaning

A lead HCW will also be appointed each week to implement a quality control program approved by the ICP board. Currently cleaning audits are undertaken by domestic staff. Whilst these would continue, an additional objective measurement of 'soil' levels at key touch points would be performed by the lead nurse on a daily basis. This valedation of cleaning and disinfection will be performed using an ATPase bioimmunofluorescence testing device such as the 3M 'Clean Trace' system. One device could be shared between the three wards. Alternatively each ward could trial a different system and each would be rotated on a monthly basis between wards (See Smart Solutions below).

Although such a system gives only a crude measure of biomaterial soil levels its use would encourage nurses to be aware of and empower them to be in control of environmental cleaning and disinfection rather than being passive witnesses to the domestic staff. A spirit of close co-operation and communication between HCWs, nuses and domestic staff would be fostered.

An R&D opportunity would be to validate the ATPase measurements against more standard bacterial sampling techniques such as plating and swabbing.

WARD BASED R&D

1. Side Room Laboratory.

A side room on one ward will be used as a part of the R&D program. Ethnographic studies will be combined with intensive environmental sampling. With patient and HCW agreement there would be video recording of every HCW/patient interaction and visitor/patient interaction. As well as deep cleaning between patients the room would be sterilised using an H2O2 fogging system. The room would be used for patients with known SSIs or colonised wounds... such as ITU transfers.

A cleaned and sterilised side room offers the perfect laboratory for the studying the transfer of microbes from patient to environment. Intensive microbiological sampling would be performed prior to a patient occupying the room, as well as regularly during occupation. All hard and soft surfaces would be studied. Patients with known infections as well as non infected patients whose skin microbiome has been sampled would both make suitable studies.

Different Area decontamination devices could be compared in their ability to sterilise the room. Different barrier products could be similarly compared.

2. Smart Solutions

The NHS Smart Solution programme could be replicated within an individual 'showcase' hospital. The SSP was recognised internationally as being the best programme of its kind. The rapid review panel (RRP) performed evaluations of products and technologies for their efficacy in HAI prevention as well as practicality. A valid criticism of the programme was that after products were evaluated there was no process to encourage NHS procurement processes to adopt these new products and technologies.

Smart solutions and other product trials have been undertaken within the Trust in the past. A matched funding formula could be developed with each study being supported by the product supplier, the Trust and the **. This programme would harness commercial resources under the control of an R&D panel similar in structure to the SS RRP. Products and technologies undergoing studies would be supplied FOC. Although participating commercial organisations would be given the right to comment on negative findings they would accept the objective findings of the studies.

The study of IPC products would inculcate a positive obsession with all areas of best aseptic practice.

This proposal fits well with the NICE policy for all NHS hospitals dealing with the threat of HAI.

NICE Quality Improvement Guide- Prevention and control of healthcare associated infections 2011

Following a referral from the Department of Health, the National Institute for Health and Clinical Excellence (NICE), in partnership with the Health Protection Agency (HPA), have developed this quality improvement guide. The guide offers advice on management or organisational actions to prevent and control healthcare-associated infections (HCAIs) in secondary care settings.

Trusts regularly review evidence-based assessments of new technology and other innovations to minimise harm from HCAIs and antimicrobial resistance (AMR).

What does this mean for people visiting, or receiving treatment in, hospitals? What does it mean for trust boards?

Quality Improvement Statements

Evidence of Achievement and Practical Examples are described for each statement.

Statement  1 Trust boards demonstrate leadership in infection prevention and control to ensure a culture of continuous quality improvement and to minimise risk to patients.
Statement  2 Trusts use information from a range of sources to inform and drive continuous quality improvement to minimise risk from infection
Statement  3 Trusts have a surveillance system in place to routinely gather data and to carry out mandatory monitoring of HCAIs and other infections of local relevance to inform the local response to HCAIs.
Statement  4 Trusts prioritise the need for a skilled, knowledgable and healthy workforce that delivers continuous quality improvement to minimise the risk from infections. This includes support staff, volunteers, agency/locum staff and those employed by contractors.
Statement  5 Trusts ensure standards of environmental cleanliness are maintained and improved beyond current national guidance.
Statement  6 Trusts work proactively in multi-agency collaborations with other local health and social care providers to reduce risk from infect
Statement  7
Trusts ensure there is clear communication with all staff, patients and carers throughout the care pathway about HCAIs, infection risks and how to prevent HCAIs, to reduce harm from infection.
Statement  8 Trusts have a multi-agency patient admission, discharge and transfer policy which gives clear, relevant guidance to local health and social care providers on the critical steps to take to minimise harm from infection.
Statement  9 Trusts use input from local patient and public experience for continuous quality improvement to minimise harm from HCAIs.
Statement  10 Trusts consider infection prevention and control when procuring, commissioning, planning, designing and completing new and refurbished hospital services and facilities (and during subsequent routine maintenance).
Statement  11 Trusts regularly review evidence-based assessments of new technology and other innovations to minimise harm from HCAIs and antimicrobial resistance (AMR).

Cleaning and QC

(Mini Smart Solutions Programme)

Area decontamination systems will be assessed for cost, effectiveness and practicality. (Once again side rooms offer the most obvious laboratory for studying contamination of a 'sterile' environment by colonised or infected patients). The Chemspec cold fogging system was trialled at BLT under the original Smart Solutions rapid review panel

UVC hand sanitisers and other equipment such as mattress covers and pillows designed to reduce HAIs will also be studied.

SSI

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Training and Education

The logistical burden of even the most basic aseptic training is a challenge in the NHS. In many ways standards have slipped over the past 20 years. A range of changes not directly related to IC have impacted on IC practice. A faster turnover of patients means that many hospitals now attempt to run at 100% bed occupancy. There has been an increase in the ratio of HCAs compared to trained nurses. Both medical and nursing students spend less time in an operating theatre environment. Mandatory training in IC is extremely limited compared to the severity of the problem of HAIs.

Reductions in septicaemia rates associated IV access have been obtained by targeted training, initially in central venous access and latterly in peripheral line care. Hand washing has probably been the biggest focus but compliance remains far from 100%. In many ways the ambition of these programmes has been far too limited.

In order to inculcate a culture of obsessive aseptic practice, a continuous programme of teaching is needed. Standard training in all current NHS IC topics shoud be rigorous and will be augmented by a much broader curriculum. Basic principles of standard hand washing, aseptic wound practice, will be reinforced but the scope of the programme will be widened to include material related to innovative technologies.

There will be regular monthly ICP training sessions and an on-line training syllabus. This will be alongside a monthly revolving (6 months) series of practical training sessions on all aspects of aseptic practice.

In Depth Contamination Studies

 

 

Skin Flora

Plastics Dressing Clinic

The PDC is to remain in the old build OPD. The reception area has recently been upgraded but the actual treatment cubicles of which there are four, are a bit tired in terms of decor and obsolete in terms of general layout and design.

Smartglass
Smartglass

The appearance compares poorly with the new build and is an obvious challenge for cleaning and disinfection. One relatively inexpensive solution to both issues would be a relatively inexpensive makeover. Removing the cubicle curtains and replacing them with Smartglass would have a transformative effect.

One immediate saving would be the redundancy of the 'deep clean' currently mandated by hospital policy after every MRSA dressing. This apparently costs the Trust around £300 every time and the cubicle can be out of use for 2 or 3 hours. This can happen at least once a week.

The Smartglass solution would be combined with a nurse-led cleaning regimen which could be efficacy tested by the same methods planned for the new ward.