A number of Trust experiences were shared at the Healthcare Associated Infections conference with the aim of examining local efforts to reduce such infections. Among these included a case study presented by the Salford Royal NHS Foundation Trust. Ann Trail, assistant director of nursing services infection control, provided an insight into how the Trust has reduced its rate of central venous catheter (CVC) related infections. Salford has a track record of achievement – having been rated as “excellent” for four consecutive years by the Care Quality Commission (previously the Healthcare Commission), and was awarded accreditation level 3 by the NHS Litigation Authority (NHSLA), in recognition of the high priority given to safety at the organisation.
In 2008, the Trust decided to build on this further – launching a quality improvement strategy aimed at reducing avoidable harm by 50% within three years. This is being achieved through a portfolio of projects designed to help staff make changes – based around the message: “safe, clean, personal care every time”. Progress is regularly reviewed by the Trust board on a monthly basis. The first of the projects to be implemented was aimed at reducing Clostridium difficile and a reduction of 70% was achieved on the pilot wards, in just one year. Across the whole of the organisation the reduction was an impressive 50%. Ann Trail explained that supporting the programme are a number of “collaboratives” focused on implementing change. A CVC “collaborative” has already been working to deliver improvements, over the last year, while other collaboratives have recently been initiated for surgical site infection, urinary catheter care and ventilatorassociated pneumonia. One of the reasons for the focus on CVC related blood stream infections (BSI) was the fact that BSIs are known to prolong the length of hospital stay by an average of seven days and increase mortality by 12% to 25%. In fact, a prevalence survey in England, carried out in 2006, found that 42.3% of BSIs were central line related. At Salford, a root cause analysis of MRSA bacteraemia showed that 30% were CVC line related.
“A contributing factor to the incidence of catheter related BSI is the fact that devices are often inserted in an urgent situation and asepsis may not be adhered to; CVCs are frequently manipulated; while patients often have underlying conditions that make them vulnerable to infection. Nevertheless, we know the potential for infection reduction is high and virtual elimination should be possible. Even in urgent situations we need to be performing insertion correctly, every time,” commented Ann Trail. The potential to have a major impact has been highlighted by the results reported by Pronovost in the US, which provided inspiration to the Trust, said Ann Trail. Some 103 ICUs in Michigan reduced CVC infection rates from 7.7 to 1.4 per 1,000 line days through “bundle” compliance, while recent data published in the BMJ suggests that this reduction has also been sustained. In the UK, Trusts have been engaged with the implementation of care bundles, based around the Department of Health’s “High Impact Interventions” (HIIs), and the National Patient Safety Agency (NPSA) recently launched its “Matching Michigan Challenge”. At Salford, the CVC improvement project commenced in February 2009 and was based around compliance to the insertion bundle and care bundle. Ann Trail explained that all of the following protocols must be adhered to, to ensure a successful outcome. If one is left out, the bundles will not prove effective:
Insertion bundle
• Hand hygiene.
• Maximal barrier precautions (hat, mask, gown, gloves and drape).
• Chlorhexidine.
• Sterile dressing.
• Clean trolley.
• Ultrasound.
Care Bundle
• Hand hygiene.
• Barrier precautions (apron and gloves).
• Chlorhexidine – skin.
• Chlorhexidine wipe – device.
• Daily review of line.
• Documentation.
The Trust uses the tools of the Institute of Healthcare Improvement to help staff introduce changes, based around the “Plan, Do, Study, Act” cycle (ww.ihi.org), while measuring and feeding back of data on improvement to staff is also viewed as crucial. Pilot sites were initially established at Salford on the intensive care unit, medical high dependency unit and renal high dependency unit, and a “faculty” was established to oversee implementation. This faculty included:
• Senior leadership.
• An executive sponsor.
• A quality improvement advisor.
• Subject experts e.g. infection control, microbiology, IV specialist and audit lead.
The aim was to reduce central line infections by 50% in the pilot site during the first year. (The Trust’s framework for change is shown in Fig. 1). Some of the early challenges encountered included the fact that there was no baseline measurement of CVC infection at the start, there was no Trustwide, electronic system for data collection which made the process laborious, and there was a need for an agreed definition of CVC infection. “No clinician wants to believe they are causing harm to their patients and obtaining agreement that a patient has an infection as a result of catheter care can be challenging. Therefore a clear definition was required,” she explained. The Trust decided to adopt the HELICS Proforma for defining CVC BSI, therefore. There was also no process in place to achieve outcome data. “The microbiologist would print off positive culture results, highlighting the ones for the pilot areas, then we would have to establish which were the significant results and whether the infection met the definition of a catheterrelated BSI. Establishing a process was not easy and this was a project in itself. “Although we did not know what our baseline figure was, we knew that bundle compliance would deliver reductions in infections, so we decided to focus on this, and we set a goal of achieving 95% compliance,” Ann Trail continued. Learning sessions were initiated to discuss and educate on best practice, changes were tested between learning sessions to establish what worked and what did not work, then this was documented so that it could be shared at the next session. At these meetings, ideas were shared, staff would discuss initiatives they wanted to test, expert speakers were invited to give presentations and successes were celebrated. Patients’ experiences were also used at every learning session, including video footage, to underline the impact that an infection has had on their lives. One patient for example, shared her feelings on having to miss her mother’s funeral due contracting a catheter-related infection. Ann Trail said that these stories had a significant impact and helped staff to remember why they were undertaking the project. “During action periods, between meetings, staff were encouraged to undertake small tests of change – to try something in one bed area, on one day, with one nurse or doctor; then, if it appeared to work, they would roll this out to two patients or perhaps onto a whole bay,” she continued. “If the change proved unsuccessful, it was not seen as a ‘failure’ – we learnt from it. It might be abandoned or the approach adapted, but staff were given the freedom to innovate; to find ways of helping them achieve compliance.”
A CVC insertion pack was developed to ensure staff had all the right equipment for best practice, while an insertion checklist was displayed on the pack. On the renal unit, they also decided to ensure that staff, who were tasked with taking patients on and off dialysis, wore purple aprons to signal that they were performing an important procedure relating to the patient’s line. “The purple aprons helped staff to focus on what they were doing and stopped others from interrupting and distracting them during the procedure,” Ann Trail explained. The medical high dependency unit has now purchased its own ultrasound machine, to ensure safer catheter insertion, while the age of the line inserted is also recorded and displayed, each day, on a laminate chart at the end of a patient’s bed. Staff reported that they found it difficult to challenge clinicians, who were sometimes resistant to the idea of wearing a mask when inserting lines, so assertiveness training was also undertaken. “This was extremely valuable as we need to challenge each other on lots of aspects of care – not just infection control,” commented Ann Trail. “The team also devised leaflets that could be handed to staff explaining what was expected of them, which proved useful. A similar leaflet was also produced for patients explaining what they could expect from the healthcare professional who was dealing with their care.” A central venous care pathway was added to the patient electronic records, which provides a mechanism for counting catheter days. The pilot areas have also moved to electronic ordering of blood cultures. This includes mandatory fields to capture important data that can aid detection of catheter-related infections, as well as prompts to send the catheter tip for testing, for example. Systems have also been introduced to ensure training and competency in catheter insertion and skills are retained in such procedures. Once the 95% bundle compliance rate was achieved, this was displayed on the notice board for staff to see and compliance continues to be monitored closely. The changes implemented resulted in improved bundle compliance and the data suggests that the Trust is on target to “match Michigan”. On the renal high dependency unit, there were no incidences of acute line infection between February 2008 and May 2009. On the intensive care unit, there were two confirmed cases of CVC related sepsis. The estimated incidence is 0.6/1,000 line days – compared to the national incidence rate of 3.5/1,000 line days and the national target of <1.4/1,000 line days. In addition, there were no CVC infections on the medical high dependency unit and no CVC related MRSA bacteraemias. “Staff want this data to be fed back to them in an accessible format,” Ann Trail added. “On the renal high dependency unit, for example, we are celebrating the fact that we have been over 200 days without a CVC infection and this is prominently displayed on the notice board with a signed certificate. Staff on the pilot units are very proud of their achievements.” The next step is to roll out the programme to theatres and surveillance systems will also need to be developed for urinary catheter care. The Trust is further considering the introduction of a dedicated central line insertion team, in the future, she revealed.
Newcastle upon Tyne
Liz Harris, head of nursing, and Elaine Coghill, senior nurse practice development, from the Newcastle upon Tyne Hospitals NHS Foundation Trust, also gave an insight into the Trust’s experience of using care bundles to reduce infection risk. One of the largest NHS foundation Trusts in the UK, Newcastle upon Tyne was spurred into action following a rise in MRSA bacteraemia that reached a total of 75 in March 2007. “This was totally unacceptable and a programme was introduced to tackle the issue,” explained Liz Harris. She reported that, in a bid to reduce the rate infections, a root cause analysis was performed. This showed that:
• 19 patients (32.2%) had a urinary catheter in situ; in two patients this had been replaced several times due to clinical and technical issues.
• 24 patients (40.6%) had, in addition to one or more peripheral cannulae, devices including lines for dialysis, plasmapheresis or parenteral nutrition, and arterial lines.
• In 16 patients (27.1%) the only risk factor identified from review of the clinical record was the insertion of a peripheral intravenous cannula.
• There was documentary evidence of open or unhealed wounds, skin lesions or loss of skin integrity for other reasons in 26 patients (43.4%).
The Trust’s programme included the implementation of tools from the Department of Health’s Saving Lives initiative (www.clean-safe-care.nhs.uk) which provide the framework to support all healthcare staff in delivering highquality care. “Consistency in compliance with evidence-based practice when undertaking clinical procedures is key,” she continued, pointing out that central to the programme is compliance with seven HIIs. The HIIs cover best practice for the following:
1 Central Venous Catheters.
2 Peripheral Intravenous Cannulae.
3 Renal dialysis catheters.
4 Prevention of surgical site infection.
5 Ventilated patients.
6 Urinary catheters.
7 Reducing the risk from C. difficile.
The decision was made at the Trust to introduce a further (eighth) intervention relating to asepsis, however, as this was considered to underpin all clinical practice. Not all of the interventions were implemented at once, to ensure that the changes were manageable. However, the root cause analysis had identified interventions 1,2, 6 and asepsis as being priority areas, so these were the first to be addressed. “Before ‘Saving Lives’ was introduced, there was a widely-held perception that infection control was a ‘nursing problem’. However, the implementation of the initiative has now been rolled out to all 6,500 clinical staff at the Trust,” Liz Harris commented. A multi-professional steering group was established to ensure implementation across the whole of the organisation. This included heads of nursing, matrons, senior clinicians, the director of infection prevention and control, microbiologists, “hotel services”, nurse consultants, and other experts in their field. A sub group was formed from this steering group for each of the HIIs and these were tasked with developing educational materials, policy and documentation to support implementation.
Liz Harris also emphasised the importance of leadership: “We had robust support from our Trust board, while senior management stressed to staff that attending sessions on implementation was mandatory. Within two weeks of initiating the programme, more than 5,500 had attended ‘drop in sessions’ on Saving Lives. Previously, there had been some division between microbiology and clinical practice, but a new director of infection prevention and control was appointed, who was a ‘man of the people’ – he succeeded in making infection control everyone’s business within the organisation.” Elaine Coghill explained that patient information was developed which included a “cannula card” advising patients to inform a member of staff should the cannula become red or sore, or if the dressing becomes loose. Leaflets aimed at patients and their relatives were also issued informing them of the aims of Saving Lives and the role they could contribute (including challenging staff). Laminated posters were used to promote key elements of the care bundles – such as aseptic technique, the types of dressing and the cleaning agents that should be used, as well as protocols for observation and documentation of a device’s status. This included new policy on the use of 2% chlorhexidine and 70% alcohol to clean the skin prior to insertion of a cannula, while staff were reminded that: a cannula should never be reinserted; a sterile, transparent dressing must be used to allow observation of the insertion site; and the time that the device has been in situ should be monitored and documented. Information was published on both the Trust’s intranet and internet sites, enabling easy access for patients and staff, while simple e-learning packages were made available which were designed to take just 5 to10 minutes to complete.
These included education on: CVC insertion, asepsis, peripheral cannulation, urinary catheter insertion and taking of blood cultures. By the end of year one, virtually all of the clinical staff had undertaken all of the packages. However, a key priority was to redesign the documentation used for cannulae which needed to be standardised across the organisation. “While some staff were effectively documenting the insertion of cannulae, there was some variation across the Trust which needed to be addressed,” explained Elaine Coghill. A sticker system was therefore introduced which enabled staff to effectively monitor how long devices had been in situ and when they needed to be removed. Cannulae sites now have to be monitored three times per day and staff are required to document their observations. These stickers contain crucial information on each cannula’s status, as well as a prompts to aid best practice. In addition, a cannula pack was introduced which incorporates everything required to perform the procedure to ensure the right cleaning agent and dressings are used and that aseptic practice is adhered to. Ten months after the launch of the programme, the Trust recorded a 24% reduction in the number of cannulae that were in situ. Furthermore, staff began to question the need for a cannula and challenged each other on the issue when required. “An earlier audit showed that, in 27.1% of patients with a bacteraemia, the only risk factor identified was the insertion of a peripheral intravenous cannula, so avoiding the unnecessary use of such devices in the first place is good news,” commented Elaine Coghill. A system was also designed to assess progress on implementation of the Saving Lives interventions, which involved a “ward accreditation” programme. This “audit” has to be performed on a monthly basis by ward sisters and the information obtained is shared with the clinical governors and risk assessment department. “Staff are asked whether or not they have received asepsis training and ‘do they know what the policy is with regards to infection control?’ There are questions on each of the interventions as well as environmental cleanliness. This is undertaken for in-patient and out-patient areas, and involves all clinical staff. Even those wards that have been successful in achieving ‘accreditation’ continue to be assessed on a monthly basis,” said Elaine Coghill. She revealed that, following the implementation of Saving Lives, there have been just 12 MRSA bacteraemias for the period 2009/2010. “Empowering staff to make changes has made a real difference at the Trust and it has encouraged departments to look at creating evidence-based bundles for other areas of practice – not just those developed by the Department of Health,” she concluded.
• The annual Healthcare Associated Infections conference is organised by Healthcare Events and sponsored by Teva. www.healthcare-events.co.uk