(c) MRSA Action UK June 2008
Standardising and improving aseptic practice across the NHS
MRSA Action UK attended the conference to learn about developments in standardising aseptic practice, as these are one of the many areas that patients have expressed concerns about. It was an excellent conference and an opportunity for clinicians to learn and share best practice, with opportunities to be involved in peer reviewing the techniques being used and developed.
Sir Robert Naylor, Chief Executive, University College London Hospitals Foundation Trust introduced the conference and outlined the importance of leadership from Board to Ward in infection prevention and control. There was an important interface with the Board of Governors and what happened on wards.
UCLH has Foundation Status and is answerable to patient representatives who sat on the Board of Governors. The focus and objectives of the Trust was now firmly around what patients expect rather than what the Government say was important - reducing trolley waits was an example of a Government objective that would not be a priority over infection prevention and control and patient safety.
The Board has an informed agenda, with Governors wishing to know that it was a good patient experience and that patients are safe. Infection prevention and control is on the agenda with the budget. Staff empowerment to challenge peers is evident on such things as staff hygiene and cleanliness - bare below the elbows, not wearing wrist watches - all staff were aware of their responsibility to challenge.
UCH had a target of 34 bacteraemias last year and had 36; they had stepped up and made renewed efforts. There had been 17 so far this year. There was personal accountability and infection prevention and control was a top priority.
There were different procedures in aseptic technique which needed standardisation to achieve best practice, there was a need to encourage champions to identify and implement evidence based best practice.
Louise Boden, Chief Nurse, University College London Hospitals Foundation Trust said it was good to be able to share best practice. Why was it so difficult to get a common way? The emphasis must be on getting it right first time every time, leadership on the ward and organisation was key, and infection prevention and control teams needed to pay attention to keeping skills up-to-date. Refresher training and observation were important. ANTT were keen to learn from other organisations, there was an invitation to contribute to peer reviews of ANTT procedure and share knowledge.
Stephen Rowley, Lead Cancer Nurse, University College London Hospitals Foundation Trust and ANTT UK Lead, gave an overview of the objectives of ANTT. ANTT considers aseptic management generally, not just in the Acute setting, it also provided an opportunity for support networking.
Why do we need the Government to tell us how to clean our hospitals, how to care and smile at patients? Standards had been allowed to fall and there was a need to leave assumptions behind us.
In 1879 Florence Nightingale highlighted the need for asepsis. Cross infection was killing patients, her notes for nursing identified poor attitude, poor asepsis and hand hygiene. Her findings still apply today. People are worried, 5,000 a year die unnecessarily from healthcare associated infections. This was the tip of an iceberg - what ratio of good to poor practice was there - 20:80?
Why was the perception of risk assessing patients different in various populations, why would aseptic procedure be any different for a baby, a child or adult patient with cancer for example?
There was a need to look at the environment for aseptic preparation. If it was not appropriate, don't walk in, carry on and make do.
The equipment was important. Ported cannula could cause problems, they were difficult to clean. Guidance is that they should only be used in an emergency for short-term use. Every time they are used they stress the vein and can cause mechanical phlebitis which can become infected. They are popular with anaesthetists and are cheap to make.
Tourniquets contribute to compromising aseptic procedure. The average tourniquet can stay in the pocket from 6 months to 3 years. Use disposable tourniquets. The RCN had stopped the practice of giving away free tourniquets, but it was still widespread practice for distributors to give complementary tourniquets.
Sterets, they are the size of a postage stamp, don't use them. 80-90% of hospitals used them up until recently.
The use of vomit bowels is common; these will compromise the aseptic process.
During 215 episodes of covert studies of aseptic technique it was observed that:
- 51% cleaned hands effectively
- 56% allowed key parts to dry
- 54% achieved non-touch compliance to key parts
ANTT was about controlling the population; you can't afford a 5% - 10% failure rate. From the study - were key parts contaminated ? Yes, 45%.
Is it possible to improve practice? Yes - if you make it a priority.
Cleaner hospitals, cleaner staff and the environment were all key components of getting it right.
Make sure someone isn't making the bed next to the patient when aseptic practice is being carried out!
Between 200 to 300 hospitals were using ANTT, there were four guidelines that had been peer reviewed - wound care, peripheral IV lines, peripheral cannula and phlebotomy. This included an ANTT cannulation pathway. Urinary catheterisation was being developed.
ANTT was recognised and part of the EPIC 2 guidelines; Department of Health - Code of Practice for the Prevention and Control of Healthcare Associated Infections; and RCN Guidelines.
ANTT was a tool to improve practice and maintain quality. It was possible to visit Trusts on request and endorse competency.
There was high turnover of Junior Doctors, and there was some progress in addressing training, universities were being sent packs.
Dr Carol Pellowe from the Richard Wells Research Centre outlined the scale of the problem with healthcare associated infections. It was believed 15-30% were preventable. The EPIC 2 update included the ANTT guidance. There was more attention and focus on healthcare associated infections, it was high on the political agenda, profound consumer dissatisfaction and added risks to healthcare workers had contributed. Patients were well informed, the centre was being contacted about the EPIC guidance stating the they knew procedures were not being adhered to, they are aware that this could leave Trusts open to litigation. Patients were involved in the peer review of the guidance which was reviewed every five years. EPIC was the first nurse-led project that began in 2001, and everyone should be aware of the need to implement standards outlined in the EPIC 2 guidelines.
In 2007 patients 31.6% of
There was a need to wash hands after several uses of hand rub and to remove jewellery before hand hygiene. The consequences of catheter related bloodstream infections are serious. Hand antisepsis and aseptic technique were critical.
EPIC offered a free programme of training for Strategic Health Authorities on an Introduction to Infection Prevention and Control. Information can be found at www.corelearningunit.nhs.uk
Guidance was specific on Central Vascular Devices as these were dangerous. They should be used only when absolutely necessary; inserted correctly and removed promptly.
EPIC would be reviewing cutaneous antisepsis in neonates.
Dr Peter Wilson, Microbiologist, UCLH Foundation Trust, spoke of how the high incidence of healthcare associated infections had become high profile with intense media and government interest. In the
The Government wanted a 60-70% reduction in 2004 with no cash made available - we were expected to just do it. An advisory panel proposed the 50% reduction and some Trusts had achieved that.
60% of bacteraemias related to IV lines, therefore care of lines was critical. 250,000 central venous catheters were used per annum, 30,000 were associated with infections, with a 10% mortality rate.
In the 1990s the attention to healthcare associated infections was on a par with the
Infection spreads to bone, blood, heart and other organs. 23% of carriers will get an infection the result can be death or consequences such as vertebral osteomylitis, which can result in a patient becoming paraplegic.
Does environmental cleaning make a difference in reducing MRSA? Yes, by a factor of 10, there is a reduction in staff carriage.
Other factors influencing the spread of infection include
- Lack of screening and unknown shedders
- Lack of single rooms (airborne reduction in single rooms)
- Failure to use topical suppression / antibiotic prophylaxis
- High bed occupancy and high prevalence
For C.diff causal factors can include
- Detergent, it doesn't kill spores, so can spread spores
- Uncontrolled antibiotic prescribing
- Poor hand hygiene
- Alcohol gel doesn't kill spores
- Environmental cleaning without chlorine
- Delayed diagnosis
- Lack of single rooms
- Not using personal protective equipment
If you suspect C.diff move into isolation, do not wait for result, a patient on a commode releases spores into the air. A patient be asymptomatic for 3 weeks after symptoms have cleared, carrying the organism, risking spread to other patients.
Acinetobacter could become the "new kid on the block". Acinetobacter can survive on various surfaces (both moist and dry) in the hospital environment, thereby being an important source of infection in debilitated patients. It can survive on medical equipment and on healthy human skin. Several species persist in the hospital environment and can cause severe, life-threatening infections. The spectrum of antibiotic resistance and survival capabilities makes Acinetobacter a threat to hospitals. They have been found 3-6 months after outbreaks in the environment, and that is with patients being strictly isolated with staff being isolated to those patients. ICUs have closed in
MRSA started this way.
ESBL was increasing with cephlasporin use, and like the other bacteria is easily spread on hands.
Klebsiella was now being treated with antibiotics that should not be empirical but the last resort.
There was a need to focus on:
- Hand hygiene
- Antibiotic prescribing
- Screening and topical suppression
- Environmental cleaning
- Once control is lost its difficult to turn around
Does ANTT help reduce healthcare associated infection?
Developing an evidence base for aseptic technique - Stephen Rowley
The ANTT Theoretical Framework is designed to assess and give assurance to:
- practice issues
- equipment issues
- environmental issues
Quality Assurance model
The Quality Assurance model takes account of staff and compliance:
1. Technique comparison
measured by staff behaviour and healthcare associated infection rates
2. Audit cycle
measured by - staff behaviour
3. Effect of intervention on surveillance
measured by healthcare associated infection rates
The model is based on assumption that improving clinical behaviour will reduce infections. Evidence has shown a reduction in contaminants with single use sterile trays.
The technique and training needs revisiting or the standard will deteriorate.
It generates peer pressure, if someone new comes into the team, anything different stands out.
Mapping surveillance and interventions to assess success
The ANTT effect
The "ANTT effect" is the percentage improvement that can be demonstrated in clinical behaviour in aseptic practice, pre and post ANTT implementation across any given staff group.
Typically, a robust ANTT implementation programme will improve clinical practice significantly in all of ANTT's component parts. As a result, ANTT has been shown to significantly help reduce hospital associated infection.
For example, Central Manchester & Manchester Children's University Hospitals NHS Trust (1000 beds) demonstrated such an effect in 2007 with a particularly robust Trust wide ANTT implementation.
Over time this effect will diminish and will require maintenance at least every 12 months.
For more information on how to be part of this valuable opportunity to learn and be involved in the ANTT programme visit http://antt.co.uk/Site/What_is_ANTT.html
If you or someone you care about has been affected by a healthcare infection and you wish to discuss this with us, please contact us at email@example.com