Healthcare Associated Infections Event
Department of Health and Stakeholders
7th November 2007
Delegates from MRSA Action UK attended the Stakeholder event with a view to sharing good practice with stakeholders and learning from each others' experiences in terms of what was working in improving things in many hospitals and to share ideas on how the good practice we had discovered could be disseminated to hospitals where improvements were appearing slow. We also wanted to see improvements across the healthcare setting including in the Primary Care Setting where healthcare infections were presenting problems in this area, which was resulting in morbidity and mortality in patients.
Derek Butler outlined ideas to representatives from the Department of Health prior to the event starting, we will remain in dialogue to share some of the better things we have seen happening, particularly in relation to the hospitals where infection rates were not showing a downward trend, Maria Cann outlined that she believed a buddying system could be implemented where there were 50 hospital trusts that were still showing an increase in the numbers of infections rather than a downward trend. The Healthcare Commission Improvement Teams needed to focus on these trusts in particular.
The event began at 10.30 am and focussed on findings from a survey that had been circulated to delegates prior to the event. This was useful as it brought together the thoughts of all the patient groups on what needed to be done. Certainly the Healthcare Commission report "What more can the NHS do?" could focus on these findings, and this set the scene for the day.
Stakeholder Event Introduced by Ross Pow
The event began with the facilitators asking the question: "What can we do to increase patient and public confidence that activities aimed at reducing Healthcare Associated Infections (HCAIs) are working?"
What would be different.... what would you expect to see every time you go into hospital to give confidence that the NHS is clean?
Janice Stevens, Programme Director for Reducing Healthcare Associated Infections Delivery Programme
Janice outlined the story of a patient who was 75 years old who had had a fall at home, and had her hips fixed, she had various health problems, she unfortunately died, which had a personal impact on Janice. She was vulnerable and susceptible to infection and it would seem inevitable, but this was not an excuse for contracting and dying from an MRSA bacteraemia. In terms of the diagnosis and the case of this lady there was more horror from the discovery of MRSA than the fact that she had renal failure - there is a great deal of fear from MRSA.
The patient has a very important role in helping to protect themselves, and inspite of everything that we tell the patient they will always still need reminding of the simpler things they can do to reduce the risk of infection. Janice related how she had given the prompts to try to minimise the risk to this lady.
MRSA figures were going in the right direction, which shows that there are some good things happening, but there is still a long way to go. C diff is only showing a small decrease and is worrying. We should be showing Zero Tolerance.
Figures and targets are just used as proxies to see that infection control is or isn't working. There is too much variation in the system, there shouldn't be a postcode lottery, so the department will be working very hard to try to address this imbalance. There was a need to really listen to patients and patient groups, and Janice was passionate about patient views.
Phil Hadridge outlined the next session where there was an opportunity to look at the survey findings and share reactions to Janice's presentation and to agree a common agenda of issues for discussion with the Parliamentary Under Secretary for Health, Ann Keen. There was flexibility in the day and it was focused on what was important for the stakeholders and what could be built on and agreed.
The event was being held in a building occupied by a company operating naval satellites, to guide ships, and also phones. There was a synergy with satellites and what we were trying to achieve. Satellites need to be clean, they were also needed for communication and sharing of information - Phil outlined that one satellite is useless, a number of different points of view is needed to come to a common set of principles. This event focused on the Patient Perspective, the NHS perspective and the Department of Health's perspective. Phil continued by introducing Cheryl Etches, Director of Nursing and Governance, Royal Wolverhampton Hospitals NHS Trust, to give a presentation about The Wolverhampton Experience.
The never ending story...... beating the bugs
In August 2005 there was a view that the target for reduction in MRSA bacteraemias was not statistically sound and unrealistic. In Maternity Services MRSA bacteraemias were showing a rising trend:
03/04 - 38
04/05 - 66
05/06 - 83
It was important to get the message across and not to miss the point, it's the issues that contribute to the target that are important. The emphasis in 2005 was on "Infection Control" rather than "Prevention", dealing with what had already happened rather than stopping it happening. In August the changes commenced, including:
These were all positive actions to change the culture. The organisation had a steer from senior level, change to put staff in who had clinical knowledge and leadership expertise. MRSA turnaround teams were invited in.
There were a number of interventions that showed instant improvement in the figures and in the environment for the staff and patients. Within three weeks of replacing the commodes the C diff rate "dropped like a stone", and it was better for the patients and staff as this was not only safer but had a better visual impact. Cheryl outlined that they had lower occupancy rates at the start of the journey, and now they were up around 90-94%, so she believes its about what patients you have in the beds rather than occupancy rates, so its not necessarily occupancy rates that have a significant impact on infection rates in every instant, its more about what you do.
In May 2006 there was a meeting with the Department of Health. The credo for change commenced. It was recognised that behaviour had to change - the Department of Health were checking out the culture of the organisation, when they visit you be sure that they want to know that you are serious - engagement with them and the processes and behaviours needed is key to success, there is no room for complacency, and they will know if you are serious about infection prevention.
Staff and patient involvement
It is important to listen to complaints and use them to improve service and change policy, the policy on wearing of uniforms outside of the hospital environment was implemented in response to a complaint. Sometimes you have to manage expectations, for example a complainant wanted a standard for visitors to adhere to, but this was unrealistic as you can't judge how "clean" visitors' clothing is.
People don't go into nursing to harm people, they don't want to see people getting infections - sometimes its inevitable because of people's vulnerability - however there must be zero tolerance, we should do everything we can to try to avoid it, its about turning policy into reality, for example - matrons will visit the car park to enforce the uniform policy if necessary and challenge. It takes courage to challenge so the champions play a really important part.
Cheryl outlined a process map showing how interventions impacted on C diff positive toxins. There was a need to review and follow up and look to see what else is happening where blips in performance show. Commode replacement, mattress replacement and continuous audits made good impacts (audit - matrons took eye off the ball and figures fluctuated), cannot be complacent. Even though Cheryl can see massive improvements she believes levels were still far too many, but interventions and the guidance from the improvement team visit have led to far fewer bacteraemias if these actions had not been taken. Infection is an insult.
What made the difference
How the improvement is being maintained
The performance reporting was a great motivator - showing green on charts for performance monitoring - who's amber - internal peer pressure - grapevine - what do we need to do differently.
Cheryl showed a video with all the team taking part in communicating their success. Dr Mike Cooper, Consultant Microbiologist outlined that 18 months ago they had one of the highest rates in the country, now they had the lowest in the region, MRSA acquisitions were steady but were now very low. Cheryl outlined the matrons high visibility, the champions, and how everyone has infection prevention in their job descriptions, communication to all staff in the organisation, whether its good or bad. Doreen Black the Ward Sister was proud of the clutter free wards, and talked of the route cause analysis, interventions. Elizabeth Shurman, Cleaner, had great pride in working on the wards. Dr Zaman spoke of the Junior Doctors' Infection Prevention Event, it was good to rethink antibiotics, an excellent microbiology quiz, good to have the handwashing reminder, now there was a culture of people being aware of the need to mitigate risk. Sally Brown, Programme Manager spoke of the way the Department of Health were able to work with teams on high impact interventions, showing great rewards for
John Rostill, Chief Executive of Worcestershire Acute Hospitals NHS Trust, went on walkabouts and saw everything was really happening, everybody was convinced that prevention was key. The video clearly demonstrated everybody was on board.
Cheryl outlined more about the Junior Doctors' Infection Prevention Event. 180 new doctors had been recruited, everyone believed this may have a negative impact on infection prevention, however the junior doctors were brought in for theoretical testing on antibiotics prescribing, they took blood cultures on a dummy and practised handwashing. It took some organising - but they came - it was a real exam. Some of the smaller things they failed on, but these were important and it was possible to identify these and put this right.
The success was down to:
Infection prevention is seen as everyone's business, even the Medical Secretary - she handles notes - everyone must gel their hands, even if they are not "seeing" a patient. But there are blips. so we refocus our efforts and implement
It's not what happens to you in life, it's how you deal with it
You need to find new things to do all of the time
Cheryl's biggest challenge is getting 5,000 people to do everything right every time
Cheryl holds the matron to account and ward sister. Formal letters are given if there are breaches in Codes of Practice and infection prevention measures are not followed, if there are other breaches then this could mean disciplinary action - that has rocked the organisation. The Chair of the Consultant's Committee is asking if he can lead on the dress code - he is well respected - he will change their minds. This "tough love" approach has impacted.
In response to questions on the SHA and disseminating good practice Cheryl outlined work within the SHA and avenues for disseminating good practice
You need to find from within, we are actually doing what's needed in the Saving Lives toolkit - it really is NIKE - Just do it
You need the right team with the right personality, ability and leadership skills to do it. It takes a leap of faith, turn away from money, and it will bring about improvements.
Click the image to see Cheryl's presentation:
Three breakout groups had picked themes to present to the Parliamentary Under Secretary for Health, Ann Keen MP, for her to take away. The groups were asked to also highlight what key things could be done in the next three months. This work was completed prior to the arrival of the Minister who was introduced and gave a presentation on work to reduce healthcare infections so far.
The Parliamentary Under-Secretary outlined her ministerial responsibility for the NHS. She had worked in NHS for 25 years and couldn't be prouder. It was a celebration of 60 years next year and its amazing achievements and treatments, about prevention and cure. Unfortunately we were now looking at consequences of where things have gone wrong, Ann wished to go on record as saying she is proud to be working with people who have caring values, they all feel disappointed when patients are let down.
Patient groups are so important, and Ann had made this a priority to attend the stakeholder event. Patients have experience and knowledge, and were important in making sure we (the Health Service) are on the right track. There was now reason to be optimistic compared to a couple of years ago. There was a need to sustain how patient safety remains a priority, it was difficult to practice within a financial budget, people need to be accountable, people should not have to wait longer than 4 hours in A&E, and this needs to be done whilst paying attention to infection prevention and control.
Ann discussed the new measures that are in place, the deep clean will take place within this financial year, and there will be a standard that each hospital should adhere to - based on the local needs of the hospital. Strategic Health Authorities will monitor and feedback to the Department of Health. The dress code must be adhered to, a pilot for uniforms for doctors with silver thread was under way - a Trust was doing this on their own initiative, white coats and were ties not to be worn - appearance was important. There were to be more nurses directly in charge of cleaning, nurses feel a great pride - everybody in a healthcare setting is important - there is no hierarchy. New legal requirement to report all MRSA and C diff to the Health Protection Agency and to Trust Boards on a quarterly basis. Matrons were to be empowered to report direct to Trust Boards.
There was no evidence to show that contracting out cleaning is having a dramatically different impact on infection rates, its easy to make political statement to say that it does. There needed to be accountability and the ability to be able to ask for what is required.
What happened to the self-discipline, why are people coming in and out of wards etc. Since June when Ann was selected she had to deal with the aftermath of the Maidstone & Tunbridge Wells findings, and had to go to Millbank and sit with patients who had been affected. It was very difficult and it was so unacceptable, there were a catalogue of serious errors from ward to Board. Ann had also been personally affected by MRSA and had witnessed good and bad practice, and had tried to relay this to the profession, so she understands our position, and knows what is expected.
The NHS Chief Executive David Nicholson has written to every Trust, Strategic Health Authority and Primary Care Trust, they are so, so aware of what they have to do. MPs of
We know what good practice is needed. C diff and antibiotic prescribing, other countries are looking to see what we are doing. Scientists and Microbiologists have been saying this would happen, and now we know.
The core information for patients is being taken forward. C diff Support met in an ad hoc way, but couldn't attend today. It was not easy, and Ann thanked us for attending, we will make a difference to save lives. This must stay top priority for the Department. Ann takes her role extremely seriously.
Question and answer session and discussion with the Minister
Microbiologists warned about C diff and MRSA, Professor Hugh Pennington President of MRSA Action UK had commented about GRE, , and gave a stark warning, there was need to keep an eye on this bacterium, because of resistance, need to nip that in the bud now, must not let this creep up.
There appeared to be conflicting evidence about dirty wards, there needed to be public confidence, we have the right to a clean environment to give a feeling of safety. Brian Duerden, agreed the Health Service should be clean, even if we can't draw a direct line with MRSA, C diff is spread through environmental contamination.
Confirmation that if standards aren't met on cleanliness then trusts will be held accountable. For Chief Executives consequences will be great. Ann will know and they will be doing it. They are being given £50 million. They will report back and be checked on. Was there a requirement to let the patient know it's been done - no, but we can look at that. Janice outlined this was reported to Boards and then to patient forums, but the public needs to know.
Hand hygiene, eye taken of the ball. Derek, targets, focus on getting patients.
Janice - need to focus, and address the whole, this takes in issues with GRE, and the new PSA target on C diff.
Ann Keen reiterated that patient safety was the number one priority.
Outcomes from The Breakout Session discussed with The Minister
Dealing with doctors, most highly paid are often the worst offenders, patients are concerned, how will that be dealt with, need to look at training that doctors receive, would appear to be lacking in infection prevention and control, potential doctors and surgeons need training. Wolverhampton - good example - test them on operational procedures - exam - if they don't meet requirements should not be allowed to practice until they do. How you deal with those that won't comply - disincentives if they don't do it - performance related pay.
Information - patient journey - needs to be standardised - need to take a clear line - needs to be the same across the board - needs to be a core basic standard. Infections - patient journey - evidence that this isn't happening, needs standard documentation on journey.
Visual impact and communication, measures being taken, reception areas, uniform. The way people present themselves, get the basics right. Visitors' policy, what's expected of visitors too.
Accreditation schemes to help implement standards and compliance. (minimum standard) - consider using this in other trusts.
Patient safety is the first duty of the NHS, down to management and leadership in those areas, should be in Job Descriptions and Contracts. Every Chief Executive now knows this is a priority.
Empowerment of patients, it was difficult, there is a duty of health professionals to speak out for those who can't.
Accountability at all levels, training for doctors.
Information being standardised with a local twist.
Patient journey, where have you been before, what's likely to be the complications.
Courtesy, minimum standards being used, where best practice is being used, share it.
We are reinforcing, and keep saying it and sharing it, it's our NHS. The Minister thanked the stakeholders for attending.
Derek Butler took the opportunity to present the Minister with information and research presenting the case for implementing the Dutch Search and Destroy Policy and, the Integrated Care Pathway developed to follow the patient, through the healthcare journey through Acute to Primary Care.
Thinking about the next three years
How can we collaborate together to help deliver on this agenda, how can we be improved as a group, and how can we participate?
How can the Department of Health work with stakeholders be improved/strengthened/designed to help delivery on this agenda?
Group should be pulled together with Chief Executives, Non Executive Directors and Clinical Staff, there was an opportunity for a larger forum, needs to be done collaboratively - with an opportunity for Chief Executives to feedback.
There was some cyncism that should not be a "tickbox exercise", action speaks louder than words, no care home sector representation, Dale Law raised the issue of the growing problem of healthcare infections and the lack of systems in place to isolate or cohort patients. It was unfortunate that C diff Support were given short notice to attend.
Nature of relationship, real ways of collaboration. Patients Bill of Rights.
Patient involvement and partnerships are important, delivery on patient empowerment, there was still a long way to go, initiatives, tools and advice should be made available, a need for testing of initiatives, not just recipients.
Department is aware of people who want to work with them, a long time since the last meeting. Continuous (two-way) communication is needed, actions need to be fed back, focus is on getting actions out to the NHS, but we don't know what's been done - this was loop to close.
Panel Discussion with:
Discussion on where we go from here
It is hard to keep communication, but not an excuse, it was too long since we last met. Broad concensus on what needs to happen. There was a suggestion of two meetings a year, the next in the Autumn. How could the Department help with communication, possible events with Chief Executives and Non-Exec Directors, and work with the NHS Confederation - there may be scope for some involvement. The Department would put a plan together to establish what events we can participate in. The outcomes from this group could be turned around in a fortnight. Establish how we build on that.
Sharing good practice across Trusts
Sharing leadership qualities we've seen. Sponsoring Director of Improvement Programme. Performance Improvement Network presentations. Mentoring systems in place. Infection Prevention Teams, development support for microbiologists etc, additional skilling to give confidence. Excellent presentation from Cheryl. Sharing knowledge.
In-house versus Externalised Cleaning Contracts
No evidence to say that inhouse cleaning contributes to lower infection rates. Pride - some contract cleaners do feel that they are part of the trust, there are also inhouse teams that are not good. It's about how contract is setup and how this is specified, and the valuing of the cleaners - its not about inhouse or outsourced.
Microbiology, Technology and Performance Management
Microbiologists are now key members of Infection Prevention Teams, they had two key roles, Microbiologist and Infection Control Doctor, most of the 500 medical microbiologists are involved in Infection Prevention. Cheryl's Microbiologist is part of the Infection Prevention Board, they would not have the confidence to support the scientific evidence. Need to combine technical expertise and performance management. Mandatory surveillance for GRE, radar is on.
Communicating with the public about hygiene
Telling patients about deep-clean. Public should be made aware. Some is disruptive, but some are not, so the public do not know its going on - the public needs to be aware. Having a deep clean is something to crow about - innovative things that trusts are thinking about it. Trusts may wish to replace things, for example carpets instead of vinyl etc. It needs to be responsive to needs. The money isn't ring-fenced to "cleaning" it will be a costed plan on "hygiene"
The day ended with everyone making a commitment to take an action to make a difference, MRSA Action UK gave a commitment to disseminating good practice and playing their part in keeping dialogue going with the Department of Health.
Summary of Event by Idenk
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