East and North Hertfordshire NHS Trust

Annual Infection Prevention and Control Conference 17 May 2012

Derek Butler and Maria Cann attended East and North Hertfordshire NHS Trust Annual Infection Prevention and Control Conference in Hatfield. Derek presented a very moving account of people who had been lost to MRSA and Clostridium difficile in both the hospital and community environment, those who had died were from all age groups, some were young and not all were being treated for life-threatening illness. Good practice was also included in the presentation giving an opportunity to show how good communication and information can make a difference to those families who are affected.

There were opportunities to network and catch up with Simon Price from Molnlycke Healthcare who was also at the conference. We also met Stephen Rowley, Clinical Director of ANTT who wishes to work with us in the future on helping to inform patients on the standards to expect in terms of Aseptic Non Touch Technique.

Jonathan Plumb, Nursing Advisor from the Medicines and Healthcare products Regulatory Agency (MHRA), the government agency which is responsible for ensuring that medicines and medical devices work and are safe, gave an overview of some of the practices that are reported that can put patients and staff at risk from infections. He believes that there is a lot of under-reporting and encouraged everyone to make reports if devices were faulty. Mattresses were commonly faulty and can be a source of contamination and infection if they were not fit for purpose, this was just one example.

Reporting adverse incidents involving medical devices can be done on-line by clinicians, healthcare and social care workers, or by patients and other members of the public. Medical device manufacturers also have an online reporting environment. The MHRA will provide alerts and recalls whenever appropriate. Full information and guidance on reporting adverse incidents is published in the first MHRA Device Bulletin of each year, and details can be found on their website at http://www.mhra.gov.uk

Sue Passfield, Senior Sister talked of the success of the measures the hospital were taking to reduce Catheter associated urinary tract infections (CAUTIs). Sue is leading the implementation of held hand bladder scanners to help assess the need for urinary catheters.

CAUTIs account for 19.7% of all hospital infections (Department of Health), patients who acquire a bacteraemia as a consequence are twice as likely to die, so minimising the use of catheters and managing the risks are an essential element of care. In the year 2000 The National Audit Office estimated the additional cost of care attributable to a CAUTI at £1,122.

The scan takes less time than it does to catheterise, and as with any invasive device it is good practice to assess whether it is needed. Using the Safety Thermometer approach, and HOUDINI, if a catheter is needed risks are managed, and focussing on catheter care will reduce the risks to the patient. The scanner had been a valued piece of equipment to the nurses using it during the trial, and more will be in use in the future.

Patients are encouraged to discuss the use of catheters, some patients prefer to have catheters and specifically request them, so patient choice is taken into account during assessment.

Dagmar Louw, Senior Sister gave an overview on the care and management of Vascular Access Devices. She was available to help discuss and demonstrate their effective use, where they can be effectively used to administer medication and help to alleviate multiple puncture sites and distress and discomfort for patients who need medication administered intravenously.

Stephen Rowley, Clinical Director of ANTT was pleased that the Trust had invited him to speak and that they were adopting the gold standard of Aseptic Non-Touch Technique

ANTT was a mandatory national standard in Australia and care facilities will be required to have implemented ANTT by January 2013, it is the de facto standard in the UK but not mandatory.

There was a lot of ambiguity about what constitutes ANTT. Aseptic means free from pathogenic micro-organisms that could cause an infection. The NICE guidelines for Infection Prevention and Control for Community Care 2012, page 206 makes reference to the use of clean technique for catheter care, yet ANTT is the de facto recognised procedure in the UK, so why advise a clean technique for catheter care when this can cause CAUTIs?

"It's almost as easy to pick up MRSA by touching the patient's environment as it is by touching the patient" Dancer et al 2009. Hand contamination of anaesthesia providers is an important risk factor for inter-operative bacterial transmission.

No other major industry would tolerate an undefined and variable approach to such a vital safety procedure; for example, it is unthinkable that the aviation industry would operate without a universal standard for servicing jet engines. Indeed, comparison with the aviation industry is sobering; while some 800 people a year die worldwide from air accidents, in 2007 around 9,000 patients died in the UK alone from MRSA and Clostridium difficile infections (National Audit Office, 2009).

The 10 principles of ANTT 1. The main infection risk to the patient is the health professional. It is essential that healthcare organisations and individual health professionals understand and address the real risks they pose to patients.

2. Health professionals must understand what asepsis is and how to establish and maintain it. Poor understanding and application of the terms "sterile", "asepsis" and "clean" have contributed to confused aseptic technique (Aziz, 2009). The aim of ANTT "from the operating theatre to the community", is the standard of asepsis.

3. Identifying and protecting key parts and key sites is paramount. Key parts are the critical parts of clinical equipment that come into direct or indirect contact with any liquid infusion, key sites and any active key parts connected to the patient. If contaminated they present a significantly high risk of infection.

4. Asepsis is achieved with standard ANTT or surgical ANTT. Standard ANTT is the technique of choice if procedures are technically uncomplicated, short in duration (approximately <20 minutes), involve small key sites and key parts, and minimal numbers of key parts. Surgical ANTT is needed when procedures are technically complex, last approximately >20 minutes, involve large open key sites, and large or numerous key parts.

5. Clinical procedures should be risk assessed to determine the need for standard or surgical ANTT. ANTT risk assessment is based on the technical challenge of the procedure, practitioner competency and the environment in which the procedure is performed. The health professional asks: "Can I maintain the asepsis of all key parts and key sites by using a general aseptic field and micro critical aseptic fields?" In other words, can the procedure be performed safely using the most simple and efficient standard ANTT? If not, surgical ANTT is used and the main aseptic field must be managed critically (see principle 6).

6. Aseptic fields are important; although the principles of ANTT remain constant, standard and surgical ANTT require different aseptic field management. Healthcare environments are typically resident with atypical, often antibiotic-resistant and invisible, microorganisms. As such, aseptic fields are important to ensure a controlled safe working space to help maintain the asepsis of key parts and key sites. ANTT uses two types of aseptic field that require different management. Common to standard and surgical ANTT is the use of critical aseptic fields to maintain the asepsis of procedure key parts. In surgical ANTT, the critical aseptic field will be a relatively large area on which only equipment that has been sterilised or is aseptic can be introduced. In standard ANTT, the main aseptic field is termed a "general aseptic field" because it does not require critical management. This is because procedure key parts can easily and optimally be protected using micro critical aseptic fields, such as caps, covers and the inside of equipment packaging.

7. Non-touch technique is the most important component of standard and surgical ANTT. Because the safest way of protecting a key part is not to touch it, the principle and practice of non-touch technique is a core element of standard ANTT and surgical ANTT (when practical to do so).

8. Appropriate infective precautions help promote and ensure asepsis. Although non-touch technique and appropriate aseptic field management are the core components of key-part and key-site protection, basic infection prevention precautions, such as effective hand cleaning and glove usage are important and help ensure asepsis.

9. Aseptic practice should be standardised across and between healthcare organisations. Typically, when HCAI rates are high in specific areas, hospitals react by standardising practice with explicit guidance. ANTT has been used to good effect reactively (Rowley and Clare, 2009) but, in the best interests of patients, it is best used proactively to standardise aseptic practice across large workforces. Standardising practice naturally reduces practice variability and the number of variables in practice. It also enables peer enforcement, monitoring of standards and research enquiry.

10. Safe aseptic technique is reliant on effective staff training in infection control, safe environments and equipment that is fit for purpose. Effective aseptic technique is dependent on healthcare organisations taking a systematic approach to asepsis management in general. The effective education and training of healthcare workers is paramount, as is ensuring equipment is fit for purpose and clinical environments promote asepsis.

The ANTT framework is available from Stephen at enquiries@antt.org

If you or someone you care about has been affected by a healthcare associated infection and you wish to discuss this with us, please contact us at info@mrsaactionuk.net

The information on this website is for general purposes only and is not a substitute for qualified medical care, if you are unwell please seek medical advice.

(c) MRSA Action UK 2012