Infection prevention society conference 2011
September 19-21 Bournemouth
We extend our thanks to Molnlycke Healthcare who made it possible for us to attend the Infection Prevention Society Conference in Bournemouth.  We were able to network with colleagues from across healthcare which provided opportunities for us to link in with Trusts infection prevention training and promote patient involvement in getting the message across about the importance of doing all we can to avoid preventable harm.  Derek took part in a video capturing colleagues signing up to the Infection Prevention Society's strategy and the vision that no patient, whether in hospital or the community is harmed as the result of an avoidable infection.

We were privileged to meet Professor Graham Ayliffe whose name is synonymous with the Ayliffe technique, recognised globally as the effective way to wash hands.  Professor Ayliffe modestly said it just happened his name began with 'A' and that he was just one of three practitioners that invented the technique.  He explained how the technique was developed in response to the need to effectively clean the hands, making sure the larger areas on the thumbs and finger nails were not missed.

We also took the opportunity to catch up with Alice from Care Fusion.   Care Fusion presented their paper on the zero tolerance approach to preventing surgical site infections.  We know these are preventable, costly and potentially serious, with many of us experiencing the misery first hand.  They account for 14% of all healthcare associated infections, that is 1 in 7.  The paper looks at the size of the problem and the interventions needed to tackle them and a summary can be downloaded at The Clinical Services Journal website

Surgical site infections - the facts

Lost in translation? Applying infection prevention to Practice
Claire Kilpartrick, Nurse Consultant, Health Protection Scotland & World Health Organisation
Jan Westbury, Senior Research Nurse/AHP Manager, Southampton University NHS Hospitals Trust
The objectives of the session were to explore the reasons why new initiatives aimed at improving infection prevention practice are 'lost in translation' and produce an outline action plan to re-energise or implement a practice initiative.
Words are important:

Professor Albert Mehrabian published a scientific theory:
7% of meaning in the words that are spoken
38% of meaning is paralinguistic (the way that the words are said)
55% of meaning is in facial expression

In the example given this may be the case, however we know how important words are.  The session was interactive with an example of addressing peripheral catheter bloodstream infections.  A lengthy piece of text was circulated, yet the key message that needed delivering was lost in the transcript, summed up all that was needed to be said was "Peripheral Vascular catheters are a major cause of bloodstream infections, a third result in death, the first question you need to ask is do I need one?"

We were asked to draw a picture that represented how we felt on the last occasion we communicated with a clinician.  A number of delegates gave negative examples that they had experienced.

Derek's symbol was a positive one that  was hands joined together representing partnership, he was asked to explain his communication, and he joined three people in a circle linking hands,  and invited two people into the middle, representing clients (in this case, patients and their carers and families).

The 5 moments of hand hygiene and what is needed in practice was discussed, putting the 5 moments into context was important, what was needed during an operation in theatre would be very different to what would happen on a ward, in a doctor's surgery or in a patient's home.  Whilst there are different settings, we always advocate washing hands between patients no matter what the setting, and before any invasive procedure or when hands are soiled with bodily fluids.  The key message was the 5 moments are an important guide for safe care and needs to be adapted to meet the circumstances of care.
Infection prevention and control at home and in everyday life
Professor Sally Bloomfield, Chairman, International Scientific Forum on Home Hygiene examined the challenges of infection prevention and control at home and in everyday life, the objectives of the session were to gain an understanding of a sustainable approach to hygiene in home and everyday life, and understand the development of antibiotic resistance outside of hospitals, impacting on home / community transmission on infection control in hospitals.  We share a common goal with a recognition of the need to move towards a more integrated infection control service considering home, hospital and community transmission, there was a particularly interesting part of the presentation dealing with laundry, and this provided clarity on the potential for transmission of MRSA through laundry, guidelines for handling laundry safely in the home setting and targeted approaches to home hygiene can be found at the IFH website.
The great disinfection debate
Most now agree that you need to remove or kill pathogens contaminating hospital surfaces in some circumstances. The question for discussion was how best to do this? In this debate, two internationally recognised experts went head to head:
The case for cleaning and conventional disinfection was given by Peter Hoffman, Consultant Clinical Scientist, at the Health Protection Agency, versus the case for cleaning and new disinfection technologies, Dr Trish Perl, Senior Epidemiologist, The Johns Hopkins Health System, USA.  The question was more about a combined approach rather than either/or, and the opinion was dramatically altered in the final analysis on the benefits of using technologies to help in reducing the bacterial load when cleaning and thinking about the environment.
Infection control challenges in sport
Annette Jeanes, Consultant Nurse and Director of Infection Prevention and Control, University College London Hospitals NHS Foundation Trust

Annette was advising the Olympic Teams on infection prevention and control and was proud to say we were going to provide a world class service fit for champions in delivering advice on taking the necessary precautions to mitigate the risk of infection for participants.  There were some interesting challenges in Annette's presentation.

The most dangerous sports were rugby with more injuries per player than any other participatory sport, cave diving, cheerleading, motorcycling, fishing, rock climbing, golf, horse riding, base jumping (fatality 1 in 60 participants).  The most dangerous was lawn bowls with high heart attack and stroke victims.

Sports injuries and illnesses during the last Winter Olympic Games showed that 54% of injuries occurred in training, 46% in competition, 11% during the games, 7% had an illness.
Muscular skeletal injury is common, viral respiratory tract and infections of the GI tract, some severe or fatal consequences have occurred eg PVL MRSA. Infection prevention in sport brings many challenges and reminds us that it is the young , fit and strong that are also vulnerable in this environment. 

Andy Holmes, Olympic gold medalist died aged 51 from Weils disease.

21 year old football player Ricky Lannetti died of CA-MRSA, starting as a skin infection, ending just 5 days later with multi-organ failure.

The Ayliffe Lecture

Sir Liam Donaldson gave a very moving presentation.  Since retiring he has taken up the position of the World Health Organisation Envoy for Patient Safety.

His presentation included the tragic story of Wayne Jowett, 18, who had been recovering from leukaemia when a fatal error occurred and a powerful anti-cancer drug was injected into the young apprentice mechanic through his spine, instead of into a vein.  The doctor realised his mistake almost immediately but medical staff were powerless to reverse the devastating effects and Wayne died a month later after his body was slowly paralysed and he suffered heart failure.

Clinical misjudgements or mistakes mean that the odds of dying as a result of being treated in hospital are 33,000 times higher than those of dying in an air crash. "In an airline industry, the evidence from scheduled airlines is the risk of death is one in 10 million.  If you go into a hospital in the developed world, the risk of death from a medical error is one in 300"
1,000,000 NHS patients every 36 hours, if this was an airline would you fly with it with a 1:300 chance of crashing? 

Sir Liam spoke of his Orange Wire article published in the Lancet.  "Imagine that a Boeing 757 aircraft engine contained an orange-coloured wire essential to its safe functioning. Imagine that an airline engineer doing a pre-flight inspection spotted that the wire was frayed in a way that suggested a systematic fault rather than routine wear and tear. Imagine what would happen next. It is likely that most 757 engines in the world would be inspected -probably within days - and the orange wire, if faulty, renewed."

Like airlines, hospitals take charge of people's lives many times a day. Yet, health care has lagged behind other industries in putting safety first in dealing with its consumers.  A systematic fault that put patients' lives at risk discovered in one country would not surely be rapidly and simultaneously corrected by health services across the world."  "When will health care pass the orange-wire test?" Engineers wouldn't simply patch up the orange wire, they would investigate the whole fleet to make sure there wasn't a problem.  In some hospitals when things go wrong, this isn't even shared within the hospital leave alone across the NHS, we have to get better at that. In ending his presentation Sir Liam spoke of those people who had been lost to medical mistakes, they won't celebrate a birthday, wedding or christening again.  Sir Liam Donaldson said, "you know when you think someone is watching over you, well the next time you have that feeling, think of them as being those who have been lost to those events, and in their honour do all you can to avoid that happening ever again"

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