Gill Hitchcock reports on how Royal Liverpool and Broadgreen University hospitals NHS trust tackled healthcare associated infections
When Diane Wake began a new role at Royal Liverpool and Broadgreen University hospitals NHS trust in 2007 she faced a major challenge. The 800-bed trust was a "national outlier" in terms of its healthcare associated infection rates and, as the trust's new executive director of nursing and operations and director of infection prevention and control, Wake was tasked with tackling this.
"We had large amounts of MRSA, an excessive rate of clostridium difficile, which I felt was totally and utterly unacceptable," she says. "You don't expect a patient who comes into the hospital to leave with something they didn't have when they arrived. For me that really set us off on a journey of what do we need to do differently in this organisation."
The journey to improvement has taken the trust through some radical changes and Wake on an eye-opening trip to Johns Hopkins hospital in Baltimore to learn about its success in tackling healthcare associated infection.
"They had published several articles in the New England Journal of Medicine, about reducing MRSA, and particularly to zero on their critical care units," Wake says.
"And that made me think, how have they done that? Patients, particularly in critical care environments, can be more susceptible to things like MRSA. And that seemed like a massive achievement."
One of the key innovations she witnessed during her five days in Baltimore was the use of hydrogen peroxide vapour for decontamination.
"When they discharged a patient who had an infection, they would clean the room and then use the hydrogen peroxide vapour to decontaminate it," Wake says. "That was something that we were not doing here in the UK and it really interested me."
Johns Hopkins was using the vapour in what Wake describes as a "reactive" way to treat equipment after an infection, but she decided to use the technique "proactively". The trust adopted a system supplied by Johnson and Johnson Medical to apply hydrogen peroxide vapour "across the board in the organisation, whenever we have discharged a patient".
Wake emphasises, however, that the vapour is not a substitute for cleaning and that the trust's cleaners have been "incredibly resourceful" in increasing the amount of cleaning of wards and departments.
She also saw that Johns Hopkins used non-ported cannulas to administer fluids into patient's veins, while Liverpool and Broadgreen was using ported cannulas. There was always a suspicion that ported cannulas could be a reservoir for pathogens, Wake explains.
"So we changed that. And we looked at how we decontaminated patients skin prior to introducing cannulas and then we embarked on a trust-wide training and education programme."
Liverpool and Broadgreen also introduced mattresses auditing. When Wake took up her post there was no regular mattress auditing, making it very difficult to control their lifespan. "Mattresses in a hospital have an eight-year life, all mattresses have a cover which is cleaned once the patient discharged," she explains.
"We did not recognise in 2007 that covers only had a life of three years, so after that timeframe, if a patient is incontinent in bed, there is a risk that if you don't change the cover after three years you can get some seep through to the mattress itself."
Following the initial audit, 80% of mattresses were condemned and replaced, and the trust now dates all its mattresses and covers and carries out weekly checks.
Changes to antibiotic prescribing and management were also introduced because, as Wake explains, there is much research to show that excessive antibiotic prescribing can result in increased clostridium difficile.
"It is about managing antibiotic prescribing well across the organisation," she says. "Certainly our pharmacy team have worked very closely with medical microbiologists, infection control teams and clinicians to make sure that we are really rigorous in ensuring that we are not prescribing inappropriately."
The infection control team was strengthened with the appointment of nurses who specialised in the field. Training for junior doctors has changed to help them with antibiotic prescribing.
"We also implemented something called a 'medicine man' which is basically the figure which we give to junior doctors to put in their pockets and it indicates, according to our antibiotic prescribing policy, if a patient had, for example, an upper respiratory tract infection or chest infection, what the right antibiotic is in the first instance."
Statistics released by the trust shows the MRSA infection rates were reduced by 88% between 2008-09 to 2011-12, representing a fall from 34 cases to four. Similarly, clostridium difficile infection declined by 84%, with a drop from 353 cases in 2008-09 to 58 in 2011-12.
Wake maintains that this improvement has resulted from a change of culture. "We really tightened up everything that we did," says Wake. "It is about everybody in the organisation being signed up to the agenda, reducing healthcare associated infection." Guardian Professional.
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