Minimising the risks of IV infection

The Infection Prevention Society’s IV Infection Conference, held at the Hilton Metropole, Brighton, covered a variety of key issues concerned with improving the safety of vascular access devices. Experts discussed the need to tackle poor awareness of the EPIC 2 recommendations and to improve training on IV therapy; and exchanged ideas on how national guidelines and best practice could be successfully implemented on a local basis. Carol Pellowe, deputy director, Richard Wells Research Centre, Thames Valley University, provided an overview of the EPIC 2 guidelines, which were commissioned by the Department of Health and developed by the university. She explained that during the 1990s, the problem of HCAIs had reached a crisis point with 9% of inpatients in England developing an infection (equating to 100,000 annually). “At this time, we spoke of ‘hospitalassociated infections’, but we now recognise these are actually ‘healthcareacquired’ – they are transferred from a hospital to the community and vice versa. It is very difficult to determine where an individual acquired the infection, but it is believed that 15-30% of HCAIs are preventable.” Over the course of the decade, the incidence of HCAIs totalled one million – resulting in increased morbidity and mortality, longer inpatient stays and longer waiting lists, greater costs and use of resources, profound “consumer” dissatisfaction, and increased risks to healthcare workers. A total of 5,000 patients died each year, as a consequence, while HCAI was implicated in a further 15,000 deaths per annum. The problem was costing the health service £1 billion each year. As the health service became much more cost conscious in the 90s, this proved to be a significant motivating factor in the drive to address the problem. There was also a cultural shift in the way patients perceived their relationship with their healthcare provider. “Patients are no longer simply ‘grateful’ – they have come to view themselves as equals and as consumers; they are more informed through the internet and increasingly question why they, or their relatives, have not been treated according to guidelines. Indeed, when such guidelines have not been followed, there have been cases where relatives have cited this failure during litigation proceedings,” Carol Pellowe commented. “Even if you are unaware of the guidelines, your patients will be,” she warned. “As we become a more litigious society, it is crucial that healthcare professionals recognise their importance.” She commented that the reason for the scale of the problem in the 90s was not simply due to increased surveillance, but to poor standards and variations in clinical practice. In addition, there was a lack of evidence-based infection prevention guidance to promote clinically effective practice. National drivers for change in the millennium have included the emergence of the evidence-based medicine movement, as well as clinical governance and the publication of evidence-based guidelines. Today, the Department of Health policy is that there should be: 24- hour infection prevention and control cover, assessment of HCAI risks to patients, information on patients’ infection status moving from one care facility to another, involvement of patient representatives and dates set to review policies.

Completing ‘the circle’

Carol Pellowe acknowledged that: “You can have policy initiatives and guidance, but you need to complete the circle. For policy to be effective, practitioners have to have heard about the guidelines and read them. The guidelines need to be implemented and compliance audited, and feedback from practice needs to continue to inform policy to complete the ‘circle’.” Key publications influencing policy have included: Getting Ahead of the Curve (2002), Winning Ways (2002). The Health Act (2006), Saving Lives (2007), Safe, Clean Care (2008) and the Health and Social Care Act (2008). In addition, in 2001, the first evidencebased EPIC guidelines for preventing HCAIs in acute settings, were published. In phase one of the EPIC project, three modules were developed – the first tackled standard principles such as hospital environmental hygiene, hand hygiene, personal protective equipment (PPE) and safe use and disposal of sharps. The other two focused on shortterm indwelling urethral catheters and central venous access devices, as these were identified as the two most serious sources of infection. Phase two was concerned with the development of complementary guidelines for primary and community care settings, under the auspices of NICE. As well as outlining standard principles for hand hygiene, personal protection equipment (PPE) and safe use and disposal of sharps, the NICE guideline for primary and community care tackled long-term urinary catheterisation, enteral feeding and central venous catheters. Despite the introduction of guidance, the HCAI third prevalence study (HIS 2007) provided a “wake-up call”, said Carol Pellowe: “Although prevalence in England was 9% in the 1990s, this only dropped to 8.2% in 2006. In the UK, the figure was 7.2%. Despite the ‘spin’, this was not significant progress. In particular, the survey found that 19.7% of patients had a UTI. It was phenomenal just how bad the situation was,” she commented. “However, the prevalence survey succeeded in highlighting the consequences including the actual cost implications.” Healthcare-acquired infection was found to cost between £4,000 and £10,000 per patient and resulted in 10 additional bed days for a case of MRSA bacteraemia and 21 days for C. difficile.