Delivering safe, clean, personal care

A number of Trust experiences were shared at the Healthcare Associated Infections conference with the aim of examining local efforts to reduce such infections. Among these included a case study presented by the Salford Royal NHS Foundation Trust. Ann Trail, assistant director of nursing services infection control, provided an insight into how the Trust has reduced its rate of central venous catheter (CVC) related infections. Salford has a track record of achievement – having been rated as “excellent” for four consecutive years by the Care Quality Commission (previously the Healthcare Commission), and was awarded accreditation level 3 by the NHS Litigation Authority (NHSLA), in recognition of the high priority given to safety at the organisation.

 In 2008, the Trust decided to build on this further – launching a quality improvement strategy aimed at reducing avoidable harm by 50% within three years. This is being achieved through a portfolio of projects designed to help staff make changes – based around the message: “safe, clean, personal care every time”. Progress is regularly reviewed by the Trust board on a monthly basis. The first of the projects to be implemented was aimed at reducing Clostridium difficile and a reduction of 70% was achieved on the pilot wards, in just one year. Across the whole of the organisation the reduction was an impressive 50%. Ann Trail explained that supporting the programme are a number of “collaboratives” focused on implementing change. A CVC “collaborative” has already been working to deliver improvements, over the last year, while other collaboratives have recently been initiated for surgical site infection, urinary catheter care and ventilatorassociated pneumonia. One of the reasons for the focus on CVC related blood stream infections (BSI) was the fact that BSIs are known to prolong the length of hospital stay by an average of seven days and increase mortality by 12% to 25%. In fact, a prevalence survey in England, carried out in 2006, found that 42.3% of BSIs were central line related. At Salford, a root cause analysis of MRSA bacteraemia showed that 30% were CVC line related.

“A contributing factor to the incidence of catheter related BSI is the fact that devices are often inserted in an urgent situation and asepsis may not be adhered to; CVCs are frequently manipulated; while patients often have underlying conditions that make them vulnerable to infection. Nevertheless, we know the potential for infection reduction is high and virtual elimination should be possible. Even in urgent situations we need to be performing insertion correctly, every time,” commented Ann Trail. The potential to have a major impact has been highlighted by the results reported by Pronovost in the US, which provided inspiration to the Trust, said Ann Trail. Some 103 ICUs in Michigan reduced CVC infection rates from 7.7 to 1.4 per 1,000 line days through “bundle” compliance, while recent data published in the BMJ suggests that this reduction has also been sustained. In the UK, Trusts have been engaged with the implementation of care bundles, based around the Department of Health’s “High Impact Interventions” (HIIs), and the National Patient Safety Agency (NPSA) recently launched its “Matching Michigan Challenge”. At Salford, the CVC improvement project commenced in February 2009 and was based around compliance to the insertion bundle and care bundle. Ann Trail explained that all of the following protocols must be adhered to, to ensure a successful outcome. If one is left out, the bundles will not prove effective: