Maintaining a bug-free environment for patients

PEAT (Patient Environment Action Team) is a continuous programme of improvement of the patient environment by a multidisciplinary team which includes a patient representative.

Environment assessments are carried out at ward/departmental level who evaluate from a patients’ perspective.
•    Cleanliness and tidiness
•    Food and food service
•    Environment
•    Privacy and dignity
•    Infection control
•    Access and external areas

The assessment results help to highlight areas for improvement and share best practice within the hospital and across healthcare organisations in England.
All annual results are published by the National Patient Safety Agency.

Key Findings
Following the annual PEAT inspections, an action plan is compiled highlighting any areas of concern and funding allocated to improve environmental standards. The action plan is reviewed on a monthly basis, by the facilities lead person for PEAT, who ensures all actions are completed in a timely manner. The action plan is tabled at the quarterly PEAT meeting for progression
   
Blackpool Trust fully complies with the Infection Prevention Section of the PEAT Audit and the team carry out checks during the annual award and continuous mini PEAT audits across all divisions and hospital sites. These mini peat audits ensure that issues around infection prevention, domestic provision and estates are addressed on a regular basis thereby continuing to improve the patient environment. Infection Prevention representation is incorporated into the PEAT steering group work and a robust working relationship ensures the environment is maintained at optimal standard for the patient, combined with a close working relationship with the domestic provision to ensure high standards of cleanliness are upheld.

Top marks for Infection Prevention
To achieve ‘excellent’ scores across the Trust, a number of initiatives have been implemented to focus on hand hygiene. A fully comprehensive hand hygiene policy and procedure are in place, which is supported by a robust education programme to raise awareness with all health care professionals. Additionally there is a close working relationship between estates and infection prevention to ensure there are the correct numbers of sinks in relation to the number of beds, which has led to the number of sinks within the Trust being increased. An annual audit of sinks ensures that all wards and departments have the correct number of sinks and also to ensure all are fully accessible and fit for purpose. In the event of any refurbishments or new builds there is a close working partnership with the facilities department to ensure that there are the right ratio of hand wash sinks and beds in line with regulations.
 
Hand hygiene audits
The hand hygiene policy and procedure comprehensively explain when alcohol hand rub is the correct mode of decontamination and when it is more appropriate to decontaminate with soap and water. Hand hygiene audits are conducted by hand hygiene champions on a monthly basis. These are based on the World Health Organization’s five moments approach to hand hygiene. Posters are readily available at all sinks to identify the correct way to decontaminate hands.
   
To obtain a true reflection of practice it is imperative that the audits are conducted as much as possible whilst health care workers are unaware, this also assists in reducing the Hawthorn effect, whereby staff alter their behaviour when being observed and revert to normal behaviour when they are no longer being audited.
   
Additionally junior doctors have been incorporated into the auditing process, and conduct audits on wards and departments completely without the knowledge of health care workers.

Monitoring performance
Hand hygiene audit results are presented to each division on a monthly basis and are divided into different disciplines of healthcare professionals. If a particular group score in the red, discussions between infection prevention professionals and the managers of the relevant groups take place. An action plan is formulated and progress monitored, in some instances there is a requirement to raise awareness increase training. If one particular division scores consecutively in the red two months in a row, they are required to present their action plan and detail how identified actions will be met, at the Hospital Infection Prevention Committee, which is chaired by the chief executive.     
   
All healthcare workers are encouraged to challenge poor hand hygiene, in instances where the challenge is not well received, names are given to senior staff to address.

Awareness training
We have adopted the Clean your Hands campaign and training and education is formulated around the ‘point of care’. Alcohol hand rub is readily available at the point of care and in additional strategic places around the ward, particularly at the entrance and exit of a ward or department. Hand hygiene leaflets are available at ward level for patients and visitors which denote how staff should be carrying out hand hygiene and what patients should expect.
        
Hand hygiene audit results are also displayed at ward level, for patients, visitors and staff to see. In addition most wards have access to hand hygiene light boxes, which are utilised to train staff in hand hygiene and also to demonstrate to visitors. Hand hygiene is part of all Induction, and mandatory updates to ensure that all health care staff are trained on an annual basis.  
     
It is also imperative that all patients receive adequate hand hygiene, and hand wipes are routinely used on the wards when patients are unable to access hand wash sinks particularly after using toilet facilities and prior to meals.

A commitment to infection control
Infection Prevention is an important measure that has been adopted throughout the Trust; all healthcare workers are committed to ensuring that healthcare associated infections are greatly reduced. There have been a number of initiatives incorporated, which have led to a change in culture within the Trust, including MRSA screening, hand hygiene, MRSA Bacteraemia counter on the Trust Intranet homepage and a performance management meetings for all incidences of MRSA Bacteraemia and avoidable incidences of Clostridium difficile infection. Mandatory Infection Prevention road shows led by executive directors are presented on a monthly basis for all new starters to the Trust; all current 4,000 employees have attended the mandatory infection prevention road shows. Infection prevention is strongly led from the board to ward to ensure commitment from all staff. Poor practice is challenged in all aspects of infection prevention.

Screening for MRSA
Following a successful six-month pilot, a rapid screening process was adopted to enable swift identification on MRSA positive patients. This test is one of the many strategies employed within the Trust to help reduce MRSA infection rates. Since the introduction of the test MRSA bacteraemia rates have fallen by 78 per cent in the first year, and incidences of MRSA Bacteraemia continue to fall, with an overall decrease of 80 per cent.
   
The Trust introduced screening for all emergency patients in April 2008. In order to ensure best quality care for patients, the decision was made to utilise the rapid screening process called Polymase Chain Reaction (PCR).         The test reduces turnaround time for MRSA results from 72 hours to just two hours. By identifying MRSA early, patients are isolated quickly and receive the decolonisation treatment to significantly reduce the risk of transmission to other patients; thereby the quality of care to patients is greatly improved.
   
The availability of rapid results quickly identifies a patient’s MRSA status, which is used to complement clinical decision making regarding the patient’s management and optimal use of single rooms. The rapid test also assists in optimising antimicrobial therapy and thereby enhancing antimicrobial stewardship. Not only has there been a reduction in the use of certain antibiotic groups, a reduction in MRSA Bacteraemia but there has also been a reduction of approximately 33 per cent in MRSA wound infections.
   
The Microbiology laboratory, operates a seven day service between 8am and 12 midnight, the average turn-around-time of results is five hours (two–eight hours). There has been approximately four per cent of patients detected as carrying MRSA. Rapid identification of positive patients ensures reassurance to the vast majority of patients and provides confidence to the MRSA carriers that targeted infection prevention protocols are initiated for them.

Benefits outway the cost
Although this screening process is more expensive than the conventional use of culture and sensitivity, the investment pays off quickly and the savings are much greater in terms of finance and the quality of care given to the patient.
   
The introduction of this process has had a significant impact on healthcare associated infections. By using this test the Trust is saving lives. The associated benefit to patients and to clinicians is that we rapidly know within a few hours the MRSA status of patients coming into our hospital. This means that we can quickly identify which patients need to be isolated and which patients can be treated on an open ward.         
Preventing hospital infections is one of the Trust’s key priorities and during the six-month trial of PCR the number of cases of MRSA bacteraemia fell by 63 per cent. The introduction of the rapid screening test along with a number of other initiatives has maintained the dramatic reduction in MRSA Bacteraemia.

Award winning campaigns
Blackpool Fylde and Wyre NHS Foundation Trust, was awarded the HCAI Technology Innovation Team award in 2009 from Department of Health & National Purchase & Supply agency for the most innovative use of a cutting edge technology to spearhead the trust healthcare associated infection programme and demonstrating a reduction of 78 per cent in MRSA bacteraemia. The Trust has also been sharing best practice nationally and internationally. A team from the Trust was invited to the European Union Parliament in Brussels and to meet the Minister and Department of Health to share the excellent work done at the Trust.
   
Preventing hospital infections is one of the Trust’s key priorities as it is one of the biggest areas of public concern. The Trust has introduced several initiatives aimed at preventing hospital infections such as the ‘Ban the Bugs’ campaign, Chlorhexidine 2% skin disinfectant, trust wide roll out of Aseptic Non touch technique, quarterly saving lives audits, a robust surgical site surveillance programme and the hand washing campaign by enforcing strict hand-washing standards for staff, patients and visitors.
   
The ‘Ban the Bug’ Campaign was an extensive programme to raise awareness of infection prevention within the hospital aimed at patients, visitors and staff. The eye-catching posters are displayed across the site both internally and externally to raise infection prevention awareness and to aid in significantly reducing the risk of acquiring an infection.
   
Chlorhexidine 2% was introduced as a skin disinfectant for the reduction of bacteria carried on the skin when inserting peripheral lines, central lines and for taking blood cultures. Aseptic non touch technique is an aseptic procedure which ensures vital parts of equipment are not touched when preparing and administering intravenous drugs, thereby reducing the risk of infection. All these initiatives have assisted in dramatically reducing the levels of MRSA Bacteraemia and wound infections.
   
The appointment of new director of infection prevention and control, enhanced and cohesive working of the infection prevention nurses, two consultant microbiologists and antibiotic pharmacist have all helped in bringing about a transformational change in the approach and attitudes of staff working in the Trust to wards infection prevention and health care associated infections.

Written by
Johanne Lickiss, Nurse Consultant Infection Prevention
Yvonne Widdows, Senior Site Services Manager
Carol Gibson, Monitoring and Residences Manager
Dr Achyut Guleri, Consultant Microbiologist.