Spreading the word, not the infection

Infection Prevention and Control (IP&C) is a priority for anyone working in the healthcare service. Whether a hospital or a community health organisation, all are striving to ensure they follow best practice and protect patients and staff from the spread of infection.

Guidelines from the Health and Social care act 2008 (2010), from the National Institute of Clinical Excellence (NICE), and national targets on reducing Methicillin Resistant Staphcoccous Aureus (MRSA) and Clostridium Difficile only drive the importance of IP&C more.

Organisations are keen to meet these targets and avoid any cases of infection spread, which can be detrimental for individual patient care and trust or organisation reputation alike.

Not surprisingly at Liverpool Community Health NHS Trust (LCH) IP&C is one of our top priorities and we have invested in a dedicated team of nurses whose job it is to advise community staff and the general public on how to prevent infection. The team includes a lead nurse, four IP&C nurses, a dental IP&C nurse, a surveillance nurse and an administrator.

IP&C in a community health setting presents its own challenges, with the focus very much on reducing risk and preventing the spread of infection in shared care settings of care homes, patients’ own homes, GP surgeries and health centres.

Infection control audits
Infection control audits carried out by the team at LCH find out what the issues are and how we can correct them to minimise the spread of infection. We carry out these audits for all LCH premises where patient care is delivered, care homes, GP surgeries and dental practices.

The aim of the audits is to assess compliance with IP&C policies and guidelines, determine the state of the environment and review clinical practice in relation to IP&C.

We’ve used the audit system throughout the organisation and it has proved beneficial in quickly assessing compliance with IP&C guidance along with issues that require further actions to remedy problems.

In 2010 all care homes within the LCH footprint were audited using an audit tool utilising the criterion specified in the Health and Social care act 2008 (DOH 2010). This audit plan proved successful in forging links between care home staff and the IP&C team, which later proved useful when investigating outbreaks of infection of the seasonal bug Norovirus, which affected some of the care homes along with the wider community this year.

More recently the team completed a detailed audit of Liverpool’s 60 independent NHS contracted dental practices and 10 community based practices. These practices have had to comply with new dental guidance the HTM 01-05. This is a document that has been released by the Department of Health to offer guidance in relation to decontamination in dental health.

All practices were visited by the Dental Infection Control Nurse and using the Infection Prevention Society (IPS) audit tool, were left with an action plan and a score indicating compliance with the tool. This audit revealed some interesting findings; it became apparent from the baseline audits that training was a big issue within dental practices. Many dental professionals had not received IP&C training since qualifying and this was something that needed to be addressed quickly.

Training
The training of staff is key to IP&C. Often it is only simple standards that need to be maintained in order to prevent infection spreading. Hand hygiene has been highlighted as the single most important measure in preventing the spread of infection. As a team we promote the Ayliffe hand hygiene technique, which was also highlighted within the cleanyourhands campaign. This is basically the simple principle of ensuring staff wash all parts of their hands and that they wash them at the correct time when delivering care. This is monitored through a peer to peer audit programme, where work colleagues in a team ensure they are each following the correct procedures.

Following on from the audit cycle undertaken in the care homes we developed an IP&C training programme, which has been delivered to care home staff, both qualified and unqualified. This was well received by those who attended and again it was particularly helpful in managing outbreaks of infection of the winter vomiting virus (Norovirus). The principles taught on the training session were put into practice by the care home staff.

Our recent work with the dental practices showed the value of training. All dental practices were initially offered two places on a three-day training programme, which covered standard precautions such as hand washing, basic microbiology, clinical governance and decontamination. The original training was reduced to two days as more practices implemented change within their workplace. 

Following on from the original audit a re-visit took place; the improvements made following the training were dramatic, with most dental clinics exhibiting best practice in infection control, scoring more than 90 per cent for their compliance levels within the HTM 01-05 guidance.
 
Surveillance
As part of our best practice in IP&C we have been carefully monitoring the number and type of infections occurring in the community and investigating any potential causes of infection. Infection issues such as MRSA blood stream infection (bacteraemia) and C.diff are a key focus for this year. Any cases that do occur are investigated to see what can be learned to ensure it doesn’t happen again. The trust has a target that must not be exceeded this year for these two serious infections set by the Strategic Health Authority.

Current challenges
The challenges we have faced as a team are typical of the issues many IP&C teams have to address when working in a community health setting. One of the key problems of the organisation is to update our current building to ensure it is fit for purpose from an IP&C perspective. 

There has been a change in healthcare in recent years with a move towards only acutely ill patients being hospitalised, reducing the number of hospital beds with other services being available to the public within the community health setting. Services provided by the trust now include intravenous therapy, minor surgery, X-ray and wound care. These procedures require environments that are clean, safe and fit for purpose. Some buildings used by the organisation were out-dated and not designed for the services we offer now.

In recent years the team has been auditing all the buildings where care by LCH staff is given to risk assess and recommend which required refurbishing to provide the right environments for clinical procedures carried out within the community now. As a result of these audits, IP&C buildings guidance and work with developers has ensured many of our buildings now include newly-designed rooms which can provide a safe setting for more high risk clinical work.

The IP&C team are now more involved in new property developments by the trust and we are an active part of the consultation process, working with architects and healthcare managers to ensure new buildings constructed are fit for 21st century community health services.

Another key challenge is the provision of domiciliary care. We have many patients who are housebound or in care homes, unable to attend treatment centres for clinical care. Domiciliary teams such as district nurses, podiatry and dental, provide care in patient homes. In these environments it is much more difficult to manage the environment in which staff are working and to put infection control procedures in place. Education and training is vital, making sure staff are up to date with the latest in IP&C best practice. 
 
Targets/performance indicators
In 2010/11 as a community trust, we met our target relating to Clostridium Difficile infection of fewer than 310 cases. The 2011/12 target is 204 cases – a 34.2 per cent reduction from the previous year. This target is a challenge for the team.

The 2010/11 target for MRSA bacteraemia infection was narrowly missed by just one case. The 2011/12 target is to decrease this incidence by 18.8 per cent, which equates to 13 cases.

These targets are set by the Strategic Health Authority to all trusts on a yearly basis.

Plans for the future
The 2011/12 work specification for the IP&C team has been devised to target these areas of infection with the aim of reducing the incidence and meeting targets being set.

The teams plan to introduce a decolonisation regime within care homes for patients returning home from inpatient settings found to be MRSA positive. These are at increased risk due to the presence of indwelling devices, such as urinary catheters, entral feeding tubes or the presence of a wound.

We are launching IP&C practice audits to defined groups of healthcare staff, to provided assurance that IP&C practices are to be undertaken and cleanliness audits at all healthcare sites using criteria will be carried out by individual buildings managers to ensure standards of cleanliness are maintained.

The team will also implement a detailed ‘Root Cause Analysis’ (RCA) investigation of Clostridium Difficile, MRSA, MSSA (Methicillin Sensitive Staphcoccous Aureus) and E-Coli bacteraemia infections. This will establish cause and produce action plans and lessons learnt. These will be then circulated to the wider health economy.

We are also auditing all independent GP practices in the LCH footprint to ensure environments are fit for the delivery of healthcare. Our clinical mandatory training has also been changed to every two years instead of three, in line with an agreed north west training schedule. Staff will therefore receive training more regularly, ensuring standards of infection control are at their highest.

For more information
www.liverpoolcommunityhealth.nhs.uk