Sarah Berger and Carmel Hurley-Watts
Resilience & Re-emergence in hand hygiene auditing – CDHB’s improvement journey
In May 2014, Canterbury DHB (CDHB) established a hand hygiene governance group made up of an inter-professional team of clinical staff as well as Quality and Infection Prevention and Control representatives. The National target has increased over time from 70% in 2013, 75% in June 2014 to 80% in June 2015. A CDHB Hand Hygiene Improvement Project Charter was written utilising the Process for Improvement. It identified the Need, Aim, Plan, Do, Study, Act (PDSA). The purpose was to report key stages and different PDSA cycles undertaken to reach an improvement from the 2013 result (62% compliance) to March 2017, reaching 80% compliance, and consistently maintaining over 80% since) while spreading the programme to all 43 CDHB inpatient areas.
CDHB applied the ‘process for improvement’ for implementation of a sustainable Hand Hygiene Programme using a multi-modal approach such as an improvement toolkit for use at a local level, service specific training, the annual campaign, frequent data dashboard reports indicating status and consistent key messages, supported by the multidisciplinary hand hygiene governance group. Compliance with the World Health Organisation’s ‘5 moments of hand hygiene’ was assessed through audits as per the Health Quality Safety Commission/Hand Hygiene New Zealand (HQSC/HHNZ) Hand Hygiene New Zealand Auditing Programme. In 3 annual audit periods, all high risk wards were measured, as well as CDHB inpatient areas.
The Hand Hygiene Programme has been implemented and embedded across all 43 CDHB in-patient areas as of 1 November 2018. Notably, for the seventh consecutive audit period the 80% threshold has been sustained with 82% compliance for the audit period 1 November 2018 – 31 March 2019.
Through demonstrated dedication to Resilience and Re-emergence of the 5-Moments Hand Hygiene principles, CDHB will strive for continued improvements towards the aspirational goal of 100%.
Dr Sarah Berger MN(Hons) MBA BA RN has recently returned to Christchurch to take up the new role of Nursing Director for Canterbury DHB Infection Prevention & Control Service. This role has been established as part of the recommendations arising from a review of the IPC service. Sarah has spent the last seven years researching and teaching at the University Hospital Heidelberg, Germany. She completed her doctoral studies in Health Services Research on facilitation of collaborative decision-making in health care teams.
Carmel Hurley-Watts BN DipN RCpN Nurse Co-ordinator, Quality & Patient Safety (Canterbury DHB Hand Hygiene Co-ordinator Portfolio). The hand hygiene programme sits within the Quality & Patient Safety team and the role holds this portfolio, managing this programme. The HH Co-ordinator role supports the hand hygiene governance group, engages with Infection Prevention & Control Services team members, plays a key role in engaging frontline staff and senior management in improving hand hygiene efforts, and planning for the annual evaluation. Carmel has been in this role for the past 4 years, and has a nursing background in Operating Theatre nursing and management, with past involvement with IP&C through holding a link nurse representative role for Operating theatres and as a member of the IPCNC NZNO specialty group.
Sink or Slime
Hand hygiene sinks have increasingly been linked to outbreaks of gram negative bacteria- including ESBL and CPE in ICUs internationally. These bacteria form biofilm in the sinks and taps, and are transmitted by splash to other patients and equipment.
After some possible transmission of gram negative bacteria between patients, in the general surgical wared at CCDHB, the ward nursing practices were surveyed. This survey showed that hand hygiene sinks were being used for disposal of a variety of protein laden fluids, and for patient drinking water. Education and practice changes were made and the nursing activity resurveyed. The nurses were committed to making changes to their practice, however needed easy alternatives to their previous practices.
Carolyn Clissold (RN, BA, MA -Nurs) has spent the last 11 years as an Infection, Prevention and Control -Clinical Nurse Specialist at Capital and Coast DHB, initially working in primary care (with GP practices, and the residential care sector) and then in the hospital role. She has been the Treasurer and is the current chair of the IPCNC. She also represent the IPCNC on the MOH Health Antimicrobial Resistance Committee which oversees the implementation of the Antimicrobial Resistance Action plan.
Gyms and Bug: A survey of gym users’ awareness relating to infection risk management
With increasing emphasis on wellness across the lifespan gym membership in New Zealand is on the rise with industry experts, Exercise Association New Zealand (ExerciseNZ, personal communication), indicating that the sector has grown by 6.5 per cent in recent years with approximately 15% of New Zealanders holding a gym membership. While the industry is focused on promoting health and wellbeing, gym services and facilities are a potential reservoir for microorganism and infection risk for users. Community acquired infections present a threat in an era of increasing anti-microbial resistance with studies revealing that MRSA is commonly found on gym surfaces (Stanforth, Krause, Starkey & Ryan, 2010) and gym bottles often contain a high microbial load (Silveria et al., 2019).
A small pilot study targeted public and private gyms in the Rotorua area, assessed gym users awareness of infection risks and strategies used to mitigate their potential within this setting. A total of 55 participants, recruited from the nine gyms completed a short online survey probing infection risk awareness and use of precautionary measures. The findings of this small study reveal gym users predominantly engage in cardio-type routines with a high level of equipment sharing during highly paced sessions where there is increased risk of cross-infection exposure. While users demonstrate a good understanding of common preventative measures, including hand hygiene, only 37% use a towel as a barrier, as recommended by the industry.
This small study is the first to explore the understanding and practices of regular gym users in the New Zealand context. The study highlights that complacency around preventative strategies presents a threat in the public domain and highlights that gyms are a potential source of community acquired infections.
Silveira, M., Scudese, E., Senna, G., Ferreira, A., Dantas, E., Ribero, L., Alvares, A., & G. (2018). Microbial contamination in shaker bottles among members of fitness centers. Journal of Exercise Physiology Online, 21(4), 134-142.
Stanforth, B., Krause, A., Starkey, C., & Ryan, T. (2010). Prevalence of community-associated Methicillin-Resistant Staphylococcus Aureus in high school wrestling environments. Journal of Environmental Health, 6(12), 12-16. doi: https://www.jstor.org/stable/26328057
Mary is a lecturer at Toi Ohomai Institute of Technology and currently involved in teaching on two programmes that emphasise infection prevention and control: The Diploma in Infection Risk Management and the Diploma in Sterilisation Technology (Level 5). She has been teaching at Toi Ohomai and its predecessor Waiariki Institute of Technology for approximately 10 years. She is currently undertaking the final paper towards a Post-Graduate Diploma in Public Health which has broadened my understanding and focus of infection prevention and control.
NZIPC Standard 8134.3 … do IPC standards survive or flourish during changing models of healthcare?
The New Zealand Health and Disability Services Standards are undergoing review to better reflect current practice and changing models of healthcare. This includes 8134.3 2008 Infection Prevention and Control. An Operative Alliance (NZ Ministry of Health) has been formed to oversee and guide operational review of all the standards. Phase One of initial sector consultation took place during 2017 – 2018. Phase Two scoping workshops have been in action during May to August 2019. These have focused on health providers such as DHB, private hospital, residential, disability and home care. Phase Three is now currently in development which includes the formation of working groups that will meet regularly for “dive deep” consultation. As recognised subject matter experts, infection prevention and control healthcare professionals must come together to strengthen strategy and future development of the ongoing revision of 8134.3 for the various healthcare services aforementioned. The IPCN College has undertaken a search of international infection prevention and control standards that are similar in presentation and/or application to NZS 8134.3. What does this reveal?
As a conference delegate the IPCN College encourages you to interact with the poster presentation question and offer your thoughts on a selection summary of recognised infection prevention and control standards or similar from first world healthcare models. Please visit this poster.
Francie resides in Auckland and has been practicing as an Infection Prevention and Control Nurse Specialist for many years in various services within the healthcare sector. Her interests include the professional development of NZ IPC Nurses; leadership styles in IPC; the surgical interface with IPC best practice principles.
End of bed hand gel
Hand sanitising gel was not at the end of each inpatient bed in CCDHB, compromising hand hygiene. This quality initiative tackled the problem with a variety of helpful interventions. These included redesign of gel holding brackets, troubleshooting fixture of brackets, routine supply of brackets to wards, and designating staff to replace brackets . However, these ‘work around’ solutions were insufficient. Budget constraints stopped the core problem, gel holding brackets of poor design, being addressed. A health culture of ‘control cost – make do’ resulted in increased work and compromised patient safety. This quality initiative provided evidence that a better product was needed (which has since been implemented).
RN, Master Health Practice (Child Health)
Henrietta has worked as a Clinical Nurse Specialist in IPC for one and a half years. She manages the hand hygiene audit for Capital and Coast DHB. Before this she worked 20+ years as an RN in Child Health at CCDHB. She is passionate about alleviating poverty, and now of course, about people using hand sanitiser.
A dramatic increase in the rate of Central Line Associated Bacteraemia (CLAB) was identified on a surgical in-patient ward despite introduction of insertion/ maintenance forms and increased in education on central lines management. All CLAB’s routinely have a Root-cause analysis (RCA) conducted which highlighted the increasing complexity of patients and, that ward practice hadn’t adapted to meet their needs.
It was identified that the patients who developed CLAB’s had additional factors that increased their infection risk. Targeted teaching and competency assessments were completed and a high risk bundle developed. The Choosing wisely initiative also prompted a review by the surgical teams as to the necessity and appropriateness of lines in this unit.
While staff were aware of how to manage central lines there was no formal process in place to let them know what to do when a patient had multiple risk factors. Education around risk factors, what can be done to reduce these risks, and development of a guideline has resulted in a better outcome for these patients.
So far we have seen a significant reduction in the CLAB rates and the number of line days throughout the hospital. Staff awareness of the importance of line management has also increased and there has been on-going collaboration between interdisciplinary roles (IV/IPC/Surgical teams).
Sarah Thomas is a Clinical Nurse Specialist in Infection Prevention & control at Hutt Valley DHB. Her background is in Medical Nursing, working in a variety of roles in Scotland and New Zealand. Sarah has special interests in improving processes for Prevention of Central Line Infections and Aseptic Technique. Sarah is originally from Dunedin and lives in the Lower Hutt with her husband and two children and is a fabulous dressmaker in her spare time.