Supporting House-bound Clients to Prevent Health Care Acquired Infections in Their Own Homes Authors: Saw Lee Karen Gordon 0
"Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around." Leo F. Buscaglia 1
Contents Executive Summary Page 4 Background to the Project Page 5 Governance Support for the Project Page 6 Introduction Page 7 The Population of City and Hackney Page 9 Aims and Objectives Page 10 The Project Team Page 10 Project Approach Page 11 Designing the Questionnaire Page 14 Taking an EBD Approach Page 13 Findings Page 14 Questionnaire Page 14 Interviews Page 19 Discussion and Reflections Page 19 Key Recommendations Page 20 Conclusion Page 21 References Page 23 2
Project Title Supporting house-bound clients to prevent health care acquired infections (HCAI) in their own homes. Keywords Infection, leaflets, quality, house-bound, questionnaires, interviews Duration of Project November 2009 to March 2011 Contact Details S. Lee (Infection Control Nurse) City and Hackney CHS Quality Improvement Team Defoe Block 50 Hoxton Street London N1 6LP 0207-601-5061 Project Team Saw Lee (Project Lead) Karen Gordon Onyeulo Ascunsion Nicholas Okonkwo Deborah Skeete Esther Banda 3
Executive Summary This report represents the outcome of a project to explore measures to further support the service users within the geographical areas of City and Hackney in the management of infection control practices. In particular, this study focused on house-bound clients; whose environment, life-style and healthneeds often posed a welcomed challenge for nursing services. Media discussions have further stigmatized and enhance misconceptions on MRSA and more recently Clostridium difficile. Therefore undertaking this project would support current infection control and prevention measures within City and Hackney Community Health Services; with the added drive of putting the health needs of our patients first- hence this is the greatest benefit of this project. Managing healthcare acquired infections is integrally linked with providing high quality care for all ; as clinical effectiveness, the patients experience and patient safety are three key aspects of priority for City and Hackney Community health Services (CHS). In addition, the following report outlines areas where improvements will immediately strengthen infection prevention and control practices, maximise patient safety and the patients experience. Whilst some aspects of the recommendations may be challenging to implement nevertheless, they represent a best practice baseline for the long term management of health care associated infections for house-bound clients. 4
Background to the Project This project Supporting house-bound clients to prevent health care acquired infections (HCAI) in their own homes, commenced in November 2009, following a successful application for support and funding from the Foundation of Nursing Studies (FoNS). The sum of 5k was received to support the key deliverables identified for this project and created the resources and opportunity to build on previous work undertaken in City and Hackney. In 2008, a study was commissioned across City and Hackney which specifically explored current and best practice locally and nationally in the management of health care associated infections (HCAI). The aims of the study were to determine what measures could be implemented to manage existing episodes of HCAIs and to minimise the incidence of new infections specifically across the community. Overall, the findings showed that the area that care is delivered is important in the prevention of infections and that there still is the need to drive partnership working with all service providers across the health economy, taking a real joined-up approach to infection prevention and control. Therefore, building on the findings from the previous study, this project was designed to explore the area that care is delivered; which in this case was our clients home. The term Health Care Associated Infection (HCAI) encompasses any infection by any infectious agent acquired as a consequence of a person s treatment by the NHS or which is acquired by a health care worker in the course of their NHS duties. Methicillin resistant Staphylococcus Aureus (MRSA), Clostridium Difficile Infection (C.diff) and other HCAIs are a significant cause of harm in the NHS and can result in patient suffering, unnecessary pain, anxiety and possible 5
death. Many HCAIs are avoidable and everyone can contribute to reducing their burden. HCAIs also impact on the efficiency of health care services by increasing costs and reducing productivity. In total it is estimated HCAIs cost the NHS around 1billion per year (Annual Plan 2009/10). Governance Support for the Project Overall this project was managed within the Quality Improvement Team (QIT), which is a nurse led team that overviews quality improvement measures across City and Hackney Community Health Services (CHS). Strategically the team lead on aspects of quality improvement; namely patient safety, patient experience and clinical effectiveness. Additionally, the team ensures that key national initiatives are implemented on a local level, this includes areas such as Essence of Care, WHO Five Moments for Hand Hygiene / Cleanyourhands Campaign and more recently the High Impact Actions for Nursing and Midwifery. On a governance level; the team is managed by the Assistant Director for Older People s Service and also reports directly to the Deputy Chief Executive, who is also the Director of Nursing and Director for Infection Prevention and Control (DIPC). The robust governance arrangements ensure that infection control is given top priority. As an organisation, City and Hackney CHS is committed to minimising the risk and preventing the spread of micro-organisms among patients, staff and visitors in the community. A significant amount of work has already been undertaken with staff; however further work was required; especially from the patients perspective on knowledge of infection control. This view was further reinforced in the Control and Prevention Sub Committee meeting where compliance to the Health and Social Care Act (2008) was discussed and in particular the need to provide suitable accurate information on infection control/prevention to service users. The FoNS programme further supported the QIT in driving the management of infection control and prevention, as it created or provided clinicians with the 6
opportunity to explore their practice in a safe non-threatening environment, as well as ensuring that any developments in practice are underpinned with evidence based practice. Ultimately, this in turn would provide house-bound patients with up to date information on infection control and prevention and at the same time further create skilled clinicians who also full embraced the Quality Improvement agenda (patient safety, patient experience and clinical effectiveness). In addition to the support received from the management within CHS; the project team received valuable support from Jayne Wright (Practice Development Facilitator at FoNS). This was particularly important during milestones of the data collection and interpretation. The theory gained from undertaking the programme of learning with the Foundation of Nursing Studies (FoNS) was also of tremendous value as it provided the exposure to new concepts such as facilitation, negotiating and experience based design. Introduction In 2003, the Community Practitioners and Health Visitors Association (CPHVA) acknowledged the important role that district nurses play within the community; as it was recognised that they deliver most of the nursing care to clients in their own home. This was demonstrated through their role in addressing public health targets such as flu immunisations and in recent years the focus on supporting clients with long term conditions. The current drive to reduce the incidents of HCAIs and the introduction of the monitoring of community acquire infections has ensured that adult community nurses (district nurses) remain in the forefront of care delivery. Based on these concepts; this study aimed to further explore what community nurses could do to support house-bound clients to prevent an community HCAI. The commitment to drive infection control and prevention across the CHS remains high on the agenda. In addition to current infection control provision, 7
several initiatives such as the implementation of the National Cleanyourhands Campaign, the Hand Hygiene strategy and participation at local community events has kept infection prevention and control in the forefront. These signal the determination of the CHS to ensure that the patients journey through healthcare is a safe one. However, for house bound clients, the availability and access to readily available materials often can be a challenge as they would have to rely on someone bringing that information to them. In recent years, the media has highlighted poor infection control practices in acute care settings. This does not mean that the community and primary care settings are safe ; but in fact it highlights the challenge of providing effective clinical care where there are no restricted boundaries and where nurses are invited guests in client s homes. In every clinical setting there is a space where care is delivered to a patient directly or indirectly. Whilst this space in the community or primary care is not defined in the same structured way the equivalent ward bed is in the acute setting it can be named and therefore prescribed in a way that renders it compliant with best practice clinical standards and maximises patient safety. The complexity of the environment in the patient s home when delivering clinical care is not a reason for non-compliance with best practice clinical care; equally, the absence of best practice clinical care in the non-acute or domestic setting is not a reason for non-compliance with best practice clinical care. Notwithstanding everyone is at risk of HCAIs, some patients are at greater risk because they are deemed medically and/or clinically vulnerable. Whilst infection prevention and control should be standard practice for every patient there are some factors of care which predispose a patient to greater risk by virtue of that factor. For instance, catheters, lines, wounds, cannulation, all invasive procedures together with poor hygiene, contaminated environment, 8
previous hospitalisation, previous antibiotic therapy, belonging to an age group in excess of a particular age (currently 65+years) etc. The Population of City and Hackney City and Hackney is an inner city borough which lies in East London. It is highly diverse and is characterised by stark variations in levels of deprivation, significant health inequalities and a rich mix of cultures, ethnic backgrounds and languages. The unique demographic profile of the population served has a significant impact on the style, scope, location and range of health services required by the resident population. The size of the resident population is dependent upon which data sources are used. According to the Office for National Statistics (ONS), there are around 208,700 people living in the borough of Hackney and 7,400 people in the City, which gives a total of 216,100 in the City and Hackney area. There are significant contrasts in the demographic characteristics of City and Hackney PCT. All of the wards in Hackney are in the top 10% most deprived wards nationally. It is the second most deprived borough in the country and the third most densely populated borough. Over half the children in Hackney are in families receiving means tested benefits (the rate for London is 34% and nationally 22%). Life expectancy at birth of males in Hackney is 75 years which compares to the London average of almost 78 years. In contrast in the City of London borough, the Barbican wards, are among the top 15% least deprived wards in England. Hackney borough is very ethnically diverse with 47% of residents identifying as white British, 11% describe their ethnic origin as Black African, 9% Black Caribbean, and 9% as south Asian. Within those that describe themselves as white other there are significant layers of complexity. The size of the Cheradi (Orthodox Jewish) community is estimated to be 15,400 which is 7% of the population of Hackney. There are also Turkish and Kurdish populations and there has been a recent increase in people from Eastern Europe, especially 9
Poland. Hackney has one of the largest refugee and asylum seeker populations in London estimated as between 16,000 and 20,000.The City is less diverse though even here 31% of the population do not identify as White British and 8% describe their ethnic origin as south Asian. The population of Hackney is expected to increase by about 3-4% every five years, reaching 248,090 in 2026 (Source: GLA). The biggest growth is expected to be in the older age groups: 40-59 years up 30% and 60-79 up 31% by 2026. Aims and Objectives The main aim of this project was to explore what further support Community Nurses could give to support house bound clients to prevent a community acquired healthcare infection. Objectives The objectives were to: Investigate the views of house-bound clients with regards to acquiring an HCAI, with the aims of exploring ways to increase client satisfaction Identify measures to reduce the incidence of HCAIs within housebound clients in order to reduce and control the incidences Devise and implement management systems and procedures for infection prevention and control for house-bound clients Work closely with the adult nursing teams to support house-bound clients to raise their confidence in the infection control service Produce client information on managing infection control in the community to raise knowledge and support practice Deliver high quality care in infection control practice The Project Team It was decided that the skills and knowledge that the Infection Control Link Practitioners have would be an asset for this project; therefore volunteers 10
were recruited from the Link Practitioners to join the project team. In total, four practitioners were chosen in addition to the Project Lead. It was also recognised that involving staff and other key stakeholders was an important aspect of ensuring that the aims and objectives of the project were successfully met. Therefore at the outset, the team strategically decided what the best approach would be, as well as clear guidance of what needed to be achieved. In addition, a meeting was set up to meet with the four Link Practitioners to discuss roles and responsibilities and to create a forum for every team member to understand what she/he was being asked to do, goals that needed to be achieved and the timescales for the project. Project Approach It was agreed that a multi-facet method of data collection would be ideal to meet the aims and objectives of the project. This included the use of questionnaires and interviews using the Experience Based Design (EBD) approach (NHS Institute for Innovation and Improvement, 2009). Designing the Questionnaires Survey was the method of choice for this project because it provided a relatively simple and straightforward approach. A questionnaire was specifically designed to suit the project aims and the nature of its respondents. At the outset it appeared really easy to design a questionnaire, but after several attempts it was recognised that it is fairly hard to produce a good questionnaire as it was imperative that the questions asked created the opportunity to get the required information as well as being simple for the clients who may not be well enough to answer the questions. Furthermore, it was important that the questionnaire did not hinder the analysis and interpretation stage. Aspects considered included: 11
Were the clients able to read and understand the questions? What type of questions would be used? What design would be used? How would the questionnaire be distributed and collected? What would the appearance and layout be? Would we need to pilot the questionnaire first? What would the target number for our responses be? Once the above factors were considered the team summarised and concluded that the following points were critical to produce a well designed questionnaire: It has to be user friendly - clear and unambiguous and uniformly workable It must be easy for respondents to understand and to answer accurately and clearly The vocabulary used must be comprehensible to all respondents It must be easy to complete, not more than 10 questions - most of the clients are elderly and lack manual dexterity Another component of using questionnaires that the team had to take into consideration was the factors that influence response rates, for example the use of covering letters and use of incentives (Hoinville et al., 1989). The team decided that a covering letter from the team leader to explain the reason for the project may help to increase response rate and that a small gift would be given to each respondent as a thank you as a small incentive. Once the team had satisfactorily answered the questions above, it was felt that data collection through interviews (using the Experience Based Design approach) would also be needed as this would allow the qualitative data which would capture feelings and experiences to be explored. 12
Taking an Experience Based Design (EBD) approach As this project centred on the experiences of the clients, it was decided that the EBD approach would be adopted; as this approach captures the experiences of clients and identifies ways to improve them (NHS Institute for Innovation and Improvement, 2009). A subsequent meeting was held to clarify what supplementary information underpinned the project, such as Values and Beliefs and how the EBD approach could be maximised. The meeting generated a lot of discussions and the opportunity to share and learn a lot from one another. It also created the opportunity to talk and listen to one another and to reflect on clinical practices. From this debate the key themes which were identified included: Patient safety Patient satisfaction Quality of patient care Value for money Patient and staff education It was a consensus decision to involve the vulnerable housebound clients in this project. This was to find out what information was important to this group of service users on infection prevention and control and responds to those needs. Involving patients in decision making about their care is important as it is recognised and fair that only patients can judge what quality care is. Focussing on the client s wants and needs ensures that healthcare services address their needs rather than what professionals perceive their needs to be. Moreover, it enables teams to focus on the rights, interests and experiences of clients; allowing them to make it a positive experience. Care delivery would be ineffective unless it is acceptable to clients. 13
In addition, this approach enabled the team to understand the experiences of healthcare from patients and staff perspective and to make meaningful and lasting improvement (NHS Institute for Innovation and Improvement, 2009). Findings In total seventy (70) questionnaires were distributed by the Link Practitioners to the housebound clients and forty-seven (47) were returned. Following further discussion with the overall Project Support Facilitator and the project team, it was decided to collect more data by undertaking interviews with eight clients to clarify the answers that we had received back. Though this method of data collection can be time intensive, the richness of data/information received back made it worth the effort. Questionnaire The results from the 47 questionnaires that were returned were analysed and the findings were as follows: 1. 50% of the respondents understand what infection control is. 14
2. 63% wanted more information about infection control. 3. The majority of the respondents get their information from the nurses (48%), GPs (19%), carers (8.5%) and the rest from the media. 15
4. 89% of the respondents were aware of the nurses washing their hands before and after attending to them. 5. 68% were comfortable to ask the nurses to wash their hands. 16
6. (68%) would like to have more information on the signs and symptoms of infection and equal proportion would like to have more information on MRSA, C. diff, diarrhoea and vomiting and disposable of healthcare waste. 7. 57% would like a visit from health professional to discuss infection control. 17
Points for Consideration: 1. 50% of the respondent understands what infection control is. Whilst 50% of clients understood what infection control is; this highlighted that 50% of clients did not. This reinforces the need to improve the awareness of infection control in the community. 2. 63% wanted more information about infection control. 63% wanted more information on infection control; this supports the previous statement above that more work needs to be done to improve education for house bound clients. 3. The majority of the respondents got their information on infection control from the nurses (48%), GPs (19%), carers (8.5%) and the rest from the media. The response to this question also confirmed previous concepts that nurses do play a role in educating clients. This also shows that it is vital that nurses have the correct information to share and are kept up to date with evidence based practices. 4. 89% of the respondents were aware of the nurses washing their hands before and after attending to them. This was encouraging as it showed that improvements have been made with hand hygiene practices; however the goal would be to have 100% awareness. 5. 68% were comfortable to ask the nurses to wash their hands. This was also encouraging as work has previously been undertaken across CHS to empower clients to ask professionals to wash their hands. 18
6. 68% would like to have more information on the signs and symptoms of infection and equal proportion like to have more information on MRSA, C. Diff, diarrhoea and vomiting and disposable of healthcare waste. This is an area which will be addressed immediately. CHS has produced several leaflets and a booklet on infection control for community patients. 7. 57% would like a visit from health professional to discuss infection control. The team had expected that more clients would have wanted a visit from a health care professional; however this was followed-up through the interviews using the EBD approach. Interviews The interviews supported that the clients had some knowledge of infection control particularly the signs and symptoms of flu. This needs to be explored further particularly in management of catheter and wound care which represented the majority of their cases. Though some patients knew about MRSA, but had little understanding of what it is. It may better to use a word that relate to them e.g. superbugs. The same applied to C.diff. There is great variation in the knowledge about the spread of infection but most of them know that hand hygiene is crucial to prevent infection and about the use of alcohol gel. Discussion and Reflections This project highlighted two main areas; firstly the importance of ensuring that house bound clients are given the tools to prevent a community health care acquired infection; and secondly, that all professionals who visit house-bound clients equally have the tools to support clients to prevent the infection. 19
The challenge of managing HCAIs is integrally linked with providing high quality care for all ; as clinical effectiveness, the patients experience and patient safety are three key aspects of priority for City and Hackney Community Health Services (CHS). In addition, the following report outlines areas where improvements will immediately strengthen infection prevention and control practices, maximise patient safety and the patients experience. The group as a whole has gained a lot of confidence in their practice as a result of this project. They felt that they are not Link Practitioners in name but also in practice and as a result, they are taking more interest in infection control. They are participating in most of the team meetings and giving talks in different aspects of infection prevention and control. The growing confidence in their practice enables them to challenge their colleagues with poor practice. Inadvertently, they have raised their profile and as a consequence their colleagues are seeking advice from them. As a result of this project, the Link Practitioners also had improved the overall attendance rate for staff undertaking infection control training. Consequently the Link Practitioners have become very good role model. As a whole, this had been a steep learning curve for all the project team but a very positive one. Recommendations This report makes the following recommendations: 1. Instrumental to ensuring all aspects of infection prevention and control are managed professionally is the close working relationship between key professionals. his must remain a priority especially between acute, community and primary care. 20
2. Effective hand-washing and hand-washing audits to be firmly undertaken across the community. 3. All clinical staff to ensure that they are kept informed of new initiatives within infection control and attend their mandatory annual infection control training. 4. Practice when and wherever appropriate will be in accordance with the High Impact Interventions care bundles for high risk interventions; particularly urinary catheters and surgical wound care as outlined by the Department of Health. 5. Embedding of Key Performance Indicators for the community as detailed below. Key Performance indicators: The reduction and control of HCAIs depends on a number of key interventions being used consistently at all times. For MRSA these are as follows: 1. 100% of appropriate patients decolonised and screened. 2. 100% pass rate for hand-hygiene audits undertaken with clinical staff. For C.diff the key interventions are as follows: 1. 100% pass rate for hand-hygiene audits undertaken with clinical staff. 2. 100% of infected patients who are symptomatic would be isolated (community approach) Conclusion In 2008/9 a previous project was commissioned which explored the management of HCIAs in the community. One of the findings and recommendations from that study was that further work was needed to support clinicians in the care delivered to house-bound patients in the management, education and prevention of infection in the community. Therefore from the outset the view was adopted that this project would build 21
on previous findings and recommendations to improve quality for service users in terms of patient safety and the patients experience. Overall, this project addressed the aims and objectives that it set out to meet; however, it also has demonstrated that there is still a considerable amount of work that needs to be done to support the staff and patients to keep infection prevention and control as a top priority. It is firmly recognised that patients are being discharged home earlier from hospital, as the management of long term conditions moves from acute to community care; this is influenced by patient choice as many patients choose to be cared for at home. However, the unpredictable domiciliary environment increases the scope for cross infection as hand washing still remains the single most important means of preventing cross infection and hence the critical need to provide evidence based education. It is acknowledged that education is key to ensuring compliance with infection control interventions and as a measure of the serious stance that infection control training remains mandatory for all staff. The adherence to national and local policies, procedures and standards require ownership and involvement of clinical and non-clinical staff across City and Hackney. This therefore will ensure that valuable tools are utilised in the prevention and control of HCAIs and ultimately they become embedded into everyday practice and are applied consistently by all staff whatever their role. Improving the quality of care, in terms of safety, effectiveness and patient experience is a central motivation for everyone working in the NHS. Over the past decade there has been impressive progress made in improving the quality of services delivered across CHS. However, undertaking this project has reinforced the need to ensure that patient safety through infection control continues to be driven at the fore front to deliver an effective and positive patient experience. 22
"When you listen, it's amazing what you can learn. When you act on what you've learned, it's amazing what you can change." Audrey McLaughlin References City and Hackney Primary Care Trust (2008) Commissioning Strategy 2008/09 2012/13. London: City and Hackney Primary Care Trust. Department of Health (2002) Getting Ahead of the Curve: A Strategy for Combating Infectious Diseases (including other aspect of health protection). A report by the Chief Medical Officer. London: Department of Health. Department of Health (2003) Winning Ways: Working Together to Reduce Healthcare Associated Infection in England. Report from the Chief Medical Officer. London: Department of Health. Department of Health (2004) Towards Cleaner Hospitals and Lower Rates of Infection: A Summary of Action. London: Department of Health. Department of Health (2006) Infection Control Guidance for Care Homes. London: Department of Health. Department of Health (2007) Essential Steps to Safe, Clean Care: Reducing Healthcare Associated Infections. London: Department of Health. Department of Health (2007) Saving Lives: Reducing Infection, Delivering Clean and Safe Care. London: Department of Health. Department of Health (2008) Clean, Safe Care: Reducing Infections and Saving Lives. London: Department of Health. Department of Health (2008) The NHS in England: The Operating Framework for 2009/10. London: Department of Health. Department of Health (2009) The Health and Social Care Act 2008. London: Department of Health. Health Protection Agency (2006) Mandatory Surveillance of Healthcare Associated Infections Report. London: Health Protection Agency. Hoinville, G. et al. (1989) Survey Research Practice. Aldershot: Gower Publishing Company. 23
National Audit Office (2004) Improving Patient Care by Reducing the Risk of Hospital Acquired Infection. London: National Audit Office. NHS Institute for Innovation and Improvement (2009) The EBD Approach: Using Patient and Staff Experiences to Design Better Healthcare Services. Coventry: NHS Institute for Innovation and Improvement. Prevention of Healthcare Associated Infection in Primary and Community Care understanding NICE Guidance. This project was supported as part of the FoNS Developing and Sustaining a Practice-based Strategy for Reducing Healthcare Associated Infections Programme in partnership with NHS London. 24