Rethinking the use of audit to drive improvement

Editorial on the use of audit in healthcare setting

Root cause analysis for Clostridium difficile infections: is it time for change?

Editoria

A model for large-scale volcanic plumes on Io: Implications for eruption rates and interactions between magmas and near-surface volatiles.

Volcanic plumes deposit magmatic pyroclasts and SO2 frost on the surface of Io. We model the plume activity detected by Galileo at the Pillan and Pele sites from 1996 to 1997 assuming that magmatic eruptions incorporate liquid SO2 from near-surface aquifers intersecting the conduit system and that the SO2 eventually forms a solid condensate on the ground. The temperature and pressure at which deposition of solid SO2 commences in the Ionian environment and the radial distance from the volcanic vent at which this process appears to occur on the surface are used together with observed vertical heights of plumes to constrain eruption conditions. The temperature, pressure, and density of the gas–magma mixtures are related to distance from the vent using continuity and conservation of energy. Similar eruption mass fluxes of order 5x10^7 kg s^1 are found for both the Pillan and the Pele plumes. The Pele plume requires a larger amount of incorporated SO2 (29–34 mass %) than the Pillan plume (up to 6 mass%). Implied vent diameters range from c. 90m at Pillan to c. 500 m at Pele. The radial extents of the optically dense, isothermal, incandescent parts of the eruption plumes immediately above the vents are 100 m at Pillan and 1300 m at Pele. Gas pressures in the vents are 20 kPa at Pillan and 2 kPa at Pele and the eruption conditions appear to be supersonic in both cases, though only just so at Pele

The design and application of surveillance systems in improving health outcomes and identifying risk factors for healthcare associated infections

The risks of patients acquiring an infection as a result of healthcare are considerable, with between 6.4% and 9.1% of patients in hospital found to have an healthcare associated infection (HCAI). These infections account for a considerable burden of disease; they are associated with significant morbidity and mortality, and incur costs to the patient, healthcare organisations and society. There is considerable evidence for measures that are effective in preventing HCAI, however there are challenges in ensuring that healthcare workers are aware of the risks and adhere to recommended practice. Surveillance systems that systematically capture, analyse and feedback data on rates of HCAI have been found to be a key component of effective infection control strategies, especially when they incorporate benchmarking. The large datasets captured by national surveillance systems also provide a unique opportunity to explore the epidemiology of HCAI, factors that contribute to their occurrence and their impact on public health. This thesis concerns the design and application of surveillance systems for infections associated with healthcare. It reflects the programme of research originating from my involvement with the development and delivery of national HCAI surveillance systems in England from the mid-1990s. This research has addressed my underpinning hypothesis that: 'there are real differences in rates of HCAI which reflect variation in clinical practice and indicate where improvement may prevent these infections'. The thesis includes eight primary publications focused on two key types of HCAI, surgical site infections (SSI) and bloodstream infections (BSI). The publications related to SSI describe my work on: the risks of SSI in terms of mortality and increased length of hospital stay; significant independent risk factors for SSI following hip prosthesis; the relationship between duration of operations and risk of SSI; inter-country comparisons of rates; an innovative approach to performance monitoring based on funnel plots; and the impact of psot-discharge surveillance on benchmarking. They are based on the analysis of data contributed to the national SSI surveillance system. A further two publications related to BSI explored trends in causative pathogens and source of methicillin resistant Staphylococcus aureus. The thesis describes the main methods and findings of these studies, their contribution to contemporary knowledge and subsequent contributions to the field, ilustrating my contribution to each of the works and my professional development as a researcher. The body of work has identified important trends in pathogens causing BSI, in particular the emergence of Escherichia coli as a major cause of these infections, and provided evidence of possible contributory factors. It has also identified factors contributing to the reduction of methicillin resistant Staphylococcus aureus as a cause of BSI. It has added to the body of knowledge on outcomes of SSI, demonstrating that SSI doubles the length of hospital stay and the more severe infections significantly increases the risk of mortality in some types of surgery. It has informed the design and delivery of SSI surveillance systems in England and Europe through identifying the impact of key risk factors, such as the duration of operation and type of hip replacement procedure, and exploring the impact of variation in application of surveillance methods, in particualr post-discharge surveillance, on rates of SSI. It has enhanced the value of surveillance as a performance monitoring through the application of innovative approaches to adjusting and comparing rates, such as the use of funnel plots for the detection of outliers. In conclusion, these analyses of data on HCAI have informed the development of national surveillance systems, improved understanding of variation in rates, and identified factors that may influence them. Further work is required to enhance and develop surveillance systems in order that they can continue to support the evaluation of effective infection prevention strategies in a rapidly changing healthcare environment

The OneTogether collaborative approach to reduce the risk of surgical site infection: identifying the challenges to assuring best practice

Background: Surgical site infections (SSI) account for 16% of healthcare associated infections, and are associated with considerable morbidity, mortality and increased costs of care. Ensuring evidence-based practice to prevent SSI is incorporated across the patient’s surgical journey is complex. OneTogether is a quality improvement collaborative of infection prevention and operating department specialists, formed to support the spread and adoption of best practice to prevent SSI. This paper describes the findings of an expert workshop on infection prevention in operating departments. Methods: A total of 84 delegates from 75 hospitals attended the workshop, comprising 46 (55%) theatre nurses/operating department practitioners; 16 (19%) infection control practitioners and 22 (26%) other healthcare practitioners. Discussion focused on evidence, policy implementation and barriers to best practice. Responses were synthesised into a narrative review. Results: Delegates reported significant problems in translating evidence-based guidance into everyday practice, lack of local polices and poor compliance. Major barriers were lack of leadership, poorly defined responsibilities, and lack of knowledge/training. Conclusions: This workshop has provided important insights into major challenges in assuring compliance with best practice in relation to the prevention of SSI. The OneTogether partnership aims to support healthcare practitioners to improve the outcomes of patients undergoing surgery by reducing the risk of SSI

Applying human factors ergonomics to the misuse of non-sterile clinical gloves in acute care

Background: Healthcare workers (HCW) are recommended to wear non-sterile clinical gloves (NSCG) for direct contact with blood and body fluids to reduce transmission of healthcare associated infections (HCAI). However, there is evidence that inappropriate NSCG-use increases the risk of transmission. Methods: A mixed methods study comprising observation of NSCG-use during episodes of care in two acute hospitals and semi-structured interviews with HCW. Qualitative data were categorised using thematic analysis. Findings were mapped to the Systems Engineering Initiative for Patient Safety (SEIPS) model and used to develop a strategy for improving NSCG-use. Results: 278 procedures performed in 178 episodes of care involved the use of NSCG. NSCG were inappropriate for 59% (165/278) procedures; risk of cross-contamination occurred in 49% (87/178) episodes. 26 HCW were interviewed; emotion and socialisation were key factors influencing decisions to use NSCG. Data from observation and thematic analysis were mapped to six interacting components of the SEIPS work-system. Interventions targeting each component were identified to inform quality improvement strategies Conclusions: Despite more than a decade of intense promotion of hand hygiene as the key measure to protect patients from HCAI, NSCG dominate routine clinical practice and potential cross-contamination occurs in half of care episodes where they are used. Such practice is associated with significant environmental and financial costs and adversely affects patient safety. The application of HFE to the complex social, professional and emotional drivers of inappropriate NSCG behaviour may be more effective than conventional approaches of education and policy in achieving the goal of preventing HAI and improving patient safety

A prevalence survey of patients with indwelling urinary catheters on district nursing caseloads in the United Kingdom: the community urinary catheter management (CCaMa) study

Background: Catheter-associated urinary tract infection (CAUTI) is common in both hospitals and the community. Aim: To investigate the prevalence of indwelling urinary catheters on district nursing caseloads in the United Kingdom (UK). Method: Participants were recruited through the Infection Prevention Society (IPS). An electronic survey was undertaken on a single day between November 2017 and January 2018. Data were analysed using descriptive statistics. Findings: 49,575 patients were included in the survey of whom 5352 had an indwelling urinary catheter. This gave a point prevalence of 10.8% [95%CI 10.53-11.07], which varied between organisations, ranging from 2.36% [95% CI 2.05-2.73] to 22.02% [95% CI 20.12-24.05]. 5% of catheters were newly-placed (within four weeks). Of these, most (77%) had a documented indication for insertion. Only half of patients with a newly-placed catheter had a plan for its removal. This varied between organisations from 20% to 96%. Only 13% of patients had a patient held management plan or ‘catheter passport’ but these patients were significantly more likely to also have an active removal plan (28/36, 78% vs 106/231, 46%, p< 0.0001). Alternative bladder management strategies had been considered for 70/267 (26%) patients. Discussion: The management of patients with an indwelling urinary catheter represents a significant component of district nursing caseloads. Given the high proportion of newly-catheterised patients without an active management plan for removal of the catheter, the establishment of an optimal management pathway should be the focus of future prevention efforts

Encouraging practitioners in infection prevention and control to publish: a cross-sectional survey

Aim: The aim of this cross-sectional survey was to determine the views of infection prevention and control practitioners (IPCPs) on publishing research. Methods: A convenience sample was obtained by approaching delegates at the 2015 Infection Prevention Society conference and data was captured via a hand-held electronic device. Findings: Of the 79 respondents most (83%) read Journal of Infection Prevention (JIP) and found it useful for informing their practice (72%). However, most (91%) had never published in JIP, and less than half (40%) published elsewhere. The main barrier to publication was not having work suitable for publication (38%). Support (37%), training in writing for publication (10%) and time (9%) were considered to be important facilitators in encouraging respondents to publish. Discussion: Strategies that support IPCPs in developing their writing skills may encourage more IPCPs to disseminate evidence to support best practice by publishing their work in peer reviewed journals

O003: the misuse of clinical gloves: risk of cross-infection and factors influencing the decision of healthcare workers to wear gloves

Clinical gloves are routinely used in the delivery of patient care but unless integrated with the ‘5 moments of hand hygiene’ have the potential to increase the risk of HCAI transmission