The past two decades have been tumultuous for all those involved in the delivery of Infection Prevention & Control (IP&C) services.
IP&C pre-pandemic was challenging, preventing cross-transmission of C.difficile, Norovirus, MRSA, Flu, and Gram-negative infections to name but a few. Add in surveillance, education, audit and high level reports and it is clear that these valuable IP&C teams were already under significant pressure. All of this of course was set (and still is) against a backdrop of major bed capacity issues.
COVID-19 entered our lives and presented the biggest challenge for IP&C teams worldwide. Yet, pre-COVID challenges remain – C.difficile, MRSA, E. coli still continue to harm patients and now there’s a need to refocus on the preventative work IP&C teams were involved in before COVID-19.
The start of the millennium saw damning media headlines about the rise of MRSA, dirty hospitals and dilapidated patient equipment. Executive teams in Trusts/Health Boards across the UK resigned when confronted with the sheer volume of hospital acquired C.difficile. Managing Swine flu and preparing for an Ebola event added further pressure with COVID-19 adding icing on an unwelcome cake!
Investment in IP&C teams during this time of political and public concern was welcome and the UK was finally in a position to develop strong IP&C leaders with sound leadership and influencing skills. Unfortunately, as nosocomial infection reduced, anecdotal evidence suggests that human resources were diverted away from infection control services.
Nevertheless, the Pandemic has refocused minds on IP&C services – not only because of the large numbers of patients acquiring COVID-19 in hospital but also because of the large numbers of tragic deaths in care homes. Many IP&C leaders are now in the unenviable position of spinning IP&C plates in hospitals, care homes and wider community services such as social care and GP surgeries.
But what does a good IP&C service across all sectors look like? Clearly it is a service which needs leadership and influence with leaders who are able to strategically assess the service, design a fit for purpose strategy and provide evidence that the strategy is working at operational level.
This article describes some of the key strategic components senior leaders need to consider when heading up an IP&C service. It also provides an opportunity to assess your service and to establish whether IP&C is fully embedded across your organisation with executive teams, divisions, directorates and clinical boards taking full responsibility for their infection control standards.
It is well known that the fundamental role of an IP&C service includes surveillance, audit and education. But it is truly astonishing how these fundamental roles have expanded over the past two decades with key initiatives such as Aseptic Non-Touch Technique (ANTT), Surgical Site Infection and bundles – all adding pressure to under resourced teams.
It will come as no surprise that an adequately resourced team is an essential component of an IP&C service. How confident are you that you have an adequately resourced team in terms of staff (including skilled admin staff) and IT resources?
Functional IT equipment, both hard and soft, is a crucial component. Software specifically designed for IP&C can rapidly identify nosocomial infection and prevent subsequent outbreaks. If outbreaks are evident the sophisticated software can often establish the source. This can be hugely helpful in terms of learning, thereby preventing similar outbreaks.
Presenting a business case for more IP&C staff is trickier, because of the revenue implications. It is complicated further by other valuable NHS services vying for finite resources. This means that senior leaders have to present succinct business cases which include a complex cost benefit analysis. Completing business cases is a skill which is not readily taught in any nurse training, yet senior IP&C leaders are expected to embrace it and are often deflated when their case fails. The case is often put on the “too hard to do” pile.
So, what can be done? A tried and tested tactic is to seek out a successful business case – even one that is not associated with IP&C. Consider, what is it about this case that makes it special? Can you apply some of the generic wording to strengthen your own case? What does the cost benefit analysis look like? Does it discuss lost bed days? If so, who in the organisation can support you in pulling similar data together? Do you have access to the latest evidence on IP&C staffing? The Journal of Hospital Infection is a fabulous resource for such information.
It is well documented that Board to Ward (and beyond) engagement and ownership is a crucial element of any infection control strategy. Healthcare Associated Infection (HCAI) harms patients and every healthcare organisation has an absolute responsibility to minimise cross infection risk. But what does ownership look like? It is certainly not the sole responsibility of the IP&C team!
About ten years ago rates of C.difficile were extremely high in my organisation and a similar picture was emerging in many hospitals across the UK. My response? Work harder and empower the IP&C team to work harder. Despite the introduction of cleaning schedules, revamped antibiotic policies, hand hygiene audits, education and campaigns, very little progress was made in reducing rates.
In seeking to understand which IP&C teams were successfully reducing their C.difficile rates, I asked Inivos with a sense of weariness for help. Inivos introduced me to the team at Royal Wolverhampton where they had been working with the Trust to implement a successful ward HPV deep clean programme.
Their C.difficile rates were exceptionally good and I looked on in envy at the cohesive work between IP&C, the Facility Team and nursing staff. But the icing on the cake was the IP&C Committee. I was fortunate that the IP&C Committee (chaired by the Medical Director) was meeting on the day of my visit and I attended with interest. I was utterly astonished at the level of attendance and ownership across all divisions.
The Committee was attended by Matrons & Consultants who were expected to present their HCAI numbers including C.difficile, MRSA/MSSA bacteraemia and outcome of Root Cause Analysis meetings. Outbreaks were discussed with particular detail around the potential source alongside results of subsequent hand hygiene and cleanliness audits and (most importantly) a plan of action to address any deficits which would include HPV cleans and increased hand hygiene audits. This process was conducted by all disciplines of staff with clear and regular feedback of results.
Seeing this example of ownership was a light bulb moment and I returned to my own organisation full of enthusiasm and passion to transfer the weight of ownership from a weary IP&C team to those who delivered care. I was fortunate that an external review from an eminent professor agreed with my findings, resulting in the formation of a multidisciplinary C.difficile Champions Group chaired by the Executive Nurse Director. This, alongside a comprehensive deep clean and ward upgrade programme resulted in a significant reduction of cases.
Once C.difficile was under control the Champions Group morphed into a functional IP&C Committee chaired jointly by the Executive Nurse and Medical Directors with a clear expectation that Divisions would continue to own the IP&C agenda.
Maintaining a functional IP&C Committee is a challenge in itself, particularly when the NHS is under severe pressure. But allowing IP&C standards to slip will result in further pressure in the system with patient harm, extended length of stay and bed closures.
How comfortable are you that your Trust/Health Board fully owns the IP&C agenda? Do you have a clear Board agreed IP&C Strategy which translates to sound IP&C practice at operational level?
This downloadable checklist of questions can help you make an assessment to establish whether IP&C is truly embedded across your organisation.
The ability to influence executive teams is another crucial skill, it is an art underpinned by science. It is vital that we understand their drivers, concerns, and challenges, including their external pressures. Once you understand their diverse pressures you are in a good position to frame your argument so they will “hear” your IP&C voice.
Use every opportunity to build your relationship with the executive team before you have an IP&C problem – it really is priority number one. This can be done by attending exec/senior leader meetings as an active participant with a ‘can do’ attitude (this is so important even when you are tired and weary). Looking at the agenda in advance and planning your input will enable you to use the meeting wisely to air your most risky and pressing IP&C issues.
Think carefully about how you frame your arguments and use evidence (consisting of data and photographs), as this is important to make sure your input is clear and concise. For example, pictures of contaminated mattress, will quickly underline the need for new ones! Numbers and rates of infection (particularly those which have associated Government targets) will also engage senior leaders as this provides the evidence that a problem exists.
Audit data can also provide the evidence as to why a problem exists – but be very clear that divisional leaders are expected to resolve their IP&C issues with support from the IP&C team. That said, try to engender a culture of “we are all in this together” whilst underlining the support the IP&C team will give to resolve their particular IP&C problem.
One particular scenario involving executives is of particular stress to IP&C leaders.
This executive scenario is often found in a bed capacity problem, the IP&C team want to close a ward but bed management are insisting that it’s impossible. You may find that even supportive executives have reopened closed beds overnight, at odds with IP&C advice.
It is easy to feel deflated and worried, but this is an ideal opportunity to put yourself in executive shoes. Making decisions about beds at 3AM is difficult and complex with ED’s and Assessment Units often citing serious patient safety issues and ambulances backing up outside. It is understandable that closed beds are reopened at times of great pressure even though an outbreak has not yet resolved and/or a deep clean has not been completed.
A good tip is to contact the on call executive before you leave work for the evening. A short concise email explaining the current situation on the outbreak ward/s and outlining the risk of opening early, aids executive decision making at 3AM.
If the outbreak is new or in full swing, it is wise to advise complete closure. But if the outbreak is nearing an end, consider if you in a position to reopen closed beds with separate staff. Can you cohort affected patients/staff at one end of the ward and reopen cleaned bays with separate staff?
Clearly, the pathogen involved needs to be taken into account when undertaking this assessment.
If, following a conversation with the Lead Infection Control Doctor, you are reasonably comfortable with opening the ward, be clear to the executive that the beds should be used as an absolute last resort.
Another tip is to calculate the risk score using the well known Health & Safety Risk Assessment tool and add it to your executive email. The email will help the executive to make an informed risk assessed decision before reopening a closed ward. The email has the added advantage of an audit trail (important for your professional accountability).
On occasion you will find beds reopened even when you have strongly advised that they remain closed. In this scenario an IP&C leader will need executive support to re-close the ward as soon as possible until the team are confident that the outbreak has been resolved.
Strategy vs. Operations
You may have spent many hours ensuring that the IP&C strategy is fit for purpose, but how confident are you that it translates to sound practice on the front line with a culture that embraces IP&C?
Whilst you may be able to say that “audit results and education compliance is fed back at the IP&C Committee”, is this enough to gain assurance that IP&C is embedded in your organisation?
Leadership walkabouts can give you and the executive team (invite them along!) the assurance that audit results truly reflect frontline IP&C. You can see for yourself whether a ward is truly clean and whether hand hygiene is optimal, but always being mindful of the Hawthorn effect. Extend the Leadership walkabout to other leaders such as facility teams & divisional leaders and they can see for themselves how well IP&C is embedded in their service. This will also give frontline workers the opportunity to relate barriers and challenges when implementing fundamental IP&C interventions. A senior IP&C practitioner can support a ward sister who is frustrated and concerned at the standard of cleanliness on the ward and ensure their concerns are escalated to a higher level if required.
Whilst the role of a senior IP&C leader is challenging and sometimes frustrating, it can be rewarding too. This article is designed to give some hints and tips to IP&C leaders, whose work can be described as an art underpinned by science. It is important to remember that the soft skills, influence, persuasion, tenacity and the ability to empathise with senior leaders is just as important as your microbiology knowledge.
But you are not alone, Inivos is able to support you in this highly pressured NHS world by introducing you to Trusts/Health Boards that do things well or preparing business cases for those all-important executive meetings. Just ask!
With huge thanks to Tracey Cooper for her insights on executive influence and leadership.
Liz Waters MBE RN Independent Consultant Nurse IP&C