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How a hospital cut its infection rate by old-fashioned principles of cleanliness

Using dedicated cleaning teams under the control of head nurses, coupled with senior managers making infection control a priority for absolutely all staff, has led a provincial hospital to achieve low rates of healthcare-acquired infection

Sue Jones
Director of nursing and infection
prevention and control
Yeovil District Hospital NHS
Foundation Trust,
Somerset, UK

England has the most sophisticated system in the world for monitoring infection rates in hospitals and has seen a reduction
of 70% in the rates of MRSA and 30% in Clostridium difficile (C. diff.). Yeovil District Hospital NHS Foundation Trust in Somerset is best in its class for low rates of healthcare-acquired infections
(HCAIs). It also scored highly in the biggest survey of patients staying overnight in English NHS hospitals emerging as the best in the southwest of England in a number of areas including
cleanliness. The results, published by the former Healthcare Commission (now the Care Quality Commission), revealed that 97% of Yeovil’s patients are happy with the cleanliness of the
wards compared to a national average of 93%. The highest standards of patient safety and infection control are top priorities for everyone at Yeovil District Hospital (YDH) and we have introduced a whole range of measures to protect our patients from infection. There is an increasingly explicit expectation that patients will receive reliable high-quality safe care. We have a highly professional infection control team including a specialist doctor, consultant microbiologists, a nurse consultant, specialist nurses and an antibiotic specialist pharmacist. They provide an extensive advice service for
staff to help them prevent and manage infection in a number of ways. The team carries out regular ward rounds and is on hand to advise on decontamination of equipment and environmental cleaning, best practice in the prevention of infection and the
management of individual patients, clusters and suspected outbreaks of infection. They conduct regular audits and surveillance to ensure staff comply with healthcare standards
and they produce guidelines and training for all staff on the prevention and management of infection. They have run a road-show visiting wards and departments across the hospital to raise the profile of C. diff. and promote the techniques used to combat it. They also discuss the importance of taking measures to prevent C. diff. with patients and visitors.
Our infection control specialists are also involved in research to improve clinical practice and they liaise with staff involved in purchasing and planning, including building and refurbishment
work, to ensure infection control issues are considered and standards maintained at all times. We are refurbishing some of our ward areas to improve the environment and limit the
risk of contamination.

Hand hygiene
Hand hygiene lies at the heart of infection prevention and control at YDH, and all staff are obliged to wash their hands or use gel between patients. Last year, most of the Trust’s 2,000 staff attended training to emphasise the importance of washing and gelling hands in clinical areas. This training also forms part of our staff induction which all staff receive within the first few days of their employment with us. Patients and visitors are urged, if they see a member of staff not doing this, to ask them to do so. The Trust also has a uniform policy prohibiting staff from wearing their uniforms out of the hospital and clinicians
who have patient contact must be bare below the elbow to avoid the risk of spreading infection through shirt-sleeves and jewellery. As part of the ‘Clean Your Hands Campaign’ the Trust introduced noise- and movement-sensitive devices at the entrance to each ward which gives messages to staff, visitors and patients entering the wards reminding them to use the
hand gel. The location of the hand gels is emphasised by a strip of red flooring across the corridor and up the walls. This has the additional benefit of dissuading patients with delirium or dementia from crossing the red line which is in a different
flooring material to the rest of the ward.

Reporting and feedback

Patients and visitors are also encouraged to report any areas they think have not been cleaned and to ask for any equipment, or used items which have been on the locker or bedside table for a long time, to be removed. A clean hospital and spotless equipment are of the utmost importance to us and the Infection Control and Prevention Team is involved in every aspect of ensuring standards are achieved and maintained. All ward and clinical areas are regularly inspected by the heads of nursing and cleaning supervisors and the results reviewed by our Patient Environment Action Group. The board of directors closely monitors infection control and hygiene standards, receiving monthly reports. The Trust puts a high priority on patient experience and focuses on real-time feedback in addition to the annual results from the national inpatient survey. With the support of the Patientand Public Involvement (PPI) group, patients are asked on discharge a range of questions which give them opportunities to comment on the hospital’s cleanliness and what could be improved. Members of PPI also support hygiene monitoring activities in line with the Standards for Better Health requirements.

Training and responsibility
At YDH, we are fortunate enough to have an excellent and loyal housekeeping team employed directly by the Trust, who receive regular training on infection control issues. Housekeepers work within the ward team, taking responsibility for cleaning and
housekeeping services, in order to maintain a safe and comfortable environment for all. Domestic assistants take responsibility for cleaning in all areas of the hospital, not just the wards, and we have a specialist cleaning team
which undertakes a rigorous programme of disinfection while carrying out specialised cleaning tasks at ward level. During any outbreak situation, this team undertakes cleaning duties as
directed by the housekeeping services manager and the infection control team. In addition to traditional cleaning methods, the Trust has recently implemented an additional new
system of cleaning using micro-fibre technology and we are leading the way in adopting innovative approaches to cleaning and decontamination. The department follows national NHS guidelines on the colour coding of all cleaning materials, including those used to clean catering departments.

Patient management
Patient management is another key area for combating infections. The Trust carries out enhanced screening for MRSA in high-risk groups and rapid isolation of suspected cases of MRSA and C. diff. cases are treated with the appropriate antibiotics, and cleaning and decontamination standards are meticulously followed. In the event of a serious case of infection, we carry out an investigation to identify learning points and any action necessary to prevent further occurrences.
Other measures include using dedicated equipment for patients with infections who are in our isolation rooms and avoiding unnecessary use of particular antibiotics which can encourage
infections. We have also recently appointed a maintenance person who works closely with the heads of nursing to ensure that any maintenance issues which could impact on infection control in clinical areas are resolved in a timely manner.
We were also grateful for the Department of Health’s additional one-off funding of £130k. This enabled us to purchase new equipment to carry out a regular deep-clean programme. It takes a day to do a whole ward and it is done bay by bay
– we move the patients out either to another bay or, if they are well enough, to the day hospital under the care of a nurse from their ward. A team of specially trained staff, who are employed by the Trust then give it a thorough steam-clean, taking the radiator covers off and washing the walls. We have also replaced the curtains around the beds with material coated with an antibacterial agent helping to minimise the spread of

Other bacterial risks
Our challenge now, with such low numbers of MRSA bloodstream infection and C. diff., is to sustain our success. We are looking at how we can combat other bacteria which put our patients at risk. These include extended-spectrum betalactamases (ESBLs) which are resistant to cephalosporins e.g. cefuroxime, cefotaxime and ceftazidime, the most widely used antibiotics in many hospitals.
To sum up, we aim to decrease all HCAIs to an irreducible minimum by working together with the whole health community particularly our community hospitals, to promote increased surveillance, good infection control practices,
maintaining a clean safe environment and prudent prescribing practice.