North Tees and Hartlepool NHS Foundation Trust has approximately 680 beds across two hospital sites, with the usual mix of emergency, medical, surgical, orthopaedic, paediatric, day surgery, haematology, chemotherapy and rheumatology wards. In common with every other hospital trust in the country, the issue of reducing hospital acquired infections (HAIs) has long been a priority at the Trust and plans were already afoot when, from April to October 2009, the Trust experienced higher than expected rates of Clostridium difficile (C.diff).
A new procedure was implemented immediately, involving an extensive team of Estates, Domestic, IPCT and nursing staff, and using five Steris BioGienie® hydrogen peroxide disinfectant delivery systems, with the aim of creating an entirely new approach to infection prevention. At first, the process was carried out reactively on the wards that were most seriously affected at the time, but the Trust’s long-term aim was to establish this level of decontamination on a yearly basis for all wards, and twice yearly for high-risk areas.
The first ward tackled under the new process was vacant, because patients and staff had moved to the Trust’s decant ward to allow refurbishment. Although this showed how much more effectively the process could be carried out, and is clearly much easier in terms of accessibility to all ward areas, emptying entire wards is an upheaval and is not always a viable option, depending on bed pressures and patient welfare. The Trust found that working bay-by-bay can be just as effective, although it does take longer to complete and there is always an increased chance of repetition; however, it is still a viable alternative should the decant ward option not be available.
As each four-bed or six-bed bay is vacated, the first step is for the maintenance team to move in to carry out any necessary work, including all electrical and plumbing tasks, floor maintenance, decorating and so on. The domestic team then move in and begin the environmental decontamination (terminal clean). The area undergoes a deep clean, which involves surface cleaning of walls, floors, ceilings and doors. Ward hygienists – two per site, who were newly appointed at the start of the process – then steam clean and wash down every bed, bedside locker and overbed table in the room, as well as items such as ventilators, volumetric pumps and nebulisers with disinfectant. The room is then sealed, and the Steris BioGienie® hydrogen peroxide disinfectant system set for biodecontamination of the room and equipment within.
The Trust has taken the process one step further, adding items such as commodes, shower chairs and drip stands – even vacuum cleaners – to the ward hygienists’ remit. Although these items are cleaned between each use by the nursing staff, which is still current practice, the items were rarely deep cleaned. This is now being done most effectively by swapping items with stock spares, and moving them away from the ward where they can be disassembled if necessary, thoroughly steam-cleaned and then fogged.
A key factor for the success of the process was the development of a detailed and easy-to-follow protocol that was put in place for the relevant staff, including check lists at each point of use, and stringent safety mechanisms for the handling of potentially hazardous chemicals.
The BioGienie® system itself is easy to programme via an intuitive touchscreen, with a wide range of fully programmable decontamination cycles and an average cycle run time of just three hours. Its tamperproof design runs on a very safe, slot-in cartridge-based system that prevents any direct contact with the disinfectant, and has a number of built-in security features, such as high visibility warning lights.
The team chose the Biogienie® because of the nature of the environment in which it was going to be used, that is, the live ward scenario. When used in the live ward it is extremely reassuring to have features such as the screen lock, which allows the hygienists, once safety checks are completed, to work in any area of the ward and not be restricted to one particular area. Once again the benefits of the Biogienie® slot-in cartridge system is of huge benefit because it eliminates the risk of exposure to chemicals to the operator, patients and staff in the vicinity of the live ward environment.
The process has been extremely successful (Table 1). When the hydrogen peroxide disinfectant systems were first purchased, C. diff levels were running at approximately 17% above the previous year, and continuation at this level would have resulted in penalties of approximately £700,000 for breaching the HAI targets set out in the Acute Services Contract.
In the first year following the installation of the new systems and protocol, C. diff was reduced by 65%. In terms of patient safety and reduction of unintended patient harm, this equates to 103 fewer patients who might have contracted hospital-acquired C. diff in the care of the Trust than in the previous 12-month period. Although this process specifically targeted C. diff, there have also been significant reductions in both MRSA and Norovirus HAIs since its inception. Emptying the wards, either completely or bay-by-bay, has encouraged ward staff to declutter and, for the first time since the introduction of Patient Environment Action Team (PEAT) assessments in 2001, both sites achieved scores of 5 or excellent in 2010, and did so again in 2011.
As a result, the wards within the Trust are now cleaner, safer, better decorated and less cluttered than at probably any point in the Trust’s history. They are more pleasant for both patients and the nursing staff who, as a result, seem to be taking more care of their environment and actively try to avoid damage to the fabric of the building. This positive effect has certainly encouraged more awareness and better compliance with correct preventative procedures within the hospital. Keeping the wards to a good standard is far easier, and there has been a positive impact on the costs incurred for repairing preventable damage and deterioration within the clinical areas, saving budget for tasks elsewhere.
Where are we now?
In line with receiving our challenging 2011/12 C. diff target, which is a reduction of 53.55% against 2010/11we reviewed and updated the Trusts ward decant programme. This involved discussions with the IPCT, Estates, Patient flow team, Domestic managers, Portering, Catering, IT & Telecoms and the Senior Clinical team. We then formally agreed the decant programme, which was based on data gathered over the previous 12 months by the Trust’s IPCT, and which helped identify trends and ‘hotspots’ and the programme then shaped accordingly.
The Trust commenced its most-challenging ward decant programme to date; between 1 August and 19 December 2011, 27 full ward decants were carried out. In some areas, as well as decluttering, maintenance, repairs, décor, deep clean and bio-decontamination being undertaken, kitchen upgrades, clean and dirty utility upgrades, flooring repairs and hand wash basin upgrades were completed, with no individual ward taking any longer than the agreed two weeks.
In 2010/11 the team was nominated and shortlisted for several national prestigious awards in recognition of their efforts and the success of the process, of which the ultimate aim is to reduce HAIs. The recognition and awards include the the Trust’s prestigious ‘Shining Stars’ awards, which is an opportunity to recognise and reward staff for their hard work, dedication, commitment and achievements. In October 2011 the ward hygienists won the accolade of North Tees & Hartlepool Shining Stars Awards ‘Team of the Year’ 2011.
The Trust significantly reduced its hospital-acquired C. diff infection by establishing a rolling programme of regular decluttering, maintenance and decontamination using BioGienie® hydrogen peroxide delivery systems.
The BioGienie® systems provide a straightforward and cost-effective method of infection control within the healthcare setting from an environmental and equipment bio-decontamination aspect. However, it must be considered while developing any business case that capital investment is not enough; the success of the process at the Trust must also be attributed to the dedication of the specialised team of ward hygienists. It is also worth considering continuing communication and working relationships with the multi-disciplinary team, as had it not been for the multi-disciplinary team being involved at every level the Trust would not have seen the reductions in HAIs shown in Table 1. The importance of a motivated team with a sound understanding of what the Trust is trying to achieve and the potential of the technology cannot be underestimated. The driver behind the successful reduction in HAIs at the Trust has clearly been the understanding, dedication, determination and commitment of the staff, who together are a great force and are extremely effective and efficient. This approach has saved lives, significantly reducing unintended harm to patients, and has had a secondary benefit of exceeding the targets set by the Department for Health as part of the compliance framework.