Sometimes you can’t see the wood for the trees… by Laura White

In September 2015 when my team and I were at the glittering Excellence in Care Awards ceremony at Easterbrook Hall after being nominated for not one, but two awards, I found myself pondering what it took for us to get from our lowest low to our highest high…

In early 2014 the Healthcare Environment Inspectorate walked into ICU unannounced and unearthed a catalogue of issues that turned our world upside down. In an instant our team went from a well-oiled machine to a rusty old tractor not knowing how to function.

The title of the blog sums up what we thought, as an organisation none of us could see what the Healthcare Inspectorate saw, we were in fact too close, too involved. For all our nursing care was never in question, we still doubted our abilities as nurses and wondered whether we were failing at the job we worked so hard at and got so much satisfaction from. The shame and embarrassment of having our place of work discussed in the newspapers and throughout the hospital, whilst trying to ‘keep it together’ still caring for critically ill patients and their families, was an overwhelmingly stressful time for all of us. The whole time we seemed to only have one question for each other…”How did this happen?” We put all our time and effort in to caring for our patients, did it matter that there wasn’t a record of the shelves being wiped down? Yes it did.

We listened to feedback, sought advice and did extensive research around the way we did things. We really dug deep and relearned our roles to include a vast new array of cleaning and infection control measures. It took months of liaising with the Infection Control Team, Domestic Services, Medics, Management, and Estates to name a few. There was clarification sought for EVERYTHING, from everyday things like bed bathing a patient to the fear of the effects of excessive Actichlor on our health.

The transition period between the inspection and the refurbishment of ICU put strain on everyone involved, however during this time it became apparent how well we pulled together, worked as a team and were committed to putting the broken pieces back together in order to be the best we could be. Staff came in to help in their own time, worked extra shifts and there was actually a lot of excitement about working in the newly refurbished unit, it was like a blank canvas. Don’t get me wrong, it wasn’t all plain sailing, the months following the inspection included periods of extremely low staff morale, increased sickness absence and an emotionally fragile workforce who at times found it difficult to talk about what happened to us. We eventually found that discussing the experience with colleagues and other professionals did help to rid us of some of the mixed emotions we were struggling with. Thankfully there did come a time when we realised we had to stop looking back and start looking forward and take the good from a bad situation.

We slowly began to regain confidence in ourselves and became very proud of our ‘new’ unit. During this time it became clear just how many of us had ‘a touch of OCD’! There were times when you could probably have eaten your dinner off the floor in ICU, and we just stopped short of putting Actichlor in our cereal! We now work relentlessly keeping our very extensive cleaning schedule up to date and everyone is involved in adhering to our philosophy of cleanliness, God help anyone who tries to put their gloves and aprons in a domestic stream waste bin! We really are acutely aware of everything now.

We knew that changing habits would be the hardest part but also that these changes had to be sustainable and over time these changes have become the new norm for us. These are the changes which are now the norm to the new staff that have joined us since the inspection and will undoubtedly evolve and develop in the future, as everything does in nursing.  The HEI inspectors have since returned to the unit and saw a drastic improvement in all aspects of cleanliness, which we knew they would.

Winning the Excellence in Care award for Infection Prevention in a way closed the chapter on the hard times we faced in 2014 and reinforced to us how we took the best from it and got to where we are today. We are dedicated, committed and knowledgeable in Infection Prevention and have regained the confidence we lost when our unit was put under the microscope.

As the saying goes “what doesn’t kill you makes you stronger”.

Laura White is the Senior Charge Nurse for ICU and Surgical HDU at DGRI

 

Dust if you must by @EGRoss85

People assume that as an infection control specialist I must live in a sterile environment or at least tidy. How wrong they are!

I read this poem recently. I think it’s great and this blog is a chance to share it with you. This is how I think we should live life. However, it caused my mind to wander

Author: Rose Milligan

 

My first thought was that if you get to the point of ‘needing’ to dust then your system is failing! If you keep an area tidy and wipe occasionally then there will be no dust.

So then dust is a systems failure.

Dust is dead skin and provides a lovely environment for bugs to grow but is it a risk?

Well that very much depends on where you are and what you are doing. I’m not undertaking any surgery in my home or office so a few piles of papers or books aren’t a risk.

The bugs have to be given access to the body. A healthy intact skin is the first barrier against infection; clean hands mean that we don’t put bugs all over the food we eat. Attending to both these aspects are fundamental to preventing infection.

Moving on from dust to another area of risk, food safety, I considered some of the choices I make on a personal level.

My team will tell you I have scant regard for sell by and even use by dates which horrify some. My perspective is that, as a healthy, informed individual, I can judge the potential impact of my risk based decision backfiring.

Pregnant, I would risk nothing. I’ve a friend who has lost a child to listeriosis and another hospitalised. Some risks are just not worth taking.

Undercooked beef burgers are a no, no for me. Salmonella, Campylobacter, E Coli 0157? No thanks! Steak tartare (raw, minced, fillet steak) from a reputable source? Oh yes!

Why? Well the mince has come from any part of the cow, including intestine where all the bugs live, fillet on the other hand is pure muscle and not where the bugs live. It’s a risk I am willing to take.

So why am I choosing to ramble on in a NHS Blog. Well as an Infection Control Team we are sometime told that our advice is inconsistent and I’d like to try to explain why sometimes this might appear to be the case.

We all have many different risk based decisions to make on a daily basis and these will depend on the vulnerability of the patient group, the activity being performed and the virulence of the organism likely to present the risk. This is why I never find infection prevention dull. It requires the application of specialist knowledge, an understanding of the patient’s clinical picture and the care being provided .There are no black and white answers, it really is 50 shades of grey (!) but whatever decision is taken, it will be made on a balance of risk.

Cleaning is important in a healthcare setting. It’s not about appeasing inspectors, it’s about risk. Dust is full of bugs but if doesn’t reach a patient it’s probably not a risk. But it does reach patients, on hands and equipment so we do need systems in place to make sure that it doesn’t build up and become a home for bugs.

So, ‘dust if you must’. Yes, there’s more to life than cleaning but let’s make a sensible assessment of what is required and if we consider the risks and do the simple things like keeping tidy then cleaning doesn’t become a major event, just the application of a simple process.

So please excuse me now as I go to attend to a low risk systems failure of my own!

Elaine Ross is Infection Control Manager at NHS Dumfries and Galloway

Those were the days… by @ElaineRoss1985

Aah yes, when nurses were mainly female, a male nurse was a novelty, we wore white dresses, American tan tights and hats that lived in our lockers on top of our lace up shoes. Hats which we only replaced following head butting a pillow whilst performing Australian lift!

Doctors were God and not to be challenged, the only walk round  we did was when the Director of Nursing popped up and asked you to take her round the patients questioning you on each one and very occasionally we were visited by minor royalty. 

Discharge planning was undertaken in the bathroom and we rolled ‘pinnies’ or did the flowers during visiting time. The green water was carefully poured down the sink in the patients’ bathroom where we encouraged them to wash themselves. Then we were surprised when they got Pseudomonas wound infections! C.difficle was unknown to us but we knew that our post op patients had diarrhoea and it had a farmyard smell. MRSA was something you got in city hospitals and if transferred from one you spent days in a side room until we knew you were “safe”. Our first infection control nurse was funded due to nationwide concern over HIV (remember those tombstone adverts everywhere?) yet HAIs kill more patients than HIV.

We were kind, compassionate and largely clueless about evidence based practice. Doctors and nurses were never questioned by patients because we knew best. I splinted and bandaged all cannula and I made countless Kaolin poultices and placed them on inflamed sites (I loved that smell). Oh yes and there were always lots of nurses and time to spend with the patients… Or was there?

So as young staff nurse at the dawn of the 90’s I was sent to take charge of a surgical ward. I was the only trained member of staff and was supported by 2 students and with another trained member coming on at 3pm. A student came running for me. A man in his late 60’s had recently had a hernia repair and now he was holding his open abdomen and the bed was covered in pink pus. A surgeon was called and examined him without gloves or hand hygiene. ‘This is already infected’. He removed a gangrenous testicle in the room. I was horrified. I stood with my arms across the door and insisted he wait until I had a sterile pack brought from theatre. Whilst this was happening I spent time trying to source a pressure relieving mattress as this chap was clearly now at high risk of developing a pressure sore and I needed to move him from the carnage that was his bed.

That man died, not of the hernia though I believe that was an entirely preventable infection, but from an infected pressure sore. He came in for a routine operation and died before his time. We had no targets and little inspection so this catastrophic event went unnoticed.That experience kindled an interest in pressure and wound care that led me to the role I have now.

These days we do have targets and inspections and I believe they have brought improvement. We count everything, we can have data overload at times but in the past we didn’t know, issues were invisible to us rising to epidemic proportions before they were addressed. Just look where we were with C.difficle a few years ago.

Now if I say we are going to miss a target or we are at risk of failing an inspection there is support and resource there that was not available to me before. But it is not simply about meeting the targets and not looking bad in the press. They have focused our attention on things that matter and that means on our patients and those who care for them.

We state as an infection control team that our vision is that no person will be harmed by a preventable infection. Despite, this we estimate in the past year around one third of all Staphylococcus Aureus Bacteraemia in NHS D&G may have been preventable. That’s amounts to 13 people and has an estimated cost of £26,000. In addition, national data indicates that in these people Staphylococcus Aureus Bacteraemia amounts to a 1 in 3 chance of dying as a result.

So next time we are checking cannula use please understand it’s not about targets it’s about people who we want to see leave hospital in a better state than when they came in and certainly not harmed by our care. 

As for those Doctors and nurses that know everything, well let’s share that with our patients and encourage them to ask. Do I need this cannula? Have you washed your hands?  Don’t take offence; take it as a compliment because you have the answers.

 

 

 

 

 

Elaine Ross is the Infection Control Manager at NHSDumfries and Galloway. Next weeks blog will be by Mr Mike Pratt Chief Pharmacist for NHS D&G.