Time to Come Clean

28 February 2007 (Last Updated February 28th, 2007 18:30)

The battle against hospital-associated infections may never be won, but there are many options for keeping them at bay. Denise M Murphy, president of the Association for Professionals in Infection Control and Epidemiology, tells Nic Paton how she thinks it should be fought.

Whether or not it was the sort of early Christmas present most infection control practitioners would have wished for is debatable. But the decision in November by Pennsylvania’s Health Care Cost Containment Council to become the first US state to publish a hospital-specific report on hospital-associated infections (HAIs) was groundbreaking and, just as importantly, a clear sign of the growing public focus on infection control.

The report, which covered 168 individual hospitals, recorded more than 19,000 infection cases in 2005, up from 11,600 in 2004, from more than 1.6 million admissions. With the Federal Centers for Disease Control and Prevention estimating that nearly 250 people die each day in the US from infections they pick up in hospital, other US states are now following Pennsylvania’s lead.

In the UK, too, HAIs have become an increasingly hot political and healthcare potato. In January a leaked internal memo from director of health protection Liz Woodeson to health secretary Patricia Hewitt suggested that the government’s three-year target to halve MRSA infections by April next year was likely to be missed and may never be achieved.

IN THE SPOTLIGHT

The increasingly harsh public spotlight on HAIs is both a challenge and an opportunity that infection control practitioners need to grasp, but too often do not, argues Denise M Murphy, president of the Association for Professionals in Infection Control and Epidemiology.

Murphy, who is also chief patient safety and quality officer at Barnes- Jewish Hospital in St Louis in the US, outlined a ten-point strategy in January that infection control practitioners should be working towards if they want to step up to take their rightful place in leading the battle against HAIs.

"The profession is in transition," says Murphy. "It is becoming more visible and at the same time more valued by clinical and administrative leaders. But there are also challenges from consumers becoming more educated about HAIs."

She stresses that progress is definitely being made. The past few years, for example, have seen a huge reduction in the number of cases of ventilator-associated pneumonia. Infections associated with cardiac and spinal surgery have also been in decline.

"In some ICUs now we are seeing as much as a 65% reduction in bloodstream infection and bloodstream pneumonia," she says. Closer team working, more individual responsibility, greater use of competitions and better sharing of data and best practice have all played a part.

But the trend towards greater public reporting and the well-meaning desire of many politicians and healthcare managers to be seen to be doing something is putting the profession under ever-greater pressure.

"Legislators are starting to feel more compelled to create mandatory laws around hospital acquired infection prevention programmes and reporting," says Murphy. "Most infection control professionals are, of course, in favour of transparency, being honest with their community and reporting the threats they face. But if states ask us to report everything, it creates a tremendous amount of information, even information overload."

There has been a hardening of attitudes as to the level of HAIs considered acceptable. Murphy says: "Instead of us simply using benchmarked statistics, we are now working towards zero tolerance. We are trying to get to the absolute minimum that we can in preventable infections. The clear resounding message is zero tolerance."

"We have seen programmes all over the country get to zero. While we know we cannot prevent all infections – some are the result of host infections that we cannot control – and we may not get to zero, we cannot be comfortable with anything other than zero.

"We have to understand what is preventable through interventions and deploy them to prevent those infections and get to zero. So workers need to understand the host factors."

TEN-POINT PLAN

There has never been a greater opportunity for infection prevention and control professionals to demonstrate their value, yet, too often, the messages delivered about HAIs are shaped by the perception and experiences of the sender, and through the ears of a frightened and mistrusting public, argues Murphy. The profession should therefore work to shape the messages going out to the public and other healthcare workers, and enforce the zero tolerance approach. This brings us to Murphy’s ten-point plan:

"The increasingly harsh public spotlight on HAIs is both a challenge and an opportunity that infection control practitioners need to grasp."

Point 1. Murphy argues that healthcare providers must be educated about infection prevention. They should be moved away from seeing infection control as "just another programme" towards regarding it as something for which each and every worker has a level of personal responsibility.

"Workers need to know that their specific role in terms of prevention starts with hand hygiene. If you do not start with the basics, people will never embrace the more complex areas," she says.

Point 2. This process needs to go up the ranks to the board of directors and executive team. They need to understand the fundamental and emerging threats to patient safety, and how the prevention of HAIs is critical to saving lives.

Point 3. The profession needs to do more to challenge medical staff in leading the effort to eliminate HAIs. Too often practitioners make the mistake of simply telling staff what to do, rather than looking at how workers can become more empowered to make decisions themselves.

Point 4. There needs to be more emphasis on influencing clinical and administration leaders.

Point 5. The profession must take more of a lead in educating the wider community. This involves engaging teachers, clergy and fitness centres to reinforce the importance of hand hygiene and how infections come into hospital.

Point 6. Data has to be transformed into usable information that can be more easily shared. "We need to get it into the hands of the nurse manager or ICU director or the board," says Murphy.

Point 7. It is important that the profession automates more of its work, so that less time is spent on data collection and more on communication and education.

Point 8. It is important for practitioners to learn better how to negotiate. Murphy explains: "When we are negotiating for the resources that we need, we must be relentless. If we are turned away, we must come back again and again, but with a stronger business case each time."

Point 9. As part of this process of increasing visibility and educating peers, infection control specialists need to spend more time and energy developing strategic partners: people with credibility and impact who can champion the HAI/infection control message throughout an organisation.

This could even mean closer links with industry and product manufacturers who, despite the natural reluctance of many medical practitioners to get too close, do in fact often have much to offer in terms of knowledge and data.

Point 10. "We need to keep the patient at the core of what we do and what we say," argues Murphy. The common thread is that everyone wants to be doing the right thing for the patient. "We need to stop using language that makes us sound like a police officer and start to sound like patient safety advocates."

NEW THINKING

This vision is, of course, ambitious, and Murphy recognises that where infection control and prevention sits within an organisation and how it is perceived will be critical to success. Practitioners, she argues, needs to stop seeing themselves as a narrow specialism; they need to be at the heart of every department and every ward. "[Infection control] needs to be aligned with a very visible healthcare executive, reporting directly into the president or vice-president for patient care."

With such a heightened role and profile, infection control and prevention specialists will inevitably need to learn new skills, in particular how to generate performance improvement and manage change. Emergency preparedness training and an understanding of emerging, not just current, threats are also likely to be increasingly important skills going forward, Murphy says.

"There has never been a greater opportunity for infection prevention and control professionals to demonstrate their value."

Communication, or rather a lack of it, is one of the most common reasons for process or system failures. Effective communication strategies and tools will therefore become a more important part of the practitioner’s armoury.

"Performance and improvement tools and methods are necessary," says Murphy. "You have to understand the root causes for the way healthcare workers perform. We need to have an understanding of behaviour science and behaviour change.

"We have to be able to do more than educate. We have to get people to change. We have to follow up and look at the barriers to sustaining change, which is often something that infection control specialists have not always understood or thought they needed in the past.

"The infection control professional of the future has to be very well rounded. It is not just someone who has the technical expertise, who is just called on when needed. It needs to be someone who is at the table, who is broadly discussing patient safety, quality improvements and improving patient outcomes."

Ultimately, for Murphy, the goal is simple: "We have to move beyond the narrow confines of patient safety to being a patient advocate."