09.03.11
HCAI-an epic battle
Professor Robert J. Pratt and Brian O’Malley outline the benefits of the epic initiative, an overlapping series of long term government commissioned research projects focused on contributing to the development of the evidence base which underpins the practice of infection prevention and control in the NHS
Over the past two decades, healthcare associated infection (HCAI) has emerged as a significant threat to patient safety. The financial and personal costs of HCAI in terms of the economic consequences to the National Health Service and the physical, social and psychological costs to patients and their relatives have increased both government and public awareness of the risks associated with healthcare interventions, and in particular the consequences of HCAI.
Department of Health strategy
All successful strategies for minimising the risk to patients of acquiring a HCAI require a multifaceted evidence-based approach that includes providing practitioners with best evidence for clinically effective practice and then supporting them to understand and use this evidence to minimise infection risks and increase patient safety. National evidence-based guidelines from the Department of Health and the National Institute for Health and Clinical Excellence in England are forming the foundations for ensuring the availability of best evidence to practitioners, and the development of an associated e-learning/blended learning programme is now supporting all NHS staff to effectively use this evidence to protect patients from the risk of preventable infections during care.
National evidence-based guidelines – the 'epic' initiative
The DH commissioned the development of national evidence-based infection prevention and control guidelines for acute, primary and community care settings from the Richard Wells Research Centre at Thames Valley University. These have become known as the 'epic' guidelines and they are systematically developed broad statements of good practice. They are driven by practice need, based on evidence, and subject to multi-professional debate, timely and frequent review, and modification. National guidelines are intended to inform the development of detailed operational protocols at local level and can be used to ensure that these incorporate the most important principles for preventing HCAI in NHS hospitals and other acute care health services.
A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective in preventing HAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority.
epic2 guidelines
The newly updated national guidelines (epic2) provide comprehensive recommendations for preventing HCAI in hospitals and other acute care settings based on the best currently available evidence. The guidelines describe standard principles for preventing HCAI-environmental hygiene, hand hygiene, personal protective equipment and the use and safe disposal of sharps-and guidance for preventing infections when using short-term indwelling urethral catheters and central venous access devices. These guidelines can be downloaded free of charge from the epic website at www.epic.tvu.ac.uk.
Potential impact of national guidelines
Although not all HCAI are preventable, many are. If healthcare workers and all other NHS employees consistently and correctly incorporated guideline recommendations into their routine working practices, the rates of HCAI would dramatically decrease. One way of encouraging this is to ensure that, like all policy initiatives, employees are trained to implement the policy.
The NHS CLU/TVU/Intuition approach
Providing this training for the 1.3 million employees of the NHS became the responsibility of the NHS Core Learning Unit which commissioned the Richard Wells Research Centre at TVU along with their Dublin-based educational development partner, Intuition Publishing, to develop an appropriate, engaging and accessible education programme, available free of charge to all NHS staff. From the outset, this project aimed to go beyond conventional education delivery models, for the first time encapsulating the evidence base for infection prevention and control procedures and communicating best practice using blended learning materials.
Programme design
The programme provides an overview of the scope and cost-to patients and to the NHS- of HcAI, describes how these are transmitted, and the fundamental steps everybody can take to break the chain of infection.
The learning programme is provided in three distinct parts. The core course is referred to as part A and two versions have been made available, tailoring language levels, technical terminology and content to suit both clinical and non-clinical staff.
Part A: Infection prevention and you – a guide for all staff working in the NHS
The core course, which consists of three modules, provides a general overview of HCAI, explores the consequences of these infections to patients and to the NHS, and reviews the standard precautions that all staff can use to prevent infections. There are two versions of part A; one for clinical and another for non-clinical staff.
Part B: Principles of infection prevention – a guide for non-clinical staff
This part of the programme was originally aimed at non-clinical staff and consists of four modules focused on hand hygiene, appropriately using personal protective equipment, safely handling and disposing of waste and sharps, and environmental cleanliness. Feedback from the service indicates that the part B materials are just as relevant to clinical staff and many programme administrators have for that reason made them available to all users, irrespective of role.
Part C: Putting theory into practice
The primary purpose of this highly interactive part of the programme is to ensure that non-clinical staff are aware of their local infection prevention and control policies and guidelines, and that they can identify sources of expert support and advice in their own work area.
Delivery and implementation
After a short pilot phase, the programme was made available to all NHS staff, at no charge, in the NHS over the internet at www.infectioncontrol.nhs.uk. It takes just a couple of minutes to register and, once an account has been created, learners can immediately access the e-learning modules. Instructor-led sessions are scheduled and delivered locally, and crucially trainers have the ability to customise the Powerpoint files to match their local requirements.
Since its launch, the programme has registered over 35,000 users on the system, with a broad range of users drawn from acute hospitals, ambulance stations, GP surgeries and dental clinics, mental health trusts and care homes throughout England. These numbers exceed the targets originally set for the programme, indicating the rapid acceptance of the materials as useful education resources across the service. In fact the uptake of the programme has shown that e-learning is increasingly being accepted by the NHS, and in part supports the growth of computer skills in the service. This significant uptake supports the direction of travel laid out in the e-learning roadmap for the NHS.
A feature of the online learning format is that the learners can access the programme from anywhere – from their normal place of work, a trust library or training room, their home or even a cyber café. This reduces the time away from their core responsibilities and minimises any adverse impact on the provision of healthcare services. With increasingly tight budgets it has thus tended to be the only affordable form of training to many trusts.
Programme marketing and support
A full-time programme marketing manager provided by Intuition, accessible by email, in person and by phone, supports the training by assisting with promotional events, on-site train-the-trainer workshops and by producing adoption tools and frequently asked question guides, etc.
Managers are able to monitor the usage and effectiveness of training on a group or individual basis using the online reporting tools. Managers can easily record, monitor and measure progress and achievement on the automated management system, making it suitable for compliance reporting purposes as required by the government's Health Act 2006. The act includes a code of practice for the prevention and control of HCAI which requires every NHS body to ensure that mechanisms are in place to provide prevention and control of infection in induction programmes for new staff and ongoing training programmes for all existing staff.
The online learning programme also helps the NHS meet the code's requirement that there should be a record of training for all staff. This is available through the reporting functionality of the learning management system, which training administrators access to download auditable evidence of uptake for individual trusts. The code of practice further strengthens the legal basis for infection control practice accountability, which is already a key area for self-assessments submitted by all providers of healthcare to the Healthcare Commission.
Integrated approach
Feedback from trusts with high levels of registration show that adoption of the programme has been supported at the highest levels in the organisation – often forming a key part of the trust's infection control strategy. In some cases staff are given protected time to complete the training, with full encouragement and support from managers. Some trusts are making the training compulsory for new recruits, while others are incorporating the training as part of the personal development plans (PDP) for staff members in the knowledge skills framework (KSF) or training programmes within the trust.
Mobile learning
In September 2006, the NHS CLU and Intuition piloted a solution, through the use of tablet PCs, with South East Devon PCT to tackle the problems of lack of accessibility to IT hardware and poor computer literacy for some staff groups. The programme is available on A4-sized tablet PCs running offline, meaning that it is truly accessible at any place and at any time. Tablet PCs help the programme reach the widest possible audience and offer a state-of-the-art e-learning experience, which is cost effective, easy to use and highly intuitive. The digitised pen removes the need for any pre-existing keyboard skills and offers a fun, user friendly platform from which to learn.
The project team is also investigating the use of the content on Blackberry® devices, potentially allowing more experienced clinicians to opt-out of annual training if they take a short refresher and can prove their continued mastery of the topics.
In addition, the programme has been opened up to student nurses and midwives and is being used at many universities across the UK.
Conclusion
All patients have the right to safe care and health service managers have a moral and legal duty to minimise any risk of adverse consequences of being cared for in the NHS. Up-to-date national evidence-based guidelines for preventing HCAI are now readily accessible via the epic website. Further, the use of blended learning programmes to educate staff on how to effectively use and incorporate this guidance into everyday clinical practice is one of the most transparently effective measures managers can take to ensure patient safety.
This article is based upon a presentation made by the authors at the sixth international conference of the Hospital Infection Society in Amsterdam on 15-18th October 2006.
www.infectioncontrol.nhs.uk
Professor Robert J. Pratt CBE FRCN RN is director of the Richard Wells Research Centre, Thames Valley University
[email protected]
www.richardwellsresearch.com
Brian O’Malley is general manager, Public Sector & Health Intuition Publishing
E: [email protected]
T: www.intuition.com
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