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‘The problem with…’ series covers controversial topics related to efforts to improve healthcare quality, including widely recommended, but deceptively difficult strategies for improvement and pervasive problems that seem to resist solution. Healthcare-associated infections (HCAIs) are the most common adverse events affecting patients.1 The pathogens responsible are often carried on health workers’ hands, and on the evidence of epidemiological and microbiological studies, in theory hand hygiene ought to break the chain of infection.2 The WHO3 promotes ‘My Five Moments for Hand Hygiene’4 as a ‘time-space’ framework to identify points in the sequence of care when hand hygiene should occur to prevent transmission. The Five Moments conceptualise risk in relation to two virtual areas: the patient zone and the healthcare zone.4 The patient zone comprises the patient and their immediate surroundings: intact skin and all inanimate surfaces in direct contact with the patient and all the surfaces handled by healthcare workers. The healthcare zone comprises everything outside the patient zone. Except for the original definition of zones provided by Sax et al ,4 no other definition of patient and healthcare zones appears to exist. The model assumes that the healthcare zone is contaminated with potentially harmful micro-organisms (ie, those able to cause exogenous infection and/or resistant to antimicrobials). The Five Moments are the dominant paradigm used to organise practice, policy and research in relation to hand hygiene. In this paper we identify five ‘inconvenient truths’ limiting the Five Moments: (1) the development of the Five Moments did not include the perspectives of stakeholders; (2) it is not always possible to implement Five Moments for all patients all the time; (3) the patient zone is not a fixed entity; (4) the Five Moments overlook barriers that reduce hand hygiene adherence; and (5) adherence to the Five Moments …

Patient safety in hospitals can be compromised by preventable adverse events (AE). Among the preventable AEs, hospital-acquired infections (HAIs) are one of the most burdensome, contributing to not only poorer patient outcomes but institutional burden through direct financial losses and increased patient length of stay. Technological innovations can enhance patient safety by automating tasks, introducing medication alerts, clinical reminders, improved diagnostic and consultation reports, facilitating information sharing, improving clinical decision-making, intercepting potential errors, reducing variation in practice, and managing workforce shortages as well as making complete patient data available. A multidisciplinary working group from three European countries was convened to discuss how to optimise the use of technology to reduce preventable AEs in acute care hospitals. The working group identified examples where they felt there were opportunities to streamline patient pathways, including antimicrobial stewardship, point of care testing, microbiology test reporting to streamline time from sample-taking to clinical decision and mobile automated dispensing systems, which can reduce the burden on overworked staff. The working group also discussed key factors that were critical to ensuring different stakeholders, both within and outside the hospital, could meaningfully contribute to improving patient safety. They agreed that technological approaches and advances would have limited impact without meaningful cultural changes at all levels of healthcare infrastructure to implement the benefits offered by current or future technologies.

Objective To assess the utility and frequency of use of the Nightingale Communication Method, during the early operational phase of the Nightingale Hospital London (NHL) 4000-bed field hospital’s intensive care unit. Design Survey-based cross-sectional assessment. Setting The intensive care unit at the Nightingale London hospital. Participants Staff working in the clinical area and therefore requiring full personal protective equipment (PPE). Intervention Survey of all staff members sampled from a single shift at the Nightingale Hospital. This investigated perceived utility and actual use of identification methods (name and role labels on visors and gowns, coloured role identification tapes) and formal hand signals as an adjunctive communication method. Main Outcome Measure Self-reported frequency of use and perceived utility of each communication and personnel identification adjunct. Results Fifty valid responses were received (72% response rate), covering all clinical professional groups. Prominent name/role identifications and coloured role identification tapes were very frequently used and were perceived as being highly useful. Formal hand signals were infrequently used and not perceived as being beneficial, with respondents citing use of individual hand signals only in specific circumstances. Conclusion PPE is highly depersonalizing, and interpersonal identification aids are very useful. Despite being difficult, verbal communication is not completely prohibited, which could explain the low utility of formal hand signals. The methods developed at the Nightingale hospital have enhanced communication in the critical care, field hospital setting. There is potential for wider application to a variety of healthcare settings, in both the current situation and future pandemic scenarios.

Since the introduction of rotavirus vaccination in England in July 2013, norovirus has become the second-largest contributor of inpatient gastroenteritis, preventing 57800 patients from being admitted annually. Economic costs amount to £297.7 million, which translates into 6300 quality-adjusted life years., Background Norovirus places a substantial burden on healthcare systems, arising from infected patients, disease outbreaks, beds kept unoccupied for infection control, and staff absences due to infection. In settings with high rates of bed occupancy, opportunity costs arise from patients who cannot be admitted due to beds being unavailable. With several treatments and vaccines against norovirus in development, quantifying the expected economic burden is timely. Methods The number of inpatients with norovirus-associated gastroenteritis in England was modeled using infectious and noninfectious gastrointestinal Hospital Episode Statistics codes and laboratory reports of gastrointestinal pathogens collected at Public Health England. The excess length of stay from norovirus was estimated with a multistate model and local outbreak data. Unoccupied bed-days and staff absences were estimated from national outbreak surveillance. The burden was valued conventionally using accounting expenditures and wages, which we contrasted to the opportunity costs from forgone patients using a novel methodology. Results Between July 2013 and June 2016, 17.7% (95% confidence interval [CI], 15.6%‒21.6%) of primary and 23.8% (95% CI, 20.6%‒29.9%) of secondary gastrointestinal diagnoses were norovirus attributable. Annually, the estimated median 290000 (interquartile range, 282000‒297000) occupied and unoccupied bed-days used for norovirus displaced 57800 patients. Conventional costs for the National Health Service reached £107.6 million; the economic burden approximated to £297.7 million and a loss of 6300 quality-adjusted life-years annually. Conclusions In England, norovirus is now the second-largest contributor of the gastrointestinal hospital burden. With the projected impact being greater than previously estimated, improved capture of relevant opportunity costs seems imperative for diseases such as norovirus.

ObjectivesHand hygiene is considered the most important preventive measure for healthcare-associated infections, but adherence is suboptimal. We previously undertook a Cochrane Review that demonstrated that interventions to improve adherence are moderately effective. Impact varied between organisations and sites with the same intervention and implementation approaches. This study seeks to explore these differences.MethodsA thematic synthesis was applied to the original authors’ interpretation and commentary that offered explanations of how hand hygiene interventions exerted their effects and suggested reasons why success varied. The synthesis used a published Cochrane Review followed by three-stage synthesis.ResultsTwenty-one papers were reviewed: 11 randomised, 1 non-randomised and 9 interrupted time series studies. Thirteen descriptive themes were identified. They reflected a range of factors perceived to influence effectiveness. Descriptive themes were synthesised into three analytical themes: methodological explanations for failure or success (eg, Hawthorne effect) and two related themes that address issues with implementing hand hygiene interventions: successful implementation needs leadership and cooperation throughout the organisation (eg, visible managerial support) and understanding the context and aligning the intervention with it drives implementation (eg, embedding the intervention into wider patient safety initiatives).ConclusionsThe analytical themes help to explain the original authors’ perceptions of the degree to which interventions were effective and suggested new directions for research: exploring ways to avoid the Hawthorne effect; exploring the impact of components of multimodal interventions; the use of theoretical frameworks for behaviour change; potential to embed interventions into wider patient safety initiatives; adaptations to demonstrate sustainability; and the development of systematic approaches to implementation. Our findings corroborate studies exploring the success or failure of other clinical interventions: context and leadership are important.

Introduction: Good hand hygiene practices reduce the risk of transmission of infection in healthcare. In common with other areas of healthcare, infection control knowledge and practice in radiography has potential for improvement. Regular hand hygiene compliance (HHC) monitoring indicated poor compliance in radiology which did not accurately reflect practice in one organisation. Using a quality improvement cycle, the process and context of work undertaken in radiology were examined in order to improve the validity and utility of HHC monitoring data collection process in the department. Methods: Following examination of the evidence base and with agreement from the radiology team, the chest X-ray process was observed and actions notated. This was then scored using the organisation and the World Health Organization five moments of hand hygiene tool. An alternative risk-based scoring system was developed. Results: The HHC score of 22% was obtained using standard measurements. Achievement of 100% compliance would require the radiographer to clean their hands nine times for each X-ray. The sequence of taking a chest X-ray was examined and two points in the process were identified as key points at which hand cleaning should take place to reduce the risk of transmission of infection. Conclusions: Cleaning hands frequently to achieve compliance expectations in this short low-risk process is neither feasible nor beneficial. A pragmatic risk-based approach to hand hygiene expectations in predictable procedures such as taking a chest X-ray reduces ambiguity and potentially increases compliance.

Highlights • Monitoring infection control by observation of hand hygiene does not include many aspects of infection control. • An infection control continuous quality improvement tool was developed and implemented in 1 organization. • Barriers and opportunities included ambiguity, consistency, and feasibility. • Monitoring the environment, isolation practices, and the knowledge was included. • Local adaptations enabled staff to monitor issues important in their workplace., Background Infection control practice compliance is commonly monitored by measuring hand hygiene compliance. The limitations of this approach were recognized in 1 acute health care organization that led to the development of an Infection Control Continuous Quality Improvement tool. Methods The Pronovost cycle, Barriers and Mitigation tool, and Hexagon framework were used to review the existing monitoring system and develop a quality improvement data collection tool that considered the context of care delivery. Results Barriers and opportunities for improvement including ambiguity, consistency and feasibility of expectations, the environment, knowledge, and education were combined in a monitoring tool that was piloted and modified in response to feedback. Local adaptations enabled staff to prioritize and monitor issues important in their own workplace. The tool replaced the previous system and was positively evaluated by auditors. Challenges included ensuring staff had time to train in use of the tool, time to collect the audit, and the reporting of low scores that conflicted with a target-based performance system. Conclusions Hand hygiene compliance monitoring alone misses other important aspects of infection control compliance. A continuous quality improvement tool was developed reflecting specific organizational needs that could be transferred or adapted to other organizations.

Intravenous (IV) devices are used frequently in healthcare both in acute and primary care settings. The associated risks of IV cannulation can be reduced by applying a bundle of evidence-based interventions, including line securement. The risks of dislodgement and movement of the IV catheter are reduced by securing the IV catheter. The minimisation of movement of the device reduces the migration of skin microorganisms along the catheter into the vein (extra luminal migration) which reduces the risk of infection. A common stabilisation method is to apply tape to stabilise the catheter and then apply an IV dressing. Alternative approaches include suturing the IV line in place, using sutureless or subcutaneous securement devices, and applying tissue adhesive. All approaches have potential advantages and disadvantages and require local evaluation to ensure feasibility and compatibility with other products. Some patient groups such as neonates, infants, and patients with allergies and compromised skin may require alternative products. The addition of effective securement devices may increase costs, and a cost-benefit assessment prior to implementation is suggested.

Summary Background Hydrogen peroxide vapour (HPV) disinfection systems are being used to reduce patients' exposure to hospital pathogens in the environment. HPV whole-room aerial disinfection systems may vary in terms of operating concentration and mode of delivery. Aim To assess the efficacy of two HPV systems (HPS1 and HPS2) for whole-room aerial disinfection of single isolation rooms (SIRs). Methods Ten SIRs were selected for manual terminal disinfection after patient discharge. Test coupons seeded with biological indicator (BI) organisms [∼10 6 colony-forming units (cfu) of meticillin-resistant Staphylococcus aureus (MRSA) or Klebsiella pneumoniae , or ∼10 5 cfu Clostridium difficile 027 spores] prepared in a soil challenge were placed at five locations per room. For each cycle, 22 high-frequency-touch surfaces in SIRs were sampled with contact plates (∼25cm 2 ) before and after HPV decontamination, and BIs were assayed for the persistence of pathogens. Findings Approximately 95% of 214 sites were contaminated with bacteria after manual terminal disinfection, with high numbers present on the SIR floor (238.0–352.5cfu), bed control panel (24.0–33.5cfu), and nurse call button (21.5–7.0cfu). Enhanced disinfection using HPV reduced surface contamination to low levels: HPS1 [0.25cfu, interquartile range (IQR) 0–1.13] and HPS2 (0.5cfu, IQR 0–2.0). Both systems demonstrated similar turnaround times (∼2–2.5h), and no differences were observed in the efficacy of the two systems against BIs ( C. difficile ∼5.1log 10 reduction; MRSA/ K. pneumoniae ∼6.3log 10 reduction). Despite different operating concentrations of hydrogen peroxide, MRSA persisted on 27% of coupons after HPV decontamination. Conclusion Enhanced disinfection with HPV reduces surface contamination left by manual terminal cleaning, minimizing the risks of cross-contamination. The starting concentration and mode of delivery of hydrogen peroxide may not improve the efficacy of decontamination in practice, and therefore the choice of HPV system may be based upon other considerations such as cost, convenience and logistics.

Background: Hand hygiene compliance scores in the anaesthetic department of an acute NHS hospital were persistently low. Aims: To determine the feasibility and validity of regular accurate measurement of HHC in anaesthetics and understand the context of care delivery, barriers and opportunities to improve compliance. Methods: The hand hygiene compliance of one anaesthetist was observed and noted by a senior infection control practitioner (ICP). This was compared to the World Health Organization five moments of hand hygiene and the organisation hand hygiene tool. Findings: In one sequence of 55 min, there were approximately 58 hand hygiene opportunities. The hand hygiene compliance rate was 16%. The frequency and speed of actions in certain periods of care delivery made compliance measurement difficult and potentially unreliable. During several activities, taking time to apply alcohol gel or wash hands would have put the patients at significant risk. Discussion: We concluded that hand hygiene compliance monitoring by direct observation was invalid and unreliable in this specialty. It is important that hand hygiene compliance is optimal in anaesthetics particularly before patient contact. Interventions which reduce environmental and patient contamination, such as cleaning the patient and environment, could ensure anaesthetists encounter fewer micro-organisms in this specialty.

BACKGROUND: Hand hygiene is monitored by direct observation to improve practice, but this approach can potentially cause information, selection, and confounding bias, threatening the validity of findings. The aim of this study was to identify and describe the potential biases in hand hygiene compliance monitoring by direct observation; develop a typology of biases and propose improvements to reduce bias; and increase the validity of compliance measurements. \ud \ud METHODS: This systematic review of hospital-based intervention studies used direct observation to monitor health care workers' hand hygiene compliance. \ud \ud RESULTS: Seventy-one publications were eligible for review. None was free of bias. Selection bias was present in all studies through lack of data collection on the weekends (n = 61, 86%) and at night (n = 46, 65%) and observations undertaken in single-specialty settings (n = 35, 49%). We observed inconsistency of terminology, definitions of hand hygiene opportunity, criteria, tools, and descriptions of the data collection. Frequency of observation, duration, or both were not described or were unclear in 58 (82%) publications. Observers were trained in 56 (79%) studies. Inter-rater reliability was measured in 26 (37%) studies. \ud \ud CONCLUSIONS: Published research of hand hygiene compliance measured by direct observation lacks validity. Hand hygiene should be measured using methods that produce a valid indication of performance and quality. Standardization of methodology would expedite comparison of hand hygiene compliance between clinical settings and organizations.

The use of vascular access devices (VAD) is common in healthcare provision but there is a significant risk of acquiring an infection. Central venous catheters (CVC) are associated with the highest risk of intravenous catheter-related bloodstream infection (CRBSI). 3M™ Tegaderm™ CHG IV dressing is a semi-permeable transparent adhesive dressing with an integrated gel pad containing chlorhexidine gluconate 2%. This product was reviewed by the National Institute for Health and Care Excellence (NICE) in 2015, recommending that Tegaderm CHG could be used for CVC and arterial line dressings in high-dependency and intensive-care settings. This article discusses issues around CRBSI, interventions to reduce the risk of CRBSI, and the use of Tegaderm CHG dressing.

Background\ud \ud Monitoring results showing poor hand hygiene compliance in a major, busy emergency department prompted a quality improvement initiative to improve hand hygiene compliance.\ud \ud \ud Purpose\ud \ud To identify, remove, and reduce barriers to hand hygiene compliance in an emergency department.\ud \ud \ud Methods\ud \ud A barrier identification tool was used to identify key barriers and opportunities associated with hand hygiene compliance. Hand hygiene imperatives were developed and agreed on with clinicians, and a framework for monitoring and improving hand hygiene compliance was developed.\ud \ud \ud Results\ud \ud Barriers to compliance were ambiguity about when to clean hands, the pace and urgency of work in some areas of the department, which left little time for hand hygiene and environmental and operational issues. Sore hands were a problem for some staff.\ud \ud Expectations of compliance were agreed on with staff, and changes were made to remove barriers. A monitoring tool was designed to monitor progress. Gradual improvement occurred in all areas, except in emergency situations, which require further improvement work.\ud \ud \ud Conclusions\ud The context of care and barriers to compliance should be reflected in hand hygiene expectations and monitoring. In the emergency department, the requirement to deliver urgent live-saving care can supersede conventional hand hygiene expectations.

This book sets out to offer a range of perceptions and perspectives related to infection prevention and control from a number of varying individuals across the health care spectrum. In relation to this as you read through the chapters it will become evident that each of the editors and contributors has offered their own unique and individualistic approach to the subject matter. Further, in some cases the standard academic conventions have been done away with and challenging, emotive and unconventional perceptions and perspectives are offered.

OBJECTIVETo identify, using a novel enhanced method of recovery, environmental sites where spores of Clostridium difficile persist despite cleaning and hydrogen peroxide aerial decontamination.DESIGNCohort study.SETTINGTertiary referral center teaching hospital.METHODSIn total, 16 sites representing high-frequency contact or difficult-to-clean surfaces in a single-isolation room or bed area in patient bed bays were sampled before and after terminal or hydrogen peroxide disinfection using a sponge swab. In some rooms, individual sites were not present (eg, there were no en-suite rooms in the ICU). Swab contents were homogenized, concentrated by membrane-filtration, and plated onto selective media. Results of C. difficile sampling were used to focus cleaning.RESULTSOver 1 year, 2,529 sites from 146 rooms and 44 bays were sampled. Clostridium difficile was found on 131 of 572 surfaces (22.9%) before terminal cleaning, on 105 of 959 surfaces (10.6%) after terminal cleaning, and on 43 of 967 surfaces (4.4%) after hydrogen peroxide disinfection. Clostridium difficile persisted most frequently on floor corners (97 of 334; 29.0%) after disinfection. Between the first and third quarters, we observed a significant decrease in the number of positive sites (25 of 390 vs 6 of 256). However, no similar change in the number of isolates before terminal cleaning was observed.CONCLUSIONPersistence of C. difficile in the clinical environment was widespread. Although feedback of results did not improve the efficacy of manual disinfection, numbers of C. difficile following hydrogen peroxide gradually declined.Infect Control Hosp Epidemiol 2017;38:1487–1492

OBJECTIVES: To determine the effect of enhanced cleaning of the near-patient environment on the isolation of hospital pathogens from the bed area and staff hands. DESIGN: Prospective randomized crossover study over the course of 1 yr. SETTING: Intensive care units at two teaching hospitals. PATIENTS: There were 1252 patients staying during enhanced cleaning and 1331 staying during standard cleaning. INTERVENTIONS: In each of six 2-month periods, one unit was randomly selected for additional twice-daily enhanced cleaning of hand contact surfaces. MEASUREMENTS AND MAIN RESULTS: Agar contact samples were taken at five sites around randomly selected bed areas, from staff hands, and from communal sites three times daily for 12 bed days per week. Patients admitted in the year commencing April 2007 were analyzed for hospital-acquired colonization and infection. Over the course of 1152 bed days, 20,736 samples were collected. Detection of environmental methicillin-resistant Staphylococcus aureus per bed-area day was reduced during enhanced cleaning phases from 82 of 561 (14.6%) to 51 of 559 (9.1%) (adjusted odds ratio, 0.59; 95% confidence interval, 0.40-0.86; p = .006). Other targeted pathogens (Acinetobacter baumannii, extended-spectrum β-lactamase-producing Gram-negative bacteria, vancomycin-resistant enterococci, and Clostridium difficile) were rarely detected. Subgroup analyses showed reduced methicillin-resistant Staphylococcus aureus contamination on doctors' hands during enhanced cleaning (3 of 425; 0.7% vs. 11 of 423; 2.6%; adjusted odds ratio, 0.26; 95% confidence interval, 0.07-0.95; p = .025) and a trend to reduction on nurses' hands (16 of 1647; 1.0% vs. 28 of 1694; 1.7%; adjusted odds ratio 0.56; 95% confidence interval, 0.29-1.08; p = .077). All 1252 critical care patients staying during enhanced and 1,331 during standard cleaning were included, but no significant effect on patient methicillin-resistant Staphylococcus aureus acquisition was observed (adjusted odds ratio, 0.98; 95% confidence interval, 0.58-1.65; p = .93). CONCLUSIONS: Enhanced cleaning reduced environmental contamination and hand carriage, but no significant effect was observed on patient acquisition of methicillin-resistant Staphylococcus aureus. TRIAL REGISTRY: ISRCTN. Identifier: 06298448. http://www.controlled-trials.com/isrctn/.

A model was developed by an infection control department to assist in the delivery of change and innovations in a challenging and complex organisation. It was entitled UNIFIES and was based on the experience gained on previous projects to introduce and sustain changes in practice. The methodology and application included lean systems and social marketing principles. The model takes into account the requirement for leadership, teamwork and time to participate. The use of metrics to determine progress, success, failure and lessons learnt are a keys aspect of the model.

Fourteen NHS hospital ward cleaning staff were interviewed about their background, job satisfaction and motivation as part of the evaluation of a new cleaning system. Four (28%) staff had attended university, five (35%) had no qualifications and the remainder had a range of educational attainments. Nine (64%) did the job to earn money, three (22%) because they liked it and two (14%) because there were no other opportunities. Repetitive tasks were undertaken routinely with tight control of method and order of working. The work was tiring and ad hoc requests increased the burden. Although all staff knew what was expected of them in their job, nine (62%) reported they “knew themselves” if they had done a good job as feedback was frequently absent or belated. Opportunities including access to the internet were limited and long hours doing extra work reduced free time. This pilot study highlights the potential of these healthcare cleaning professionals to contribute and develop given the opportunities.

We compared the performance of Vermop ultramicrofibre cloths/mops (UMF) with water (UMF + water) or impregnated with a novel copper-based biocide (UMF + CuWB50; 300 mg/L) with standard cleaning using cotton mops/cloths with Hospec detergent. Six sites were sampled with contact plates to enumerate total viable (bacterial) counts (TVCs) and with the 3M Clean-Trace ATP assay to assess cleaning efficacy. Statistical analysis revealed that one hour post-cleaning TVC levels were lower when using UMF + CuWB50 (75% reduction) compared with standard cleaning or UMF + water (45% and 35% reductions, respectively). There was a small overall residual effect when cleaning with UMF + CuWB50 (11.7% reduction in TVCs, p = 0.209). ATP levels were reduced more with UMF + CuWB50 than with standard cleaning or UMF + water. UMF( ± CuWB50) cleaning was more effective than standard cleaning (~78% vs. 61% reduction of ATP levels, respectively). This hospital implementation study demonstrates overall superior cleaning performance of UMF, which is enhanced with CuWB50, compared with standard cleaning.

We compared the performance of an ultramicrofibre (UMF)-based system with or without a novel copper-based biocide (CuWB50) with standard cleaning using Actichlor Plus in four hospital wards in a crossover study design, and analysed our results using univariate and multivariate statistics. We measured total viable counts (TVCs) and ATP levels in 10 near-patient sites three times weekly, one hour before and after cleaning. Standard cleaning reduced TVCs further than UMF cleaning with water, but UMF cleaning with CuWB50 produced equivalent TVC reduction. Furthermore we identified a ‘residual effect’ with UMF + CuWB50, conferring TVC suppression for up to a week after application. ATP results did not correlate with TVCs. We conclude that UMF-based cleaning with CuWB50 results in TVC reductions equivalent to hypochlorite-based standard cleaning, with the added advantages of a residual effect that keeps TVCs lower between cleaning rounds.

Multiple routes are proposed within the nursing and healthcare literature for implementing traditional and reflexive research evidence into practice. Knowledge transfer is a relatively new field of inquiry, which, as both a process and a strategy, can lead to the utilisation of research findings and improved outcomes for patients. Nurse leaders and the public have recognised the need to ensure that evidence-based practice is introduced expeditiously. Nurses working at an advanced level of practice, such as consultant nurses, use all forms of knowledge in sophisticated ways to lead the integration of research findings into diverse practice settings. Within healthcare organisations evidence-based practice is far more likely to occur when it is linked to implementing healthcare policy in practice. The current international, collaborative knowledge transfer research agenda includes the need to learn if knowledge transfer programmes, structures, frameworks and theories are working, and if not, why not. The knowledge transfer process is illustrated by consultant nurses using the knowledge-to-action framework to underpin two recent UK policy examples: safeguarding vulnerable adults and the prevention of Clostridium difficile. For the future, clinical academic partnerships are required to foster a culture of evidence-based practice through practical engagement, and the sharing of nursing knowledge and expertise in a systematic way, both to improve patient care and address the current research—practice gap.

Aim: To establish the cost-effectiveness of screen-A ing and treating meticillin-sensitive Staphylococcus aureus (MSSA) carriers, potentially reducing both financial and clinical burdens of managing healthcare-acquired infections. Methods: A decision health economic model analysed the impact of a ‘screen and treat’ strategy for Hospital inpatients from the perspective of the UK National Health Service. Results: Cost savings in excess of £600k and around 840 potential infections could be avoided in a 70,000 patient cohort, at a nasal carriage prevalence of 30%. For 2000 high infection risk cardiothoracic surgery patients, cost savings could reach £8,636 per annum. The dominance of the ‘screen and treat’ strategy holds for plausible variations in the model parameter values and simple modelling of secondary transmission. Conclusion: Adopting rapid screening and treating MSSA nasal carriers should be clinically and financially advantageous, compared to current strategies of not screening, even under conservative assumptions for costs and probabilities of managing infections.

Background Traditional laundry decontamination relies on thermal disinfection that degrades textiles. We investigated the ability of a novel copper-based biocidal compound, CuWB50, to assist in the decontamination of swatches purposely contaminated with Staphylococcus aureus and Acinetobacter during "real-life" low-temperature machine washing with and without 2 commercial detergents. Methods Contaminated and noncontaminated swatches were attached to ballast sheets and washed in cold water for 15 minutes in an industrial Electrolux machine. We assessed colony-forming units (cfu) on the swatches and in the postwash water. Results Low-temperature machine washing produced only partial reductions in viable methicillin-resistant Staphylococcus aureus and Acinetobacter calcoaceticus baumannii counts on swatches and resulted in cross contamination of other swatches in the same wash. Washing with CuWB50 alone at high concentration (100 mg/L), however, resulted in superior decontamination compared with water alone, whereas washing with a combination of detergent and CuWB50 at low concentration (5 mg/L) yielded synergistic and complete decontamination of swatches and postwash water. Conclusion Our results show highly effective laundry decontamination using CuWB50 with detergent at low temperature and are timely both in terms of rising energy costs and textile degradation issues.

Background This study aimed to establish the feasibility and cost-effectiveness of rapid molecular screening for hospital-acquired meticillin-resistant Staphylococcus aureus (MRSA) in surgical patients within a teaching hospital. Methods In 2006, nasal swabs were obtained before surgery from all patients undergoing elective and emergency procedures, and screened for MRSA using a rapid molecular technique. MRSA-positive patients were started on suppression therapy of mupirocin nasal ointment (2 per cent) and undiluted chlorhexidine gluconate bodywash. Results A total of 18 810 samples were processed, of which 850 (4·5 per cent) were MRSA positive. In comparison to the annual mean for the preceding 6 years, MRSA bacteraemia fell by 38·5 per cent (P < 0·001), and MRSA wound isolates fell by 12·7 per cent (P = 0·031). The reduction in MRSA bacteraemia and wound infection was equivalent to a saving of 3·78 beds per year (£276 220), compared with the annual mean for the preceding 6 years. The cost of screening was £302 500, making a net loss of £26 280. Compared with 2005, however, there was a net saving of £545 486. Conclusion Rapid MRSA screening of all surgical admissions resulted in a significant reduction in staphylococcal bacteraemia during the screening period, although a causal link cannot be established.

We investigated three novel highly charged copper-based inorganic biocidal formulations for their activity against organisms highly relevant to healthcare-associated infection.The three copper-based formulations were tested: (i) against clinical isolates of methicillin-resistant Staphylococcus aureus (MRSA), Legionella pneumophila, Acinetobacter calcoaceticus/baumannii (ACCB), glycopeptide-resistant Enterococcus and spores of Clostridium difficile in time-kill assays; (ii) for their ability to decontaminate ultramicrofibre (UMF) cloths; and (iii) for their cytotoxicity to human skin and intestinal epithelial cells.All three copper-based formulations were potently biocidal down to concentrations of 1 ppm for both stationary- and log-phase organisms, and they were all active against C. difficile spores. At 150 ppm, they achieved a complete (6 log10) kill of MRSA and ACCB mostly within 1 h. This biocidal activity was not achieved by copper sulphate or the inorganic binders used in the formulations. All three copper-based formulations completely decontaminated UMF cloths containing MRSA, ACCB or C. difficile spores, suggesting that any of these copper-based formulations would be highly beneficial in the healthcare environment. All three copper-based formulations and copper sulphate were not cytotoxic to human epithelial cells up to concentrations of 100-200 ppm.All three of the novel copper-based biocidal formulations, but not their components (copper sulphate and inorganic binders), have potent activity against organisms highly relevant to healthcare-associated infections.

Introduction The number of national hand-hygiene campaigns has increased recently, following the World Health Organisation’s (WHO) “Save Lives: clean your hands” initiative (2009), which offers hospitals a multi-component hand-hygiene intervention. The number of campaigns to be evaluated remains small. Most evaluations focus on consumption of alcohol hand rub (AHR). We are not aware of any evaluation reporting implementation of all campaign components. In a previously published report, we evaluated the effects of the English and Welsh cleanyourhands campaign (2004–8) on procurement of AHR and soap, and on selected healthcare associated infections. We now report on the implementation of each individual campaign component: provision of bedside AHR, ward posters, patient empowerment materials, audit and feedback, and guidance to secure institutional engagement. Method Setting: all 189 acute National Health Service (NHS) hospitals in England and Wales (December 2005–June 2008). Six postal questionnaires (five voluntary, one mandatory) were distributed to infection control teams six-monthly from 6 to 36 months post roll-out. Selection and attrition bias were measured. Results Response rates fell from 134 (71 %) at 6 months to 82 (44 %) at 30 months, rising to 167 (90 %) for the final mandatory one (36 months). There was no evidence of attrition or selection bias. Hospitals reported widespread early implementation of bedside AHR and posters and a gradual rise in audit. At 36 months, 90 % of respondents reported the campaign to be a top hospital priority, with implementation of AHR, posters and audit reported by 96 %, 97 % and 91 % respectively. Patient empowerment was less successful. Conclusions The study suggests that all campaign components, apart from patient empowerment, were widely implemented and sustained. It supports previous work suggesting that adequate piloting, strong governmental support, refreshment of campaigns, and sufficient time to engage institutions help secure sustained implementation of a campaign’s key components. The results should encourage countries wishing to launch coordinated national campaigns for hospitals to participate in the WHO’s “Save Lives” initiative, which offers hospitals a similar multi-component intervention.

Background: Monitoring of hand hygiene compliance (HHC) by observation has been used in healthcare for more than a decade to provide assurance of infection control practice. The validity of this information is rarely tested. \ud \ud Aim: To examine the process and validity of collecting and reporting HHC data based on direct observation of compliance.\ud \ud Methods: Five years of HHC data routinely collected in one large National Health Service hospital trust were examined. The data collection process was reviewed by survey and interview of the auditors. HHC data collected for other research purposes undertaken during this period were compared with the organizational data set.\ud \ud Findings: After an initial increase, the reported HHC remained unchanged close to its intended target throughout this period. Examination of the data collection process revealed changes, including local interpretations of the data collection system, which invalidated the results. A minority of auditors had received formal training in observation and feedback of results.\ud \ud Conclusion: Whereas observation of HHC is the current gold standard, unless data collection definitions and methods are unambiguous, published, carefully supervised, and regularly monitored, variations may occur which affect the validity of the data. If the purpose of HHC monitoring is to improve practice and minimize transmission of infection, then a focus on progressively improving performance rather than on achieving a target may offer greater opportunities to achieve this.

We assessed the ability of the residues of an alcohol-based hand gel (hand gel A) and an Aloe vera-based CuAL42 copper biocide-containing hand gel (hand gel B), to support the survival of meticillin-resistant Staphylococcus aureus (MRSA) and Acinetobacter calcoaceticus-baumannii (ACCB). One-millilitre samples of hand gels A and B were spread over marked 20 cm2 areas and dried overnight. MRSA or ACCB (1 × 104 CFU) were spread onto the dried residue and contact plated at various times. MRSA and ACCB survived for 8 hours on hand gel A residue, whilst MRSA did not survive on hand gel B residue and ACCB survived less than 30 min. Low concentrations of hand gel A facilitate the growth of ACCB, but this is not the case for hand gel B. Hand gel A is extensively used in UK hospitals and its residue left on high-touch surfaces may support the survival of bacteria that cause healthcare-acquired infections.