In 2022, a pilot scheme of seconded harm-free care nurse specialists was introduced by the Newcastle upon Tyne Hospitals NHS Foundation Trust. These roles were introduced to focus on several aspects of harm, including urinary tract infection (UTI), catheter-associated urinary tract infection (CAUTI) and intravenous (IV) line safety and awareness. As the two seconded harm-free care nurse specialists, we worked closely with the infection prevention and control (IPC) team, as well as the specialist continence service and anaesthetics department, to provide direct and indirect care Trust-wide. The primary focus was the reduction of infection through surveillance, education and auditing.
A variety of small-scale focused quality improvement (QI) projects were implemented in a number of clinical areas throughout the Trust, alongside targeted education relating to harm-free care, embedding gold standards of best practice. Clinical areas that required intervention to reduce instances of infection and improve patient care outcomes were a prime focus throughout the QI projects and targeted education. These areas were identified through surveillance and audit work.
UTI and CAUTI prevention
The aim of the project led by the harm-free care nurse specialist for UTI and CAUTI prevention (Amy Griffiths) was to implement and promote best practice for UTI and CAUTI and to reduce the number of urinary catheters in situ to assist in achieving an overall reduction in Gram-negative bloodstream infections. The project involved monthly surveillance of urinary catheters, clinical ‘walk arounds’, targeted education, and support with patient reviews across multiple directorates. Pre- and post-education questionnaires were used to measure improvement in staff knowledge.
Both a proactive and reactive approach was used throughout the QI project. Proactively, urinary catheter surveillance was captured 1 day each month to provide a snapshot image of the average number of urinary catheters in each clinical area. Data were analysed and fed back to clinical areas on a regular basis. The surveillance enabled the number of urinary catheters that were in situ for more than 28 days to be counted, as well as those that were in situ on admission from the community, patients being actively treated for a UTI, those with suprapubic catheters and patients undertaking intermittent catheterisation. In areas found to have a significant increase in the number of urinary catheters, a reactive approach was taken to investigate why the increase had occurred and staff education and support with patient catheter reviews was provided to these areas.
IV line safety
The aim of the QI project led by the harm-free care nurse specialist for IV safety (Pasqua Fitzgibbon) was to improve IV device care and management, increase staff knowledge, and improve compliance with correct care. The overarching aim was to reduce healthcare-associated infections associated with methicillin-resistant Staphylococcus aureus bacteraemias across many directorates. Baseline audits were carried out and staff questionnaires were distributed to build an understanding of current practice and knowledge prior to the project implementation. Clinical walk arounds and education sessions were then implemented to standardise equipment use and ensure best practice guidelines were followed.
Staff engagement
Although the QI projects were run separately in relation to each specialty, we worked very closely together to improve staff engagement and deliver targeted education. Staff engagement and building rapport were very important to us as we wanted to adopt an open culture for staff to feel confident to seek guidance, support and additional training. This significantly contributed to the success of the projects.
Throughout the projects we worked collaboratively with many different staff and specialist services, including the infection control team, clinical educators, ward sisters and charge nurses, and harm-free care leaders. We also received regular feedback from our individual teams and managers for support and guidance. A multidisciplinary, collaborative approach contributed to the success of the projects.
Education
Harm-free-care-targeted education had a primary focus of supporting clinical areas to achieve the outcomes of local and national standards, advocating gold standards of best practice to improve staff engagement, patient safety and care. Targeted education was implemented through a series of different methods to capture large numbers of staff with numerous different learning styles.
One-to-one and patient-focused education was carried out with staff across clinical areas. In addition to these sessions, visual education tools, including display boards and posters, were created and displayed in many clinical areas as a visual learning guide and a visual prompt of best practice guidance relating to harm-free care targeting UTI, CAUTI and IV lines. Planned education sessions were arranged with clinical areas to ensure best practice guidance was followed and to ensure staff competence.
However, with the increasing strain on NHS services and staffing pressures it became more difficult to pull staff away from clinical areas for education and training, therefore we had to revaluate our education styles to coincide with the rising pressures.
Drop-in sessions
Drop-in education sessions were restarted within the Trust and were led by the harm-free care nurse specialists. They were given a 3-4-hour time slot in a single location and staff were simply able to drop in and out of the session when able. Sessions were designed to provide very short, snappy updates around aspects of harm-free care without the need to take staff away from clinical areas for long periods at a very difficult time in healthcare. These sessions originally worked very well, and we encouraged many nurse specialists from a wide range of specialties to join with us for these sessions to give updates to staff on many different aspects of harm-free care.
Staff from all disciplines attended these sessions, including healthcare assistants, student nurses, physiotherapists, ward management, staff nurses and doctors. We received fantastic feedback from these sessions, and staff liked the informal education style and felt it was a good opportunity to ask questions and discuss any concerns.
‘Trolley dash’ education
As we moved towards winter pressures, the attendance at the drop-in sessions started to decline. Therefore, we had to look at other ways to educate our staff. This is when the ‘trolley dash’ was implemented. The ‘trolley dash’ was pioneered by the harm-free care nurse specialists to give important education and practice updates to staff in clinical areas without removing them from clinical areas. We simply took an education board on wheels to the clinical areas and carried out bite-size education sessions in the ward, usually at the nurses' station. These sessions were very short, lasting no longer than 10 minutes each.
‘We received enthusiastic feedback from staff, who enjoyed this informal, concise update style of education’
We received enthusiastic feedback from staff, who enjoyed this informal, concise update style of education and felt that, because it took place in their clinical area, they could ask questions relating to specific patients under their care. Often support would be provided for care plan management to support care in line with best practice. This enhanced the confidence and knowledge of staff.
After the proven success of this education style, the ‘trolley dashes’ were introduced into many other clinical areas and around 1517 staff were educated across the Trust in this way over a 10-month period. These dashes have since been replicated by many other services within the Trust, including the IPC team, practice development nurse specialists, clinical educators, and other specialist teams. This focused QI work and targeted education style has since been shared with staff in other NHS trusts, who have now replicated this education style following our success. Widespread advertising of education sessions contributed to the success of the project and attendance at education sessions. Advertisements were shared through the Trust intranet, posters and through our harm-free care newsletter.
Results
The focused QI project and targeted education work has had several positive results. An increase in patient safety was the most significant outcome and this was demonstrated through a reduction in infection rates and a reduction in the number of inappropriate urinary catheters and IV lines within specific clinical areas. Staff knowledge and awareness of gold standard best practice was also significantly improved by up to 23% in some areas, which led to better patient outcomes.
This work highlights that focused QI projects have a positive impact due to their targeted approach and ability to concentrate on specific aspects of harm-free care.
We are delighted that this work has been highlighted and commended with a Bronze award in the Infection Prevention Nurse of the Year category of the BJN Awards 2023 and we hope that, by sharing details of our work, this will allow other services to replicate similar work within their own areas.