On a cold and dreary day early in March, one of those days where nothing seems to be going quite right, I started to receive messages from my fantastic compatriots in the Infection Prevention Society (IPS) IV Forum suggesting that I was hiding something. Feeling totally confused, they revealed to me that I had been shortlisted for the Vascular Access Nurse of the Year Award – I was and remain totally amazed as I had no idea that they had nominated me. I am immensely honoured to receive this award, but feel it is vital to make it clear that this would not have been possible without the support of my colleagues, who continue to work with me both on the development of a vascular access bacteraemia surveillance tool, for which I was nominated, and within my working role in the IV Team and Infection Prevention Team at the Royal Wolverhampton NHS Trust.
The majority of my career has been dedicated to critical care nursing. I found critical care an immensely rewarding specialty, and felt privileged to be part of a team of professionals caring for patients, while supporting their families and friends through the most stressful of life experiences.
Life-threatening infections
I enjoyed the strong teamwork that results; however, I was keenly aware of the risks faced by acutely ill patients requiring support from the multitude of invasive devices necessary for their recovery. The life-threatening harm that can result from device-related infections became increasingly apparent as a senior nurse, made especially upsetting when considering that these can result from preventable issues surrounding device insertion and ongoing management. My work with the Wolverhampton Infection Prevention Team to reduce these infections, with many interventions based on implementation of the Matching Michigan Project recommendations (Bion et al, 2013), led to my furthering my career within patient safety, following on to the creation of a nurse-led IV/Outpatient Parenteral Antimicrobial Therapy (OPAT) Team, where I currently work. This role continues to require the surveillance of bacteraemias across the organisation related to all invasive devices, from urinary catheters to pacemakers, referred to as device-related hospital-acquired bacteraemias.
Teamwork to solve a problem
As a result of the many years that I have been involved with this surveillance, I realised that, despite extensive work by both myself and my team, especially our fantastic healthcare assistants during daily data collection, the eventual establishment of an accurate vascular access device (VAD) infection rate per 1000 indwelling line days did not enable easy cross-comparison with other organisations. And I could find little reliable data to make our results meaningful. I rapidly realised that the inability to assess our own performance against that of others originated from a variety of issues, including a lack of standardisation of vascular access-related bacteraemia criteria and definition of included devices.
While co-ordinator of the IPS IV Forum, I started to focus on how this could be achieved by working with other trusts, and the inception of the Device Related Infection Prevention Practices (DRIPPs) collaborative, supported by BD, has really enabled the implementation of this work.
The DRIPPs project consists of two dedicated workstreams, focused on the provision of up-to-date evidence-based resources created to assist healthcare workers in the reduction of infections associated with the two main groups of medical devices: urinary catheters and VADs. An initial workshop to identify what resources would be helpful was attended by a wide variety of healthcare workers at a launch event in 2019, following which specialist nurses from associated professional organisations worked together in small groups towards their creation.
Surveillance tool
My pre-existing interest in creating a standardised method of reporting VAD-associated bacteraemias led to my involvement in the creation of a surveillance tool. I and my colleagues from other organisations recognised that we needed to ensure simplicity and ease of use of the documents to be created, as we wanted them to be available to all healthcare staff whatever their levels of support and available resources. There was also an awareness of the necessity for agreement on three crucial elements required in order for surveillance to be cross-comparable, these being the criteria for VAD infection, the terminology used to describe different device types and a standardised method of calculation of device infection rate.
First, we focused on the criteria to be adopted for VAD-related and associated bacteraemias. As critical care units across the NHS have already adopted a definition from Public Health England for quality improvement work (Gerver et al, 2018), it was felt appropriate for this to be adapted for use with all VADs in all clinical areas. Second, as there exists widely differing terminology used by different organisations when referring to an increasing variety of VADs, we decided to use the nomenclature devised by Schults et al (2021) as this is comprehensive and enables wide coverage of device type.
Third, we considered how to express a rate. The gold standard reporting of bacteraemias per 1000 device days is notoriously difficult to achieve, often due to the challenges in obtaining accurate device removal dates. It was therefore decided to guide users of the tool on how this can be calculated primarily if line dwell days were available to them, but also to demonstrate how other more simple comparisons of rate could be achieved, for example per 1000 bed days, often readily available from organisations' information departments. The simplest to achieve, and additionally included, is recording and feedback of the number of days since the last device-related bacteraemia, which, although only a snapshot statement, can prove powerful for staff teams and is easily displayed in clinical areas.
The initial version of the toolkit was then completed with the addition of a template for reporting back to departments or organisations, depending on the size of the work undertaken. Detailed explanatory supporting notes to encourage and guide the user during implementation were also provided.
Testing and innovations
The toolkit was tested for some time with the assistance of a colleague in a similar role in a central London NHS Trust, prior to distributing to a wider group of vascular access and infection prevention specialist nurses in 2021. Excitement surrounding the potential use of the tool attracted additional innovation to the project, adding more skills and approaches brought by the new professionals involved in the work. A colleague from Luton and Dunstable University Hospital came up with the ingenious idea of creating a score system attached to the bacteraemia definition to identify if a bacteraemia is either line associated or related. Another colleague from Liverpool shared the Excel workbook they had developed for line-associated bacteraemia surveillance, and a third member of the group with data analytical experience combined the original toolkit with the bacteraemia calculator to make the current Excel workbook-based document. This development further enables the immediate provision of graphical data to provide a visual reflection of the data collected, highlighting areas of concern where additional support may be best focused and high-quality care improvements initiated.
Criteria for the definition of paediatric and neonatal line infections have now also been added to the calculator, making the tool applicable for use in any hospital-based healthcare system. The working party is now using the document to compare VAD-related infections within our home organisations and for the first time can compare our performance immediately in a standardised supportive fashion.
Initial launching of the document in November 2022 at the IPS IV Forum conference received an enthusiastic welcome from both within the NHS and further afield and we are now seeking funding to support the creation of a software application, potentially as part of a suite of urinary catheter and intravenous device care tools resulting from the DRIPPs collaborative work. This would help to ensure a robust foundation to the surveillance tool, making it more user friendly for clinical teams already facing extensive pressure in their daily roles.
As a group we are excited about the potential use of the document in quality improvement work in future, and are hopeful that it will support future initiatives to improve patient safety relating to the care of VADs.
Recognising a team effort
I believe I was nominated for this award in part as a result of the persistence demonstrated throughout the pandemic. Yet, bizarrely, the pandemic afforded me the opportunity to maintain contact with distant colleagues through that most isolating of times for healthcare workers. I found this hugely supportive. As a result, on a personal basis, I have found this work extremely rewarding and have immensely enjoyed working with my peers from other NHS trusts. It has gone some way to breaking down the silos of care that can exist within organisations when not working together collectively.
I appreciate greatly the friendships that I have gained as a result of this work, and it is only as a result of their dedicated support, energy and innovative creative input that the surveillance tool has come to be. I remain delighted to have received this award, but the wider team must also gain future recognition as this tool gains strength with further development.
Here's to nurses and what we can achieve by working together to improve care for our patients!