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  • Writer's pictureLilian Chiwera

Reactive global IPC measures – are they a sign of a false economy?

I couldn’t help but start this blog with the Duchess of Cambridge’s festive message: the Covid pandemic has made us realise how much we need each other! How true this is. Within #InfectionPrevention prevention and I would like to believe that in many other walks of life, covid has brought all of us closer together. This brings to life #IPCWithoutBorders! I must say that I managed to shock myself this year & possibly many others by starting to be drawn more towards global infection prevention and control (IPC), adding to my tireless campaigns promoting the global uptake of surgical site infection (SSI) surveillance & prevention. As mentioned in my previous blog: ‘No patient wants to be that 1% or 0.0001%’ which is below the national average! This applies to all patients, irrespective of where they are residing. As I told one of our #SurgicalSiteInfection #SSI local champions recently, I now want to change the #SSIPrevention world! It’s true, my wish is to continue sharing acquired generic IPC and SSI knowledge across the UK and beyond. So how did I get on this year with #IPCWithoutBorders?

My journey started with presentations for university students in Zimbabwe after being introduced to Marcelyn by Felicity. Wow, what a journey it’s been since. Not only have I undertaken presentations via zoom and am scheduled to do more; I have also managed to facilitate Zimbabwe’s affiliation with the Infection Prevention Society (IPS), thanks to Rafaela Franca (IPS international Engagement Committee Coordinator). I look forward to seeing more countries following suit. This has been a huge achievement for me over and above my many achievements in #SurgicalSiteInfection #SSIPrevention. I say a huge achievement for me, but in fact, all my achievements to date have been realised through collaborative working partnerships with teams and individuals I have worked with so far who have all been brilliant – thank you for your love and support!

I also managed to join Friends of African Nursing (FoAN) and Infection Control Africa Network (ICAN) online conferences this year for the first time ever. I didn’t know much about these organisations before, but this #Covid pandemic shifted my thinking. After spending some time on the frontline during the first wave of the pandemic; an experience which was sobering in many respects, I decided to engage more in #IPCWithoutBorders work. Why then did my focus shift from just a strong #SSI focus to a more generic global IPC focus? The simple answer is – it dawned to me how so interconnected we’re globally from an infectious disease perspective. Well, surely this can’t be a new concept, someone is probably whispering that to me… Yes, it’s not a new concept, I know, but being involved with a pandemic first-hand, rather than just reading about it has been an eye opener. An infectious disease problem in Africa or any country in the world, if not managed well can easily become a global problem – see my Twitter remarks here. I highlighted Professor Tim Walsh from Oxford University ‘s comments in a previous blog - ‘a problem currently seen from afar will quickly come into focus much closer to home.’ So, I will continue active #SSI campaigns but in my spare time, I will also find opportunities to share #IPC #SSI messages with the global community.

So, what did I learn from global IPC interactions in 2021?

We all know that most settings in African are financially challenged, I would like to think that with this current pandemic, all countries are financially challenged to a certain extend as they have had to secure or borrow funding to support failing businesses and unemployment, as well as pump more money into the development of covid vaccines. With this virus that causes covid constantly mutating, governments are having to find more resources to support ongoing vaccination campaigns. It’s been challenging! So, if it’s this challenging in first world countries, what more in developing countries?

In my first presentation to Zimbabwe University students, I challenged many of their thinking about poor resources being a hindrance to robust infection control surveillance programmes in the country. To a certain extend yes but given the many organisations like IPS who offer membership at discounted rates, surely, they should be able to convince their healthcare leadership to fund education that will make a difference for all patients locally or globally. Furthermore, they should work hard to convince local policy makers to provide more funding whenever possible. As an example, they could do pieces of work to demonstrate healthcare acquired infection costs locally and then use their data to request funds. I challenged them to go back and be the change they wanted to see in others! I really hope I will hear positive news and outcomes. I gave an example of the work I undertook with colleagues at Guy’s & St Thomas’ NHS Foundation where we demonstrated significant cost savings through championing robust SSI data collection & utilisation to improve patient safety; to let them know it can be done. Achieving academic qualifications is important, but in this case, I wanted students to go back to their settings and convince their mangers to start and support ongoing IPC surveillance programmes.

A question for those in academia

How many of your students undertake dissertations with funding that is available to them through their universities or colleges, or through other grants or research funds? How many of them subsequently use their study findings to change practice and are they supported to do so? What if they are junior doctors on rotations who start a project then leave it unfinished as they move to their next placement? Is funding solely there to develop students so they can pass their courses and move on with their lives? I’d ask further - what benefit is any research work that is undertaken by students in healthcare settings if there are no means to facilitate utilisation of findings for continual quality improvement? If audits are undertaken for example, and the results are not fed back to those who can use the information to inform and improve patient outcomes, what use are they? ‘This is not good enough’ was my take home message to all students who promised to get back to their facilities and speak to their managers. Whether these students did as they said they would, considering all other competing priorities, remains to be seen.

Feedback and follow up

In my #SSIPrevention journey to date, feedback of surgical site infection incidences to clinicians and following up SSI detailed investigations and associated action plans was a pinnacle to our success. I remember telling my colleagues at the very beginning that if my job was all about data collection, then I was not interested in pursing it. I found myself spending more time with clinicians following this up or feeding back data rather than being in the office ‘crunching data’ during initial campaigns. This made the biggest difference in my opinion. I will therefore follow up and evaluate any work that I undertake for global infection prevention to ensure that it is worth the time invested. I want to see change and am hoping to hear good stories coming from Zimbabwe!

Proactive vs. Reactive IPC

I listened to fantastic presentations from the ICAN conference, hearing all about work that had been done is several countries to establish the status quo from an #InfectionPrevention perspective. Some countries did gap analyses and identified work that is needed. However as most allude to, funding for continuity and establishment of sustainable IPC programmes is often lacking. Funding for studies is good, but what happens afterwards to me is the most important aspect to consider before funds are issued in my opinion. Why would anyone fund a project, and not do anything about outcomes from that project? Perhaps, the project is done by a student as part of their academic qualifications, as mentioned above, I’d be thinking that even educational institutions must be thinking about how to use data they collect via their students to inform and improve experiences globally. This does not apply only to Africa, but all countries so I think food for thought here for all of us!

One speaker mentioned that IPC scores were introduced during an #Ebola outbreak in one country, only to be dropped after the outbreak, but guess what? There was another outbreak after this IPC scoring system was dropped. This highlights problems associated with reactive #IPC. We need continuity, thus anyone considering funding a project or audits should already be thinking about how they can fund or support any work that emanates from outcomes or recommendations from that piece of work. So, how is this going to be monitored? I believe this can be done with domestic or donor funds and I certainly have ideas on how monitoring can be done. We need proactive approaches, and we need them now, let’s not wait for another potentially worse pandemic than the current one before prioritising PROACTIVE rather than REACTIVE IPC. I actually heard someone saying: ‘IPC IS NOT JUST FOR OUTBREAKS’. I’d say, let’s do good proposals and generate data we can use to ask for more funding for sustaining IPC services globally. For anyone funding a project, be prepared to provide more funding for follow up work and most importantly funding to embed best practice recommendations arising from proposed projects or research work into stable IPC programmes. Clear communication between researchers and policymakers is required. But where will novice researchers get confidence to raise their voices when they feel their work could make a difference to the lives of many? I feel those in positions to influence should shout out loud! In an article for the Health Services Journal (HSJ), Neil Wigglesworth says ‘cutting infection prevention funding is a false economy and I would add that lack of infection prevention funding is also a false economy. In the context of student education of those funding research projects, and proactive vs. reactive IPC; I’d say let’s take our time to think of the bigger picture. We should prioritise proactive IPC by investing in programmes that will truly transform patient safety globally. This will save us lots of money in the long run and will help us to better the health for all, so we’re not ‘firefighting’ all the time and losing more money in the process.

Why does IPC have to be like a battle where you’re fighting to win hearts and minds?

One speaker suggested talking about mortality linked to #HCAI to win hearts and minds. From their experience, using this method improved compliance and engagement. This is a fantastic idea, but I was left wondering – do we need to wait until someone dies of an infection or it’s been declared a serious incident before we start acting. From my experience in pharmaceutical industry, we were taught that we had to get things right first time every single time because the costs of non-compliance were just too high. Imagine not getting the right ingredients in an intravenous fluid bag or sending a product out to the market that is contaminated!! It was e never event and so I feel we should all endeavour to ensure our systems are designed right and staff adequately trained, empowered, and supported to deliver the best outcomes for our customers or patients. In this case, we need IPC programmes that are fit for purpose. I have used #InThisTogether many times during this pandemic and I’m positive everyone now acknowledges that in #InfectionPrevention, the actions of one person does affect all of us. Now let’s use our collective voices during this pandemic or any outbreaks to bring about and maximise opportunities. Mentorship and supportive supervision will certainly help to enable us to meet sustainable development goals globally, most importantly saving as many lives as we can.

Another key theme coming from the ICAN conference was the infodemic problem. Lay people are suffering most from the infodemic during this pandemic. We have seen how this has affected vaccine uptake globally at a critical time in our lives. Where do we even begin? Some beliefs and mistrust people have, are so deep rooted! With a reported link between poor infrastructure or WASH and infodemics. IPC practitioners in developing countries need lots of support to empower them to tackle some of these issues. I have read stories of people who died after refusing or after postponing vaccination due to the infodemic problem, this is heart-breaking. I encourage all of us to play a part in spreading the right messages to combat this problem. Let’s not give up, we must keep going!

The FoAN online conference presented to me another thrilling experience. How knowledgeable all speakers were! I felt there was a lot of good messages that came through and some feedback on work being undertaken. I still wanted to hear more about what is really happening on the ground to demonstrate that people were utilising the knowledge acquired over may years. Perhaps this has been happening in previous conferences so I may well have missed that feedback. To reassure myself and as part of my feedback to conference organisers, I highlighted my desire to see more action from Africa rather than just ‘preaching best practice’. In other words, it would be nice to hear them saying, we did this audit, and this is what we found then did blah blah blah, look where we’re now! I always refer to what Neil Wigglesworth says in his #HumanFactors #Ergonomics talks when he quotes Russ et al 2013 - ‘training is a weak #PatientSafety intervention.’ Yes, I would love to provide more training and education for others but would very much want to get feedback and follow up plans where action is required, otherwise Neil will think I’m just wasting my time lool! I have been privileged to undertake #SSI presentations in many NHS hospitals in the UK so support those establishing their #SSI surveillance and prevention services and am delighted to see progress that some are making! I will need to follow up on some of my friends progress though as some work has been disrupted by this current pandemic. I look forward to seeing progress being made also in Africa in due course.

I want positive feedback but…

It’s a wonderful feeling to see people you have supported excel in #SSIPrevention. For me, it’s always a beautiful feeling when my work prevents another patient from getting that avoidable SSI or harm. My down to earth, wonderful dad with a heart of gold was a teacher for 47 years! I have often heard people say how much they appreciated my dad during their school years and how they went on to be so successful in life. This makes me even wonder how many nurses, doctors, teachers, admin staff and people with various other professions my dada taught and never complains about why some of them didn’t come back to say thank you. I admire teachers – they educate millionaires and yet most of them spend their lives struggling to make ends meet. Think about it! So yes, in as much as I want results from all my IPC or SSI education sessions, I must acknowledge that in some instances things will not go according to plan but that should not stop me from doing what I believe is right. That said, we should aim to consistently apply the PDSA cycle and aim to get positive results or experiences in any quality improvement work that we undertake. I’m always open to us learning and improving things together whenever possible and in the talks, I have done so far, I can testify that I have gained lots of new knowledge whilst sharing what I know.

We need each other more now than ever before

In the Duchess of Cambridge’s own words – indeed covid has made us all realise how much we all need each other. I concur with her words on Britain’s kindness and goodwill! This is where I say I’m proud to and feel lucky to be living in Britain where all this kindness and goodwill is flourishing. My parents have always been the kindest and generous people I’ve ever known 😊. Despite them not having much for us, they have always extended a hand to help someone else less fortunate. Now with this upbringing combined with Britain’s kindness & goodwill spirit, I’m sure you can now see where this desire to help others is coming from. I do not have enough money myself but that will never stop me from trying to help others with knowledge that I acquired from other people’s kindness and generosity. I am delighted to have been collaborating with the Surgical Infection Society Europe (SIS-E), a society focusing on surgical infections with sister societies in North America and Asia. I look forward to continuing this collaborative knowledge sharing partnership together with other societies in the United Kingdom (IPS, Hospital Infection Society (HIS), Cardiac SSI Network, One Together, Get It Right the First Time (GIRFT), Federation of Infection Societies (FIS) and many others globally. I must never forget to mention Neil, my former boss who gave me lots of opportunities to develop myself for the benefit of many people in the UK and across the globe.

To conclude, our global response to this pandemic has been fantastic to date although inequalities in vaccination coverage still exist. The infodemic problem is a new global challenge we must all fight, as it’s certainly impacting vaccine update. It’s great to see that numerous collective global efforts were evidenced during country lock downs and raising funds for producing much needed vaccines as everyone tried their best to curb the spread of the virus that causes Covid. Let’s not forget however, that reactive IPC is like operating on a false economy. If we use money to invest wisely and support good IPC programmes globally and hopefully prevent many infectious diseases and associated problems linked with lack of water, sanitation and hygiene (WASH) infrastructure / facilities globally for example, then we’re being prudent with our resources. If we’re constantly donating money to firefight rather than careful investments in the first place, perhaps we ought to rethink our approach in my opinion. From what I heard from ICAN conference, there are a lot of people keen to make changes who don’t want to just rely on donations. So, for those in a position to donate money, let’s think about how we can support the development of sustainable #IPC programmes, not only in Africa but throughout the world so we aim to get it right first time for each patient. We all know how costly infections are so carefully investing our money will have enormous human and economic positive outcomes. I think reactive global IPC measures may be a sign of a false economy.

Well, it is nearly Christmas, a time to be Merry and to be generous. Don’t say I never do anything for you, I pay a monthly subscription to keep you entertained with my blogs. So, this blog is my gift to you all, make sure you read it 😊.

Thank you all for your support in 2021. Merry Xmas & here’s hoping 2022 will be better for us all.

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