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  • Writer's pictureLilian Chiwera

To mandate or not to mandate Healthcare Associated Infection surveillance?

In my experience of working in Infection Prevention over several years, I have heard of the term ‘mandatory data’ countless number of times. So I have asked myself on numerous occasions - Is it mandates that drive us locally or it’s the passion or desire to promote #PatientSafety & reduce all avoidable infections? During many of my talks, I have come up with what I call my personal quotes because no one has the courage to quote me lol 😊. One of my favourite quotes is ‘No patient wants to be that 1% or 0.0001%’ which is below the national average! I like this quote very much because even if your organisation rates are low, we should still aim for zero avoidable harm. Here’s why:

a) if it, was you, you would not want to be the one who gets an infection that doesn’t get reviewed because the organisation is within the set standard for compliance with mandatory regulations

b) being an advocate for our patients requires us to have a ‘do unto others as I would have them do unto me’ attitude. In other words, if I was looking after me, I’d do everything possible to prevent avoidable harm

c) as Florence Nightingale would say: Do the sick no harm; therefore, our aim should always be to aim for the moon and if we miss it we’d land on the stars.

Of course, I acknowledge that in some circumstances, infections are unavoidable due to clinical indications for surgery for example, i.e., someone presenting with a perforated bowel with ‘4-quadrant’ pus. Even then, I still feel that in patients with similar comorbidities, if some have residual infection after surgery and others don’t then perhaps peer reviews may be recommended to provide an opportunity to learn from each other. I believe that in anything we do, there’s always room for improvement.

What are HCAI mandates, and do they really work?

Mandatory healthcare associated infection (HCAI) surveillance outputs are used to monitor progress on controlling key health care associated infections and for providing epidemiological evidence to inform action to reduce them’. Previous work suggests mandates work when used to performance manage as in the case of MRSA bacteraemia in England. I would love for mandates to be used to create friendly competition which leads to improved performance and patient outcomes. I use the term friendly competition, as I feel this is the best way of using these mandates especially when making data comparisons with others. Using mandates for punitive purposes can be useful where patient safety is at risk, but I don’t think this should be the norm. A ‘no blame culture’ should be adopted at local level to enable human factors approaches to be adopted which facilitates consideration of system design elements and other operational pressures. When it comes to sharing data widely, you need good surveillance data that is utilised or shared across all settings in a transparent manner for accurate benchmarking that engenders growth and improvement in those organisations with room for improvement. Without good, standardised surveillance methods, it can be difficult to utilise mandates appropriately especially in SSI surveillance. I previously shared Jon’s reflective blog on the English MRSA miracle which clearly highlights a success story that came about because of strictly mandating collecting and reporting of this data. So yes, mandates do work, but in my opinion, we must make sure we use similar data collection methods & that we utilise data in a non-punitive way particularly in surgical site infection #SSI surveillance and prevention to promote transparency.

I ‘mourn’ a lot about why we only mandate orthopaedics SSI surveillance in England and not cardiac or caesarean section (CS) for example. My colleague Melissa Rochon has done lots of work in cardiac SSI surveillance and prevention; work which has helped many organisations within the #CardiacSSI network. This is fantastic work which must be applauded. So why hasn’t anyone taken notice and mandated cardiac SSI surveillance yet? It’s not that I don’t acknowledge the devastation that is brought about by an infected prosthetic joint, I do. However, I do wonder though that having seen what mandating #SSI surveillance in orthopaedics has achieved in terms of improving patient outcomes, why not make it norm for all the other surgical specialties and fund good surveillance that enables us to generate data that can be used to inform and improve clinical practice?

A pilot study done by Public Health England on CS SSIs, highlighted that CS SSIs are associated with a significant human and economic burden which can be alleviated by good HCAI surveillance. So why is this not mandatory yet? Well, I’m sure someone is already saying we don’t have money for it. I have shared many times the work in adult cardiac surgery that we conducted in my current Trust where we demonstrated significant savings by having a small team coordinating SSI surveillance for a large organisation. Read our published paper here if you don’t believe it can be done. Furthermore, our work on CS SSI surveillance and prevention clearly demonstrates benefits of good HCAI surveillance. As already highlighted above, cardiac surgery and CS surgery are not mandated SSI surveillance specialties in England. So, what drove us? The simple answer is we wanted to make a difference for our patients. Multidisciplinary teams were ready to collaborate with our infection control surveillance team to collect vital SSI data that could be used to inform and improve our surgical pathways, thereby promoting safe surgery. Didn’t we do well? Our results suggest we replicated that English MRSA miracle from Jon’s reflections, this time on surgical site infections. I hope this justifies why SSI surveillance should be mandated for all surgical specialties.

So, what then – to mandate or not to mandate?

I think we should consider mandatory HCAI reporting, that includes SSI surveillance for all surgical specialties. Funding should be provided to organisations to undertake good HCAI surveillance that enables data to be utilised to inform and improve clinical practice. Yes, my new buzz word is #InformAndImproveClinicalPractice. There you have it – so let’s all convince our policy makers or politicians to fund more HCAI surveillance for our healthcare organisations to enable us to do all we can to prevent all avoidable harm. Certainly, new mobile technologies that my friends are evaluating can be utilised to ease data collection burden. I look forward to seeing the progress with these new innovative technologies. Most importantly, let’s use our data in a ‘no blame culture’ non punitive manner like we did in my current Trust & reap fantastic patient safety benefits.

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