Abstract
This is my first editorial as Editor in Chief of the Journal and on behalf of the IPS Board and the Editorial Board I would like to take the opportunity to thank Jennie Wilson for her leadership and enthusiasm for the role over the past four years. The scope of the Journal of Infection Prevention is to provide a publication route for the infection prevention and control (IPC) community to share scientific, practice-based and implementation research and to encourage enquiry and debate. Jennie has been instrumental in broadening the reach of the Journal through PubMed Central indexing and taking it a step closer to Medline indexing.
Another means of communicating learning and research is at international conferences and having just returned from Infection Prevention 2018 in Glasgow, I wanted to share my reflections on some of the plenary, concurrent and poster presentations. In the Annual Cottrell Lecture titled ‘Surveillance by Objectives: Using Measurement in the Prevention of Healthcare Associated Infections’, Professor Jennie Wilson reinforced why we need to use surveillance data to drive our actions not just nationally, but more importantly locally. Building on her thought-provoking editorial in the last issue of JIP, Jennie also asked us to look beyond the numbers and to be inherently curious about the possible explanations for the data. These explanations may increasingly be found in social deprivation and health inequalities and are particularly pertinent to the current focus on reducing Escherichia coli (E. coli) bacteraemias.
This leads me to the topic of the entertaining debate ‘This house believes that E. coli bacteraemias can be reduced by 50%’ between Professor Jacqui Riley (for the motion) and Dr Tim Boswell (against the motion). Professor Riley’s case focused on several factors: our success against methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C. diff) and the fact that targets (or ‘ambition’ in England) work; there is an evidence base on which to base our interventions (Wilson et al., 2015) and that ‘experts’ think it can be done. Dr Boswell was not all gloom and doom, but suggested that 50% was unattainable. His reasoning includes: E. coli is different from MRSA and C. diff in terms of epidemiology and transmission; there is a considerable proportion of infection that are community onset and therefore the current hospital-based interventions are somewhat irrelevant (Boswell, 2018). He also pointed to the geographic differences in E. coli bacteraemias between the north and south of England, picking up again of the potential for the differences to be related to social determinants of health. The delegates voted 60:40 with Dr Boswell and against the motion. My personal reflections on the debate are that Jennie Wilson’s request that we be curious means that we have to question how and why system changes and IPC interventions may and may not work. Much of our health and ‘social’ care is delivered outside hospital and as the aging population grows there has to be a more integrated approach to IPC across the healthcare economy. The Lansley reforms had a profound and negative effect on the community IPC service and chanting the mantra that infection prevention is everyone’s business, in a primary health and social care service that is underfunded and lacking in specialist resource, has little chance of success.
Professor Wing Hong Seto’s presentation about campaign fatigue struck a chord with me, as I had been struck by the recent social media concentration on vaccinating NHS staff against influenza and the amount of resource that is being used in ‘Flu Fighter’ and ‘Jabathon’ campaigns. Professor Seto concentrated on hand hygiene campaigns and spoke compellingly about how he and colleagues in Hong Kong refreshed their hand hygiene efforts. Social marketing has become part and parcel of our IPC interventions and yet there has been minimal evaluation of their success. Earlier in the year, I heard Enrique Castro Sanchez presenting about the evaluation gaps in UK social marketing campaigns that focused on infections (Casto Sanchez et al., 2018). In the 17 campaigns that had published reports, few measured impact or evaluated acceptability and sustainability for different participants. Similarly, only single reports demonstrated a clear link between the intervention and the outcome; measured environment or competing factors to ensure that the change could be attributed to the intervention or identified unpredicted changes or consequences. A number of the poster presentations at the conference focused on the success of various ‘campaigns’ including hand hygiene, influenza vaccination and oral hygiene, but few evaluated them in terms of the indicators above. We need to be more curious and systematic about reporting what works, how and for whom if we are to make best use of specialist IPC resources.
My final reflection is that IPC is increasingly becoming part of collaborations to improve fundamental aspects of nursing and allied healthcare to prevent infection and improve patient outcomes. The ‘evidence’ for the composition of the various components of these collaborative interventions is lacking, but I would argue that fundamental care such as hydration, nutrition, oral hygiene, elimination and mobility is a priori for all patients in hospital and residents in social care. Martin Kiernan reflected this in his presentation about what might work to prevent non-ventilator healthcare-associated pneumonia (NV-HAP). His question was ‘Had we placed the prevention of NV-HAP in the too difficult box?’ It is currently the most common healthcare-associated infection (HCAI) but attracts the least attention in terms of our infection prevention efforts. Building on his presentation from last year, Martin asserted that a NV-HAP bundle, created from a ‘common sense’ evidence base looked suspiciously like ‘good care’. My role as a researcher takes me into a range of clinical and social care environments to observe care and speak with healthcare staff. My observations have led me to conclude that fundamental care has become task-orientated and largely delegated to a support workforce that is temporary/agency, and that good care is not as easy as it sounds or should be. The evidence from studies into the relationship between high quality and safe care is clear that care from registered practitioners is associated with better patient outcomes (Aiken et al., 2014). IPC practitioners are highly skilled, persuasive and knowledgeable; we have a key role in promoting and collaborating with colleagues to make fundamental care a priority. It matters.