Healthcare-acquired infections (HCAIs) are a major cause of morbidity and mortality in hospitals, and strategies to control infections focus on both antimicrobial stewardship and infection control activities.1–6 When these interventions have been successfully applied they have proved effective in reducing the incidence of HCAIs.6–8 However, the major challenges in implementing any change in practice within a healthcare setting are firstly achieving the engagement of hospital staff at all levels and secondly, ensuring staff compliance with new policies over the longer term.9
In order to effectively implement change in a healthcare setting, there needs to be clear evidence to support the suggested change, such as evidence derived from research studies, together with clinical or patient experience. The suggested change should fit with the strategic direction of the organisation, and resources must be available to support the change.10 Furthermore, having a multidisciplinary focus and a dedicated project lead are critical to the successful implementation of any change in policy.10,11
A recent study carried out in Antrim Area Hospital, a district general hospital within the Northern Health and Social Care Trust (NHSCT) in Northern Ireland, investigated the effect of changing the disinfectant used for environmental decontamination on the incidence of healthcare-acquired MRSA (HA-MRSA).12 The change from a sodium dichloroisocyanurate (NaDCC)-based product to a chlorine dioxide (ClO2) 275ppm-based product resulted in a significant immediate decrease in HA-MRSA cases by 0.095 cases/100 bed days (p=0.001; 95% CIs: –0.04 to –0.15 cases/100 bed days), and a decreased trend of HA-MRSA cases by 0.003 cases/100 bed days (p=0.001; 95% CIs: –0.005 to –0.001 cases/100 bed days) during the 23-month follow-up period. Based on these reductions, the potential cost savings to the hospital were estimated to be £276,000 per year, assuming a cost of €8673 (£6845) per MRSA case.13
This cost saving relates to opportunity costs through the release of isolation rooms and reduced lengths of stay. It does not take into account additional savings that result from treating MRSA bacteraemia. The purpose of this report is to describe the implementation of this change across the NHSCT, which led to a significant and sustained reduction in the incidence of HA-MRSA in the Antrim Area Hospital.
The NHSCT is one of five Health and Social Care Trusts in Northern Ireland. It serves a population of approximately 436,000 and covers a geographical area of 1733 square miles. The NHSCT consists of two acute hospitals: Antrim Area Hospital, containing 447 beds; and Causeway Hospital, which contains 213 beds. These hospitals provide acute medical, surgical, ICU, neonatal, paediatric, urology and maternity services for the NHSCT. Furthermore, the NHSCT consists of five rehabilitation wards (135 beds), a psychiatric hospital (121 beds), and community facilities, such as day care centres, treatment rooms, seven residential homes and five children’s homes. Following the control of an outbreak of Clostridium difficile infection (CDI) in the NHSCT in August 2008, it was decided to change the disinfectant used for routine environmental decontamination from a NaDCC-based product to a ClO2-based product. This decision was based on the reported superiority of ClO2 over hypochlorite-based products against a range of pathogens including MRSA and C. difficile.14,15
The change from NaDCC to ClO2 275ppm was implemented throughout the whole of the NHSCT. The introduction of the ClO2 275ppm based disinfectant occurred in a phased manner between April and November 2011. In order to ensure a seamless transition from the chlorine-based product to the ClO2-based product, clear communication with staff members in all Trust facilities was essential. This included nursing, nursing auxiliary, domestic services staff and occupational therapy staff. This was facilitated through establishing an implementation team, which consisted of the Trust Microbiologist, the Head of Pharmacy and Medicines Management, Lead Infection Control Nurse, Domestic Services Manager, Health and Safety Officer and representatives of Clinimax Ltd (the manufacturer of Difficil-S, the ClO2 275ppm product that was introduced). This team met on a monthly basis following the initial change to ClO2 275ppm, and then every two months once the product was in routine use throughout the whole Trust.
The use of the ClO2-based disinfectant involved mixing two sachets of powder with 10 litres of cold water, which provided a stock solution of 275ppm ClO2. The expiry date of this solution was 14 days after preparation. This stock solution could be further diluted for use on floors and walls. It was recommended that staff preparing this solution wear personal protective equipment (PPE), such as an apron and gloves. Staff training on the use of the ClO2 275ppm disinfectant was provided by representatives from Clinimax Ltd. Training was delivered on the correct preparation and use of this product on each ward to nursing, nursing auxiliary, and domestic services staff until 75% of all relevant staff in each area were trained.
Following this, link nurses were identified who were then responsible for the training of new nursing and nursing auxiliary staff on their ward or department, to ensure that all staff were appropriately trained on the correct preparation and use of this product. Company representatives also provided the same training to community staff in each of the NHSCT community facilities. Cascade training was delivered to community supervisors, key staff and managers, to ensure that any new staff or staff who missed the initial training sessions were trained appropriately. In addition, company representatives were available in person or by telephone to advise on issues arising during the implementation period with minimal delay in resolving these issues. A register was created to record all personnel who were trained and the date of training, so that managers could be assured that this had been undertaken, and also identify ongoing training needs due to change of staff, temporary staff and return of staff from long-term sickness absences.
In the NHSCT, environmental disinfectants required by all wards and departments were supplied by the pharmacy department. After the switchover from NaDCC to ClO2 275ppm, the latter product became the only agent for routine environmental decontamination stocked by the NHSCT pharmacy departments. This helped to ensure that ClO2 275ppm was the only product that was used in the Trust for environmental decontamination.
One hazard that has been associated with exposure to cleaning products is the precipitation or exacerbation of asthma.16 In particular, chlorine bleach has been reported as the most common cleaning agent to be associated with upper and lower respiratory symptoms in domestic cleaning workers.17 In order to ensure there was no increase in adverse reactions experienced by staff as a result of the change from NaDCC to ClO2, the number of reports to Occupational Health of adverse reactions associated with the use of both of these products was recorded. Between November 2011 and October 2012, a total of 19 adverse reactions associated with the use of ClO2 were reported to the NHSCT Occupational Health Department.
These adverse reactions included skin, nose and eye irritation and respiratory complaints. No further adverse reactions have been reported to Occupational Health since October 2012. This figure was not significantly different (p=0.309) from the eight adverse reactions associated with the use of NaDCC, which were reported to the Occupational Health Department between November 2009 and October 2011.
As with any new product introduced into practice, there was initial scepticism with regards to its effectiveness, with nursing staff reporting the tarnishing of taps and discolouration of patient chairs as a result of the use of this product. On further investigation, it became apparent that tap damage was due to the build-up of hard water residue and the chair discolouration was actually the original chair colour showing through a previous build-up of dirt resulting from inadequate cleaning. Whenever damage to ward furniture was reported by nursing and hotel services staff, infection control staff promptly investigated this to determine the cause.
Prompt feedback to each ward/department identified areas with good practice and areas where further staff training was required. In addition, representatives from Clinimax Ltd carried out audits on the use of this product at regular intervals. These audits focussed on the preparation and storage of the ClO2-based disinfectant in a well-ventilated area according to Control of Substances Hazardous to Health (COSHH) guidance, the use of PPE and the documentation of the expiry date of the stock solution. Figure 1 outlines the results of these audits. Where poor performance was identified, for example when wards were not correctly stating the expiry date on bottles of stock solution, further training was provided by both infection control nurses and company representatives. Problems identified as a result of the use of ClO2 275ppm were discussed at the implementation group meeting where solutions were identified.
Figure 1: Results of audits on the use of a ClO2 275ppm across all wards and departments in the NHSCT.
During the implementation of the new disinfectant into routine use, several challenges were encountered by the implementation team. The main challenges and how these were resolved are described below:
(a) The National Colour Coding Scheme for hospital cleaning materials and equipment18 outlines a colour code for all cleaning materials (cloths, mops buckets, gloves and apron), which depends on the area being cleaned.
The colour codes were as follows: red for materials used in bathrooms, washrooms, showers, toilets and basins; blue for materials used in general areas; green for materials used in catering departments, ward kitchen areas and patient food service areas, and yellow for materials used in isolation areas.18 When the ClO2 275ppm was introduced into the NHSCT, the bottles in which this disinfectant was prepared had different coloured lids to comply with the National Colour Coding Scheme for hospital cleaning materials and equipment.
Posters outlining the preparation guidelines for ClO2 and the use of the appropriately coloured bottle for the area being cleaned were placed in the dirty utility room on each ward and in community treatment rooms. However, during the course of this switchover, it became apparent that these posters were unsuitable for use in community treatment rooms because the NPSA colour coding system did not apply to community facilities and consequently caused confusion among community staff. Therefore, separate posters for hospital and community departments were supplied. These provided a clear, concise message on the use of this product that was specific to the target audience.
(b) Domiciliary staff (community nurses, health visitors, community midwives and community occupational therapists) generally used smaller volumes of the ClO2 275ppm based disinfectant. Once reconstituted, ClO2 is stable for 14 days, after which time it has to be discarded. Therefore these groups of staff reported a large volume of wastage with the use of the product. In order to reduce this, Clinimax Ltd designed smaller 500ml containers in which to store the reconstituted product.
(c) Another challenge for domiciliary staff (community nurses, health visitors, community midwives and community occupational therapists) related to the issue of the carriage of the ClO2-based disinfectant in their cars, where the heat of the car may deactivate the product. The Trust Infection Control Team agreed that these staff groups would continue to clean small pieces of equipment with detergent and water, followed by disinfection with an alcohol wipe. The piece of equipment would then be bagged and brought to the staff member’s base, where it would be decontaminated with ClO2 275ppm. For larger pieces of equipment, transport was arranged to take the item for central decontamination.
The result of the successful change from the use of a NaDCC-based environmental disinfectant to a ClO2-based product was that a significant reduction in the incidence of HA-MRSA in Antrim Hospital was observed.12 It has been documented that dominant organisational culture can significantly impact the ability of ward leaders to implement changes in practice.19
Furthermore, strong leadership, sympathetic cultures, appropriate monitoring and feedback systems and engagement with internal and external facilitators have been reported as contributing to the most successful implementation of change.19
In this current setting, the establishment of an implementation group consisting of Microbiology, Pharmacy, Infection Control, Health and Safety and Domestic Services managers provided strong leadership and a consistent message of the change to be implemented. Company representatives were initially available on site to facilitate this change by providing staff training, monitoring and auditing the use of the new disinfectant on hospital wards and in domiciliary areas, and providing direct feedback to hospital staff.
In addition, issues with the use of this product were identified as a result of staff feedback and reported back to the implementation team whereby solutions were rapidly put in place. This facilitation, together with the constant dialogue that occurred between Trust managers, company representatives, and ward staff, the visible presence of the trainers in the hospital and the establishment of a project team with the remit to monitor and deal with issues over the transition period were key to the successful implementation of this change in practice.
The successful change from a chlorine based environmental disinfectant to a chlorine dioxide based disinfectant resulted in a significant decrease in the incidence of HA-MRSA in Antrim Area Hospital, with potential cost savings of £276,000 per year.
Key to the successful implementation of this change was the establishment of a multidisciplinary implementation group, which provided strong leadership and a clear consistent message of the change to be implemented.
Comprehensive staff training, including cascade training were essential to ensure that the new disinfectant was used correctly in all areas and to minimise any potential adverse effects experienced from the use of this product.
Continual monitoring and audit on the use of the new disinfectant coupled with direct feedback to ward staff, helped to identify and address problems with the use of this product, which was necessary to maintaining this change in practice over the longer term.
Multidisciplinary involvement and having a dedicated project lead are essential to the successful implementation of any change in policy within healthcare settings.
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