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Bevan Exemplar Cohort 1 Projects

Complexity Thinking in Healthcare Associated infections (HCAI)

Mike Simmons and Sharon Daniel

Hywel Dda University Health Board

Hywel Dda University Health Board (HDUHB) acknowledged that infection in our elderly population arriving from primary to secondary care is a major concern with exponential numbers of Escherichia coli (E. coli) bacteraemia by the end of 2013.

They agreed to take a complexity approach to solving and set a target of reducing E. coli bacteraemia as a common patient-focused endpoint.

Initiatives to be tested by two competing rules:

  • First do no harm; and
  • Second, seek and take the positive action.

Quality Interventions Introduced:

  • Enhanced laboratory reporting: educating to “nudge” requesting clinicians towards evidence based infection management.
  • End user engagement in education sessions for GPs, secondary care, nursing and residential homes, frailty, diabetic, incontinence and other specialist services.
  • Social media engagement as well as more direct targeted work with local population.

Outputs Observed:

Fall in urine submissions (approx 12,000 per year) across HDUHB but primary loss is in negative samples: quality improvement through education of service users in when it is appropriate to send urine samples – positive samples continue at similar number per month.

E. coli bacteraemia rate plateau by end of 2015 and was maintained to end April 2016 but more recently has seen a further increase.

However, review of positive blood cultures across Wales shows a possible plateau now developing in the Hywel Dda population while other health board areas may be approaching the levels formerly only seen in Hywel Dda.

This Project Supports Prudent Healthcare:

  • Goal one is, “First do no harm,” which is fundamental to Prudent principles.
  • We have engaged in public with focus groups, readers panel, monthly public facing publication, blogging ( ) and Twitter.
  • We are seeking to educate the use of nationally agreed approaches through education of teams in primary and secondary care to ensure a consistent, quality based approach to infection management.

Anticipated Benefits:

Increased understanding of the infection management needs of patients in primary care.

  • An increasingly knowledgeable patient population.
  • Reduction in all aspects of infection through better management and reduction in E. coli bacteraemia as a surrogate marker of all infection but also seeing other infections decline. However, other markers are being reviewed as discussed and may prove a better marker of “all infections”.
  • Empowerment of all staff in the understanding and management of all aspects of infection.
  • Reduction in waste of NHS resources through more appropriate sampling practices and reduction in antimicrobial prescribing.