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Working practices and success of infection prevention and control teams: a scoping study

Published:November 21, 2014DOI:https://doi.org/10.1016/j.jhin.2014.10.006

      Summary

      Little research has been undertaken on how infection prevention and control (IPC) teams operate and how their effectiveness is assessed. This review aimed to explore how IPC teams embed IPC throughout hospitals, balance outbreak management with strategic aspects of IPC work (e.g. education), and how IPC team performance is measured. A scoping exercise was performed combining literature searches, evidence synthesis, and intelligence from expert advisers. Eleven publications were identified. One paper quantified how IPC nurses spend their time, two described daily activities of IPC teams, five described initiatives to embed IPC across organizations following legislation since 1999 in the UK or changes in the delivery of healthcare, and three explored the contribution of IPC intermediaries (link nurses and champions). Eight publications reported research findings. The others reported how IPC teams are embedding IPC practice in UK hospitals. In conclusion, there is scope for research to explore different models of IPC team-working and effectiveness, and cost-effectiveness. Other topics that need addressing are the willingness and ability of ward staff to assume increased responsibility for IPC and the effectiveness of intermediaries.

      Keywords

      Introduction

      Infection prevention and control (IPC) teams originated in the UK in the 1950s with the introduction of IPC nurses to support the work of clinical microbiologists.
      • Jenner A.E.
      • Wilson J.A.
      Educating the infection control team – past, present and future. A British perspective.
      The purpose of the newly introduced post-holders was to educate clinicians, conduct surveillance, investigate outbreaks of infection and ensure that clinical staff implemented IPC guidelines.
      • Jenner A.E.
      • Wilson J.A.
      Educating the infection control team – past, present and future. A British perspective.
      The role was considered a success from the outset and IPC teams have been established in many countries.
      • Murphy D.M.
      • Hanchett M.
      • Olmstead R.N.
      • Farber M.
      • Lee T.B.
      • Haas J.P.
      Competency in infection prevention: a conceptual approach to guide current and future practice.
      • Quattrin R.
      • Pecile A.
      • Conzut L.
      • Majori S.
      • Brusaferro S.
      • The GISIO Group
      Infection control nurse: a national survey.
      • Carrico R.M.
      • Rebmann T.
      • English J.F.
      • Mackey J.M.
      • Nones Cronin S.
      Infection prevention and control competencies for hospital-based healthcare personnel.
      • Friedman C.
      • Barnette M.
      • Buck A.S.
      • et al.
      Requirements for infrastructure and essential activities of infection control and epidemiology in out-of-hospital settings: a Consensus Panel report.
      Formal preparation for IPC nurses has since been introduced, allowing them to assume responsibility for technical aspects of IPC.
      • Murphy D.M.
      • Hanchett M.
      • Olmstead R.N.
      • Farber M.
      • Lee T.B.
      • Haas J.P.
      Competency in infection prevention: a conceptual approach to guide current and future practice.
      • Worsley M.A.
      The role of the infection control nurse.
      Training is compulsory in some countries, but in others, including the UK, it is not mandatory. Over the years, workload has expanded in response to increased patient throughput, ageing patient populations, increase in numbers of invasive procedures placing patients at high risk of healthcare-associated infection (HCAI), and growing demand for surveillance and audit to meet public expectations of a clean, safe hospital environment.
      • Gordts B.
      Models for the organisation of hospital infection control and prevention programmes.
      Since the 1990s IPC teams have expanded to include new roles. In the UK and numerous other countries, link nurse schemes and ‘champions’ have been introduced.
      • Dawson S.J.
      The role of the infection control link nurse.
      • Lewis T.
      • Edwards C.
      How clinical champions can improve quality.
      Post-holders are clinical staff with a remit to liaise with the IPC team to implement policies and guidelines at ward level. Legislation in the UK introduced from 1999 onwards required all health workers to accept responsibility for IPC. Similar developments are taking place in some other countries.
      • California Department of Public Health
      Healthcare associated infections: information systems and technology.
      It is suggested that the new approach has changed the working practices of IPC teams in the UK. Instead of providing technical support, they are now required to adopt a more strategic role, working closely with clinicians to embed IPC throughout hospitals.
      • Charani S.
      • Holmes A.H.
      Antimicrobial stewardship programmes: the need for wider engagement.
      The literature is replete with accounts of how outbreaks of infection or particularly troublesome pathogens have been controlled, and the impact of specific IPC procedures, care bundles and special campaigns.
      • Backman C.
      An integrative review of infection prevention and control programs for multi-drug resistant organisms in acute care hospitals: a socio-ecological perspective.
      • Gould D.J.
      • Moralejo D.
      • Drey N.S.
      • Chudleigh J.H.
      Interventions to improve hand hygiene compliance in patient care (update).
      Outbreak control and special initiatives usually involve input from IPC teams, but their activities are not described in detail in these accounts. By contrast, few empirical studies explore the daily working practices of IPC teams. This scoping exercise aimed to identify studies concerning whether and how IPC teams work across boundaries to embed IPC throughout hospitals, how they balance management of outbreak situations and other untoward events, alongside strategic aspects of IPC work such as education, and how their performance is assessed.

      Methods

      Scoping exercises are recommended when little is known about a topic. The aim is to identify gaps in knowledge and opportunities for research.
      • Davis K.
      • Drey N.
      • Gould D.J.
      What are scoping studies? A review of nursing literature.
      This review adopted an established methodology for undertaking scoping exercises combining literature-searching and evidence synthesis with expertise from accepted leaders in the field likely to have privileged knowledge through their networks.
      • Arksey H.
      • O'Malley L.
      Scoping studies: towards a methodological framework.
      Works that addressed the activities of the core IPC team, link nurses and champions were searched for. Accounts of outbreak control, management of specific pathogens, and IPC involvement in campaigns were excluded since the aim was to look at daily working practices of IPC teams and interaction with clinicians.
      A two-armed approach was taken to search the titles and abstracts of papers combining the search terms Infection Control/, infection control, healthcare associated infection, hospital acquired infection, healthcare acquired infection and combinations of all these search terms with intermediary nursing, intermediary, linking agents, facilitators, change agents, champion, opinion leaders and link nurse. The following databases were searched: Medline, CINHAL and Embase, and a general web browser (Google Scholar). Key journals were hand-searched for relevant publications: Journal of Hospital Infection, American Journal of Infection Control, Infection Control and Hospital Epidemiology, Journal of Infection Control. Once relevant papers had been identified, their reference lists were hand-searched. The Cochrane Database of Reviews was also searched. Conference abstracts and posters were excluded, as they did not contain sufficient information for consideration. The aims of the exercise were discussed with recognized experts in the field of IPC to locate other relevant publications, including those in the grey literature and initiatives in progress not yet published. The experts identified from our networks came from England, Wales, Canada, Australia, and the USA.

      Results

      The searches identified 251 publications. The abstracts were read independently by two reviewers to establish whether their content captured the required information. Once potentially eligible papers had been identified, they were read in detail and information was extracted to document aims, methods, analysis, and findings.
      On detailed reading, 11 papers fulfilled the eligibility criteria. Seven were identified through electronic searching.
      • Uchida M.
      • Stone P.
      • Conway L.J.
      • Pogorzelska M.
      • Larson E.L.
      • Raveis V.H.
      Exploring infection prevention: policy implications from a qualitative study.
      • Damschroder L.J.
      • Banaszak-Holl J.
      • Kowalski C.P.
      • et al.
      The role of the ‘champion’ in infection prevention: results from a multisite qualitative study.
      • Saint S.
      • Kowalski C.P.
      • Banaszak-Holl J.
      • Forman J.
      • Damschroder L.J.
      • Krein S.L.
      How active resistors and organizational constipators affect health care-acquired infection prevention efforts.
      • Williams L.
      • Burton C.
      • Rycroft-Malone J.
      What works: a realist evaluation case study of intermediaries in infection control practice.
      • Jones G.
      • Brooks J.
      • Garton T.
      • Aplin S.
      Implementing a ward accreditation programme to drive improvements in infection prevention.
      • Barry D.
      • Carter Y.
      Developing satellite roles within infection control prevention teams to fulfil responsibilities.
      • Conroy L.J.
      • Raveis V.H.
      • Pogorzelska-Maziarz M.
      • Uchida M.
      • Stone P.W.
      • Larson E.L.
      Tensions inherent in the evolving role of the infection preventionist.
      Three reports were obtained by hand-searching.
      • Parker J.
      Establishing an infection control accreditation programme to control infection.
      • Barrett C.D.
      • Hilder D.
      • Prieto J.
      Infection control team workforce project.
      • Trundle C.M.
      • Farrington M.
      • Anderson L.
      • Redpath C.K.
      GRASPing infection: a workload measurement tool for infection control nurses.
      An additional report was suggested by expert adviser.

      Gallagher R. Perceptions of the role of the infection control team. Unpublished BSc dissertation, University of Hertfordshire, UK; 2006.

      Four studies originated from the USA.
      • Damschroder L.J.
      • Banaszak-Holl J.
      • Kowalski C.P.
      • et al.
      The role of the ‘champion’ in infection prevention: results from a multisite qualitative study.
      • Saint S.
      • Kowalski C.P.
      • Banaszak-Holl J.
      • Forman J.
      • Damschroder L.J.
      • Krein S.L.
      How active resistors and organizational constipators affect health care-acquired infection prevention efforts.
      • Conroy L.J.
      • Raveis V.H.
      • Pogorzelska-Maziarz M.
      • Uchida M.
      • Stone P.W.
      • Larson E.L.
      Tensions inherent in the evolving role of the infection preventionist.

      Gallagher R. Perceptions of the role of the infection control team. Unpublished BSc dissertation, University of Hertfordshire, UK; 2006.

      Two were reported by the same team and appeared to represent different aspects of one large study.
      • Damschroder L.J.
      • Banaszak-Holl J.
      • Kowalski C.P.
      • et al.
      The role of the ‘champion’ in infection prevention: results from a multisite qualitative study.
      • Saint S.
      • Kowalski C.P.
      • Banaszak-Holl J.
      • Forman J.
      • Damschroder L.J.
      • Krein S.L.
      How active resistors and organizational constipators affect health care-acquired infection prevention efforts.
      The remaining reports were from the UK.
      • Williams L.
      • Burton C.
      • Rycroft-Malone J.
      What works: a realist evaluation case study of intermediaries in infection control practice.
      • Jones G.
      • Brooks J.
      • Garton T.
      • Aplin S.
      Implementing a ward accreditation programme to drive improvements in infection prevention.
      • Barry D.
      • Carter Y.
      Developing satellite roles within infection control prevention teams to fulfil responsibilities.
      • Parker J.
      Establishing an infection control accreditation programme to control infection.
      • Barrett C.D.
      • Hilder D.
      • Prieto J.
      Infection control team workforce project.
      • Trundle C.M.
      • Farrington M.
      • Anderson L.
      • Redpath C.K.
      GRASPing infection: a workload measurement tool for infection control nurses.

      Gallagher R. Perceptions of the role of the infection control team. Unpublished BSc dissertation, University of Hertfordshire, UK; 2006.

      Publications quantified how IPC nurses spend their time, described daily activities, initiatives to embed IPC across organizations in the wake of legislation or changes in healthcare, and the contribution of IPC intermediaries.
      • Damschroder L.J.
      • Banaszak-Holl J.
      • Kowalski C.P.
      • et al.
      The role of the ‘champion’ in infection prevention: results from a multisite qualitative study.
      • Saint S.
      • Kowalski C.P.
      • Banaszak-Holl J.
      • Forman J.
      • Damschroder L.J.
      • Krein S.L.
      How active resistors and organizational constipators affect health care-acquired infection prevention efforts.
      • Williams L.
      • Burton C.
      • Rycroft-Malone J.
      What works: a realist evaluation case study of intermediaries in infection control practice.
      • Jones G.
      • Brooks J.
      • Garton T.
      • Aplin S.
      Implementing a ward accreditation programme to drive improvements in infection prevention.
      • Barry D.
      • Carter Y.
      Developing satellite roles within infection control prevention teams to fulfil responsibilities.
      • Conroy L.J.
      • Raveis V.H.
      • Pogorzelska-Maziarz M.
      • Uchida M.
      • Stone P.W.
      • Larson E.L.
      Tensions inherent in the evolving role of the infection preventionist.
      • Parker J.
      Establishing an infection control accreditation programme to control infection.
      • Barrett C.D.
      • Hilder D.
      • Prieto J.
      Infection control team workforce project.
      • Trundle C.M.
      • Farrington M.
      • Anderson L.
      • Redpath C.K.
      GRASPing infection: a workload measurement tool for infection control nurses.

      Gallagher R. Perceptions of the role of the infection control team. Unpublished BSc dissertation, University of Hertfordshire, UK; 2006.

      Eight publications reported research findings.
      • Uchida M.
      • Stone P.
      • Conway L.J.
      • Pogorzelska M.
      • Larson E.L.
      • Raveis V.H.
      Exploring infection prevention: policy implications from a qualitative study.
      • Damschroder L.J.
      • Banaszak-Holl J.
      • Kowalski C.P.
      • et al.
      The role of the ‘champion’ in infection prevention: results from a multisite qualitative study.
      • Saint S.
      • Kowalski C.P.
      • Banaszak-Holl J.
      • Forman J.
      • Damschroder L.J.
      • Krein S.L.
      How active resistors and organizational constipators affect health care-acquired infection prevention efforts.
      • Williams L.
      • Burton C.
      • Rycroft-Malone J.
      What works: a realist evaluation case study of intermediaries in infection control practice.
      • Conroy L.J.
      • Raveis V.H.
      • Pogorzelska-Maziarz M.
      • Uchida M.
      • Stone P.W.
      • Larson E.L.
      Tensions inherent in the evolving role of the infection preventionist.
      • Barrett C.D.
      • Hilder D.
      • Prieto J.
      Infection control team workforce project.
      • Trundle C.M.
      • Farrington M.
      • Anderson L.
      • Redpath C.K.
      GRASPing infection: a workload measurement tool for infection control nurses.

      Gallagher R. Perceptions of the role of the infection control team. Unpublished BSc dissertation, University of Hertfordshire, UK; 2006.

      The other three papers reported how IPC teams are working to change IPC practice in the UK.
      • Jones G.
      • Brooks J.
      • Garton T.
      • Aplin S.
      Implementing a ward accreditation programme to drive improvements in infection prevention.
      • Barry D.
      • Carter Y.
      Developing satellite roles within infection control prevention teams to fulfil responsibilities.
      • Parker J.
      Establishing an infection control accreditation programme to control infection.

      Daily activities of the core infection prevention and control team

      An early initiative in an English National Health Service (NHS) hospital pre-dating legislative changes targeted at IPC since 1999 applied a workload measurement tool to quantify the type of activities undertaken by IPC nurses over a period of five months and the amount of time spent on each.
      • Trundle C.M.
      • Farrington M.
      • Anderson L.
      • Redpath C.K.
      GRASPing infection: a workload measurement tool for infection control nurses.
      Analysis revealed a ‘fire brigade’ approach in which nurses turned from one crisis to another, focusing on management of outbreak situations and other events demanding immediate attention at the expense of strategic activities such as education and policy development. A second study compared the activities of two IPC teams qualitatively. One team visited clinical areas daily.

      Gallagher R. Perceptions of the role of the infection control team. Unpublished BSc dissertation, University of Hertfordshire, UK; 2006.

      Clinical staff were reported to appreciate the accessibility and high level of visibility afforded by this model of service delivery. The second team identified potential problems by inspecting microbiology reports but seldom undertook clinical visits. Neither study reported the impact of the IPC team on patient or organizational outcomes. Another study reported daily organization and working practices of IPC teams in four National Health Service hospitals.
      • Barrett C.D.
      • Hilder D.
      • Prieto J.
      Infection control team workforce project.
      Data were collected by telephone interview to document working practices, staffing levels, decision-making and reporting mechanisms for IPC personnel. By contrast with the earlier studies, all four IPC teams reported a strategic approach to engagement with staff in clinical areas.
      • Trundle C.M.
      • Farrington M.
      • Anderson L.
      • Redpath C.K.
      GRASPing infection: a workload measurement tool for infection control nurses.

      Gallagher R. Perceptions of the role of the infection control team. Unpublished BSc dissertation, University of Hertfordshire, UK; 2006.

      Auditing was mainly devolved to wards, and the results were used to identify areas requiring particular attention. Daily ward rounds were not undertaken except in one hospital where they were performed by link nurses. Finally a study from the USA explored how the work of IPC teams is expanding in response to changes in the delivery of healthcare, not in response to specific legislation.
      • Conroy L.J.
      • Raveis V.H.
      • Pogorzelska-Maziarz M.
      • Uchida M.
      • Stone P.W.
      • Larson E.L.
      Tensions inherent in the evolving role of the infection preventionist.
      Interviews with 19 IPC personnel in 11 hospitals in different geographical areas of the USA reported lack of resources to undertake increasing workload and uncertainty created by shifting boundaries as ward staff assumed more of their traditional responsibilities. The most effective ways of persuading clinical staff to comply with IPC guidelines were reported to be personal interaction, use of champions, and providing evidence of the effectiveness of IPC interventions to clinical staff to demonstrate their effectiveness through evidence demonstrated through metrics.

      Initiatives to embed infection prevention and control activities

      Uchida et al. explored the impact of newly introduced mandatory reporting of HCAIs on IPC teamwork in six acute hospitals in California, obtaining qualitative interview data from 25 members of staff (IPC personnel, clinicians, and managers).
      • Uchida M.
      • Stone P.
      • Conway L.J.
      • Pogorzelska M.
      • Larson E.L.
      • Raveis V.H.
      Exploring infection prevention: policy implications from a qualitative study.
      The new reporting requirements were perceived to have affected the day-to-day functioning of the IPC team. Workload and productivity were thought to have increased and there was a sense that IPC personnel needed to be more accessible and visible to clinicians. There was no evidence to substantiate these claims through patient or organizational outcomes, however.
      A second US-based study obtained qualitative interview data from 38 staff in six hospitals to explore how IPC policies and guidelines were implemented after Medicare reimbursement ceased to be available for patients who had developed specific types of HCAI, prompting increased incentive for IPC.
      • Saint S.
      • Kowalski C.P.
      • Banaszak-Holl J.
      • Forman J.
      • Damschroder L.J.
      • Krein S.L.
      How active resistors and organizational constipators affect health care-acquired infection prevention efforts.
      The initial interview in each hospital was conducted with a key member of the IPC team. Additional interviews were with their contacts. Analysis disclosed active resistance to implementation of new IPC policies, especially when they conflicted with ingrained practices. Senior medical staff members were major resisters and their influence was a barrier to progress because of their position as opinion leaders within the organization. ‘Constipators’ were senior managerial staff who blocked policy implementation, apparently for no logical reason. Several strategies were suggested for improving collaboration, including increased use of champions and involving clinical staff reputed to be resistant to change in IPC decision-making.
      The remaining two initiatives in this section were reported from the UK in response to the government's Saving Lives initiative.
      • Department of Health
      Saving Lives: reducing infection, delivering clean and safe care.
      One IPC team developed a quality improvement programme based on metrics: staff dress code, hand hygiene compliance, cleanliness of the patient environment and attendance at updates and educational events by link nurses.
      • Parker J.
      Establishing an infection control accreditation programme to control infection.
      The programme was initiated in high-risk areas then extended to all wards. Clinical areas were required to undertake their own audits to document local standards against those set by the IPC team. Overt and covert surveillance by the IPC team was also undertaken. Detailed metrics were not disclosed in the paper but overall compliance with IPC policies and guidelines was reported to have increased. Meticillin-resistant Staphylococcus aureus (MRSA) bloodstream infections declined by 39% and hospital-acquired MRSA isolates declined by 60% over 12 months. Further cycles of quality improvement were required before decline in Clostridium difficile infections.
      A similar but more sophisticated scheme in a second NHS hospital adopted a system of metrics agreed by a specially convened project team with targets built around a traffic lights system.
      • Jones G.
      • Brooks J.
      • Garton T.
      • Aplin S.
      Implementing a ward accreditation programme to drive improvements in infection prevention.
      Targets were based on audit of high-impact activities outlined in the government Saving Lives policy document (care of urinary catheters, peripheral and central intravenous cannulae, ventilator-associated pneumonia, and cleaning and decontamination).
      • Department of Health
      Saving Lives: reducing infection, delivering clean and safe care.
      Hand hygiene audits were undertaken quarterly. Wards maintained computerized databases of progress and were awarded full accreditation (green) status when the mainly ward-reported data achieved overall scores of 95–100% (combined results from all the audits). Full accreditation status lasted one year. Wards achieving scores of 85–94.9% were placed on amber alert and were reconsidered six months later, having received specific feedback to help meet targets. Wards scoring <85 were placed on red alert. The system is reported to be fully embedded throughout the organization, with 85% high-performing ‘exemplar’ wards reporting no MRSA or C. difficile infections 2012‒2013. There were no reports from the USA.
      Discussion of these papers with expert advisers indicated that broadly similar schemes are being implemented in other UK hospitals.

      Intermediaries

      Barry described how satellite IPC roles (audit and surveillance nurses, IPC patient liaison nurses and IPC staff educators) were created in one London NHS hospital to enable core members of the IPC team to concentrate on strategic activities.
      • Barry D.
      • Carter Y.
      Developing satellite roles within infection control prevention teams to fulfil responsibilities.
      Post-holders' key responsibilities were not described in detail and the success of the scheme was not revealed.
      The remaining papers presented exclusively qualitative data. Working in a hospital in Wales, Williams et al. evaluated the effectiveness of a link nurse scheme from the perspectives of post-holders, clinicians, and managers.
      • Williams L.
      • Burton C.
      • Rycroft-Malone J.
      What works: a realist evaluation case study of intermediaries in infection control practice.
      Link nurses strived to be facilitative, accessible, and to give positive messages to clinicians, especially when delivering performance feedback. Ward staff and managers were appreciative of the link nurse contribution. Successful improvements in IPC practice, for which quantified evidence was not provided in the article, were attributed to their high physical presence in clinical areas. Damschroder et al. undertook 48 interviews in six US hospitals to explore the ability of IPC champions to implement IPC policies and practices from the perspectives of senior executives, managers, and clinicians.
      • Damschroder L.J.
      • Banaszak-Holl J.
      • Kowalski C.P.
      • et al.
      The role of the ‘champion’ in infection prevention: results from a multisite qualitative study.
      Qualitative analysis demonstrated that champions working alone could introduce new equipment, but were unable to effect behaviour change, even when the change was inexpensive and appeared straightforward. Failure was attributed to the need for improved collaborative working and appeared most marked in organizations where inter-professional relations were thought to be poor.

      Discussion

      Little information is available to explain how IPC teams operate. Some innovative practice is being reported from the UK, but more work is needed to disseminate good practice and there are clear gaps in the information available.
      The original purpose of the IPC nurse was to interact with ward staff on behalf of clinical microbiologists.
      • Jenner A.E.
      • Wilson J.A.
      Educating the infection control team – past, present and future. A British perspective.
      • Worsley M.A.
      The role of the infection control nurse.
      The greater emphasis placed on IPC over time and provision of specialist training gradually increased their knowledge and technical expertise. Legislative and other changes in healthcare systems in the UK and USA now seem to have resulted in a situation where daily interaction of the IPC team with ward staff is transferred to intermediaries, despite the different priorities for IPC teams between the UK and USA: in the USA, surveillance is the primary function, whereas in the UK, IPC staff undertake less surveillance and their role in educating staff and supporting implementation of IPC activities has a greater focus. IPC nurses oversee the work of intermediaries and are adopting other outreach strategies to embed IPC at ward level, targeting areas considered to be at greatest risk of HCAI. Outreach takes the form of devolved audit with reliance on ward staff to record metrics. Only the most sophisticated schemes appear to provide comprehensive cover throughout all clinical areas.
      • Jones G.
      • Brooks J.
      • Garton T.
      • Aplin S.
      Implementing a ward accreditation programme to drive improvements in infection prevention.
      • Parker J.
      Establishing an infection control accreditation programme to control infection.
      Where intermediaries are used, considerable reliance appears to be placed on their contribution, with little attempt to measure success formally. As the link nurse role was originally conceived, post-holders were members of the ward team with particular interest in IPC, and were offered in-house training with a remit to liaise between the core IPC team and clinical colleagues.
      • Dawson S.J.
      The role of the infection control link nurse.
      • Teare E.L.
      • Peacock J.
      • Dakin H.
      • Bates L.
      • Grant-Casey J.
      Build your own infection control link nurse: an innovative study day.
      Their role was to promote adherence to guidelines, identify local problems, and to undertake limited surveillance. Payment for these additional responsibilities was not mentioned, and objective measurement of success was not discussed. Recently published guidelines for developing IPC link nurse schemes do not address these issues.
      • Royal College of Nursing
      The role of the link nurse in infection prevention and control (IPC): developing a link nurse framework.
      Champions coming from a similar background are identified, frequently by senior managers, as individuals with particular ability to operate as opinion leaders and to effect change despite the informal nature of the role.
      • Marra A.
      • Guastelli L.R.
      • Araujo C.M.P.
      Positive deviance; a new strategy for increasing hand hygiene compliance.
      The publications retrieved lacked details of the appointment, preparation, and remuneration of link nurses and champions, and of incentives for assuming additional responsibility.
      In reports focusing on the work of IPC intermediaries, post-holders, clinicians, and managers appear to place a premium on the ‘emotional labour’ of IPC work.
      • Damschroder L.J.
      • Banaszak-Holl J.
      • Kowalski C.P.
      • et al.
      The role of the ‘champion’ in infection prevention: results from a multisite qualitative study.
      • Williams L.
      • Burton C.
      • Rycroft-Malone J.
      What works: a realist evaluation case study of intermediaries in infection control practice.
      • Barry D.
      • Carter Y.
      Developing satellite roles within infection control prevention teams to fulfil responsibilities.
      Intermediaries' success is assessed in terms of accessibility and the acceptability of advice and feedback. Similarly Conroy reported that the influence of champions was important when clinicians needed to be persuaded to change practice.
      • Conroy L.J.
      • Raveis V.H.
      • Pogorzelska-Maziarz M.
      • Uchida M.
      • Stone P.W.
      • Larson E.L.
      Tensions inherent in the evolving role of the infection preventionist.
      Focus on these ‘softer’ aspects of IPC work does not fit with zero tolerance attitudes to lack of compliance with IPC guidelines now emerging in the UK and USA, where audits of key IPC activities have become mandatory, performance feedback is increasingly targeted at individuals, results are made available to service users and the public, and persistent lack of compliance may culminate in formal warning and ultimately termination of employment.
      • FitzGerald D.
      • Moore G.
      • Wilson A.P.R.
      Hand hygiene after touching a patient's surroundings: opportunities most commonly missed.
      • Chou T.
      • Kerridge J.
      • Kulkami M.
      • Wickman K.
      • Malow J.
      Changing the culture of hand hygiene compliance using a bundle that includes a violation letter.
      • Ellingston K.
      • Muder R.R.
      • Jain R.
      • et al.
      Sustained reduction in the clinical incidence of methicillin-resistant Staphylococcus aureus colonization or infection associated with a multifaceted infection control intervention.
      • Assananasen S.
      • Edmond M.
      • Bearman G.
      Impact of 2 different levels of performance feedback on compliance with infection control process measures in 2 intensive care units.
      Tough and increasingly punitive attitudes have introduced a new element into the work of IPC teams. The support they receive to enable them to undertake it does not appear to have been explored.
      The scoping exercise did not identify any information about the effectiveness of core IPC teams or economic evaluation relating to IPC team activity.
      More research is required to establish whether outreach working by IPC teams is becoming the norm, the different models that exist, their effectiveness, and cost-effectiveness. Further work is also needed to explore how effectively ward staff and intermediaries are prepared to assume accountability for IPC, and how accurately, safely, and effectively they perform their devolved responsibilities. The appointment, preparation, updating, and incentives offered to intermediaries are additional areas meriting investigation. Devolution of routine IPC activity should enable IPC teams to focus on strategic work such as education, troubleshooting, policy development and implementation, but the scoping exercise did not locate information on any of these issues. Further studies could be undertaken to establish how IPC teams go about the more strategic aspects of their work. Such studies could explore the impact on patient and organizational outcomes, as well as preparation and updating to enable them to fulfil the increasingly technical aspects of their work. These aspects might include the introduction and evaluation of ward-based metric systems and the management of antimicrobial resistance, which is becoming imperative.
      • Department of Health and Department for Environmental and Rural Affairs
      Five year antimicrobial resistance strategy 2013 to 2018.
      Although most HCAIs are reported from well-recognized clinical areas where patients are at particular risk, problems can arise in any part of the hospital. There is scope for research to explore how IPC teams select areas for more intensive monitoring and how decisions about IPC effectiveness are reached when metrics are used.
      Most of the research studies identified in this review used qualitative methodologies to investigate the operation of IPC teams.
      • Uchida M.
      • Stone P.
      • Conway L.J.
      • Pogorzelska M.
      • Larson E.L.
      • Raveis V.H.
      Exploring infection prevention: policy implications from a qualitative study.
      • Damschroder L.J.
      • Banaszak-Holl J.
      • Kowalski C.P.
      • et al.
      The role of the ‘champion’ in infection prevention: results from a multisite qualitative study.
      • Saint S.
      • Kowalski C.P.
      • Banaszak-Holl J.
      • Forman J.
      • Damschroder L.J.
      • Krein S.L.
      How active resistors and organizational constipators affect health care-acquired infection prevention efforts.
      • Williams L.
      • Burton C.
      • Rycroft-Malone J.
      What works: a realist evaluation case study of intermediaries in infection control practice.
      • Conroy L.J.
      • Raveis V.H.
      • Pogorzelska-Maziarz M.
      • Uchida M.
      • Stone P.W.
      • Larson E.L.
      Tensions inherent in the evolving role of the infection preventionist.
      • Barrett C.D.
      • Hilder D.
      • Prieto J.
      Infection control team workforce project.

      Gallagher R. Perceptions of the role of the infection control team. Unpublished BSc dissertation, University of Hertfordshire, UK; 2006.

      Future research could employ mixed methodologies to explore not only how IPC teams and stakeholders perceive their impact but also objective evidence to demonstrate effectiveness.
      The scoping exercise did not identify how IPC teams balance everyday service delivery with management of outbreaks or other situations demanding immediate attention. Despite huge strides in the control of MRSA and C. difficile, risks of HCAI in increasingly elderly and vulnerable patient populations are ongoing. How IPC teams apportion their time and allow for crisis management remains an important area of enquiry to avoid the situation reported by Trundle in the era that predated the new legislation, to ensure that organizational needs for IPC are continuously monitored and met.
      • Trundle C.M.
      • Farrington M.
      • Anderson L.
      • Redpath C.K.
      GRASPing infection: a workload measurement tool for infection control nurses.

      Acknowledgements

      We would like to thank the people who provided expert advice to the project and to D. Edwards for her assistance with literature searching.

      Conflict of interest statement

      None declared.

      Funding sources

      This work was undertaken with a research development grant from the Welsh National Institute for Social Care and Health Research.

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