This final issue concludes our IPS Digest series, celebrating the extraordinary work showcased at IP2025. This edition highlights innovation, technology, and learning in infection prevention and control; from the use of digital tools and AI to support clinical decision-making, to international collaborations tackling antimicrobial resistance. We also reflect on improvement through learning, featuring projects that apply the Patient Safety Incident Response Framework (PSIRF) to strengthen safety, promote multidisciplinary collaboration, and prevent future harm.
As we close this series, we extend our appreciation to all contributors whose work continues to inspire excellence across the IPC community.
- Digitally Standardised Infection Prevention and Control (IPC) Advice: A Strategy to Reduce Infection Rates
Recognising the challenge of inconsistent Infection Prevention and Control (IPC) documentation, a quality improvement project was launched to eliminate ambiguity, ensure uniformity, and support new staff. The initiative, developed under the Trust’s Essential Care Framework and the Improving 2gether programme, focused on embedding standardised digital tools into the electronic patient record (EPR).
Implementation and Impact
In collaboration with the IPC Team, mandatory templates, checklists, and controlled vocabularies were piloted in clinical areas. Data collected, including documentation time and clinician feedback, demonstrated measurable success.
Results showed a reduction in documentation time and significantly enhanced consistency and retrievability of IPC information, improving compliance with national standards. Crucially, the intervention was associated with a 30.8% reduction in IPC-related incidents over three years. Clinician feedback confirmed greater confidence and clarity in guidance.
This project validates standardised digital documentation as a scalable, sustainable model that streamlines workflows and is a powerful lever for enhancing patient safety and reducing healthcare-associated infections.
Author: Simona Stelian (Senior IPCN) Birmingham Community Healthcare NHS Foundation Trust
- AMR in action (including One Health): Enhancing Antimicrobial Stewardship and Infection Prevention and Control through UK-Ghana Partnership
Theme: AMR in action (including One Health)
Aim: To strengthen a long-standing healthcare partnership between London and Ghana hospitals by enhancing antimicrobial stewardship (AMS) and IPC through education and quality improvement initiatives.
Methods: Since 2019, the partnership between University College London Hospitals NHS Foundation Trust (UCLH), the University of Health and Allied Sciences, and Ho Teaching Hospital has improved AMS through the Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) programme. Initially focused on hospital pharmacists, it supported research-led interventions that improved antibiotic prescribing, surveillance, governance, and detection of falsified medicines. In 2023, the project expanded to a hub-and-spoke model centred on IPC leadership to strengthen AMS and IPC practices.
Results: A gap analysis revealed the need to strengthen IPC programmes. UCLH teams visited two regional hospitals to assess practices and prioritise improvements in hand hygiene, cleaning, waste disposal, and sharps safety. Educational sessions involving AMS and IPC leads from five hospitals were delivered, focusing on sustainability and capacity building.
Conclusion: Effective improvement requires strong baseline assessment and sustainable, locally owned interventions. This partnership highlights the value of capacity building, collaboration, and multidisciplinary engagement in tackling antimicrobial resistance and strengthening IPC practices.
Authors: Hail, L. Farragher, M, Panesar, P. Dodoo, C. Jani Y.H, Infection Prevention & Control team. University College London Hospital (UCLH)
- Reducing blood culture contamination: Outcomes from a Nurse-Led Educational Quality Improvement Project
Blood culture contamination (BCC) leads to unnecessary antimicrobial use, higher healthcare costs, and growing antimicrobial resistance. persistently high BCC rates exceeding the recommended 3% prompted a quality improvement project to evaluate the impact of a nurse-led educational intervention. conducted between September 2021 and December 2021 in a secondary hospital, the project involved nurses responsible for blood culture collection. The intervention comprised a 30-minute structured training on optimal collection techniques and contamination prevention, delivered using a “train-the-trainers” model led by Infection prevention and Control (IPC) link nurses. Knowledge was assessed before and after the sessions, followed by continuous monitoring and feedback to sustain practice changes.
A total of 85.9% (122 of 142) nurses participated in both training and assessments. Post-intervention, knowledge scores significantly improved from 71.05% to 92.15%. Correspondingly, BCC rates dropped markedly from 7.9% in 2021 to 2.3% in 2024, achieving and maintaining rates below the international benchmark.
This study demonstrates that a nurse-led, education-driven approach, reinforce through IPC leadership and regular feedback, can effectively and sustainably reduce BCC. It highlights the critical role of empowering nursing staff through structured education, standardized procedures, and interdisciplinary collaboration in advancing antimicrobial stewardship.
Author: Susana Filipe– Local Health Unit – Baixo Mondego (Portugal)
- Implementing SWARM Huddles as a Replacement for PSIRF Audits: Enhancing Incident Review, Staff Engagement, and Patient Safety Outcomes in Clinical Practice.
This Service improvement initiative evaluated the effectiveness of SWARM huddles as a replacement for PSIRF audits in enhancing incident review processes, staff engagement, and patient safety outcomes at West Hertfordshire Teaching Hospital. While the Patient Safety Incident Response Framework (PSIRF) standardises learning from incidents, it is often time-consuming and limits real-time engagement. To address this, multidisciplinary SWARM huddles were introduced in February 2025 bringing together doctors, nurses, pharmacists, therapists and Infection Prevention and Control teams within 24–48 hours of an incident to identify causes, agree actions and share learning promptly.
Comparative analysis between January–August 2024 and the same period in 2025 demonstrated a significant improvement in incident closure rates, rising from under 50% to over 90%. Review times decreased from several weeks to within 48 hours, reflecting greater efficiency, accountability and responsiveness. Staff feedback highlighted enhanced collaboration, engagement and satisfaction with the SWARM process compared to PSIRF audits. Overall, SWARM huddles proved to be a more dynamic and inclusive approach to incident review, facilitating rapid learning, reinforcing quality standards and delivering measurable improvements in patient safety and team culture across the organisation.
Author: Shaly Selva Grace Earnest (Infection Prevention and Control), West Hertfordshire Teaching Hospitals NHS Trust
- Enhancing Antimicrobial Stewardship: Impact of the EOLAS App on Improving Strict Adherence to AMS Protocols in Clinical Practice
Theme: Use of digital/AI solutions for enhanced IPC
This Change initiative evaluated the impact of the EOLAS App on adherence to antimicrobial stewardship (AMS) protocols and its role in enhancing clinical decision-making at West Hertfordshire Teaching Hospital. Antimicrobial resistance (AMR) remains a major global threat, and this innovative digital tool was introduced in November 2024 to provide real-time AMS guidance, prescribing support and access to key resources such as the Medusa IV guide and renal dosing tools. Data on the use of Clostridioides difficile-risk antibiotics (co-amoxiclav, cephalosporins, and fluoroquinolones) from September 2023 to August 2025 were analysed pre- and post-app launch.
Findings revealed a sustained reduction in high-risk antibiotic use following the introduction of EOLAS app, indicating improved compliance with AMS protocols. Co-amoxiclav and cephalosporin prescribing notably declined, while fluoroquinolone use showed a consistent downward trend. User feedback highlighted enhanced confidence in prescribing, ease of use and seamless integration into clinical workflows.
Overall, the EOLAS App demonstrated a positive and measurable impact on antibiotic prescribing behaviour, supporting safer, evidence-based practice and improved infection prevention standards. Its integration with electronic health records further strengthened its utility, showcasing digital innovation as a powerful enabler in the fight against antimicrobial resistance.
Author: Shaly Selva Grace Earnest, Infection Prevention and Control, (West Hertfordshire Teaching Hospitals NHS Trust)
- Pathway to safe care, Power of PSIRF in Infection Prevention.
Infection Prevention and Control teams traditionally used Root Cause Analysis (RCA) to investigate patient safety incidents. RCA focused on individual errors, where improvements in patient care were often short-term or superficial. missing wider systemic and human factors that contribute to harm. NHS England recognised these limitations and developed the Patient Safety Incident Response Framework (PSIRF).
This study shows how the Infection Prevention and Control Team at Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT) applied PSIRF principles to drive sustainable, system-level improvements in patient safety linked to urinary catheter use.
Following thematic review of incidents related to urinary catheters, a Quality summit was organised which was facilitated by the Trust’s Patient Safety and Quality Improvement teams. 80 stakeholders including patients explored real-world barriers / enablers to safe practice using the Systems Engineering Initiative for Patient Safety (SEIPS) framework. 5 key improvement areas were identified: staff training, care standardisation, documentation and communication, procurement and stock management, and better understanding of patient pathways. Staff reported greater engagement and ownership, while patient contributions provided powerful insights into lived experiences. This PSIRF-aligned, system-based approach has strengthened collaboration, reduced blame culture, and is driving four ongoing quality improvement projects, supporting the development of resilient, sustainable patient safety outcomes across the organisation.
Authors: G. Matthews (Senior Infection Prevention and Control Nurse) and S. Finch-Turner (Infection Prevention and Control Nurse), Gloucestershire Hospitals NHS Foundation Trust
- Implementing a Digitised Review of Care Process Incorporating PSIRF and SEIPS in Patients with a Hospital Acquired Clostridioides difficile
In response to a letter from NHSE and after reviewing the limitations of previously used methods of investigating cases of hospital acquired Clostridioides difficile infections the University Hospitals of Derby and Burton (UHDB) Infection Prevention and Control (IPC) team developed an online review tool. This tool was designed using the principles of Patient Safety Incident Framework (PSIRF) and System Engineering Initiative for Patient Safety (SEIPS) and utilises the risk management system, Datix. A Datix incident is raised when there is a case of hospital acquired C. difficile infection and is attributed to the area the infection occurred. A review of care involving Microbiology, Antimicrobial Pharmacists, Clinical Teams, and the IPC team is arranged to take place within 3 working days and the Datix is completed as a live document during the review within the attributed area. Each Clinical area owns the investigation and learning from the review and the findings are shared with the local clinical team utilising a ‘learning on a page’ format. This process allows real time access to incident reports and system analytics, facilitating timely decision-making and corrective actions. Findings are discussed at Divisional Governance meetings as well as being reported through IPC governance and reporting structure to facilitate the sharing of good practice and learning. One of the notable outcomes is the significant increase in medical engagement in reviews, with a 19% increase in attendance from the start of this process. From findings our laboratory has increased testing of stool samples by 4% to ensure the prompt diagnosis of infection to increase good patient outcomes This process has been rolled out with other HCAI’s and in other teams within the Trust.
Author: Catherine Miles (Lead Nurse IPC), University Hospitals of Derby and Burton NHS Foundation Trust
- Developing a surveillance framework and digital tool for Vascular Access Device-Relate Bloodstream Infections (VAD-BSI): improving patient safety through local data and national insight
It is well known that patients with an inadequately managed indwelling vascular access device (VAD) are at greater risk of infection and increased risk of mortality compared to those without. This presents a significant burden to the National Health Service (NHS) by prolonging hospital stays and the need for additional treatment. Currently there is no digital surveillance tool for the standardised collection of data relating to these infections. As part of the Device Related Infection Prevention Practices (DRIPP) initiative, a multidisciplinary collaborative of nurses and healthcare specialists from five NHS Trusts have worked together to develop a score-based digitalised data surveillance tool using standardised criteria. A Microsoft excel spreadsheet was used incorporating dropdown options, allowing standardised data entry and immediate graphical data visualisation for clinical feedback and reporting. Repeated cyclical assessment and amendment by the team enabled ongoing development of the tool, optimising relevance of the information collected. The tool was trialled in the five trusts over two years, and user feedback obtained by completion and submission of a Likert scale questionnaire. Findings: Completion of the tool using standardised criteria enabled accurate VAD-BSI data collection across the included organisations, facilitating comparison and benchmarking between them. User feedback proved the tool easy to use with appreciation of the increased access to real time data. The use of excel prompted challenges for some members of the team, who required additional support in troubleshooting basic data entry issues. One organisation used the tool to demonstrate reduced incidence of line related infections by implementing weekly line audits and education. Another identified improved visibility of blood culture contamination rates, prompting local policy change and improved anti-microbial stewardship. The data collected is undergoing deeper epidemiological analysis and the findings are to be published. Significance: Further testing of the tool is underway, and opportunities to develop a robust stand-alone application being explored. This could enable wider roll out of its use across more organisations, and may help to improve future VAD care, thus reducing the national burden of VAD-BSIs and improving patient safety.
Authors: Sue Rowlands, Ryan George, Valerie Wortley, Jane Hodson, Felicity Kempson, Stephanie Depinto, Jincy Jerry (New Cross Hospital)
