Table 3 CPE toolkit implementation overview

Awareness and reach

Familiarity amongst IPC frontline staff

• The CPE toolkit came out in early 2014. (…) I think it was very well publicised (IPC frontline staff 14).

• I remember when I was a nurse on the shop floor I would have no idea and I only know because I’m in this job. (IPC frontline staff 15)

Unfamiliarity amongst general frontline staff

• I’m not aware of anything other than what we’re doing at the moment. (General frontline staff 11)

• I have heard of it but I haven’t read it. (General frontline staff 3)

Awareness raising effect of outbreaks

• When we had our outbreak on the ward, so that’s how we became aware of it, from the infection control team. (General frontline staff 4)

Multiple CPE toolkit communication channels

• Because I’m an infection prevention matron and it came through my manager. (IPC frontline staff 6)

• Because somebody emailed it to me to read when we first came across CPE. (IPC frontline staff 3)

CPE toolkit implementation and impact pathway

Proximity to CPE as trigger for change

• It’s just an experience I don’t want to go through again but it’s been definitely an experience that obviously was needed to go through to learn from it. And we certainly have. And even though it’s been negative for patients to contract CPE, we’ve come out with a positive outcome that people have learnt and hopefully it won’t happen again. (General frontline staff 4)

CPE toolkit as reference document

• All of our problems preceded the national guidance. (…) But obviously we’ve made sure that we were at least as a minimum in line with national guidance. (IPC frontline staff 1)

Alignment with the CPE toolkit considering circumstances/Local adaptions

• The policy has been adapted as we’ve experienced more patients or the particular issues their nursing usually brings with them. (IPC frontline staff 21)

• We’ve slightly moved the goalposts because of incidences we know that have happened. Incidents elsewhere, so those become alert areas.” (General frontline staff 20)

• We used the guidelines what the suggestions were and if we thought it wasn’t enough then we tightened that suggestion up and put it into the policy. (IPC frontline staff 16)

• Our policy is different in that in the toolkit it talks about isolation in the side rooms. Because we’ve had the problems that we’ve had we have an isolation ward. (IPC frontline staff 8)

• We put a lot of emphasis on infection prevention, because it’s a cancer hospital and infection is something that kills cancer patients. They’re compromised and in the latter stages of disease. So we put a lot of emphasis on infection prevention, full stop. (IPC frontline staff 4)

Interdisciplinary development process for local CPE plans

• We extracted what was relevant out of the CPE toolkit. There was a few of us that were looking at it, a couple of nurses and a microbiologist at the time. We used the toolkit quite heavily. (IPC frontline staff 15)

• Well, obviously, any policy that we have would be a collaboration between [Pause]. Well, looking at national guidelines and discussing it within the team. We have a nurse consultant and myself who would pull it together and take it forward from there, and then we have a structure whereby we’d ratify it through the infection control committee. (IPC frontline staff 1)

Multiple local CPE plan communication channels

• It was mentioned at meetings like [the] infection control committee, which has attendance from all divisions. There was email communication from top down so Chief Exec and Medical so that went to at least all the consultant bodies. I did talk with every divisional audit meeting. Infection Control committees. So that’s where it must have gone down to division. (IPC frontline staff 17)

• We’ve spent a lot of time promoting it and talking about it. We’ve done loads of education on the ward. We’ve gone to the staff and we’ve invaded their handovers to speak about it and told them what to do, why it’s important. (IPC frontline staff 13)

• We’ve done a lot of work in terms of publicising CPE around the Trust. So we did a video for example, just giving a short I think it’s a four minutes lecture on CPE. That’s hopefully casting. We showed that to all infection control practitioner training sessions. We produced some information sheets. (IPC frontline staff 2)

Implementation challenge

• They [general frontline staff] know what they’re doing so they’re dealing with CPE, they’re managing it every day, they probably wouldn’t be able to tell you what it was. (General frontline staff 11)

• It’s easy to write a policy you know, I’ve done that. It was easy to write the CPE policy, but actually how to implement it was a nightmare. (IPC frontline staff 19)

• So, enforcing those, enforcing that change, making people aware of why we’re doing that is a… is still a challenge. (IPC frontline staff 5)

Views and responses to the CPE toolkit

Usefulness

• I think looking through them it was very useful, yeah. (IPC frontline staff 7)

• I think the tool kit is actually quite comprehensive. There is always room for improvement, but actually it contains quite a lot of information and as I say the flow chart I think was very good and you have updated it I know a number of times and we have updated our policy in the light of that. (IPC frontline staff 9)

Non-applicability

• There’s a lot of very fundamental practicalities. In theory, you can think, ‘Oh, this is fine. We have a side room; we can do this,’ and then you think, the shower is seven doors down – does that increase or reduce the contamination risks, insisting on showering? (IPC frontline staff 21)

• I think it’s a guidance written around policy, written around assuming that everything takes place but it doesn’t seem to fit real life, the actual care that goes on. (IPC frontline staff 5)

Lack of specificity and evidence base

• I think at the time they were quite useful but the more we had to sort of deal with it they were a little bit too vague. (…) I suppose if they were to put the guidelines out there and it was just so new and they couldn’t be specific because we were all learning about it weren’t we. (IPC frontline staff 16)

• I think it’s the epidemiology that’s missing. (…) It does make you question the evidence that is informing those policy decisions, and it does for me. When I’m giving the education, it feels like a little bit hollow. And if anybody asks me a question I couldn’t answer it. (IPC frontline staff 6)

Length and lack of accessibility

• I think initially when I first saw them I was terrified because they were really long and all the different appendices I found it really difficult to put together. If I was working on the ward I would not have been able to do it. (IPC frontline staff 19)

Uncertainty about CPE toolkit target group

• There’s lots of information and people don’t read it, people won’t read it. You’ve got to make it more…simpler. I as an infection control nurse could understand that but I’m not completely sure that A, people have the time to read that on the wards and B, they completely understand what it is. So, it depends on who you’re directing it at. (IPC frontline staff 14)

CPE toolkit improvement suggestions

Updates including further evidence

• For the toolkit itself the time’s right for, following this evaluation, obviously, to re-address it. And to address how it fits into the UK – well, English – epidemiology now. Because I think this is a moving target, really, and we need to adapt. The guidelines are four years old already and the numbers have increased dramatically. Things have changed particularly, so I think that now’s the opportunity, once we have a feel for what the issues are from the toolkit itself, so it’s prime time to do this work. (IPC frontline staff 1)

• I think it would be useful having a CPO document and highlighting the differences between CPO and CPE would be good. (IPC frontline staff 23)

• It said here, the working group recognises when compared to other organisms (…) these were all being considered elsewhere. Now I think for someone like me I need to know where the elsewhere is. (IPC frontline staff 23)

• It would be good to have sort of links to subject matter experts to be able to ask them sort of questions and interpret what we should do in certain situations. (IPC frontline staff 5)

• I’d prefer a live update, a live updated website that I can refer my staff to so that they’re aware of where there are concerns and problems. (IPC frontline staff 5)

Target group representative involvement

• The early iteration of the toolkit was not practical. The later one, the one that eventually came out, I’d like to think that’s because people like me who attended those meetings help shape the thing into reality. It became more useful and we used it as a basis for writing our policies. (IPC frontline staff 4)

Emphasis on local adaptions and tailored information

• We will take the guidelines under advice and adapt them as appropriate for our local situation. I think some smaller trusts might feel it was more difficult to go against perceived national guidance. (…) I think you need to adapt it to what’s going on locally and use that as your basis and then justify how you’ve changed from it. If that was spelt out to people, and how they might change it if their circumstances were different, that might help colleagues out there who are maybe less sure of what to do. (IPC frontline staff 1)

• If I had a little bit of abbreviated information with the most important aspects as regards the emergency department, then I can disseminate those to our doctors so they are more in the know. (General frontline staff 3)

Additional visualisations

• I really like a world map, you know where you have got the different color-coded countries, where they have had problems etc., I think that’s really informative, I really like that and it gives a very visual picture to people as to the spread of this organism as to how rapidly its spreading in a very short time. (IPC frontline staff 9)