CSIRO PUBLISHING
Australian Health Review, 2015, 39, 359–362 http://dx.doi.org/10.1071/AH14077
Case study
Thinking differently: working together for better care Patrick Bolton1 PhD, FRACGP, FRACMA, Conjoint Associate Professor Hilary Crilly2 MA(OXON), MPHP, Health Economics and Outcomes Research Director Ketty Rivas3,4 RN, GradDip Comm Diseases, MN Adv Dip Governm, Patient Safety and Health Outcomes Officer 1
School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW 2052, Australia. Email: [email protected] 2 Becton Dickinson, 4 Research Park Drive, North Ryde, NSW 2113, Australia. Email: [email protected] 3 Prince of Wales Hospital, High Street, Randwick, NSW 2031, Australia. 4 Corresponding author. Email: [email protected]
Abstract. This paper describes the development and outcomes from ‘joint working’ between Prince of Wales Hospital and BD (Becton, Dickinson and Company) in Australia. ‘Joint working’ is a term used within the English National Health Service to describe health system and industry partners working together to create novel service models which benefit patients. The joint working process broadened the perspective of both parties through learning from each other and so enhanced the range of tools they each bring to their work. What is known about the topic? Collaboration between industry – specifically the pharmaceutical industry – and English National Health Service providers under the rubric “joint working” has been used successfully to pool skills, experience and/or resources for the joint development and implementation of patient centred projects. This process has required identification of the common interest of both parties and care to ensure the public interest is maintained. What does this paper add? Descriptions of collaboration between public hospital and private industry to deliver improved health outcomes have not been widely published. Joint working has not previously been described in the Australian context. This paper describes an experiment which addresses both of the gaps. What are the implications for practitioners? Opportunities may exist to improve patient outcomes through collaboration between public health providers and industry. Received 22 August 2014, accepted 21 November 2014, published online 22 January 2015
Introduction This paper describes the development and outcomes from ‘joint working’ between Prince of Wales Hospital (POWH) and BD (Becton, Dickinson and Company) in Australia. ‘Joint working’ is a term used within the English National Health Service (NHS) to describe health system and industry partners working together for the benefit of patients.1 We hypothesised that such public–private joint working could be of local value if the different paradigms within each sector were complementary, including if this encouraged new ways of thinking. Insights are suggested for future public private collaboration. BD sought to gain greater understanding of the priorities and operation of the hospital as seen by the executive level. BD’s most usual contact within the hospital is with front-line clinical, laboratory and procurement professionals. BD wanted to explore a different approach, working with the public sector to find areas where joint working could produce additional benefits. Such an approach requires in-depth understanding of facility needs and priorities. Journal compilation Ó AHHA 2015
POWH sought to use joint working to bring additional nonmaterial resources to manage areas of concern in which BD could add value. These emerged in areas such as sharps injury prevention, infection prevention and control initiatives, as well as improvement of pre-analytical variables. POWH hoped to benefit from skills, perspective and a culture different to its own, particularly the discipline required by commerciality, and saw that these cultural benefits may be most valuable in the long-term. Case study Setting POWH is a 438-bed public teaching hospital in Sydney (NSW, Australia). BD is a leading medical technology company. Method This paper was prepared by each stakeholder reflecting independently on elements of the joint working and also based on detailed notes from a strategic planning day. www.publish.csiro.au/journals/ahr
360
Australian Health Review
Sequence of events The relationship began opportunistically through a chance meeting between the POWH Director of Medical Services and the Managing Director of BD in Australia. The parties identified broad interest in working together for the reasons set out above. There followed a series of meetings that were valuable from an understanding and trust-building perspective. A common interest emerged around procedures (‘the procedures’) that breach the physical integrity of patients, including intravenous (i.v.) cannulation and phlebotomy. The procedures create three intersecting risks: patient infection, sharps injuries and issues following from errors in specimen collection. The procedures are performed frequently and are fundamental to patient outcomes and staff safety. For example, up to 70% of patients in acute care hospitals receive a peripheral i.v. cannula,2 and at least 18 000 healthcare employees in Australia suffer needlestick and sharps injuries every year.3 This common interest did not translate into tangible outcomes. It was thought that sharing efforts to deliver concrete deliverables may address this and provide a platform to explore culture change and strategic issues. Areas where BD and POWH activities overlapped were identified to this end. Early products of these discussions included: *
*
*
*
*
a small audit of phlebotomy procedures conducted by BD across wards representative of the whole of POWH using a standardised tool that addressed each area of risk. This identified variance from best practice and hospital policy, and the information was presented in a report to the Infection Prevention and Control Committee of POWH. a proposal to conduct a small observational study of cannulaflushing practices to highlight variations in practice and opportunities for improvement in infection prevention and control, medication safety and time savings, and for BD to plan for more extensive trial work in this area in the longer term. Ultimately, hospital support was not obtained because this was perceived to be a commercial activity. BD support for POWH staff in the creation of a report on the hospital-wide hand-hygiene project. ongoing BD support for practical in-service training assistance to POWH in the areas of phlebotomy and peripheral i.v. cannulation. introducing BD business leaders to POWH clinical leads with the aim of fostering opportunities to explore areas of mutual interest and future collaboration.
A major initiative BD has experience and strong employee engagement around strategic planning related to developing and executing key business objectives. We sought to replicate an element of this in clinician engagement around system changes relating to the procedures within POWH. An off-site ‘Safety First. Always’ workshop was planned as a locally novel format for clinicians at all levels to discuss issues and suggest system changes. The day was described as a ‘strategic planning day’ with the stated purpose being to ‘achieve clinician engagement through a process of strategic planning to influence infection prevention and related outcomes’.
P. Bolton et al.
Participants Eighteen participants identified as key influencers and/or representatives from medical and nursing staff were invited to participate. These included nurses, physicians, surgeons, trainee doctors and hospital staff, including those with expertise in infection control and healthcare worker safety. Fifteen people attended from all the invited groups, except the surgeons. The meeting was run by a BD expert facilitator. Three staff from BD provided administrative support. All other costs associated with the day were met by POWH. Although BD had no commercial interest in the day, it benefited through enhanced understanding of issues involved in healthcare risk management and prioritisation.
Results The first theme to emerge from discussion was the need to ensure that harm prevention was ‘top of mind’. Discussion followed about whether adequate consideration was given to the necessity for the procedures, and the consequences of a perception that doctors should be ‘doing’ something (e.g. a default position may be to insert an i.v. cannula rather than not to insert one). Many junior staff members have not experienced the negative impact of risks related to the procedures such as i.v. cannula-associated septicaemia. As a result, such procedures may be seen as ‘routine’, with minimal associated risk and subject to a ‘casual’ approach. The ‘top of mind’ theme generated discussion about the need for multidisciplinary senior leadership and organisational focus to educate junior staff and support a different pattern of basic activity with increased teamwork and communication. A further aspect of ‘top of mind’ related to worker safety, with a focus generally on care of the patient rather than the clinician and a failure to appreciate the potential impact of a sharps injury. Perceptions offered included a sense of embarrassment in reporting sharps injuries and a feeling of needing to ‘get on with the job’ rather than spending time reporting. An overall sense exists that ‘it will not happen to me’. Discussion followed that awareness of the importance of the risks associated with the procedures should be improved through initiatives to incorporate them into the organisation’s culture through the mission/vision process, education (including personal stories) and engagement of senior staff. Selected adverse events should be treated as critical incidents, reviewed individually and give rise to recommendations to prevent recurrence. Standardised procedures, credentialing and checklists could be used to improve procedure standardisation, and audit and feedback used to drive behaviour change and uptake of preferred ‘best’ practices. The possibility of engaging patients in driving behaviour was discussed. The second key theme was the need for the physical environment to support good practice. This discussion had several elements: (1) recognition of, and better support for, hospital cleaning and the opportunity to engage domestic services staff more completely in the mission of the organisation; (2) the use of technology, in particular information technology, to support service provision; (3) standardisation of equipment and layout of equipment to support staff to make improved choices about
Thinking differently: towards a new mode of public private collaboration
the procedures; and (4) the use of standardised checklists as a tool to support better practice. BD’s capacity to facilitate meetings was also used by the POWH Pharmacy Department with a separate day to develop a Departmental vision and methodology for priority setting. Various suggestions arising from the workshop have been implemented. A working group was established comprising nurses and junior medical officers to work on the ‘4S’ strategies for venepuncture: selecting the most appropriate equipment, standardising access to the equipment, standardised knowledge and sustained improvement. BD helped organise a ‘Sharps Safety Session’ with presentation by a nurse who has occupationally acquired HIV from a needlestick injury. This personal story highlighted the significance of sharps injuries, reinforcing the need for reporting and prevention through vaccination and appropriate use of personal protective equipment and safety-engineered devices. The number of needle stick injuries fell following the introduction of these strategies from 88 in 2012 to 73 in 2013. There have been 36 reported needle stick injuries in the period January– June 2014. The use of standardised checklists as a tool to support better practice was taken up by a focus group of junior medical officers who identified matters that may be usefully included in a checklist for daily ward rounds. This has subsequently been trialled. A template to review Staphylococcus aureus bacteraemia (SABs) systematises a team-based approach to review these critical incidents. The approach aims to highlight areas for improvement, ensuring team learning, with the ultimate goal of zero SABs. Patient consequences of SAB infections are incorporated into the reporting template to drive data collection. There have been 19 notifications since November 2013, eight of which identified opportunities for practice change. The pharmacy planning day assisted the Pharmacy Department to define its focus and priorities and sparked several concrete proposals for service improvement. Discussion Problems Both parties experienced some concerns as they explored a new way of working. For POWH, this related to ‘stepping outside’ the traditional public model by collaborating with medical industry and managing the perception or actuality of conflict of interest. BD was keen to avoid any suggestion of conflict of interest and hence was unable to engage as fully as otherwise may have been possible. The priorities of the stakeholders varied with competing demands on time. A simple practical problem was gaining consistent participation in work groups within the hospital environment because immediate patient care concerns take precedence. The complexity of the hospital environment means that there is a need to influence many stakeholders to effect change; this can be challenging, even with a high level of leadership. The most obvious outcomes to date have been the phlebotomy audit and BD’s facilitation of meetings. The latter was also seen in NHS joint working, where company skills
Australian Health Review
361
used by the NHS partners included strategic planning, meetings organisation and facilitation and project management.1 Intangibles include the exchange of ideas and impact of the planning days in subsequent hospital improvement activities. The greatest benefit for BD was understanding of the workings of the hospital and breadth of relationships, together with validation of the proposition that BD can deliver value beyond its products. Any commercial gain for BD was indirect, arising from an increased focus within the hospital on employee safety and phlebotomy practices, with potential altered product choices in these areas. Several strategies may be considered to enable more productive future joint working, as follows. *
*
*
It would be beneficial to start with a clearly defined area of work that is understood as a priority for all parties, where a win–win can be achieved. An overall project charter could include what success looks like and how this is to be measured. Consideration should be given to the appropriate level for ownership and oversight within each organisation to ensure appropriate governance and facilitate and signal organisational acceptance of activities that are outside the norm. A greater understanding at the outset by both partners of the operations of the other would allow for an appreciation of likely challenges and more efficient benefits realisation.
The above factors reflect a need to be clear from the outset regarding the value proposition for each stakeholder. Recognition and acceptance is also required that outcomes cannot be fully anticipated and that to enforce a strict framework potentially stifles innovation. The test of partnership working would be a further collaboration with explicit objectives whereby a commercial gain for a company is acceptable as enabling hospital objectives. Lessons learned The joint working process broadened the perspective of both parties through learning from each other and so enhanced the range of tools they each bring to their work. The parties have established a mutual respect, understanding and trusting relationship that would enable future initiatives. In the process of exploring a new approach there has been a worthwhile contribution to hospital services, with insights provided for future public–private joint working initiatives to contribute to improvements in care. Competing interests The authors have the interests arising from their respective sources of employment. References 1
Department of Health/Association of British Pharmaceutical Industries (ABPI). Moving beyond sponsorship: interactive toolkit for joint working between the NHS and the pharmaceutical industry. 2010. Available at: http://webarchive.nationalarchives.gov.uk/20130107105354/; http://www. dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicy AndGuidance/DH_082840 [verified 27 April 2014].
362
Australian Health Review
P. Bolton et al.
2 Rickard CM, Webster J, Wallis M, March N, McGrail M, French V, Foster L, Gallagher P, Gowardmand J, Zhang L, McClymont A, Whitby M. Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial. Lancet 2012; 380: 1066–74. doi:10.1016/S0140-6736(12)61082-4
3 Murphy C. Improved surveillance and mandated use of sharps with engineered sharp injury protections: a national call to action. Healthc Infect 2008; 13: 33–37. doi:10.1071/HI08019
www.publish.csiro.au/journals/ahr
Australian Health Review, 2015, 39, 359–362 http://dx.doi.org/10.1071/AH14077
Case study
Thinking differently: working together for better care Patrick Bolton1 PhD, FRACGP, FRACMA, Conjoint Associate Professor Hilary Crilly2 MA(OXON), MPHP, Health Economics and Outcomes Research Director Ketty Rivas3,4 RN, GradDip Comm Diseases, MN Adv Dip Governm, Patient Safety and Health Outcomes Officer 1
School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW 2052, Australia. Email: [email protected] 2 Becton Dickinson, 4 Research Park Drive, North Ryde, NSW 2113, Australia. Email: [email protected] 3 Prince of Wales Hospital, High Street, Randwick, NSW 2031, Australia. 4 Corresponding author. Email: [email protected]
Abstract. This paper describes the development and outcomes from ‘joint working’ between Prince of Wales Hospital and BD (Becton, Dickinson and Company) in Australia. ‘Joint working’ is a term used within the English National Health Service to describe health system and industry partners working together to create novel service models which benefit patients. The joint working process broadened the perspective of both parties through learning from each other and so enhanced the range of tools they each bring to their work. What is known about the topic? Collaboration between industry – specifically the pharmaceutical industry – and English National Health Service providers under the rubric “joint working” has been used successfully to pool skills, experience and/or resources for the joint development and implementation of patient centred projects. This process has required identification of the common interest of both parties and care to ensure the public interest is maintained. What does this paper add? Descriptions of collaboration between public hospital and private industry to deliver improved health outcomes have not been widely published. Joint working has not previously been described in the Australian context. This paper describes an experiment which addresses both of the gaps. What are the implications for practitioners? Opportunities may exist to improve patient outcomes through collaboration between public health providers and industry. Received 22 August 2014, accepted 21 November 2014, published online 22 January 2015
Introduction This paper describes the development and outcomes from ‘joint working’ between Prince of Wales Hospital (POWH) and BD (Becton, Dickinson and Company) in Australia. ‘Joint working’ is a term used within the English National Health Service (NHS) to describe health system and industry partners working together for the benefit of patients.1 We hypothesised that such public–private joint working could be of local value if the different paradigms within each sector were complementary, including if this encouraged new ways of thinking. Insights are suggested for future public private collaboration. BD sought to gain greater understanding of the priorities and operation of the hospital as seen by the executive level. BD’s most usual contact within the hospital is with front-line clinical, laboratory and procurement professionals. BD wanted to explore a different approach, working with the public sector to find areas where joint working could produce additional benefits. Such an approach requires in-depth understanding of facility needs and priorities. Journal compilation Ó AHHA 2015
POWH sought to use joint working to bring additional nonmaterial resources to manage areas of concern in which BD could add value. These emerged in areas such as sharps injury prevention, infection prevention and control initiatives, as well as improvement of pre-analytical variables. POWH hoped to benefit from skills, perspective and a culture different to its own, particularly the discipline required by commerciality, and saw that these cultural benefits may be most valuable in the long-term. Case study Setting POWH is a 438-bed public teaching hospital in Sydney (NSW, Australia). BD is a leading medical technology company. Method This paper was prepared by each stakeholder reflecting independently on elements of the joint working and also based on detailed notes from a strategic planning day. www.publish.csiro.au/journals/ahr
360
Australian Health Review
Sequence of events The relationship began opportunistically through a chance meeting between the POWH Director of Medical Services and the Managing Director of BD in Australia. The parties identified broad interest in working together for the reasons set out above. There followed a series of meetings that were valuable from an understanding and trust-building perspective. A common interest emerged around procedures (‘the procedures’) that breach the physical integrity of patients, including intravenous (i.v.) cannulation and phlebotomy. The procedures create three intersecting risks: patient infection, sharps injuries and issues following from errors in specimen collection. The procedures are performed frequently and are fundamental to patient outcomes and staff safety. For example, up to 70% of patients in acute care hospitals receive a peripheral i.v. cannula,2 and at least 18 000 healthcare employees in Australia suffer needlestick and sharps injuries every year.3 This common interest did not translate into tangible outcomes. It was thought that sharing efforts to deliver concrete deliverables may address this and provide a platform to explore culture change and strategic issues. Areas where BD and POWH activities overlapped were identified to this end. Early products of these discussions included: *
*
*
*
*
a small audit of phlebotomy procedures conducted by BD across wards representative of the whole of POWH using a standardised tool that addressed each area of risk. This identified variance from best practice and hospital policy, and the information was presented in a report to the Infection Prevention and Control Committee of POWH. a proposal to conduct a small observational study of cannulaflushing practices to highlight variations in practice and opportunities for improvement in infection prevention and control, medication safety and time savings, and for BD to plan for more extensive trial work in this area in the longer term. Ultimately, hospital support was not obtained because this was perceived to be a commercial activity. BD support for POWH staff in the creation of a report on the hospital-wide hand-hygiene project. ongoing BD support for practical in-service training assistance to POWH in the areas of phlebotomy and peripheral i.v. cannulation. introducing BD business leaders to POWH clinical leads with the aim of fostering opportunities to explore areas of mutual interest and future collaboration.
A major initiative BD has experience and strong employee engagement around strategic planning related to developing and executing key business objectives. We sought to replicate an element of this in clinician engagement around system changes relating to the procedures within POWH. An off-site ‘Safety First. Always’ workshop was planned as a locally novel format for clinicians at all levels to discuss issues and suggest system changes. The day was described as a ‘strategic planning day’ with the stated purpose being to ‘achieve clinician engagement through a process of strategic planning to influence infection prevention and related outcomes’.
P. Bolton et al.
Participants Eighteen participants identified as key influencers and/or representatives from medical and nursing staff were invited to participate. These included nurses, physicians, surgeons, trainee doctors and hospital staff, including those with expertise in infection control and healthcare worker safety. Fifteen people attended from all the invited groups, except the surgeons. The meeting was run by a BD expert facilitator. Three staff from BD provided administrative support. All other costs associated with the day were met by POWH. Although BD had no commercial interest in the day, it benefited through enhanced understanding of issues involved in healthcare risk management and prioritisation.
Results The first theme to emerge from discussion was the need to ensure that harm prevention was ‘top of mind’. Discussion followed about whether adequate consideration was given to the necessity for the procedures, and the consequences of a perception that doctors should be ‘doing’ something (e.g. a default position may be to insert an i.v. cannula rather than not to insert one). Many junior staff members have not experienced the negative impact of risks related to the procedures such as i.v. cannula-associated septicaemia. As a result, such procedures may be seen as ‘routine’, with minimal associated risk and subject to a ‘casual’ approach. The ‘top of mind’ theme generated discussion about the need for multidisciplinary senior leadership and organisational focus to educate junior staff and support a different pattern of basic activity with increased teamwork and communication. A further aspect of ‘top of mind’ related to worker safety, with a focus generally on care of the patient rather than the clinician and a failure to appreciate the potential impact of a sharps injury. Perceptions offered included a sense of embarrassment in reporting sharps injuries and a feeling of needing to ‘get on with the job’ rather than spending time reporting. An overall sense exists that ‘it will not happen to me’. Discussion followed that awareness of the importance of the risks associated with the procedures should be improved through initiatives to incorporate them into the organisation’s culture through the mission/vision process, education (including personal stories) and engagement of senior staff. Selected adverse events should be treated as critical incidents, reviewed individually and give rise to recommendations to prevent recurrence. Standardised procedures, credentialing and checklists could be used to improve procedure standardisation, and audit and feedback used to drive behaviour change and uptake of preferred ‘best’ practices. The possibility of engaging patients in driving behaviour was discussed. The second key theme was the need for the physical environment to support good practice. This discussion had several elements: (1) recognition of, and better support for, hospital cleaning and the opportunity to engage domestic services staff more completely in the mission of the organisation; (2) the use of technology, in particular information technology, to support service provision; (3) standardisation of equipment and layout of equipment to support staff to make improved choices about
Thinking differently: towards a new mode of public private collaboration
the procedures; and (4) the use of standardised checklists as a tool to support better practice. BD’s capacity to facilitate meetings was also used by the POWH Pharmacy Department with a separate day to develop a Departmental vision and methodology for priority setting. Various suggestions arising from the workshop have been implemented. A working group was established comprising nurses and junior medical officers to work on the ‘4S’ strategies for venepuncture: selecting the most appropriate equipment, standardising access to the equipment, standardised knowledge and sustained improvement. BD helped organise a ‘Sharps Safety Session’ with presentation by a nurse who has occupationally acquired HIV from a needlestick injury. This personal story highlighted the significance of sharps injuries, reinforcing the need for reporting and prevention through vaccination and appropriate use of personal protective equipment and safety-engineered devices. The number of needle stick injuries fell following the introduction of these strategies from 88 in 2012 to 73 in 2013. There have been 36 reported needle stick injuries in the period January– June 2014. The use of standardised checklists as a tool to support better practice was taken up by a focus group of junior medical officers who identified matters that may be usefully included in a checklist for daily ward rounds. This has subsequently been trialled. A template to review Staphylococcus aureus bacteraemia (SABs) systematises a team-based approach to review these critical incidents. The approach aims to highlight areas for improvement, ensuring team learning, with the ultimate goal of zero SABs. Patient consequences of SAB infections are incorporated into the reporting template to drive data collection. There have been 19 notifications since November 2013, eight of which identified opportunities for practice change. The pharmacy planning day assisted the Pharmacy Department to define its focus and priorities and sparked several concrete proposals for service improvement. Discussion Problems Both parties experienced some concerns as they explored a new way of working. For POWH, this related to ‘stepping outside’ the traditional public model by collaborating with medical industry and managing the perception or actuality of conflict of interest. BD was keen to avoid any suggestion of conflict of interest and hence was unable to engage as fully as otherwise may have been possible. The priorities of the stakeholders varied with competing demands on time. A simple practical problem was gaining consistent participation in work groups within the hospital environment because immediate patient care concerns take precedence. The complexity of the hospital environment means that there is a need to influence many stakeholders to effect change; this can be challenging, even with a high level of leadership. The most obvious outcomes to date have been the phlebotomy audit and BD’s facilitation of meetings. The latter was also seen in NHS joint working, where company skills
Australian Health Review
361
used by the NHS partners included strategic planning, meetings organisation and facilitation and project management.1 Intangibles include the exchange of ideas and impact of the planning days in subsequent hospital improvement activities. The greatest benefit for BD was understanding of the workings of the hospital and breadth of relationships, together with validation of the proposition that BD can deliver value beyond its products. Any commercial gain for BD was indirect, arising from an increased focus within the hospital on employee safety and phlebotomy practices, with potential altered product choices in these areas. Several strategies may be considered to enable more productive future joint working, as follows. *
*
*
It would be beneficial to start with a clearly defined area of work that is understood as a priority for all parties, where a win–win can be achieved. An overall project charter could include what success looks like and how this is to be measured. Consideration should be given to the appropriate level for ownership and oversight within each organisation to ensure appropriate governance and facilitate and signal organisational acceptance of activities that are outside the norm. A greater understanding at the outset by both partners of the operations of the other would allow for an appreciation of likely challenges and more efficient benefits realisation.
The above factors reflect a need to be clear from the outset regarding the value proposition for each stakeholder. Recognition and acceptance is also required that outcomes cannot be fully anticipated and that to enforce a strict framework potentially stifles innovation. The test of partnership working would be a further collaboration with explicit objectives whereby a commercial gain for a company is acceptable as enabling hospital objectives. Lessons learned The joint working process broadened the perspective of both parties through learning from each other and so enhanced the range of tools they each bring to their work. The parties have established a mutual respect, understanding and trusting relationship that would enable future initiatives. In the process of exploring a new approach there has been a worthwhile contribution to hospital services, with insights provided for future public–private joint working initiatives to contribute to improvements in care. Competing interests The authors have the interests arising from their respective sources of employment. References 1
Department of Health/Association of British Pharmaceutical Industries (ABPI). Moving beyond sponsorship: interactive toolkit for joint working between the NHS and the pharmaceutical industry. 2010. Available at: http://webarchive.nationalarchives.gov.uk/20130107105354/; http://www. dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicy AndGuidance/DH_082840 [verified 27 April 2014].
362
Australian Health Review
P. Bolton et al.
2 Rickard CM, Webster J, Wallis M, March N, McGrail M, French V, Foster L, Gallagher P, Gowardmand J, Zhang L, McClymont A, Whitby M. Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial. Lancet 2012; 380: 1066–74. doi:10.1016/S0140-6736(12)61082-4
3 Murphy C. Improved surveillance and mandated use of sharps with engineered sharp injury protections: a national call to action. Healthc Infect 2008; 13: 33–37. doi:10.1071/HI08019
www.publish.csiro.au/journals/ahr
