Carol Pellowe

Intermittent self catheterisation with hydrophilic, gel reservoir, and non-coated catheters: a systematic review and cost effectiveness analysis

Objective To determine the most effective and cost effective type of catheter for patients performing intermittent self catheterisation in the community. Design Systematic review and meta-analysis. Results were incorporated into a probabilistic Markov model to compare lifetime costs and quality adjusted life years (QALYs). Data sources We searched Medline, Embase, and Cochrane and Cinahl databases from 2002 to 18 April 2011 to identify studies comparing hydrophilic, gel reservoir, and non-coated intermittent catheters. Earlier guidelines were used to identify papers published before 2002. To capture studies comparing clean and sterile non-coated intermittent self catheterisation, each database was searched from its date of inception to 18 April 2011. Main outcome measures Clinical outcomes included symptomatic urinary tract infection (UTI), bacteraemia, mortality, patient preference or comfort, and number of catheters used. The economic model included downstream complications of UTI and cost effectiveness was calculated as incremental cost per QALY gained. Results Eight studies were included in the systematic review. Most were conducted in patients with spinal cord injuries, and most of the included patients were men. People using gel reservoir and hydrophilic catheters were significantly less likely to report one or more UTIs compared with sterile non-coated catheters (absolute effect for gel reservoir = 149 fewer per 1000 (95% confidence interval −7 to 198), P=0.04; absolute effect for hydrophilic = 153 fewer per 1000 (−8 to 268), P=0.04). However, there was no difference between hydrophilic and sterile non-coated catheters when outcomes were measured as mean monthly UTIs (mean difference = 0.01 (−0.11 to 0.09), P=0.84) or total UTIs at 1 year (mean difference = 0.18 (−0.50 to 0.86), P=0.60). There was little difference in the incidence of one or more UTIs for people using clean versus sterile non-coated catheters (absolute effect = 12 fewer per 1000 (−134 to 146), P=0.86). Although the most effective, gel reservoir catheters cost >£54 350 per QALY gained and are therefore not cost effective compared with clean non-coated self catheterisation. Conclusion The type of catheter used for intermittent self catheterisation seems to make little difference to the risk of symptomatic UTI. Given large differences in resource use, clean non-coated catheters are most cost effective. However, because of limitations and gaps in the evidence base and the designation of non-coated catheters as single use devices, we recommend a precautionary principle should be adopted and that patients should be offered a choice between hydrophilic and gel reservoir catheters.

A systematic review of structured compared with non-structured breastfeeding programmes to support the initiation and duration of exclusive and any breastfeeding in acute and primary health care settings

Policies and guidelines have recommended that structured programmes to support breastfeeding should be introduced. The objective of this review was to consider the evidence of outcomes of structured compared with non-structured breastfeeding programmes in acute maternity care settings to support initiation and duration of exclusive breastfeeding. Quantitative and qualitative studies were considered. Primary outcomes of interest were initiation of breastfeeding and duration of exclusive breastfeeding. Studies that only considered community-based interventions were excluded. An extensive search of literature published in 1992-2010 was undertaken using identified key words and index terms. Methodological quality was assessed using checklists developed by the Joanna Briggs Institute. Two independent reviewers conducted critical appraisal and data extraction; 26 articles were included. Because of clinical and methodological heterogeneity of study designs, it was not possible to combine studies or individual outcomes in meta-analyses. Most studies found a statistically significant improvement in breastfeeding initiation following introduction of a structured breastfeeding programme, although effect sizes varied. The impact on the duration of exclusive breastfeeding and duration of any breastfeeding to 6 months was also evident, although not all studies found statistically significant differences. Despite poor overall study quality, structured programmes compared with standard care positively influence the initiation and duration of exclusive breastfeeding and any breastfeeding. In health care settings with low breastfeeding initiation and duration rates, structured programmes may have a greater benefit. Few studies controlled for any potential confounding factors, and the impact of bias has to be considered.

Adherence to Antiretroviral Therapy: Appropriate Use of Self-Reporting in Clinical Practice

Abstract Purpose: This study investigated the factors that may affect adherence to antiretroviral therapy in people with HIV infection and compared the use of three self-report tools to determine client adherence. Method: A descriptive, cross-sectional study of 260 HIV-infected clients attending nine HIV outpatient centers in England was conducted using researcher-administered instruments. Self-reports of adherence were assessed using the Morisky Medication Adherence Scale (MMAS), Reported Adherence to Medication Scale (RAM), and the Patient Adjustment to Medication Scale (PAM). Results: Univariate analysis of clients’ self-reports indicated a number of associations with adherence. Significant associations with less adherent behavior identified by two or more self-report tools were the reported use of recreational drugs, p = .001; living alone, p = .041; feeling depressed, p = .02; being influenced by the media, p = .037; and lack of a close confidant, p = .037. Greater adherence was associated with clients reporting a positive mental attitude to HIV infection, p = .038. Principal component analysis (PCA) of each self-report tool identified two well-recognized constructs: intentional nonadherence and nonintentional nonadherence. In addition, a third construct of following instructions was identified from PAM, a scale developed by the authors. Subsequent regression analysis failed to confirm the associations with adherence suggested by the univariate analysis. Conclusion: This study suggests that the design and use of self-report tools to identify client’s adherence to complex antiretroviral regimens may need to measure individual constructs of adherence to accurately assess adherence behavior.

The epic project. Updating the evidence-base for national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England: a report with recommendations:

The evidence underpinning infection prevention and control guidelines requires updating at regular intervals as advances in technology and new research findings may influence guideline recommendations. The evidence-base for national guidelines published in 20011 for preventing healthcare-associated infections in hospitals in England has recently been updated using systematic review methods. A critical assessment of the updated evidence indicates that the current guidelines remain robust, relevant and appropriate, but that adjustments need to be made to some guideline recommendations. Periodically updating the evidence base and making necessary adjustments to guideline recommendations is essential, in order to maintain their validity and authority.

Using a blended e-learning model to provide accessible infection prevention and control training for NHS staff: The NHSU/TVU/Intuition approach

ver the past two decades, healthcare-associated infections (HCAI) have emerged as a significant threat to high quality health care. The technological advances made in the treatment of many diseases and disorders are being undermined by the transmission of infections within healthcare settings, especially the emergence of antimicrobial resistant strains of Staphylococcus aureus and enterococci that are now endemic in some healthcare environments. The financial and personal costs of HCAI in terms of the economic consequences to the National Health Service (NHS) and the physical, social and psychological costs to patients and their relatives have increased both government and public awareness of the risks associated with healthcare interventions and in particular the consequences of HCAI. The risk of acquiring HCAI continues to attract intense media interest. Reports of dirty hospitals and stories of healthcare workers failing to observe even the most rudimentary hygiene and other infection prevention and control measures are causing profound anxiety among service users. The public is fast losing confidence in the NHS to safely care for them and this dissatisfaction has propelled HCAI to the top of an increasingly urgent political healthcare agenda. The Department of Health (DH) has focused a number of initiatives on combating HCAI, including the development of national evidence-based infection prevention and control guidelines for acute and primary care settings (Pratt et al, 2001; Pellowe et al, 2003), a research programme to identify a range of effective strategies for combating antimicrobial resistance and more recently setting out a strategy for reducing HCAI and improving environmental hygiene in healthcare settings (DH, 2002; DH, 2004). DH strategy emphasises the importance of ensuring that infection prevention and control training is included in the induction programme for all NHS staff, both clinical and nonclinical, including agency and locum staff, and that this training becomes part of their continuing personal development plans. Professor Christine Beasley, the chief nursing officer at the DH has since taken responsibility for actualising many aspects of this strategy, especially ensuring that the required training is made available for all 1.3 million NHS staff by the end of 2005. Providing that training became the responsibility of the NHS University (NHSU), which commissioned the Richard Wells Research Centre at Thames Valley University London (TVU) along with their Dublin-based educational development partner, Intuition Publishing Ltd, to develop an appropriate and accessible state-of-the-art blended e-learning training programme. In this article, we describe how we designed and structured the programme so that it can be used as an essential tool in orientation/induction, staff development and in-service education programmes for all NHS staff.

Informing the Future – a review of nursing roles and responsibilities in community infection control (part two):

I. Princ@aILeciurer (Re~earch), Richard Wells Research Cenire, Thames Valley Uniuer~iiy London W5 2E.S 2. Senior Leclurer. Richard We& Research Centre, Thames Volley University London W5 2BS 3. Independent naining and Research Consultant Ashmanhaugh. No#oIk 4. Principal Leclurer and Deputy DirectoA Uichard Wels Research Cenlre. Thames Valley University London W52B5 5. Communily Infeclion Control Nurse. Department of Pubhc Health, ShropJhire Heaflh Aulhority 6. Research Assislanl. Richard W e h Research Centre, Thames VMey Universily London W5 2BS Z Pro/essor of Nursing and Direclo< Richard Wels Research Centre, Thames Valey University London W5 2BS

A systematic review of structured versus non-structured breastfeeding programmes to support the initiation and duration of exclusive breastfeeding in acute and primary healthcare settings

Executive Summary Background: Breastfeeding has many important health benefits for the woman and her baby. Despite evidence of benefit from a large number of well conducted studies, breastfeeding uptake and the duration of exclusive breastfeeding remain low in many countries. In order to improve breastfeeding rates, policy and guidelines at global, individual country level and in local healthcare settings have recommended that structured programmes to support breastfeeding should be introduced. The objective of this review was to consider the evidence of outcomes of structured compared with non‐structured breastfeeding programmes in acute maternity care settings to support initiation and duration of exclusive breastfeeding. Review methods: The definition of structured programme used included a multi‐faceted or single intervention approach to support breastfeeding; definition of non‐structured included support offered within standard care. The review considered quantitative and qualitative studies which addressed outcomes following the introduction of a structured programme in acute healthcare settings to support breastfeeding compared with no programme. The primary outcomes of interest were uptake of breastfeeding and duration of exclusive breastfeeding (only breast milk, including milk expressed). Studies which only considered community based interventions were not included. Search strategy: A search of the literature published between 1992 and 2010 was conducted, which followed a four step process. After a limited search of MEDLINE and CINAHL to identify key words contained in the title or abstract and index terms to describe relevant interventions, a second extensive search was undertaken using identified key words and index terms. The third step included a search of reference lists and bibliographies of relevant articles and the fourth step included a search of grey and unpublished literature and national databases Methodological quality: Methodological quality was assessed using checklists developed by the Joanna Briggs Institute. Two independent reviewers conducted critical appraisal and data extraction. Results: Twenty‐six articles were included; one randomised controlled trial, two non randomised trials, one cross‐sectional study, five systematic reviews, 15 cohort studies and two descriptive studies. Due to the poor quality of evidence presented and clinical and methodological heterogeneity of study designs, including definitions of breastfeeding and duration of follow‐up, it was not possible to combine studies or individual outcomes in meta‐analyses, therefore findings are presented in a narrative form. In most studies the structured programme of interest reflected some or all of the Baby Friendly Hospital Initiative ‘Ten Steps’. Most studies found a statistically significant improvement in initiation of breastfeeding following introduction of a structured breastfeeding programme, although effect sizes varied widely. The impact of introducing a structured programme on the duration of exclusive breastfeeding and duration of any breastfeeding was also evident, although not all studies found statistically significant differences. At hospital discharge or within the first week post‐birth, implementation of a structured programme appeared to increase duration of exclusive breastfeeding and the duration of any breastfeeding compared with usual care. After hospital discharge and up to six months post‐birth, use of structured programmes also appeared to support continued duration of exclusive and any breastfeeding although differences in outcomes were not reported across all included studies. At six months, three of five studies which included data on longer‐term outcomes showed women were statistically significantly more likely to be exclusively breastfeeding. Only one of these studies compared outcomes following implementation of BFHI. Conclusions: Despite the poor overall quality of studies, structured programmes, regardless of content, compared with standard care appear to influence the uptake and duration of exclusive breastfeeding and any breastfeeding. In healthcare settings with low breastfeeding uptake and duration rates, structured programmes may have a greater benefit. In countries where breastfeeding uptake is already high, the benefit is less apparent. The extent to which structured programmes in different maternity acute care settings have a significant effect on the duration of exclusive breastfeeding at six months is less clear. Most of the recommendations of this review were based on observational studies and retrospective data collection. Few studies controlled for any potential confounding factors and the impact of bias has to be considered. Implications for practice: Acute maternity care settings should implement structured programmes to support breastfeeding as part of routine maternity care. Programmes can replicate an existing programme, such as the BFHI, in full or in part, or be specifically developed to support implementation of evidence to reflect the needs and demands of the local healthcare organisation. In healthcare settings which have a high uptake of breastfeeding, resources may be better directed at improving support for duration of exclusive breastfeeding in the community. Implications for research: Further high quality RCTs are needed which address the impact of introduction of structured programmes on womens experiences of infant feeding, on the role of the relevant healthcare professionals and on short and longer‐term health outcomes. Prospective data capture to inform economic analyses should also be undertaken. Trial interventions need to be well defined and implementation processes described to inform reproducibility across different locations and different country settings. Research is also needed to address the issue of which elements of a structured programme are likely to lead to the most clinical and cost effective use of healthcare resources and to address how sustainable these interventions are in health systems facing increased economic pressures.

The use of an e-learning infection prevention programme in the pre-registration nursing curriculum.

The infection prevention e-learning project initiated by the NHS University was launched in September 2005 and is now administered by the NHS Core Learning Unit. It was intended to be the definitive infection prevention programme for all NHS staff both clinical and non-clinical; however, a higher education institution saw its potential for use in the pre-registration nursing programme and trialled it in the Common Foundation Programme (CFP). This article describes the use of the programme in the CFP and an evaluation of the students’ experience of e-learning.

ICNA regional workshops — using national evidence-based guidelines to reduce the risk of catheter-related urinary tract infections: report of post-workshop activities and outcomes

ollowing the publication in 2001 of national evidence-based guidelines for preventing healthcare-associated infections, a series of one-day workshops were conducted throughout ICNA regions. These aimed to support key healthcare professionals to use the guidelines as a catalyst to develop local strategies to promote clinical effectiveness and reduce the incidence of catheter-associated urinary tract infections in acute care settings. Almost 600 practitioners attended these highly interactive workshops and positively evaluated this opportunity to have a structured day out to reflect on current infection prevention practice and to develop quality improvement plans. A follow-up questionnaire to participants demonstrated that respondents engaged in a wide range of post-workshop activities, including policy review and development, audit, in-service education, and establishing various working groups to identify and plan for changes in local guidelines and in clinical practice. Most respondents reported achievements in the objectives of their quality improvement plan. The format of these workshops, set within the context of clinical governance, can be adapted to other key areas of infection prevention and control practice, and is recommended.

Infections and their control: a historical perspective Swb Newsom Infections and their control: a historical perspective Sage/Infection Prevention Society £17.95 235pp 9781849204538 1849204535

BILL NEWSOM, an eminent, but now retired, medical microbiologist, provides a personal but engaging review of infections and our attempts to control them. it is a fascinating social history of what has become an essential service, and Newsom highlights the need to be aware of past struggles and avoid repeating mistakes.