Jacqui Prieto

epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England

Executive Summary National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were commissioned by the Department of Health (DH) and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were published in January 2001.1 These guidelines describe the precautions healthcare workers should take in three areas: standard principles for preventing HCAI, which include hospital environmental hygiene, hand hygiene, the use of personal protective equipment, and the safe use and disposal of sharps; preventing infections associated with the use of short-term indwelling urethral catheters; and preventing infections associated with central venous catheters. The evidence for these guidelines was identified by multiple systematic reviews of experimental and non-experimental research and expert opinion as reflected in systematically identified professional, national and international guidelines, which were formally assessed by a validated appraisal process. In 2003, we developed complementary national guidelines for preventing HCAI in primary and community care on behalf of the National Collaborating Centre for Nursing and Supportive Care (National Institute for Healthand Clinical Excellence).2 A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective in preventing HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. Consequently, the DH commissioned a review of new evidence published following the last systematic reviews. We have now updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the original epic guidelines published in 2001 remain robust, relevant and appropriate but that adjustments need to be made to some guideline recommendations following a synopsis of the evidence underpinning the guidelines. These updated national guidelines (epic2) provide comprehensive recommendations for preventing HCAI in hospitals and other acute care settings based on the best currently available evidence. Because this is not always the best possible evidence, we have included a suggested agenda for further research in each section of the guidelines. National evidence-based guidelines are broad principles of best practice which need to be integrated into local practice guidelines. To monitor implementation, we have suggested key audit criteria for each section of recommendations. Clinically effective infection prevention and control practice is an essential feature of protecting patients. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of healthcare in NHS hospitals in England can be minimised.

Intermittent catheterisation for long‐term bladder management (abridged cochrane review)

To review the evidence on strategies to reduce UTI, other complications or improve satisfaction in intermittent catheter (IC) users by comparing: (1) one catheter design, material or technique versus another; (2) sterile technique versus clean; or (3) single‐use (sterile) or multiple‐use (clean) catheters.

Interventions to minimise the initial use of indwelling urinary catheters in acute care: a systematic review.

BACKGROUND Indwelling urinary catheters (IUC) are the primary cause of urinary tract infection in acute care. Current research aimed at reducing the use of IUCs in acute care has focused on the prompt removal of catheters already placed. This paper evaluates attempts to minimise the initial placement of IUCs. OBJECTIVES To evaluate systematically the evidence of the effectiveness of interventions to minimise the initial placement of IUCs in adults in acute care. DESIGN Studies incorporating an intervention to reduce the initial placement of IUCs in an acute care environment in patients aged 18 and over that reported on the incidence of IUC placement were included in the review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist has been used as a tool to guide the structure of the review. DATA SOURCES MEDLINE, CINAHL, EMBASE, National Health Service Centre for Review and Dissemination and Cochrane Library. REVIEW METHODS A systematic review to identify and synthesise research reporting on the impact on interventions to minimise the use of IUCs in acute care published up to July 2011. RESULTS 2689 studies were scanned for eligibility. Only eight studies were found that reported any change (increase or decrease) in the level of initial placement of IUCs as a result of an intervention in acute care. Of the eight, six had an uncontrolled before-after design. Seven demonstrated a reduction in the initial use of IUCs post-intervention. There was insufficient evidence to support or rule out the effectiveness of interventions due to the small number of studies, limitations in study design and variation in clinical environments. Notably, each study listed the indications considered to be acceptable uses of an IUC and there was substantial variation between the lists of indications. CONCLUSIONS More work is needed to establish when the initial placement of an IUC is appropriate in order to better understand when IUCs are overused and inform the development of methodologically robust research on the potential of interventions to minimise the initial placement of IUCs.

The misuse and overuse of non-sterile gloves: application of an audit tool to define the problem

Background: The use of non-sterile gloves (NSG) has become routine in the delivery of health care, often for procedures for which they are not required; their use may increase the risk of cross contamination and is generally not integrated into hand hygiene audit. This paper describes a small-scale application and validation of an observational audit tool devised to identify inappropriate use of NSG and potential for cross contamination. Methods: Two observers simultaneously observed the use of NSG during episodes of care in an acute hospital setting. The inter-rater reliability (IRR) of the audit tool was measured corrected for chance agreement using Kappa. Results: A total of 22 episodes of care using NSG were observed. In 68.6% (24/35) of procedures there was no contact with blood/body fluid; in 54.3% (19/35) NSG-use was inappropriate. The IRR was 100% for eight of 12 components of the tool. For hand hygiene before and after NSG removal it was 82% (Kappa = 0.72) and 95% (Kappa = 0.87). Conclusions: In this small-scale application of a glove-use audit tool we demonstrated over-use and misuse of NSG and potential for cross transmission on gloved hands. The audit tool provides an effective mechanism for integrating glove use into the audit of hand hygiene behaviour.

epic3: revised recommendation for intravenous catheter and catheter site care

epic3: revised recommendation for intravenous catheter and catheter site care H.P. Loveday *, J.A. Wilson , J. Prieto , M.H. Wilcox c Richard Wells Research Centre, College of Nursing, Midwifery and Healthcare, University of West London, London, UK b Faculty of Health Sciences, University of Southampton, Southampton, UK Microbiology and Infection Control, Leeds Teaching Hospitals and University of Leeds, Leeds, UK

“It's easier to stick a tube in”: a qualitative study to understand clinicians’ individual decisions to place urinary catheters in acute medical care

Background Indwelling urinary catheters (IUCs) placed in acute care are a leading cause of healthcare-associated urinary tract infection. Despite initiatives to minimise the placement of IUCs, levels of inappropriate use are still considered unacceptable. IUC practice is difficult to change, and factors influencing clinicians’ decisions need to be better understood. Objective To explore why clinicians decide to place IUCs in acute medical care. Methods We conducted a qualitative study in the emergency department and acute medical wards of a 1200+ bed hospital, undertaking 30 retrospective think aloud and 20 semistructured interviews with nurses and physicians who made the decision to place an IUC. A purposive sample and thematic analysis were used. Results Opinions on when an IUC was warranted varied considerably. Inconsistency in decision-making was caused by differing beliefs on when an IUC was appropriate for each clinical indication. Numerous patient and non-patient factors, including clinical setting, resources, patient age and gender and staff workload, also impacted on each decision. Assessing when the benefit of an IUC outweighed the risk could be problematic due to conflicting goals. Conclusions These findings help to explain why clinicians sometimes deviate from IUC best practice guidance and resist interventions to modify practice. In order to engage nurses and physicians in change, interventions to reduce IUC use should acknowledge and respond to the complexity and lack of clarity often faced by clinicians making the decision to place an IUC. However, it is equally important that inconsistencies in IUC-related beliefs are recognised, investigated and, where appropriate, challenged.

Infection control team workforce project

Many features of the NHS conspire to make workforce planning different and difficult. It is often integrated with other planning processes. There are few available guidelines for workforce configurations of infection control (IC) teams or evidence that assesses the effectiveness of different staffing configurations. A telephone survey of IC practice in four NHS trusts in England was undertaken to assist an NHS foundation trust to evaluate the workforce options for reconfiguring their IC team. The calls were semi-structured, recorded qualitative data and lasted 30-40 minutes. The thematic analysis revealed three IC themes: working practices, workforce profiles and governance issues, and suggested that multi-disciplinary, hospital-based IC teams have a strategic approach to engagement with clinical areas. The background, purpose and findings of the survey are reported and the implications for the future evidence base of IC practice.

Guest editorial [Principles of infection prevention]

Principles of infection prevention are notoriously difficult for healthcare workers to grasp and to apply consistently in practice. Moreover, the interpretation of these principles within policies and practice guidelines is not always clear or presented in ways to enable ready application to practice. Often a guideline statement can generate more questions than it resolves. Take, for example, infection prevention guidelines on contact isolation precautions. This topic has generated huge controversy over the years as the underpinning evidence base is limited and ambiguous. Contact precautions require hand hygiene and the wearing of personal protective equipment (PPE), usually gloves and an apron or gown, for all contact with the infectious patient and their environment. In contrast, the standard infection prevention precautions applied to all patients requires, in addition to hand hygiene, a more selective approach to use of PPE depending on the activity being undertaken. The indiscriminate use of PPE as part of contact precautions implies that standard precautions cannot be relied upon to reduce risks for transmission of potentially infectious organisms. For healthcare workers, this has the potential to undermine the value of hand hygiene, which is paradoxical, since it is so often declared to be the ‘single, most effective’ infection prevention measure. And yet, quite understandably, healthcare workers question this, deducing that hand hygiene cannot be all that effective, otherwise there would not be a need to wear gloves all of the time. In recent years there has been a huge increase in unnecessary glove use in healthcare, which can increase rather than decrease the risk of transmission of infection when gloves are not removed at the points in care when hand hygiene is indicated (Wilson et al., 2015). It was back in 1996 that the Hospital Infection Control Practices Advisory Committee (HICPAC) in the USA first introduced the concept of contact precautions as part of a major review and update of its guideline for isolation precautions. At that time, Jackson and Lynch drew attention to the difficulties with a two-tiered system of infection prevention precautions. They suggested that the recommendation to use contact precautions perhaps had more to do with the problem of poor adherence to standard precautions and

Urinary bag decontamination for long-term use: a systematic review.

A systematic review of research on urinary drainage bag decontamination methods was conducted to evaluate existing evidence for practice related to long-term urinary catheter users. Six trials were found that met inclusion criteria. In addition, 9 clinical practice guidelines about urinary catheter care from 3 English-speaking countries were examined. Two studies were of modest quality; they included a randomized trial of 54 persons in a rehabilitation hospital and a laboratory comparison of 5 decontamination products. Three other articles included in the review were case series. All were published between 1985 and 1994. Bleach (NaClO) solutions of varying concentrations (0.06%-1%) were most often tested, and results were similar in controlling microbial contamination in the drainage bags. However, the studies often lacked definitions or standardization of key outcome measures such as safety and ease of the procedure and integrity of the drainage bag. The clinical practice guidelines differed in advice on bag decontamination, and some did not address it. Further research is recommended to evaluate the efficacy of decontamination procedures in patients with long-term indwelling catheters and drainage bags.

Infection Control Nurses Association Research and Development Group: research strategy for 2005 to 2010

he Research and Development Group was reestablished in October 2004 to advance the Infection Control Nurses Associations research aspirations. This strategy is the result of the work of the group since its first meeting in January 2005. The draft strategy was discussed and approved by branch representatives and the National Executive Committee in June 2005. It sets out the background and objectives for the research and development strategic plan for the period 2005 to 2010. The strategy will be launched at the ICNAs annual conference in Torquay in September 2005.