Lesley Price

Core components for effective infection prevention and control programmes: new WHO evidence-based recommendations

Health care-associated infections (HAI) are a major public health problem with a significant impact on morbidity, mortality and quality of life. They represent also an important economic burden to health systems worldwide. However, a large proportion of HAI are preventable through effective infection prevention and control (IPC) measures. Improvements in IPC at the national and facility level are critical for the successful containment of antimicrobial resistance and the prevention of HAI, including outbreaks of highly transmissible diseases through high quality care within the context of universal health coverage. Given the limited availability of IPC evidence-based guidance and standards, the World Health Organization (WHO) decided to prioritize the development of global recommendations on the core components of effective IPC programmes both at the national and acute health care facility level, based on systematic literature reviews and expert consensus. The aim of the guideline development process was to identify the evidence and evaluate its quality, consider patient values and preferences, resource implications, and the feasibility and acceptability of the recommendations. As a result, 11 recommendations and three good practice statements are presented here, including a summary of the supporting evidence, and form the substance of a new WHO IPC guideline.

A pragmatic randomized controlled trial of 6-step vs 3-step hand hygiene technique in acute hospital care in the United Kingdom

OBJECTIVE To evaluate the microbiologic effectiveness of the World Health Organizations 6-step and the Centers for Disease Control and Preventions 3-step hand hygiene techniques using alcohol-based handrub. DESIGN A parallel group randomized controlled trial. SETTING An acute care inner-city teaching hospital (Glasgow). PARTICIPANTS Doctors (n=42) and nurses (n=78) undertaking direct patient care. INTERVENTION Random 1:1 allocation of the 6-step (n=60) or the 3-step (n=60) technique. RESULTS The 6-step technique was microbiologically more effective at reducing the median log10 bacterial count. The 6-step technique reduced the count from 3.28 CFU/mL (95% CI, 3.11-3.38 CFU/mL) to 2.58 CFU/mL (2.08-2.93 CFU/mL), whereas the 3-step reduced it from 3.08 CFU/mL (2.977-3.27 CFU/mL) to 2.88 CFU/mL (-2.58 to 3.15 CFU/mL) (P=.02). However, the 6-step technique did not increase the total hand coverage area (98.8% vs 99.0%, P=.15) and required 15% (95% CI, 6%-24%) more time (42.50 seconds vs 35.0 seconds, P=.002). Total hand coverage was not related to the reduction in bacterial count. CONCLUSIONS Two techniques for hand hygiene using alcohol-based handrub are promoted in international guidance, the 6-step by the World Health Organization and 3-step by the Centers for Disease Control and Prevention. The study provides the first evidence in a randomized controlled trial that the 6-step technique is superior, thus these international guidance documents should consider this evidence, as should healthcare organizations using the 3-step technique in practice. Infect Control Hosp Epidemiol 2016;37:661-666.

Developing nursing students' decision making skills: Are early warning scoring systems helpful?

This paper is presented to contribute to the emerging debate on Early Warning Scoring Systems. The Early Warning Scoring System was introduced, and has been implemented internationally, to aid in the identification of the patient whose condition is deteriorating. Early identification of patient deterioration is of vital importance for patient safety. Therefore how we teach this skill to students and how they become competent and confident in its utilisation, interpretation and subsequent clinical decision-making is crucial. The paper initially explores the competence of student nurses in this area. The discussion then focuses on three models of clinical decision making to illustrate why the introduction of Early Warning Scoring Systems has hindered student nurses in the development of the decision-making skills required to identify and manage the patient whose condition is deteriorating.

Perception of risk: a study of A&E nurses and NHS managers

This exploratory study investigates perceptions of two groups of NHS staff, of a range of risks, topical and relevant to accident and emergency (A&E). Literature suggests that the effectiveness of a risk management strategy is lessened if staff exposed to risk, and managers, have different perceptions of the nature and severity of the risk. A self-administered questionnaire was distributed to registered A&E nurses and to Trust managers at directorate level and above, working in five large inner-city NHS Trusts. Managers and nurses were asked to quantify their perceptions of nine defined adverse events. They were also asked to identify the jobholder with day-to-day responsibility for managing four specific risks. Completed forms were obtained from 38 per cent of managers and nurses. Results showed broadly that managers tended to quantify risks of violence and stress to A&E nurses less highly than did nurses. By contrast, they tended to quantify risks to patients more highly than did nurses. Overall, a coherent pattern of difference in risk perception between the two groups was identified. It is argued that identification of differences of perception is an essential part of the risk management process. Illustrations are given of ways in which these differences can undermine the effectiveness of a risk management strategy.

A pilot validation in 10 European Union Member States of a point prevalence survey of healthcare-associated infections and antimicrobial use in acute hospitals in Europe, 2011.

We present a pilot validation study performed on 10 European Union (EU) Member States, of a point prevalence survey (PPS) of healthcare-associated infections (HAIs) and antimicrobial use in Europe in 2011 involving 29 EU/European Economic Area (EEA) countries and Croatia. A total of 20 acute hospitals and 1,950 patient records were included in the pilot study, which consisted of validation and inter-rater reliability (IRR) testing using an in-hospital observation approach. In the validation, a sensitivity of 83% (95% confidence interval (CI): 79–87%) and a specificity of 98% (95% CI: 98–99%) were found for HAIs. The level of agreement between the primary PPS and validation results were very good for HAIs overall (Cohen’s κappa (κ):0.81) and across all the types of HAIs (range: 0.83 for bloodstream infections to 1.00 for lower respiratory tract infections). Antimicrobial use had a sensitivity of 94% (95% CI: 93–95%) and specificity of 97% (95% CI: 96–98%) with a very good level of agreement (κ:0.91). Agreement on other demographic items ranged from moderate to very good (κ: 0.57–0.95): age (κ:0.95), sex (κ: 0.93), specialty of physician (κ: 0.87) and McCabe score (κ: 0.57). IRR showed a very good level of agreement (κ: 0.92) for both the presence of HAIs and antimicrobial use. This pilot study suggested valid and reliable reporting of HAIs and antimicrobial use in the PPS dataset. The lower level of sensitivity with respect to reporting of HAIs reinforces the importance of training data collectors and including validation studies as part of a PPS in order for the burden of HAIs to be better estimated.

Effectiveness of interventions to improve the public’s antimicrobial resistance awareness and behaviours associated with prudent use of antimicrobials: a systematic review

Background A global antimicrobial resistance (AMR) awareness intervention targeting the general public has been prioritized. Objectives To evaluate the effectiveness of interventions that aim to change AMR awareness and subsequent stewardship behaviours amongst the public. Methods Five databases were searched between 2000 and 2016 for interventions to change the publics AMR awareness and/or antimicrobial stewardship behaviours. Study designs meeting the Cochrane Effective Practice and Organization of Care (EPOC) criteria, non-controlled before-and-after studies and prospective cohort studies were considered eligible. Participants recruited from healthcare settings and studies measuring stewardship behaviours of healthcare professionals were excluded. Quality of studies was assessed using EPOC risk of bias criteria. Data were extracted and synthesized narratively. Registration: PROSPERO international prospective register of systematic reviews (PROSPERO 2016: CRD42016050343). Results Twenty studies were included in the review with nine meeting the EPOC criteria. The overall risk of bias was high. Nineteen studies were conducted in high-income countries. Mass media interventions were most common (n = 7), followed by school-based (n = 6) and printed material interventions (n = 6). Seventeen studies demonstrated a significant effect on changing knowledge, attitudes or the publics antimicrobial stewardship behaviours. Analysis showed that interventions targeting schoolchildren and parents have notable potential, but for the general public the picture is less clear. Conclusions Our work provides an in-depth examination of the effectiveness of AMR interventions for the public. However, the studies were heterogeneous and the quality of evidence was poor. Well-designed, experimental studies on behavioural outcomes of such interventions are required.

The reliability of the McCabe score as a marker of co-morbidity in healthcare-associated infection point prevalence studies

This study aimed to ascertain the reliability of the McCabe score in a healthcare-associated infection point prevalence survey.   A 10 European Union Member States survey in 20 hospitals (n = 1912) indicated that there was a moderate level of agreement (κ = 0.57) with the score. The reliability of the application of the score could be increased by training data collectors, particularly with reference to the ultimately fatal criteria. This is important if the score is to be used to risk adjust data to drive infection prevention and control interventions.

Cross-sectional survey of meticillin-resistant Staphylococcus aureus home-based decolonization practices in Scotland

BACKGROUND Despite limited evidence of meticillin-resistant Staphylococcus aureus (MRSA) decolonization efficacy, the practice of decolonization for both pre-admission and on-admission patients is growing. Recent research within National Health Service (NHS) Scotland revealed low rates of treatment and consequent low efficacy in home-based decolonization. As no national guidelines on home-based decolonization currently exist, practices within NHS Scotland may be variable. AIM To establish current pre-admission MRSA home-based decolonization protocols and patient advice within NHS Scotland. Similarities and differences were identified to determine possible sources of variability. METHODS Cross-sectional survey distributed electronically to MRSA Screening Project Managers within each NHS geographical region in Scotland (N = 15). FINDINGS Thirteen out of 15 NHS regions responded; one region reported no standard protocol. From the remaining 12 regions, 100% recommended use of mupirocin and antiseptic bodywash daily for five days; this was the only consistent aspect of practice across responding regions. Variation was noted in advice regarding method of mupirocin application, bodywash product and volume of bodywash recommended. Six regions (50%) specified bodywash skin contact time, yet these times varied across regions. Mouth care was advocated by three regions (25%). Daily change of facecloths and clothes was endorsed by five regions (41.7%); four regions (33.3%) promoted daily towel changes. Only one region (8.3%) suggested daily bedroom cleaning; three regions (25%) advised changing bed linen daily. CONCLUSIONS Variation in protocols and patient advice may influence efficacy of home-based decolonization and further research may inform the development of evidence-based clinical guidelines.

Toward improving the World Health Organization fifth moment for hand hygiene in the prevention of cross-infection

BACKGROUND The World Health Organization describes that there are 5 moments during a health care encounter when hand hygiene should be performed. This research explores a number of explanatory hypotheses to inform future intervention development with regard to improving compliance with the fifth moment. METHODS A sequential, mixed-methods study was conducted using nonparticipant observation and a survey with focus groups informing the development of the questionnaire. A total of 484 participants were observed and 410 returned a postobservation questionnaire; a response rate of 85%. Analysis explored the role of organizational culture, professional culture/practice, and individual-level variables in explaining compliance with the fifth moment. RESULTS Ninety-three percent of participants performed hand hygiene following the fifth moment. Compliance varied between regions, but not by professional group. More than 65% indicated that the fifth moment was clearly defined, achievable, valuable, encouraged, and widely known. However, 60% suggested that it was repetitive. There was a positive relationship between the performance of hand hygiene following the fifth moment and the perception that it was widely known. CONCLUSIONS Interventions to improve compliance with the fifth moment should focus on promoting awareness of the fifth moment and how it should be implemented in practice. Mechanisms for raising awareness should include education and role modeling.

What are the ‘active ingredients’ of interventions targeting the public's engagement with antimicrobial resistance and how might they work?

Objectives Changing public awareness of antimicrobial resistance (AMR) represents a global public health priority. A systematic review of interventions that targeted public AMR awareness and associated behaviour was previously conducted. Here, we focus on identifying the active content of these interventions and explore potential mechanisms of action. Methods The project took a novel approach to intervention mapping utilizing the following steps: (1) an exploration of explicit and tacit theory and theoretical constructs within the interventions using the Theoretical Domains Framework (TDFv2), (2) retrospective coding of behaviour change techniques (BCTs) using the BCT Taxonomy v1, and (3) an investigation of coherent links between the TDF domains and BCTs across the interventions. Results Of 20 studies included, only four reported an explicit theoretical basis to their intervention. However, TDF analysis revealed that nine of the 14 TDF domains were utilized, most commonly ‘Knowledge’ and ‘Environmental context and resources’. The BCT analysis showed that all interventions contained at least one BCT, and 14 of 93 (15%) BCTs were coded, most commonly ‘Information about health consequences’, ‘Credible source’, and ‘Instruction on how to perform the behaviour’. Conclusions We identified nine relevant TDF domains and 14 BCTs used in these interventions. Only 15% of BCTs have been applied in AMR interventions thus providing a clear opportunity for the development of novel interventions in this context. This methodological approach provides a useful way of retrospectively mapping theoretical constructs and BCTs when reviewing studies that provide limited information on theory and intervention content. Statement of contribution What is already known on this subject? Evidence of the effectiveness of interventions that target the public to engage them with AMR is mixed; the public continue to show poor knowledge and misperceptions of AMR. Little is known about the common, active ingredients of AMR interventions targeting the public and information on explicit theoretical content is sparse. Information on the components of AMR public health interventions is urgently needed to enable the design of effective interventions to engage the public with AMR stewardship behaviour. What does this study add? The analysis shows very few studies reported any explicit theoretical basis to the interventions they described. Many interventions share common components, including core mechanisms of action and behaviour change techniques. The analysis suggests components of future interventions to engage the public with AMR.