Robert J. Pratt

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.

Public perception and the social and microbiological significance of uniforms in the prevention and control of healthcare-associated infections: an evidence review

Background: There is significant public concern in England about health carers wearing uniform in public places and that contaminated uniforms may contribute to the spread of healthcare-associated infections (HCAI). Evidence of a link between contaminated uniforms and HCAI, or that wearing uniforms in public spaces may contribute to the spread of infection from the healthcare environment to the wider community, has not previously been systematically assessed. Methods: A comprehensive review was conducted that focused on patient perceptions of the significance and infection risks of uniforms and microbiological and clinical evidence of the infection risks to patients from contaminated uniforms. Results: Uniforms play an important role in the publics perception of healthcare professionals. This is constructed from social and cultural images leading patients to judge the professionalism and trustworthiness of practitioners based on the clothes they wear. The colour and design of uniforms may reinforce socially constructed concepts of cleanliness that result in unachievable expectations. Evidence directly related to the laundering of uniforms is limited. Small scale studies show that uniforms and white coats become progressively contaminated during clinical care and most microbial contamination originates from the wearer of the uniform. Although some studies theorise that uniforms may transmit HCAI, no studies demonstrated this in practice. A small number of studies evaluated the phases of the wash cycle in hospital laundries for patient linen but not uniforms. They indicate that micro-organisms are removed and killed during laundering, and dilution during washing and rinsing is important. Significant reductions in micro-organisms occur at lower temperatures more commonly used in home laundering. A small number of studies show that home laundering provides effective decontamination. We found no recent studies that accounted for advances in domestic washing machine and detergent technology or that addressed the theoretical infection risk linked with wearing uniforms in public places. Conclusion: Despite the limited amount and quality of the evidence, the general publics perception is that uniforms pose an infection risk when worn inside and outside clinical settings. This is reinforced by media comment and a lack of clear, accessible information and may have a damaging effect on the relationship between professionals and patients and the public image of healthcare workers. There is no good evidence to suggest uniforms are a significant risk, that home laundering is inferior to commercial processing of uniforms or that it presents a hazard in terms of cross-contamination of other items in the wash-load with hospital pathogens. It is essential that the evidence is considered in a balanced way and not over-emphasised in the development of uniform policy and that the general principles of infection control are stressed.

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.

Supporting evidence-based infection prevention and control practice in the National Health Service in England. The NHS/TVU/Intuition Approach

All successful strategies for preventing healthcare-associated infections require a multifaceted evidence-based approach that includes providing practitioners with the best evidence for clinically effective practice and then supporting them to understand and use this evidence to minimise infection risks and increase patient safety. This paper describes how national evidence-based guidelines from the Department of Health and the National Institute for Health and Clinical Excellence in England form the foundations for ensuring the availability of best evidence to practitioners, and how the development of an associated e-learning/blended learning programme is now supporting all NHS staff to effectively use this evidence to protect patients from the risk of preventable infections during care.

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.

Tuberculosis and infection control: a review of the evidence

xposure to patients with infectious tuberculosis is a well-recognised hazard of health care and although the risks associated with this hazard cannot be completely eliminated, they can be controlled and minimised. Risk reduction strategies rely upon a hierarchy of control measures to prevent the nosocomial transmission of tuberculosis in healthcare settings. In this article, the authors discuss the background to these strategies and review the evidence that underpins clinically effective administrative and engineering controls and personal respiratory protection. The authors conclude with recommendations and guide readers to further sources of reliable information.

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.

Healthcare governance and the modernisation of the NHS: infection prevention and control

Q uality is central to the governments programme for modernising the NHS and clinical quality is at the heart of this agenda. The recent introduction of corporate governance with controls assurance and clinical governance in the NHS has established a framework for providing such excellence in clinical care. Governance applies to all healthcare activities and provides an ideal opportunity for infection prevention and control practitioners to improve the quality of their service and reduce the risk of patients acquiring preventable healthcare-associated infections (HAI). This paper will discuss the introduction of governance in the NHS, describe the key principles of clinical governance and relate these to infection prevention and control.

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

Pandemic A (H1N1) 2009 influenza—an enhanced hazard during pregnancy

As the second wave of the global pandemic of 2009 H1N1 influenza (‘swine flu’) continues to escalate during the coming months, countries throughout the world are anticipating a surge of patients with serious, often life-threatening influenza-related complications being admitted to hospitals, many requiring intensive care and advanced technological cardiac and respiratory support. In countries in the northern hemisphere, the simultaneous arrival of the usual epidemics of seasonal influenza (‘winter flu’) will further exacerbate the impact of influenza on vulnerable populations. There is good quality evidence which shows that pregnant women are among those who may be at a significantly increased risk of severe illness and complications from influenza. If (or when) the numbers of pregnant women requiring hospitalisation rise during the coming weeks and months, midwifery and obstetric services will be tested and stressed as never before. In Member States of the European Union (EU) and in many other countries throughout the world, national and local influenza preparedness plans are being incrementally deployed. Midwives and all other health-care providers need to ensure that they remain competent in responding appropriately to these strategies and keep up to date with the rapidly changing dynamics of the first global pandemic of the 21st Century.