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National Clinical Guideline Centre (UK). Infection: Prevention and Control of Healthcare-Associated Infections in Primary and Community Care: Partial Update of NICE Clinical Guideline 2. London: Royal College of Physicians (UK); 2012 Mar. (NICE Clinical Guidelines, No. 139.)

Cover of Infection: Prevention and Control of Healthcare-Associated Infections in Primary and Community Care

Infection: Prevention and Control of Healthcare-Associated Infections in Primary and Community Care: Partial Update of NICE Clinical Guideline 2.

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5Standard Principles

5.1. Introduction

The updated review question in this chapter is:

  • Education of patients, carers and healthcare workers.

The new review question in this chapter is:

This chapter introduces hand decontamination, personal protective equipment (PPE) and sharps. Several new questions and updates are included in the hand decontamination, PPE and sharps chapters. Key health and safety legislation1,3,4,68,115 has also been considered when drafting these recommendations.

The GDG considered the addition of the patient information hand decontamination review question in this update as a key area paramount to patient safety. This is also an area where there is variation in practice and important equality issues were identified.

The GDG has prioritised three recommendations in this chapter as a key priority for implementation, see sections 5.2.1.1 and 5.2.2.4.

Standard Principles provide guidance on infection control precautions that should be applied by all healthcare workers to the care of patients in community and primary care settings. These recommendations are broad principles of best practice and are not detailed procedural protocols. They need to be adapted and incorporated into local practice guidelines.

5.2. Education of patients, carers and their healthcare workers

To improve patient outcomes and reduce healthcare costs, it is essential that everyone providing care in the community is educated about hand decontamination, the appropriate use of gloves and protective clothing, and the safe disposal of sharps. Adequate supplies of soap, alcohol rub, towels and sharps bins must be made available wherever care is delivered and this may include providing healthcare workers undertaking home visits, with their personal supply. Patients and carers should request that healthcare workers follow these principles.24

The following recommendations have been updated based on the evidence reviewed in the standard principles chapters for hand hygiene, personal protective equipment and the safe use and disposal of sharps in chapters 6, 7 and 8, respectively.

5.2.1.1. Recommendations

Recommendations
1.

Everyone involved in providing care should be:

Relative values of different outcomesThe GDG have added “and the safe use …” of sharps to this recommendation.
The safe use of sharps is very important as identified from the evidence of the sharps review question (see section 8.4.1.4). Although no specific review question was asked for this recommendation, the review questions for sharps safety devices feed into this recommendation.
The GDG wish to emphasise the safe use of sharps, and want to increase the awareness of safe sharps use and reduce injuries.
Trade off between clinical benefits and harmsThe clinical benefit from education about standard principles (hand decontamination, personal protective equipment and sharps) would lead to decreased healthcare-associated infections, sharps injuries and a better understanding of why standard principles are important.
Potential harms could be from poor or inaccurate education and therefore it is important to consider how this education should be delivered, see also 8.4.1.4
The use of sharps safety devices in section 8.4.1.4 concludes that sharps injuries were still occurring despite safety devices being introduced and this was linked to a lack of, or ineffective, training. GDG consensus was that without adequate education sharps injuries will continue to be a problem.
Economic considerationsHand decontamination products, PPE and sharps disposal equipment are designed to reduce the transmission of microorganisms between healthcare workers, patients, and the environment. Healthcare workers should be educated about the proper use of such materials in order to properly perform their job. Any small increase in time or resource use is likely to be outweighed by a reduced rate of infection and injury.
Quality of evidenceSee also the review questions in chapter 8 regarding safe use of sharps.
No RCTs were identified for safety needle devices, but several observational studies were identified. These studies had several limitations and were all very low quality.
Other considerationsMinor changes made from the original recommendation. ‘In the community’ has been removed from the recommendation as the GDG considered that this may be confusing and may be interpreted as not including GP surgeries and care home. The safe use of sharps has been reviewed in the sharps chapter 8.
The GDG have prioritised this recommendation as a key priority for implementation as they considered that it has a high impact on outcomes that are important to patients, has a high impact on reducing variation in care and outcomes, leads to a more efficient use of NHS resources, promotes patient choice and means that patients reach critical points in the care pathway more quickly. See section 4.1 for further details.
Recommendations
2.

Wherever care is delivered, healthcare workers mustu have available appropriate supplies of:

Relative values of different outcomesThe GDG have added “personal protective equipment” to the list of supplies that must be provided.
The most important outcome is to protect healthcare workers from health care associated infections and prevent cross contamination of infections from patient to patient.
Trade off between clinical benefits and harmsHealthcare workers are required by law to be provided with appropriate supplies of hand decontamination products, PPE and sharps disposal equipment (Health and Safety at Work Act 19741, Health and Safety Regulations 20024, Control of Substances Hazardous to Health Regulations 2002115, Management of Health and Safety at Work Regulations 19993, Health and Social Care Act 200868).
This recommendation complies to current legislation and safeguards individuals from the risk, or any increased risk, of being exposed to health care associated infections or of being made susceptible, or more susceptible, to them.68
Economic considerationsHand decontamination products, PPE and sharps disposal equipment are designed to reduce the transmission of microorganisms between healthcare workers, patients, and the environment. Healthcare workers must be provided with the materials necessary to properly perform their job. Where healthcare workers are not currently provided with appropriate supplies, this recommendation may be associated with an implementation cost.
Noncompliance with this recommendation may be associated with costs in the form of fines or litigation.
Quality of evidenceSee sharps waste disposal chapter, which refers to Safe Management of Healthcare Waste.72
No specific clinical evidence review was applicable for this recommendation.
However, evidence was reviewed for effectiveness of different types of gloves and gowns versus aprons in the personal protective equipment chapter.
Other considerationsThe updated recommendation includes supplies of gloves and PPE. The term ‘must’ is used as it is covered by legislation (Health and Safety at Work Act 1974,1 Health and Safety Regulations 2002,4 Control of Substances Hazardous to Health Regulations 2002,115 Management of Health and Safety at Work Regulations 1999,3 Health and Social Care Act 200868) in line with the guidance from the NICE Guidelines Manual (2009)’.182
The GDG have prioritised this recommendation as a key priority for implementation as they considered that it has a high impact on outcomes that are important to patients, has a high impact on reducing variation in care and outcomes and promote equality. See section 4.1 for further details.
u

In accordance with current health and safety legislation (at the time of publication of the guideline [March 2012]): Health and Safety at Work Act 1974, Management of Health and Safety at Work Regulations 1999, Health and Safety Regulations 2002, Control of Substances Hazardous to Health Regulations 2002, Personal Protective Equipment Regulations 2002, and Health and Social Care Act 2008.

5.2.2. Review question

What information do healthcare professionals, patients and carers require to prevent healthcare-associated infections in primary and community care settings?

5.2.2.1. Focus of the review

The review aimed to inform the GDG about what information should routinely be provided to patients and carers to prevent healthcare-associated infections. Hand decontamination was acknowledged to be simple, yet extremely effective and necessary for the prevention of healthcare-associated infections. Hence, the GDG decided to prioritise the information needs of patients and carers regarding their own hand decontamination and healthcare worker hand decontamination for the purposes of this review.

See Evidence table G.1.1, Appendix G.

5.2.2.2. Evidence reviewed

Qualitative studies (focus group discussions, interviews), surveys and observational studies evaluating patients’ perceptions regarding their own hand decontamination and participation in health care worker hand decontamination were included in the review. The findings were analysed and themes which emerged consistently were noted and are presented. Twenty two studies were included in this review.

The review included studies looking at different populations and settings, including developing countries. This contributes to the strength as well as the limitations of the quality of evidence. Including information from indirect settings and populations may limit the applicability of the findings to patients cared for in the community in the UK. However, many themes were consistent irrespective of these differences and therefore will also most likely be applicable to the UK. Some of the included qualitative studies are of good quality and report in detail the sampling strategies, methods used and the analysis. Some studies have poor sampling strategies and did not report verification of results or triangulation of findings with participants. Details of methods and analysis were also not provided. The qualitative studies using interviews and focus group discussions may be in general, at risk of responder bias as people may give responses depending on the interviewer’s status, style of questioning and the associated circumstances. Also, studies which used structured observations may be at risk of observer bias as people may behave differently when they are aware of being observed.

Among the surveys included, some do not report validation and piloting of questionnaires.

Details about the quality and applicability that are specific to the themes found are documented alongside the themes in Table 6.

Table 6. Summary of findings and study quality.

Table 6

Summary of findings and study quality.

5.2.2.3. Economic evidence

No economic evidence was identified.

5.2.2.4. Recommendations

Recommendations
3.

Educate patients and carers about:

Relative values of different outcomesThe reduction of healthcare-associated infections through increased awareness and practice of hand decontamination is important. The involvement of patients in their own and healthcare workers’ hand decontamination in healthcare settings will be likely to contribute to better practice of hand decontamination.
Trade off between clinical benefits and harmsPatient education has the potential to improve awareness and encourage hand decontamination compliance which may result in fewer healthcare-associated infections. The potential clinical harms are minor (skin irritation, perceived inconvenience) and are outweighed by the potential benefits.
Economic considerationsThe GDG discussed patient education in the context of routine healthcare practice. It was expected that any impact on time and resource use would be minimal and would likely be offset by a reduction in infections.
Quality of evidenceEvidence was obtained from a wide range of study designs, ranging from large scale surveys to qualitative studies using interviews, focus groups, and structured observations.
There are limitations (such as indirectness of populations) in the evidence. Most studies were not designed to identify the strength of association between knowledge, attitude or perception about hand decontamination in affecting behaviours.
However, the themes which emerged about the perception and factors which encourage or discourage hand decontamination are consistent across settings and populations, increasing the confidence that these findings are applicable to patients in the community.
Other considerationsThe GDG considered equality issues, in particular, language and disability, for example, lack of mobility and cognitive impairment in the implementation of this recommendation. Language barriers should not be a reason for non-provision of information. The GDG also considered that additional support may be required for patients and carers with learning difficulties.
The GDG also discussed that there might be concerns about using handrubs that contain alcohol. It is important that patients are aware of the pros and cons of using these products. If religious beliefs are a source of concern, the patients could be made aware of the official stand of religious bodies about the product. For example, the official position of Muslim Councils of Britain is that “External application of synthetic alcohol gel, however is considered permissible within the remit of infection control because (a) it is not an intoxicant and (b) the alcohol used in the gels is synthetic, i.e., not derived from fermented fruit. Alcohol gel is widely used throughout Islamic countries in health care setting”178.
When information is available, the GDG felt it would be useful to direct the patients to these information sources to clarify the positions. The GDG were aware that not all patients may be comfortable in asking health care workers to wash their hands and that they will need encouragement to do so along with education. The review looked at factors which encouraged patients to do so and be more involved in hand decontamination of healthcare workers. The GDG prioritised this recommendation as a key priority for implementation as they considered that it has a high impact on outcomes that are important to patients, has a high impact on reducing variation in care and outcomes, leads to a more efficient use of NHS resources and promotes equalities. See section 4.1 for further details.

5.3. Research recommendation

1. What are the barriers to compliance with standard precautions of infection prevention and control that patients and carers experience in their own homes?

Why this is important

Recent changes to the delivery of healthcare mean that care is increasingly delivered within a patient’s home environment. Infection prevention in this setting is just as important as in hospital. There are currently approximately six million unpaid carers in the UK, a number that is likely to increase with an aging population. The association between carer training and infection rates is unknown. No evidence of surveillance of healthcare-associated infections in the community is currently available in the UK.

A qualitative study is needed to investigate the themes surrounding the barriers to patient and carer compliance with the standard principles of infection prevention in their own homes. It would be important to assess whether lack of awareness or knowledge is a barrier. If patients and carers have received education this should be assessed to see if this was applicable to the patient’s home setting. Areas of low compliance in the home environment need to be identified. The findings could have far-reaching implications for discharge planning and duty of care.

Copyright © 2012, National Clinical Guideline Centre.

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Bookshelf ID: NBK115282

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