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National Collaborating Centre for Nursing and Supportive Care (UK). Infection Control: Prevention of Healthcare-associated Infections in Primary and Community Care [Internet]. London: Thames Valley University; 2003 Jun. (NICE Clinical Guidelines, No. 2.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Infection Control: Prevention of Healthcare-associated Infections in Primary and Community Care [Internet].

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Summary

Guidelines for preventing healthcare-associated infections in primary and community care: summary of the recommendations and the development of the guidelines

Summary of Recommendations

The following guidance is evidence based and the grading for each recommendation is shown.

This guideline makes recommendations on both the standard principles for preventing healthcare-associated infections and measures for preventing infections associated with three specific aspects of care – the use of long-term urinary catheters, enteral feeding systems and central venous catheters.

Standard principles

The recommendations on standard principles provide guidance on infection control precautions that should be applied by all healthcare personnel to the care of patients in community and primary care settings.

The recommendations are divided into four distinct interventions:

  • hand hygiene
  • the use of personal protective equipment
  • the safe use and disposal of sharps
  • education of patients, their carers and healthcare personnel.

Hand hygiene

SP1.

Hands must be decontaminated immediately before each and every episode of direct patient contact or care and after any activity or contact that could potentially result in hands becoming contaminated. [B]

SP2.

Hands that are visibly soiled, or potentially grossly contaminated with dirt or organic material, must be washed with liquid soap and water. [A]

SP3.

Hands must be decontaminated, preferably with an alcohol-based hand rub unless hands are visibly soiled, between caring for different patients or between different care activities for the same patient. [A]

SP4.

Before regular hand decontamination begins, all wrist and ideally hand jewellery should be removed. Cuts and abrasions must be covered with waterproof dressings. Fingernails should be kept short, clean and free from nail polish. [D]

SP5.

An effective handwashing technique involves three stages: preparation, washing and rinsing, and drying. Preparation requires wetting hands under tepid running water before applying liquid soap or an antimicrobial preparation. The handwash solution must come into contact with all of the surfaces of the hand. The hands must be rubbed together vigorously for a minimum of 10–15 seconds, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers. Hands should be rinsed thoroughly before drying with good quality paper towels. [D]

SP6.

When decontaminating hands using an alcohol handrub, hands should be free from dirt and organic material. The handrub solution must come into contact with all surfaces of the hand. The hands must be rubbed together vigorously, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers, until the solution has evaporated and the hands are dry. [D]

SP7.

An emollient hand cream should be applied regularly to protect skin from the drying effects of regular hand decontamination. If a particular soap, antimicrobial hand wash or alcohol product causes skin irritation an occupational health team should be consulted. [D]

Use of personal protective equipment

SP8.

Selection of protective equipment must be based on an assessment of the risk of transmission of microorganisms to the patient, and the risk of contamination of the healthcare practitioners’ clothing and skin by patients’ blood, body fluids, secretions or excretions. [D H&S]

SP9.

Gloves must be worn for invasive procedures, contact with sterile sites and non-intact skin or mucous membranes, and all activities that have been assessed as carrying a risk of exposure to blood, body fluids, secretions or excretions, or sharp or contaminated instruments. [D H&S]

SP10.

Gloves must be worn as single-use items. They must be put on immediately before an episode of patient contact or treatment and removed as soon as the activity is completed. Gloves must be changed between caring for different patients, and between different care or treatment activities for the same patient. [D H&S]

SP11.

Gloves must be disposed of as clinical waste and hands decontaminated after the gloves have been removed. [D H&S]

SP12.

Gloves that are acceptable to healthcare personnel and that conform to European Community (CE) standards must be available. [H&S]

SP13.

Sensitivity to natural rubber latex in patients, carers and healthcare personnel must be documented, and alternatives to natural rubber latex gloves must be available. [H&S]

SP14.

Neither powdered gloves nor polythene gloves should be used in healthcare activities. [D H&S]

SP15.

Disposable plastic aprons should be worn when there is a risk that clothing may become exposed to blood, body fluids, secretions or excretions, with the exception of sweat. [D H&S]

SP16.

Full-body fluid-repellent gowns must be worn where there is a risk of extensive splashing of blood, body fluids, secretions or excretions, with the exception of sweat, onto the skin or clothing of healthcare personnel (for example when assisting with childbirth). [D H&S]

SP17.

Plastic aprons should be worn as single-use items, for one procedure or episode of patient care, and then discarded and disposed of as clinical waste. [D H&S]

SP18.

Face masks and eye protection must be worn where there is a risk of blood, body fluids, secretions or excretions splashing into the face and eyes. [D H&S]

SP19.

Respiratory protective equipment, for example a particulate filter mask, must be used when clinically indicated. [D H&S]

Safe use and disposal of sharps

SP20.

Sharps must not be passed directly from hand to hand, and handling should be kept to a minimum. [D H&S]

SP21.

Needles must not be recapped, bent, broken or disassembled before use or disposal. [D H&S]

SP22.

Used sharps must be discarded into a sharps container (conforming to UN3291 and BS 7320 standards) at the point of use by the user. These must not be filled above the mark that indicates that they are full. [D H&S]

SP23.

Containers in public areas must be located in a safe position, and must not be placed on the floor. They must be disposed of by the licensed route in accordance with local policy. [D H&S]

SP24.

Needle safety devices must be used where there are clear indications that they will provide safer systems of working for healthcare personnel. [D H&S]

SP25.

Everyone involved in providing care in the community should be educated about standard principles and trained in hand decontamination, the use of protective clothing and the safe disposal of sharps. [D]

SP26.

Adequate supplies of liquid soap, handrub, towels and sharps containers should be made available wherever care is delivered. [D]

Care of patients with long-term urinary catheters

These guidelines apply to adults and children and should be read in conjunction with the guidance on Standard Principles. These guidelines focus on preventing infection. However, because infection has a complex inter-relationship with encrustation and blockage, these aspects of catheter management are also addressed.

The recommendations are divided into five distinct interventions:

  • education of patients, their carers and healthcare personnel
  • assessing the need for catheterisation
  • selection of catheter drainage options
  • catheter insertion
  • catheter maintenance.

Education of patients, their carers and healthcare personnel

UC1.

Patients and carers should be educated about and trained in techniques of hand decontamination, insertion of intermittent catheters where applicable, and catheter management before discharge from hospital. [D]

UC2.

Community and primary healthcare personnel must be trained in catheter insertion, including suprapubic catheter replacement and catheter maintenance. [D]

UC3.

Follow-up training and ongoing support of patients and carers should be available for the duration of long-term catheterisation. [D]

Assessing the need for catheterisation

UC4.

Indwelling urinary catheters should be used only after alternative methods of management have been considered. [D]

UC5.

The patient’s clinical need for catheterisation should be reviewed regularly and the urinary catheter removed as soon as possible. [D]

UC6.

Catheter insertion, changes and care should be documented. [D]

Catheter drainage options

UC7.

Following assessment, the best approach to catheterisation that takes account of clinical need, anticipated duration of catheterisation, patient preference and risk of infection should be selected. [C]

UC8.

Intermittent catheterisation should be used in preference to an indwelling catheter if it is clinically appropriate and a practical option for the patient. [A]

UC9.

For urethral and suprapubic catheters, the choice of catheter material and gauge will depend on an assessment of the patient’s individual characteristics and predisposition to blockage. [D]

UC10.

In general, the catheter balloon should be inflated with 10ml of sterile water in adults and 3–5ml in children. [D]

UC11.

In patients for whom it is appropriate, a catheter valve can be used as an alternative to a drainage bag. [A]

Catheter insertion

UC12.

All catheterisations carried out by healthcare personnel should be aseptic procedures. After training, healthcare personnel should be assessed for their competence to carry out these types of procedures. [D]

UC13.

Intermittent self-catheterisation is a clean procedure. A lubricant for single-patient use is required for non-lubricated catheters. [A]

UC14.

For urethral catheterisation, the meatus should be cleaned before insertion of the catheter, in accordance with local guidelines/policy. [D]

UC15.

An appropriate lubricant from a single-use container should be used during catheter insertion to minimise urethral trauma and infection. [D]

Catheter maintenance

UC16.

Indwelling catheters should be connected to a sterile closed urinary drainage system or catheter valve. [D]

UC17.

Healthcare personnel should ensure that the connection between the catheter and the urinary drainage system is not broken except for good clinical reasons, (for example changing the bag in line with manufacturer’s recommendations). [D]

UC18.

Healthcare personnel must decontaminate their hands and wear a new pair of clean, non-sterile gloves before manipulating a patient’s catheter, and must decontaminate their hands after removing gloves. [D]

UC19.

Carers and patients managing their own catheters must wash their hands before and after manipulation of the catheter, in accordance with the recommendations in the Standard Principles Section (Section 2). [A]

UC20.

Urine samples must be obtained from a sampling port using an aseptic technique. [D]

UC21.

Urinary drainage bags should be positioned below the level of the bladder, and should not be in contact with the floor. [D]

UC22.

A link system should be used to facilitate overnight drainage, to keep the original system intact. [D]

UC23.

The urinary drainage bag should be emptied frequently enough to maintain urine flow and prevent reflux, and should be changed when clinically indicated. [D]

UC24.

The meatus should be washed daily with soap and water. [A]

UC25.

Each patient should have an individual care regimen designed to minimise the problems of blockage and encrustation. The tendency for catheter blockage should be documented in each newly catheterised patient. [D]

UC26.

Bladder instillations or washouts must not be used to prevent catheter-associated infection. [A]

UC27.

Catheters should be changed only when clinically necessary, or according to the manufacturer’s current recommendations. [D]

UC28.

Antibiotic prophylaxis when changing catheters should only be used for patients with a history of catheter-associated urinary tract infection following catheter change , or for patients who have a heart valve lesion, septal defect, patent ductus or prosthetic valve. [B]

UC29.

Reusable intermittent catheters should be cleaned with water and stored dry in accordance with the manufacturer’s instructions. [D]

Care during enteral feeding

These guidelines apply to adults and children and should be read in conjunction with the guidance on Standard Principles.

The recommendations are divided into four distinct interventions:

  • education of patients, their carers and healthcare personnel
  • preparation and storage of feeds
  • administration of feeds
  • care of insertion site and enteral feeding tube.

Education of patients, their carers and healthcare personnel

EF1.

Patients and carers should be educated about, and trained in the techniques of hand decontamination, enteral feeding and the management of the administration system before being discharged from hospital. [D]

EF2.

Community staff should be trained in enteral feeding and management of the administration system. [D]

EF3.

Follow-up training and ongoing support of patients and carers should be available for the duration of home enteral tube feeding. [D]

Preparation and storage of feeds

EF4.

Wherever possible pre-packaged, ready-to-use feeds should be used in preference to feeds requiring decanting, reconstitution or dilution. [A]

EF5.

The system selected should require minimal handling to assemble, and be compatible with the patient’s enteral feeding tube. [B]

EF6.

Effective hand decontamination must be carried out before starting feed preparation. [A]

EF7.

When decanting, reconstituting or diluting feeds, a clean working area should be prepared and equipment dedicated for enteral feed use only should be used. [D]

EF8.

Feeds should be mixed using cooled boiled water or freshly opened sterile water and a no-touch technique. [D]

EF9.

Feeds should be stored according to manufacturer’s instructions and, where applicable, food hygiene legislation. [D]

EF10.

Where ready-to-use feeds are not available, feeds may be prepared in advance, stored in a refrigerator, and used within 24 hours. [D]

Administration of feeds

EF11.

Minimal handling and an aseptic no-touch technique should be used to connect the administration system to the enteral feeding tube. [C]

EF12.

Ready-to-use feeds may be given for a whole administration session, up to a maximum of 24 hours. Reconstituted feeds should be administered over a maximum 4-hour period. [C]

EF13.

Administration sets and feed containers are for single use and must be discarded after each feeding session. [B]

Care of insertion site and enteral feeding tube

EF14.

The stoma should be washed daily with water and dried thoroughly. [D]

EF15.

To prevent blockage, the enteral feeding tube should be flushed with fresh tap water before and after feeding or administrating medications. Enteral feeding tubes for patients who are immunosuppressed should be flushed with either cooled freshly boiled water or sterile water from a freshly opened container. [D]

Care of patients with central venous catheters

These recommendations apply to the care in the community of all adults and children with central venous catheters (CVCs) that are being used for the administration of fluids, medications, blood components and/or total parenteral nutrition (TPN). They should be used in conjunction with the recommendations on Standard Principles.

These recommendations do not specifically address the more technical aspects of the care of patients receiving haemodialysis, who will generally have their CVCs managed in dialysis centres.

The recommendations are divided into four intervention categories:

  • education of patients, their carers and healthcare personnel
  • general asepsis
  • catheter site care
  • standard principles for catheter management.

Education of patients, their carers and healthcare personnel

CVC1.

Before discharge from hospital, patients and their carers should be taught any techniques they may need to use to prevent infection and safely manage a central venous catheter. [D]

CVC2.

Community healthcare personnel caring for a patient with a central venous catheter should be trained, and assessed as competent, in using and consistently adhering to the infection prevention practices described in this guideline. [D]

CVC3.

Follow-up training and support should be available to patients with central venous catheters and their carers. [D]

General asepsis

CVC4.

An aseptic technique must be used for catheter site care and for accessing the system. [B]

CVC5.

Before accessing or dressing central vascular catheters, hands must be decontaminated either by washing with an antimicrobial liquid soap and water, or by using an alcohol handrub. [A]

CVC6.

Hands that are visibly soiled or contaminated with dirt or organic material must be washed with soap and water before using an alcohol handrub. [A]

CVC7.

Following hand antisepsis, clean gloves and a no-touch technique or sterile gloves should be used when changing the insertion site dressing. [D]

Catheter site care

CVC8.

Preferably, a sterile, transparent, semipermeable polyurethane dressing should be used to cover the catheter site. [A]

CVC9.

If a patient has profuse perspiration, or if the insertion site is bleeding or oozing, a sterile gauze dressing is preferable to a transparent, semi-permeable dressing. [D]

CVC10.

Gauze dressings should be changed when they become damp, loosened or soiled, and the need for a gauze dressing should be assessed daily. A gauze dressing should be replaced by a transparent dressing as soon as possible. [D]

CVC11.

Transparent dressings should be changed every 7 days, or sooner if they are no longer intact or moisture collects under the dressing. [A]

CVC12.

Dressings used on tunnelled or implanted CVC sites should be replaced every 7 days until the insertion site has healed, unless there is an indication to change them sooner. [A]

CVC13.

An alcoholic chlorhexidine gluconate solution should be used to clean the catheter site during dressing changes, and allowed to air dry. An aqueous solution of chlorhexidine gluconate should be used if the manufacturer’s recommendations prohibit the use of alcohol with their product. [A]

CVC14.

Individual sachets of antiseptic solution or individual packages of antiseptic-impregnated swabs or wipes should be used to disinfect the dressing site. [D]

CVC15.

Healthcare personnel should ensure that catheter-site care is compatible with catheter materials (tubing, hubs, injection ports, luer connectors and extensions) and carefully check compatibility with the manufacturer’s recommendations. [D]

General principles for catheter management

CVC16.

The injection port or catheter hub should be decontaminated using either alcohol or an alcoholic solution of chlorhexidine gluconate before and after it has been used to access the system. [C]

CVC17.

In-line filters should not be used routinely for infection prevention. [D]

CVC18.

Antibiotic lock solutions should not be used routinely to prevent catheter-related bloodstream infections (CRBSI). [A]

CVC19.

Systemic antimicrobial prophylaxis should not be used routinely to prevent catheter colonisation or CRBSI, either before insertion or during the use of a central venous catheter. [A]

CVC20.

Preferably, a single lumen catheter should be used to administer parenteral nutrition. If a multilumen catheter is used, one port must be exclusively dedicated for TPN, and all lumens must be handled with the same meticulous attention to aseptic technique. [D]

CVC21.

Preferably, sterile 0.9 percent sodium chloride injection should be used to flush and lock catheter lumens. [D]

CVC22.

When recommended by the manufacturer, implanted ports or opened-ended catheter lumens should be flushed and locked with heparin sodium flush solutions. [D]

CVC23.

Systemic anticoagulants should not be used routinely to prevent CRBSI. [D]

CVC24.

If needleless devices are used, the manufacturer’s recommendations for changing the needleless components should be followed. [D]

CVC25.

When needleless devices are used, healthcare personnel should ensure that all components of the system are compatible and secured, to minimise leaks and breaks in the system. [D]

CVC26.

When needleless devices are used, the risk of contamination should be minimised by decontaminating the access port with either alcohol or an alcoholic solution of chlorhexidine gluconate before and after using it to access the system. [D]

CVC27.

In general, administration sets in continuous use need not be replaced more frequently than at 72 hour intervals unless they become disconnected or a catheter-related infection is suspected or documented. [A]

CVC28.

Administration sets for blood and blood components should be changed every 12 hours, or according to the manufacturer’s recommendations. [D]

CVC29.

Administration sets used for total parenteral nutrition (TPN) infusions should generally be changed every 24 hours. If the solution contains only glucose and amino acids, administration sets in continuous use do not need to be replaced more frequently than every 72 hours. [D]

Introduction

These guidelines were directly funded by the Department of Health (England) with additional funding from The National Institute for Clinical Excellence (NICE).

NICE commissioned the development of these guidelines from Thames Valley University under the auspices of the National Collaborating Centre for Nursing and Supportive Care. The full guidelines for preventing healthcare-associated infections in community and primary care are published by Thames Valley University and are available on its website <www.richardwellsresearch.com>, the NICE website <www.nice.org.uk> and on the website of the National Electronic Library for Health <www.nelh.nhs.uk>.

These guidelines were developed by a multidisciplinary Guideline Development Group (GDG) that represented all key stakeholders and included a patient representative (Appendix A).

Due to the breadth of the guideline, several members were appointed for their specialist knowledge of a particular medical device.

Conflicts of interest were formally monitored throughout the guideline development period and none was noted.

The aim of the group was to develop recommendations for practice based on the available evidence and knowledge of the practicalities of clinical practice.

The group met at approximately monthly intervals and followed the working procedures outlined by NICE.

During the scoping exercise, patient groups were contacted for their advice and visits made to specialist centres to discuss issues with patients and staff. Arrangements were made with a patients’ organization to give extra support to the patient representative to be able to comment on all devices (Full Scope Appendix B).

Background and context to the Guidelines

The prevalence of healthcare-associated infections in patients in primary and community care settings in the United Kingdom is not known. Many infections in these patients may have been acquired in hospital and only identified following early discharge into the community. The risk of infection will also be influenced by the use of various medical devices, such as urinary and central venous catheters and enteral feeding systems.

Incorporating evidence-based infection prevention and control advice into routine clinical care activities is believed to be important in reducing the incidence of preventable healthcare-associated infections.(1) Consequently, guidelines for preventing healthcare-associated infections in caring for patients in primary and community care settings were commissioned.

Scope and Purpose of the Guidelines

The scope of these guidelines was established at the start of the guideline process, following a period of consultation, including a survey and focus group discussions with community and primary care practitioners. This consultation process has been previously described (2) and the full scoping exercise is available from the NICE website <www.nice.org.uk> (Appendix B).

These guidelines were developed to help prevent healthcare-associated infections (HAI) in community and primary care. They provide guidance for standard infection control precautions that may be applied by all healthcare personnel to the care of all patients in community and primary care settings. They also provide guidance to non-professional carers, patients and their families.

These guidelines are intended to be broad principles of best practice which need to be incorporated into local practice guidelines. Four sets of guidelines have been developed:

  • Standard Principles for preventing healthcare-associate infections in community and primary care;
  • Guidelines for preventing infections associated with the use of long-term urinary catheters;
  • Guidelines for preventing infections associated with the use of enteral feeding systems;
  • Guidelines for preventing infections associated with the use of long-term central venous catheters.

Each set of guidelines follows an identical format, which consists of:

  • a glossary;
  • the intervention heading;
  • a headline statement describing the key issues being addressed;
  • a synthesis of the related evidence and corresponding evidence grade;
  • an economic opinion, where appropriate;
  • guideline recommendation(s) with the corresponding recommendation grade(s);
  • a bibliography listing the cited evidence.

Finally, at the end of each section there is a description of areas for further research, suggested audit criteria, and a bibliography of all evidence reviewed.

Methodology

The guidelines were developed using a systematic review process and associated protocols (Appendix C). In each set of guidelines a more detailed description is provided.

For each set of guidelines, an electronic search was conducted for current national and international guidelines. They were retrieved and subjected to critical appraisal using the AGREE Instrument, (3) which provides “a framework for assessing the quality of clinical practice guidelines.”

Where guidelines met the AGREE criteria they were included as part of the evidence base supporting each set of guidelines. They were also used to verify professional consensus. The emphasis given to each guideline depended on the rigour of its development and its comprehensiveness in relation to the review questions. In some instances they were used as the primary source of evidence.

Review questions for the systematic reviews of the literature were developed for each set of guidelines following advice from key stakeholders and expert advisors.

Searches were constructed for each set of guidelines using relevant MeSH (medical subject headings) and free-text terms. On completion of the main search, an economic filter was applied. The following databases were searched:

  • Medline
  • Cumulated Index of Nursing and Allied Health Literature (CINAHL)
  • Embase
  • The Cochrane Library:
  • The National Electronic Library for Health
  • The NHS Centre for Reviews and Dissemination (CRD)
    • CRD includes 3 databases: Database of Abstracts of Reviews of Effectiveness (DARE), NHS Economic Evaluation Database(NHS EED), Health Technology Assessment (HTA)Database
  • Health CD Database
  • Health Management Information Consortium Database
  • The National Research Register
  • The Web of Science
  • The Institute of Health Technology
  • Health CD Database
  • Health Management Information Consortium Database
    • HMIC includes 3 databases: The Department of Health Library and Information Service (DHData), Health Management Information Service (HELMIS) from the Nuffield Institute and the Kings Fund Database.

The results of each search including abstracts were printed. The first sift of citations involved a review of the abstracts. Studies were retrieved if they were:

  • relevant to a review question;
  • primary research/systematic review/meta-analysis;
  • written in English.

Where there was no abstract, the full article was retrieved.

No research designs were specifically excluded but wherever possible, in use rather than in vitro studies were retrieved.

The second sift involved a critical review of the full text, and articles relevant to a review question were critically appraised. The SIGN data extraction form (4) was used to document the results of critical appraisal (Available from the SIGN website http://www.sign.ac.uk). A form for descriptive studies was designed by us based on the SIGN methodology.

Following critical appraisal, the evidence was tabulated and reports written for each review question. The evidence was graded using the categories described by Eccles and Mason (2001) (5) and reproduced below:

Categories of evidence

IaEvidence form meta-analysis of randomised controlled trials
IbEvidence from at least one randomised controlled trial
IIaEvidence from at least one controlled trial without randomisation
IIbEvidence from at least one other type of quasi-experimental study
IIIEvidence from non-experimental descriptive studies, such as comparative studies, correlation studies and case-control studies
IVEvidence from expert committees reports or opinions and/or clinical experience of respected authorities

The evidence tables and reports were presented to the GDG for discussion. At this stage, expert advice derived from seminal works and appraised national and international guidelines were considered. Following extensive discussion the guidelines were drafted.

Although economic opinion was considered for each review question, the economic scope described above did not identify any high quality cost effectiveness evidence, e.g., economic evaluations alongside randomised controlled trials. As a result, simple decision analytic modelling was employed using estimates from published literature and expert opinion from the GDG. Results were estimated initially for a “base case,” i.e., the most likely scenario. These results were then subjected to sensitivity analysis where key parameter values were varied. Areas were targeted where the impact on resource use was likely to be substantial. In addition, where there was no evidence of difference in clinical outcomes between interventions, simple cost analyses were performed to identify the potential resource consequences.

Factors influencing the guideline recommendations included:

  • the nature of the evidence;
  • the applicability of the evidence;
  • costs and knowledge of healthcare systems.

Consensus within the GDG was mainly achieved though discussion facilitated by the group chair. Where necessary, agreement was arrived at by open voting.

The grading scheme suggested by Eccles and Mason (2001) (5) was used to define the strength of recommendation and is reproduced below.

Recommendation gradeEvidence
ADirectly based on category 1 evidence
BDirectly based on:
Category II evidence, or
Extrapolated recommendation from category 1 evidence
CDirectly based on:
Category III evidence, or
Extrapolated recommendation from category I or II evidence
DDirectly based on:
Category IV evidence, or
Extrapolated recommendation from category I, II or III evidence

External consultation

These guidelines have been subject to extensive external consultation with registered stakeholders (see NICE website for consultation process and stakeholders). The guidelines will be reviewed in two years (2005).

References

1.
Haley RW, Culver DH, White JW, Morgan WM, Grace TG, Munn VP, Hooton TM. The Efficacy of Infection Surveillance and Control Programs in Preventing Nosocomial Infections in US Hospitals. American Journal of Epidemiology. 1985;121(2):182–205. [PubMed: 4014115]
2.
Pellowe CM, MacRae ED, Loveday HP, Reid P, Harper P, Robinson N, Pratt RJ. The scope of guidelines to prevent healthcare-associated infections. British Journal of Community Nursing. 2002;7(7):374–378. [PubMed: 12131854]
3.
The AGREE Collaboration. Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument. London: St. George’s Hospital Medical School; Jun, 2001.
4.
Scottish Intercollegiate. Guidelines Network. SIGN 50: A guideline developer’ handbook. Edinburgh: 2001.
5.
Eccles M, Mason J. How to develop cost-conscious guidelines. 16. Vol. 5. Southampton: Health Technology Assessment; 2001. p. 78. [PubMed: 11427188]

Appendix A. Guideline Development Group (GDP)

  • Chairperson: Dr Anne Mulhall
  • Independent Consultant
  • Project Manager: Carol Pellowe
  • Thames Valley University
  • Project Director: Professor Robert Pratt
  • Thames valley University
  • Peter Harper
  • Senior Lecturer (Research),
  • Thames Valley University
  • Dr Nicky Robinson
  • Reader,
  • Thames Valley University
  • Dr Sarah Chieveley Williams
  • Consultant Anaesthetist
  • University College Hospital NHS Trust
  • Harrow
  • Mr PJR Shah
  • Senior Lecturer in Urology and Consultant Urologist
  • UCL Hospital NHS Trust
  • Dr Jim Newey
  • General Practitioner
  • Weaver Vale Practice, Runcorn
  • Daphne Colpman
  • Continence Adviser
  • UCL Hospitals NHS Trust
  • Nicola Pratelli
  • Community Infection Control Nurse
  • South West London Health Protection Unit
  • Mrs Carolyn Wheatley
  • Patient representative
  • Patients on Intravenous
  • & Nasogastric Nutrition Therapy (PINNT)
  • Lisa Cooper
  • Head of Dietetics
  • St Catherine’s Hospital, Wirral
  • Heather Loveday (Research)
  • Principal Lecturer
  • Thames Valley University
  • Dr Godfrey Smith
  • Honorary Consultant Microbiologist
  • Royal Liverpool Hospital
  • Mr Joe Peters
  • Consultant Surgeon
  • Princess Alexandra Hospital,
  • Professor David Silk
  • Consultant Physician
  • Central Middlesex Hospital
  • Jo Bray
  • Nutrition Nurse Specialist
  • Central Middlesex Hospital
  • Anne Carroll
  • Community Infection Control Nurse
  • South West Kent PCT
  • Ian McQuarrie
  • District Nurse Team Leader
  • Langthorne Health Centre, London
  • Gerry Richardson
  • Research Fellow (Health Economist)
  • Centre for Health Economics, York
  • Elizabeth McInnes
  • Senior Research and Development Fellow
  • NCC for Nursing & Supportive Care

Appendix B. Full Scope for the guideline to prevent healthcare associated infection in primary and community care

1. Objective

1.1.

The National Institute for Clinical Excellence has commissioned a clinical guideline for patients, carers and clinicians on the prevention of healthcare associated infection (HCAI) in primary and community care. The guideline will provide advice on effective and cost-effective care using the best available evidence.

1.2.

The commission received from the Department of Health and the National Assembly for Wales

We would like NICE to produce a guideline on infection control in primary and community care.

This guideline will be expected to address a standard approach to preventing and controlling healthcare associated infections in primary and community care and additional guidance for selected healthcare interventions with a potential risk for infection.

2. Title

Clinical guideline for the prevention and control of healthcare associated infection in primary and community care.

3. Clinical Need and Practice

3.1.

As complex care is increasingly performed in primary and community care settings, the risk of infections associated with healthcare interventions increases. This can result in increased morbidity and mortality, greater costs and use of resources and profound consumer dissatisfaction.

3.2.

This guideline will assist clients and all healthcare providers involved in direct patient care to minimise the risk of infection.

3.3.

Guideline developers will work closely with service users and carers to ensure that the guidelines are understandable to clients and their carers.

4. Population

This guideline will apply to patients of all ages receiving healthcare interventions in primary and community care.

5. Health care setting

5.1.

The guideline will cover the care received from primary and community health care professionals who have direct contact with and make decisions concerning the care of patients and will offer ’best practice’ advice on preventing healthcare-associated infections. It will describe a standard set of infection prevention measures that anyone giving or receiving care in primary and community care can follow.

5.2.

The guideline will also be compatible with guidelines for the prevention of hospital-acquired infections, and will influence discharge planning.

5.3.

This is an NHS guideline. Although it will address the interface with other services, such as those provided by social services, secure settings and the voluntary sector, it will not include services exclusive to these sectors.

6. Interventions and treatment

In addition to standard principles for preventing healthcare associated infections, the guideline will describe measures for preventing infections associated with the use of long-term urinary catheters, central venous catheters and enteral feeding systems.

6.1.

This guideline will be appropriate for use in preventing infections associated with all direct care activities. It will also assist clients to prevent infections when managing aspects of their own care.

6.2.

This guideline will focus on using a ’standard approach’ for preventing infections and will include issues associated with:

  • hand hygiene;
  • use of personal protective equipment;
  • use and disposal of needles and sharp instruments.
6.3.

This guideline will not include advice on the diagnosis, treatment and management of specific infections.

6.4.

This guideline will not include advice on the insertion of central venous catheters or enteral feeding systems as these activities are carried out in acute care facilities.

7. Presentation

The guideline will be available in three forms:

7.1.

The full guideline containing the evidence base used by the developers.

7.2.

A short form version, using a standard template, which will form the Institute's guidance to the NHS including a clinical practice algorithm.

7.3.

The guideline will be accompanied by a version prepared specifically for patients and their carers. This patient/carer version will interpret the recommendations made in the Institute’s short form version and will be designed to help patients to make informed choices about their care.

8. Status

8.1.

This scoping statement has been the subject of a four week period of consultation with stakeholders. The scope has been re-drafted and submitted to the Guidelines Advisory Committee and subsequently the Institute’s Guidance Executive, for approval. The development of the guideline will begin in the autumn of 2001.

8.2.

Information on the guidelines development process, stakeholder involvement and the progress of this guideline is available on the website http://www​.nice.org.uk/.

Appendix C. The Systematic Review Process

Systematic Review Questions

Review questions were devised based on the scope of the review and advice from the Guideline Development Group, stakeholders including professional bodies and patient groups.

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Literature Search

Databases to be searched were identified together with search strategy, i.e., relevant medical subject headings (MESH), free text and thesaurus terms.

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Sift 1

Abstracts of all articles retrieved from the search were reviewed against pre-determined inclusion criteria, e.g. relevant to a review question, primary research/systematic review/meta-analysis, written in English.

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Sift 2

Full text of all articles meeting inclusion criteria were reviewed against pre-determined criteria to identify primary research which answers review questions.

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Critical Appraisal

All articles which describe primary research, a systematic review or, a meta-analysis were independently critically appraised by two appraisers. Consensus and grading was achieved through discussion in the context of pre-determined grading criteria.

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Evidence Tables

Evidence tables for accepted and rejected studies were generated and used to create evidence summary reports. The summary reports were, in turn, used as the basis for guideline writing.

Copyright © 2003, Richard Wells Research Centre at Thames Valley University.
Bookshelf ID: NBK49289

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