PubMed Health. A service of the National Library of Medicine, National Institutes of Health.

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.)

Appendix D2003 guideline appendices

D.1. Methods and systematic review process

D.1.1. Methods

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)116 and reproduced below:

Catagories 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 grading scheme suggested by Eccles and Mason (2001)116 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).

D.1.2. Systematic review process

D.1.2.1. Standard principles

Systematic review process

Five sets of guidelines were identified as a result of the search for national and international guidelines. These were retrieved and appraised using the AGREE instrument466. The appraisal for the epic phase 1 guidelines was undertaken by three external independent appraisers381. These were regarded as sufficiently robust to be used as a basis for these guidelines with additional searches for outstanding questions (SP Appendix 1).

After appraisal, search questions were developed from advice received from focus groups, stakeholders and our specialist advisers (Appendix SP2). The following systematic review questions were used:

Hand hygiene search questions
  1. What is the evidence that contaminated hands are a cause of healthcare-associated infection?
  2. Which hand disinfection agents are the most effective at removing/reducing organisms responsible for healthcare-associated infection?
  3. When must hands be disinfected in relation to patient care activities?
  4. What is the most effective hand washing technique for removing/reducing organisms responsible for healthcare-associated infection?
  5. Which hand disinfection agents are least toxic to users?
  6. Is there any cost effectiveness evidence relating to the above?
  7. What are the training and education implications for staff and patients?

In setting up the search the following MeSH terms were used: infection control; cross infection; universal precautions, equipment contamination; disease transmission; chlorhexidine; disinfectants; soaps; anti-infective agents; surface-active agents; handwashing; hand; skin; epidermis; nails. In addition, the following thesaurus and free text terms were used: antisepsis; sterilisation; decontamination.

These databases were searched from 1998 onwards: Medline, Cumulated Index of Nursing and Allied Health Literature (CINAHL), Embase, The Cochrane Library, National Electronic Library for Health, The NHS Centre for Reviews and Dissemination (CRD), The National Research Register, The Web of Science, The Institute of Health Technology, Health CD Database, Health Management Information, Consortium Database.

Search Results: 21219 articles were identified. These articles were initially sifted to determine if they related to infections associated with hand hygiene, were written in English, were primary research or were a systematic review or a meta-analysis, and appeared to inform one or more of the review questions. Following this first sift, 160 full text articles were retrieved. Using the same criteria as in the first sift, retrieved full-text articles were then re-sifted to select those for critical appraisal. A total of 24 full text articles were independently critically appraised by two appraisers. Consensus and grading was achieved through discussion. Following critical appraisal, 23 were accepted into the study (1 was rejected).

Protective clothing search questions
  1. Which glove materials are least toxic to healthcare workers (HCWs) for general use?
  2. What is the evidence that hands need to be disinfected following the use of gloves?
  3. What is the evidence that HCWs use gloves appropriately, as a part of Standard Principles?
  4. What is the evidence that the uniforms/clothes of HCWs are a source of healthcare-associated infection?
  5. What is the evidence that the use of protective clothing reduces the incidence of healthcare-associated infection?
  6. Is there any cost effectiveness evidence relating to the above?
  7. What are the training and education implications for staff and patients?

In setting up the search the following MeSH terms were used: infection control; cross infection; universal precautions; equipment contamination; disease transmission; protective clothing; disposable equipment; masks; protective gloves; eye protective devices. In addition the following thesaurus and free text terms were used: antisepsis; disinfection; sterilisation; decontamination; face shield; goggles; apron; uniform; gown; clothing; visor; hood.

The databases were searched as described above.

Search Results: 8611 articles were identified. These articles were initially sifted to determine if they related to infections associated with personal protective equipment, were written in English, were primary research or were a systematic review or a meta-analysis, and appeared to inform one or more of the review questions. Following this first sift, 95 full text articles were retrieved. Using the same criteria as in the first sift, retrieved full-text articles were then re-sifted to select those for critical appraisal. A total of 7 full text articles were independently critically appraised by two appraisers. Consensus and grading was achieved through discussion. Following critical appraisal, all were accepted into the study.

Sharps search questions
  1. What is the evidence that recommended modes of use and disposal of sharps reduce the incidence of sharps injury in healthcare workers?
  2. What is the evidence that education and training interventions improve healthcare workers adherence to recommended modes of practice?
  3. What is the evidence that the use of needle-free devices reduce occupational exposure to bloodborne pathogens?
  4. Is there any cost effectiveness evidence relating to the above?
  5. What are the training and education implications for staff and patients?

In setting up the search the following MeSH terms were used: infection control; cross infection; universal precautions, equipment contamination; disease transmission; needlestick injuries; needles; syringes; occupational exposure; occupational accident; medical waste disposal; blood-borne pathogens. In addition the following thesaurus and free text terms were used: antisepsis; disinfection; sterilisation; decontamination; blood-borne virus; exposure prone procedure; post exposure prophylaxis; sharp; puncture; percutaneous injury; epi pen; vacutainer; resheath.

The databases were searched as described above.

Search Results: 7938 articles were identified. These articles were initially sifted to determine if they related to the safe use and disposal of sharps, were written in English, were primary research or were a systematic review or a meta-analysis, and appeared to inform one or more of the review questions. Following this first sift, 84 full text articles were retrieved. Using the same criteria as in the first sift, retrieved full-text articles were then re-sifted to select those for critical appraisal. A total of 4 full text articles were independently critically appraised by two appraisers. Consensus and grading was achieved through discussion. Following critical appraisal, all were accepted into the study.

Evidence tables for accepted and rejected studies were generated and used to create summary reports, including evidence grades (Appendix SP3). The summary reports were used as the basis for guideline writing.

D.1.2.2. Urinary catheterisation

Two sets of guidelines were identified as a result of the search for national and international guidelines. These were retrieved and appraised using the AGREE instrument.466 The appraisal for the epic phase 1 guidelines was undertaken by two external independent appraisers.381 These were regarded as sufficiently robust to be used as a basis for these guidelines with additional searches for outstanding questions (Appendix UC1).

After appraisal, search questions were developed from advice received from focus groups, stakeholders and our specialist advisers (Appendix UC2). The following systematic review questions were used:

  1. If it is necessary to catheterise, which approach – indwelling urethral*/suprapubic/intermittent results in the lowest rates of infection?
  2. Is the management or type of drainage system a factor in colonisation/infection?
  3. Is the frequency or method of changing catheters (indwelling, suprapubic) a factor in colonisation/infection?
  4. Does monitoring urinary pH assist in the prevention of encrustation and blockage of long term indwelling catheters?
  5. Which catheters materials cause least irritation/encrustation/blockage?
  6. Does the use of bladder irrigation/instillation*/washout*, prevent/reduce encrustation and symptomatic urinary tract infection?
  7. Does the use of antibiotic prophylaxis at the time of changing catheters reduce symptomatic infection?
  8. Which method of cleaning and storing intermittent catheters result in the lowest rates of colonisation/infection?
  9. Is there any cost effectiveness evidence relating to the above?
  10. What are the training and education implications for staff and patients?

In setting up the search the following MeSH terms were used: infection control; cross infection; community-acquired infections; disease transmission; urinary tract infections; urinary catheterization; indwelling catheters; antibiotic prophylaxis; irrigation; biofilms; hydrogen ion concentration; urease; proteus; proteus infections; providencia; morganella. In addition the following thesaurus and free text terms were used: intermittent catheterisation; uretheral catheterisation; suprapubic catheterisation; bacteriuria*; pyuria; encrustation; blockage; non blocker; bladder irrigation; washout; bladder instillation.

These databases were searched from 1985 onwards: Medline, Cumulated Index of Nursing and Allied Health Literature (CINAHL), Embase, The Cochrane Library, National Electronic Library for Health, The NHS Centre for Reviews and Dissemination (CRD), The National Research Register, The Web of Science, The Institute of Health Technology, Health CD Database, Health Management Information, Consortium Database.

Search Results: 7387 articles were identified. These articles were initially sifted to determine if they related to infections associated with long term urinary catheters, were written in English, were primary research or were a systematic review or a meta-analysis, and appeared to inform one or more of the review questions. Following this first sift, 978 full text articles were retrieved. Using the same criteria as in the first sift, retrieved full-text articles were then re-sifted to select those for critical appraisal. A total of 75 full text articles were independently critically appraised by two appraisers. Consensus and grading was achieved through discussion. Following critical appraisal, 34 were accepted into the study (41 were rejected).

Evidence tables for accepted and rejected studies were generated and used to create summary reports, including evidence grades (Appendix UC3). The summary reports were used as the basis for guideline writing.

Following our reviews, guidelines were drafted which described 28 recommendations within the below 5 intervention categories:

  1. Education of patients, their carers and healthcare personnel;
  2. Assessing the need for catheterisation;
  3. Selection of catheter drainage system;
  4. Catheter insertion;
  5. Catheter maintenance.

D.1.2.3. Enteral feeding

Three sets of guidelines were identified as a result of the search for national and international guidelines. These were retrieved and appraised using the AGREE instrument.466 As all were written prior to 1995, they did not score highly in some areas and their contribution has been used as expert opinion only. (See Appendix EF1)

After appraisal, search questions were developed from advice received from focus groups, stakeholders and our specialist advisers (See Appendix EF2). The following systematic review questions were used:

  1. Was one type of feeding system superior to others in terms of infection rates?
  2. Did the administration of the feed contribute to infection?
  3. Was it safe to reuse equipment used in the administration of feeds?
  4. Were there any storage issues that contribute to infection?
  5. Was the stoma site a source of infection?
  6. Was there any cost effectiveness evidence relating to the above?
  7. What were the training and education implications for staff and patients?

In setting up the search the following MeSH terms were used: cross infection; community acquired infection; infection control; food contamination; equipment contamination; enteral nutrition, nutritional support, gastrostomy, gastroenterostomy, jejunostomy. In addition the following thesaurus and free text terms were used: home nutrition; home artificial nutrition; PEG feed; tube feed; tube nutrition; gastric feed; gastric nutrition; enteral feed; enteric feed; nasoenteric; intragastric; post-pyloric; percutaneous; transpyloric; gastrojejunostomy; gastroduodenostomy; duodenostomy.

These databases were searched from 1990: Medline, Cumulated Index of Nursing and Allied Health Literature (CINAHL), Embase, The Cochrane Library, National Electronic Library for Health, The NHS Centre for Reviews and Dissemination (CRD), The National Research Register, The Web of Science, The Institute of Health Technology, Health CD Database, Health Management Information, Consortium Database.

Search Results: 19369 articles were identified. These articles were initially sifted to determine if they related to infections associated with enteral feeding, were written in English, were primary research or were a systematic review or a meta-analysis, and appeared to inform one or more of the review questions. Following this first sift, 301 full text articles were retrieved. Using the same criteria as in the first sift, retrieved full-text articles were then re-sifted to select those for critical appraisal. A total of 42 full text articles were independently critically appraised by two appraisers. Consensus and grading was achieved through discussion. Following critical appraisal, 30 were accepted into the study (12 were rejected).

Evidence tables for accepted and rejected studies were generated and used to create summary reports, including evidence grades (Appendix EF3). The summary reports were used as the basis for guideline writing.

Guidelines were then drafted which described 15 recommendations within the below 4 intervention categories:

  1. Education of patients, their carers and healthcare personnel;
  2. Preparation and storage of feeds;
  3. Administration of feeds;
  4. Care of insertion site and enteral feeding tube.

D.1.2.4. Central venous catheters

After this appraisal, we systematically searched, retrieved and appraised additional supporting evidence published since the HICPAC guidelines were developed (CVC Appendix 2). This search was confined to elements of infection prevention where expert members of the Guideline Development Group indicated new developments or changes in technology had occurred, or where pertinent new experimental trials or systematic reviews had been published.

The following systematic review questions were used:

  1. Should the catheter insertion site be protected by a dressing and, if so, which type of dressing should be used and how frequently should it be changed?
  2. Which antiseptic/disinfectant was best for: preparation of the skin site (cutaneous antisepsis) prior to central venous catheter insertion; cleansing of the entry site once the catheter was in place (if any such evidence exists that routine cleansing prevents infections); cleaning the catheter hub and/or injection ports prior to accessing the system?
  3. Should the catheter be routinely flushed before or after accessing. If so, which solution, e.g., heparin or normal saline, should be used?
  4. Would low-dose systemic anticoagulation reduce the risk of bloodstream infections?
  5. Was the maintenance of a closed system, e.g., Vygon Bionector 2 Connection Accessory, practicable, effective in reducing infection complications, and cost-effective?
  6. Did stopcocks and three-way taps increase the risk of catheter colonisation* and/or bloodstream infections?
  7. Did the use of inline filters (in-line filtration of microbes/endotoxins) prevent bloodstream infections?
  8. How frequently should the intravenous catheter administration set be changed?

In setting up the search the following MeSH terms were used: Infection control; cross infection; universal precautions; equipment contamination; disease transmission; bacteremia; chlorhexidine; povidone iodine; anticoagulants; sepsis; central venous catheterisation; indwelling catheters; parenteral nutrition. In addition the following free text terms were used: PICC; TPN; catheter hub; catheter port; dressings; flushing solutions.

These databases were searched from 1998: Medline, Cumulated Index of Nursing and Allied Health Literature (CINAHL), Embase, The Cochrane Library, National Electronic Library for Health, The NHS Centre for Reviews and Dissemination (CRD), The National Research Register, The Web of Science, The Institute of Health Technology, Health CD Database, Health Management Information, Consortium Database.

Search Results: 4650 articles were located. They were initially sifted to determine if they related to infections associated with central venous catheters, were written in English, were primary research or were a systematic review or a meta-analysis, and appeared to inform one or more of the review questions. Following this first sift, 153 full text articles were retrieved. Using the same criteria as in the first sift, retrieved full-text articles were then re-sifted to select those for critical appraisal. A total of 18 full text articles were independently critically appraised by two appraisers. Consensus and grading was achieved through discussion. Following critical appraisal, 11 were accepted into the study (7 were rejected).

Evidence tables for accepted and rejected studies were generated and used to create evidence summary reports (see CVC Appendix 3). The summary reports along with the primary evidence from the Expert Review of the HICPAC Guidelines, were used as the basis for guideline writing.

Previously, a similar process had informed the development of national guidelines for preventing CRBSI in hospitals associated with the insertion and maintenance of CVCs commissioned by the Department of Health (England) and published in 2001.381 It is expected that patients in primary and community care settings would have a CVC inserted or replaced in hospital where these guidelines apply. Consequently, recommendations for the selection of the best type of catheter and insertion site and the optimum aseptic technique required during CVC placement are not included in guidance for community and primary healthcare personnel* as these issues are addressed in the above guidelines for acute care facilities. However, it is good practice for hospital and relevant community nursing staff to discuss in advance the selection of the most appropriate type of catheter in relation to the available skills and resources in the community to care for patients with different types of central vascular access devices.

Following our reviews, guidelines were drafted which described 29 recommendations within the below 4 intervention categories:

Education of patients, their carers and healthcare personnel;

  1. General asepsis;
  2. Catheter site care;
  3. Standard principles for catheter management.

These guidelines apply to caring for all adults and children in the community with CVCs which 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 for preventing healthcare-associated infections (HAI).

Although these recommendations describe general principles of best practice that apply to all patients in the community using long-term central vascular access devices, they 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.

Because these recommendations describe broad general statements of best practice, they need to be adapted and incorporated into local practice guidelines.

D.2. Full scope (2003)

D.2.1. Objective

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.

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.

D.2.2. Title

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

D.2.3. Clinical Need and Practice

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.

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

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

D.2.4. Population

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

D.2.5. Health care setting

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.

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

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.

D.2.6. 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.

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.

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

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

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.

D.2.7. Presentation

The guideline will be available in three forms:

4.

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

5.

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

6.

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.

D.2.8. Status

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.

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

D.3. Search strategy (2003)

D.3.1. Hand Hygiene - Systematic Review Process

D.3.1.1. Systematic Review Questions

Search questions
  1. What is the evidence that contaminated hands are a cause of healthcare-associated infection?
  2. Which hand disinfection agents are the most effective at removing/reducing organisms responsible for healthcare-associated infection?
  3. When must hands be disinfected in relation to patient care activities?
  4. What is the most effective hand washing technique for removing/reducing organisms responsible for healthcare-associated infection?
  5. Which hand disinfection agents are least toxic to users?
  6. Is there any cost effectiveness evidence relating to the above?
  7. What are the training and education implications for staff and patients?

D.3.1.2. Databases and Search Terms Used

DATABASES

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), THE NATIONAL RESEARCH REGISTER, THE WEB OF SCIENCE, THE INSTITUTE OF HEALTH TECHNOLOGY, HEALTH CD DATABASE, HEALTH MANAGEMENT INFORMATION CONSORTIUM DATABASE.

MESH TERMS

infection control; cross infection; universal precautions, equipment contamination; disease transmission; chlorhexidine; disinfectants; soaps; anti-infective agents; surface-active agents; handwashing; hand; skin; epidermis; nails.

THESAURUS AND FREE TEXT TERMS

antisepsis; sterilisation; decontamination

D.3.1.3. Search Results

Total number of articles located = 21219

Sift 1 Criteria

Abstract indicates that the article: relates to infections associated with hand hygiene, is written in English, is primary research or a systematic review or a meta-analysis, and appears to inform one or more of the review questions.

Articles Retrieved

Total number of articles retrieved from sift 1 = 160

Sift 2 Criteria

Full Text confirms that the article relates to infections associated with hand hygiene is written in English, is primary research or a systematic review or a meta-analysis, and informs one or more of the review questions.

Articles Selected for Appraisal

Total number of articles selected for appraisal during sift 2 = 24

D.3.1.4. Critical Appraisal

All articles which described primary research, a systematic review or, a meta-analysis and met the sift 2 criteria were independently critically appraised by two appraisers. Consensus and grading was achieved through discussion.

Accepted and Rejected Evidence

Total number of articles accepted after critical appraisal = 23

Total number of articles rejected after critical appraisal = 1

D.3.1.5. 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.

D.3.2. Protective Clothing - Systematic Review Process

D.3.2.1. Systematic Review Questions

Search questions
  1. Which glove materials are least toxic to health care workers (HCWs) for general use?
  2. What is the evidence that hands need to be disinfected following the use of gloves?
  3. What is the evidence that HCWs use gloves appropriately, as a part of Standard Principles?
  4. What is the evidence that the uniforms / clothes of HCWs are a source of healthcare-associated infection?
  5. What is the evidence that the use of protective clothing reduces the incidence of healthcare-associated infection?
  6. Is there any cost effectiveness evidence relating to the above?
  7. What are the training and education implications for staff and patients?

D.3.2.2. Databases and Search Terms Used

DATABASES

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), THE NATIONAL RESEARCH REGISTER, THE WEB OF SCIENCE, THE INSTITUTE OF HEALTH TECHNOLOGY, HEALTH CD DATABASE, HEALTH MANAGEMENT INFORMATION CONSORTIUM DATABASE.

MESH TERMS

infection control; cross infection; universal precautions; equipment contamination; disease transmission; protective clothing; disposable equipment; masks; protective gloves; eye protective devices.

THESAURUS AND FREE TEXT TERMS

antisepsis; disinfection; sterilisation; decontamination; face shield; goggles; apron; uniform; gown; clothing; visor; hood.

D.3.2.3. Search Results

Total number of articles located = 8611

Sift 1 Criteria

Abstract indicates that the article: relates to infections associated with protective clothing, is written in English, is primary research or a systematic review or a meta-analysis, and appears to inform one or more of the review questions.

Articles Retrieved

Total number of articles retrieved from sift 1 = 95

Sift 2 Criteria

Full Text confirms that the article relates to infections associated with protective clothing is written in English, is primary research or a systematic review or a meta-analysis, and informs one or more of the review questions.

Articles Selected for Appraisal

Total number of articles selected for appraisal during sift 2 = 7

D.3.2.4. Critical Appraisal

All articles which described primary research, a systematic review or, a meta-analysis and met the sift 2 criteria were independently critically appraised by two appraisers. Consensus and grading was achieved through discussion.

Accepted and Rejected Evidence

Total number of articles accepted after critical appraisal = 7

Total number of articles rejected after critical appraisal = 0

D.3.2.5. 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.

D.3.3. Sharps - Systematic Review Process

D.3.3.1. Systematic Review Questions

D.3.3.2. Search questions

  1. What is the evidence that recommended modes of use and disposal of sharps reduce the incidence of sharps injury in health care workers?
  2. What is the evidence that education and training interventions improve health care workers adherence to recommended modes of practice?
  3. What is the evidence that the use of needle-free devices reduce occupational exposure to bloodborne pathogens?
  4. Is there any cost effectiveness evidence relating to the above?
  5. What are the training and education implications for staff and patients?

D.3.3.3. Databases and Search Terms Used

DATABASES

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), THE NATIONAL RESEARCH REGISTER, THE WEB OF SCIENCE, THE INSTITUTE OF HEALTH TECHNOLOGY, HEALTH CD DATABASE, HEALTH MANAGEMENT INFORMATION CONSORTIUM DATABASE.

MESH TERMS

infection control; cross infection; universal precautions, equipment contamination; disease transmission; needlestick injuries; needles; syringes; occupational exposure; occupational accident; medical waste disposal; blood-borne pathogens.

THESAURUS AND FREE TEXT TERMS

antisepsis; disinfection; sterilisation; decontamination; blood-borne virus; exposure prone procedure; post exposure prophylaxis; sharp; puncture; percutaneous injury; epi pen; vacutainer; resheath.

D.3.3.4. Search Results

Total number of articles located = 7938

Sift 1 Criteria

Abstract indicates that the article: relates to infections associated with sharps, is written in English, is primary research or a systematic review or a meta-analysis, and appears to inform one or more of the review questions.

Articles Retrieved

Total number of articles retrieved from sift 1 = 84

Sift 2 Criteria

Full Text confirms that the article relates to infections associated with protective clothing is written in English, is primary research or a systematic review or a meta-analysis, and informs one or more of the review questions.

Articles Selected for Appraisal

Total number of articles selected for appraisal during sift 2 = 7

D.3.3.5. Critical Appraisal

All articles which described primary research, a systematic review or, a meta-analysis and met the sift 2 criteria were independently critically appraised by two appraisers. Consensus and grading was achieved through discussion.

Accepted and Rejected Evidence

Total number of articles accepted after critical appraisal = 4

Total number of articles rejected after critical appraisal = 0

D.3.3.6. 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.

D.3.4. Long-term Indwelling Urinary Catheters - Systematic Review Process

D.3.4.1. Databases and Search Terms Used

DATABASES

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), THE NATIONAL RESEARCH REGISTER, THE WEB OF SCIENCE, THE INSTITUTE OF HEALTH TECHNOLOGY, HEALTH CD DATABASE, HEALTH MANAGEMENT INFORMATION CONSORTIUM DATABASE.

MESH TERMS

infection control; cross infection; community-acquired infections; disease transmission; urinary tract infections; urinary catheterization; indwelling catheters; antibiotic prophylaxis; irrigation; biofilms; hydrogen ion concentration; urease; proteus; proteus infections; providencia; morganella.

THESAURUS AND FREE TEXT TERMS

intermittent catheterisation; uretheral catheterisation; suprapubic catheterisation; bacteriuria; pyuria; encrustation; blockage; non blocker; bladder irrigation; bladder washout; bladder instillation.

D.3.4.2. Search Results

Total number of articles located = 7387

D.3.5. Enteral Feeding - Systematic Review Process

D.3.5.1. Databases and Search Terms Used

DATABASES

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

MESH TERMS

infection control; cross infection; community-acquired infections; food contamination; equipment contamination; enteral nutrition, nutritional support, gastrostomy, gastroenterostomy, jejunostomy.

THESAURUS & FREE TEXT TERMS

PEG feed; tube feed; tube nutrition; gastric feed; gastric nutrition; enteral feed; enteric feed; naso enteric feed or nutrition; intra gastric feed or nutrition; post pyloric feed or nutrition; percutaneous feed or nutrition; transpyloric feed or nutrition; gastrojejunostomy; gastroduodenostomy; duodenostomy. Exclusions: letters

D.3.5.2. Search results

Total number of articles located = 19639

D.3.6. Central Venous Catheters - Systematic Review Process

D.3.6.1. Databases and Search Terms Used

DATABASES

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), THE NATIONAL RESEARCH REGISTER, THE WEB OF SCIENCE, THE INSTITUTE OF HEALTH TECHNOLOGY, HEALTH CD DATABASE, HEALTH MANAGEMENT INFORMATION CONSORTIUM DATABASE.

MESH TERMS

Infection control; cross infection; universal precautions; equipment contamination; disease transmission; bacteremia; chlorhexidine; povidone iodine; anticoagulants; sepsis; central venous catheterisation; indwelling catheters; parenteral nutrition.

THESAURUS AND FREE TEXT TERMS

PICC; TPN; catheter hub; catheter port; dressings; flushing solutions.

D.3.6.2. Search Results

Total number of articles located = 4,650

D.4. Key audit criteria (2003)

D.4.1. Standard principles

AimCriteria
To ensure all healthcare personnel have access to appropriate hand decontamination equipment and protective clothing wherever they deliver careAll healthcare personnel should have an appropriate supply of hand decontamination equipment, gloves, aprons and protective clothing in their care setting.

Standard 100%

Data collection: self audit
Ensure that all healthcare personnel are trained and competent in hand decontamination and risk assessment.All healthcare personnel involved in care are trained and updated.

Standard 100%

Data collection: review of staff education records
To ensure that all healthcare personnel respond appropriately to any sharps injuryAll healthcare personnel should be aware of their local sharps injury policy and how to access appropriate help should they sustain a sharps injury.

Standard 100%

Data collection: direct questioning
To ensure patients and carers are informed and educated about standard principles.All patients and carers are aware of the need to:
Decontaminate their hands;
Use protective clothing;
Dispose of sharps safely.

Standard 100%

Data collection: direct questioning of patients and carers.

D.4.2. Urinary catheterisation

AimCriteria
Identify all patients with LTC, their clinical need for catheterisation, assessed and documented.All patients should have a patient record that documents the reason for catheterisation, type of catheter, catheter insertion, changes and care.

Standard 100%

Data collection: review of patient notes
Ensure that all healthcare personnel are trained and competent in urinary catheterisation.Healthcare personnel receive training and updates in the management of urinary catheters.

Standard 100%

Data collection: review of staff education records
To prevent catheter-related urinary tract infections (CR-UTI) associated with LTCAll healthcare personnel decontaminate their hands and wear a new pair of non-sterile gloves before manipulating the system.

Standard 100%

Data collection: observation/ self audit
To reduce the incidence of CR-UTI by maintaining a closed system.All long-term catheters must be connected to a sterile closed drainage system or valve

Standard 100%

Data collection: observation
To reduce the incidence of CR-UTI caused by blocking.All newly catheterised patients should have a patient record that documents the integrity of the catheter at first change and adjustments made to their change schedule accordingly.

Standard 100%

Data collection: review of patient notes
To ensure patients and carers are informed and educated about catheter managementAll patients and carers are aware of the need to:
Decontaminate their hands;
Keep the system closed.

Standard 100%

Data collection: direct patient questioning of patients and carers.

D.4.3. Enteral feeding

AimCriteria
Identify all patients undergoing HETF are linked to a Nutrition Support Team or community specialist for ongoing support.All patients should have a patient record that documents their contact person for ongoing support.

Standard 100%

Data collection: Review of patient notes
Ensure that all healthcare personnel are trained and competent in administration of HETF.All healthcare personnel involved in the care of people receiving enteral feeding are trained and updated

Standard 100%

Data collection: Review of staff education records
To prevent infections associated with the administration of HETF.All healthcare personnel decontaminate their hands before starting feed preparation and manipulating the system.

Standard 100%

Data collection: Observation/ self audit, incidence of HETF related infection.
To prevent infections associated with the administration of HETF by maintaining a closed system.Ready–to-hang feeds are used wherever possible, and hung for no longer than the maximum recommended time.

Standard 100%

Data collection: Observation/ patient records, incidence of HETF related infection.
To prevent infections associated with the administration of HETF caused by blocking.All patients should have a patient record that documents the care of their enteral tube, including flushing regimen
Standard 100%

Data collection: Review of patient notes, incidence of HETF related infection.
To ensure patients and carers are informed and educated about HETF.All patients and carers are aware of the need to:
Decontaminate their hands;
Keep the system closed.
Standard 100%
Data collection: direct patient questioning of patients and carers.

D.4.4. Central venous catheters

AimCriteria
Identify all patients with central venous catheters.All patients should have a patient record that documents the reason for CVC placement, type of catheter, catheter insertion site, catheter replacements and care.

Standard 100%
Data collection: Review of patient notes
Ensure that all healthcare personnel are trained to implement these guidelines and assessed as competent.

Support healthcare personnel to consistently adhere to guideline recommendations.
All healthcare personnel involved in the care of people with CVCs receive training and updates in the management of CVCs.

Standard 100%

Data collection: Review of staff education records/direct observation/self-audit
Assess the need for continuing venous access on a regular basis and remove a CVC as soon as clinically possible in order to reduce the risk for infection.Evidence of regular and frequent assessment of the need for CVC and catheter discontinuation rates when the catheter is no longer essential for medical management.

Standard 100%

Data collection: Review of patient notes
Ensure that patients and carers are informed and educated about the management of their CVC.All patients and carers are aware of the need to:
Decontaminate their hands when manipulating the system;
Use aseptic technique when manipulating or accessing the system.

Standard 100%

Data collection: direct patient questioning of patients and carers.

D.5. AGREE Monitoring Appraisal Forms (2003)

D.5.1. Standard precautions

Table 1Guideline for Hand Hygiene in Health-Care Settings Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

Domain1total2total3total4total5total6total
Item1234567891011121314151617181920212223
Appraiser 133282121643343312143331333410415
Appraiser 2444123111644444212344441643310112
Appraiser 3443114121833344412244441643310325
Appraiser 4444123131822144111544411344412314
Total15151343124842813121116151048116151512581513144211516 (268)

Table 2Domain scores

DomainScore
Domain 1Maximum possible score = 4 × 3 × 4 = 48
Standardised domain score is: (43/48) × 100 = 90%
Domain 2Maximum possible score = 4 × 4 × 4 = 64
Standardised domain score is: (28/64) × 100 = 44%
Domain 3Maximum possible score = 4 × 7 × 4 = 112
Standardised domain score is: (81/112) × 100 = 72%
Domain 4Maximum possible score = 4 × 4 × 4 = 64
Standardised domain score is: (58/64) × 100 = 91%
Domain 5Maximum possible score = 4 × 3 × 4 = 48
Standardised domain score is: (42/48) × 100 = 88%
Domain 6Maximum possible score = 4 × 2 × 4 = 32
Standardised domain score is: (16/32) × 100 = 50%

Table 3The epic Project. National Evidence-based guidelines for preventing healthcare-associated infections. Jan 2001

Domain1total2total3total4total5total6total
Item1234567891011121314151617181920212223
Appraiser 1444124331114444443273442132327426 (76)
Appraiser 2444124331114444443273442132327426 (76)
Appraiser 34441244421444444442844421434310325(83)
Total88836866236888888682688440464248417

Table 4Domain scores

DomainScore
Domain 1Maximum possible score = 4 × 3 × 3 = 36
Standardised domain score is: (36/36) × 100 = 100%
Domain 2Maximum possible score = 4 × 4 × 3 = 48
Standardised domain score is: (36/48) × 100 = 75%
Domain 3Maximum possible score = 4 × 7 × 3 = 84
Standardised domain score is: (82/84) × 100 = 98%
Domain 4Maximum possible score = 4 × 4 × 3 = 48
Standardised domain score is: (40/48) × 100 = 83%
Domain 5Maximum possible score = 4 × 3 × 3 = 36
Standardised domain score is: (24/36) × 100 = 67%
Domain 6Maximum possible score = 4 × 2 × 3 = 24
Standardised domain score is: (17/24) × 100 = 71%

Table 5Health Canada - Hands

Domain1total2total3total4total5total6total
Item1234567891011121314151617181920212223
Appraiser 1442104141104413311174342133339415 (64)
Appraiser 24331011215131211110223292125112 (41)
Appraiser 3442104141101323421164343144239426 (65)
Appraiser 412254121811112118323191113314 (37)
Total1313935134124337115910545113101484510792612517 (207)

Table 6Domain scores

DomainScore
Domain 1Maximum possible score = 4 × 3 × 4 = 48
Standardised domain score is: (35/48) × 100 = 73%
Domain 2Maximum possible score = 4 × 4 × 4 = 64
Standardised domain score is: (33/64) × 100 = 52%
Domain 3Maximum possible score = 4 × 7 × 4 = 112
Standardised domain score is: (51/112) × 100 = 46%
Domain 4Maximum possible score = 4 × 4 × 4 = 64
Standardised domain score is: (45/64) × 100 = 70%
Domain 5Maximum possible score = 4 × 3 × 4 = 48
Standardised domain score is: (26/48) × 100 = 54%
Domain 6Maximum possible score = 4 × 2 × 4 = 32
Standardised domain score is: (17/32) × 100 = 53%

Table 7ICNA Protective Clothing

Domain1total2total3total4total5total6total
Item1234567891011121314151617181920212223
Appraiser 143411214181313211123341112114224 (50)
Appraiser 2343101141711111117313181113112 (37)
Appraiser 3322721418111311194143121113112 (41)
Appraiser 4334101141711121118313282136213 (43)
Total13131338641643046495443613614739646166511 (171)

Table 8Domain scores

DomainScore
Domain 1Maximum possible score = 4 × 3 × 4 = 48
Standardised domain score is: (38/48) × 100 = 79%
Domain 2Maximum possible score = 4 × 4 × 4 = 64
Standardised domain score is: (30/64) × 100 = 47%
Domain 3Maximum possible score = 4 × 7 × 4 = 112
Standardised domain score is: (36/112) × 100 = 32%
Domain 4Maximum possible score = 4 × 4 × 4 = 64
Standardised domain score is: (39/64) × 100 = 61%
Domain 5Maximum possible score = 4 × 3 × 4 = 48
Standardised domain score is: (16/48) × 100 = 33%
Domain 6Maximum possible score = 4 × 2 × 4 = 32
Standardised domain score is: (11/32) × 100 = 34%

Table 9ICNA Hand Contamination Guidelines

Domain1total2total3total4total5total6total
Item1234567891011121314151617181920212223
Appraiser 1123621216111211183442132114336 (43)
Appraiser 233391131611111117312171113112 (34)
Total456153252122223222156563203227448 (77)

Table 10Domain scores

DomainScore
Domain 1Maximum possible score = 4 × 3 × 2 = 24
Standardised domain score is: (15/24) × 100 = 63%
Domain 2Maximum possible score = 4 × 4 × 2 = 32
Standardised domain score is: (12/32) × 100 = 38%
Domain 3Maximum possible score = 4 × 7 × 2 = 56
Standardised domain score is: (15/56) × 100 = 27%
Domain 4Maximum possible score = 4 × 4 × 2 = 32
Standardised domain score is: (20/32) × 100 = 63%
Domain 5Maximum possible score = 4 × 3 × 2 = 24
Standardised domain score is: (7/24) × 100 = 29%
Domain 6Maximum possible score = 4 × 2 × 2 = 16
Standardised domain score is: (8/16) × 100 = 50%

D.5.2. Urinary catheterisation

Table 11PHLS Ward Urinary Catheters Guidelines

Domain1total2total3total4total5total6total
Item1234567891011121314151617181920212223
Appraiser 13238414110111111173341111113325 (44)
Appraiser 2212531116111111173341111135213 (37)
Appraiser 333393131811211118312171113314 (39)
Total8682210383243343333229710329335118412 (120)

Table 12Domain scores

DomainScore
Domain 1Maximum possible score = 4 × 3 × 3 = 36
Standardised domain score is: (22/36) × 100 = 61%
Domain 2Maximum possible score = 4 × 4 × 3 = 48
Standardised domain score is: (24/48) × 100 = 50%
Domain 3Maximum possible score = 4 × 7 × 3 = 84
Standardised domain score is: (22/84) × 100 = 26%
Domain 4Maximum possible score = 4 × 4 × 3 = 48
Standardised domain score is: (29/48) × 100 = 60%
Domain 5Maximum possible score = 4 × 3 × 3 = 36
Standardised domain score is: (11/36) × 100 = 31%
Domain 6Maximum possible score = 4 × 2 × 3 = 24
Standardised domain score is: (12/24) × 100 = 50%

Table 13The epic Project. National Evidence-based guidelines for preventing healthcare associated infections. Jan 2001

Domain1total2total3total4total5total6total
Item1234567891011121314151617181920212223
Appraiser 1444124331114444443273442132327426 (76)
Appraiser 2444124331114444443273442132327426 (76)
Appraiser 34441244421444444442844421434310325(83)
Total88836866236888888682688440464248417

Table 14Domain scores

DomainScore
Domain 1Maximum possible score = 4 × 3 × 3 = 36
Standardised domain score is: (36/36) × 100 = 100%
Domain 2Maximum possible score = 4 × 4 × 3 = 48
Standardised domain score is: (36/48) × 100 = 75%
Domain 3Maximum possible score = 4 × 7 × 3 = 84
Standardised domain score is: (82/84) × 100 = 98%
Domain 4Maximum possible score = 4 × 4 × 3 = 48
Standardised domain score is: (40/48) × 100 = 83%
Domain 5Maximum possible score = 4 × 3 × 3 = 36
Standardised domain score is: (24/36) × 100 = 67%
Domain 6Maximum possible score = 4 × 2 × 3 = 24
Standardised domain score is: (17/24) × 100 = 71%

D.5.3. Enteral feeding

Table 15Enteral and Parenteral Nutrition in the Community – British Association for Parenteral and Enteral Nutrition. Nov 1994

Domain1total2total3total4total5total6total
Item1234567891011121314151617181920212223
Appraiser 144412412181114111102242104116415 (50)
Appraiser 233410423110111211184232113216213 (48)
Total7782283521822262221864742173212628

Table 16Domain scores

DomainScore
Domain 1Maximum possible score = 4 × 3 × 2 = 24
Standardised domain score is: (22/24) × 100 = 92%
Domain 2Maximum possible score = 4 × 4 × 2 = 32
Standardised domain score is: (18/32) × 100 = 56%
Domain 3Maximum possible score = 4 × 7 × 2 = 56
Standardised domain score is: (18/56) × 100 = 32%
Domain 4Maximum possible score = 4 × 4 × 2 = 32
Standardised domain score is: (21/32) × 100 = 65%
Domain 5Maximum possible score = 4 × 3 × 2 = 24
Standardised domain score is: (12/24) × 100 = 50%
Domain 6Maximum possible score = 4 × 2 × 2 = 16
Standardised domain score is: (8/16) × 100 = 50%

Table 17Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. ASPEN 1993

Domain1total2total3total4total5total6total
Item1234567891011121314151617181920212223
Appraiser 133410313181111334144341121113213 (50)
Total33410313181111334144341121113213

Table 18Domain scores

DomainScore
Domain 1Maximum possible score = 4 × 3 × 1 = 12
Standardised domain score is: (10/12) × 100 = 83%
Domain 2Maximum possible score = 4 × 4 × 1 = 16
Standardised domain score is: (8/16) × 100 = 50%
Domain 3Maximum possible score = 4 × 7 × 1 = 28
Standardised domain score is: (14/28) × 100 = 50%
Domain 4Maximum possible score = 4 × 4 × 1 = 16
Standardised domain score is: (12/16) × 100 = 75%
Domain 5Maximum possible score = 4 × 3 × 1 = 12
Standardised domain score is: (3/12) × 100 = 25%
Domain 6Maximum possible score = 4 × 2 × 1 = 8
Standardised domain score is: (3/8) × 100 = 38%

Table 19American Gastroenterological Association – Guidelines for the use of enteral nutrition. Nov 1994)

Domain1total2total3total4total5total6total
Item1234567891011121314151617181920212223
Appraiser 112251121511122119133291113112 (33)
Appraiser 2312611114111211183332111113112 (34)
Total43411223292224322174664202226224

Table 20Domain scores

DomainScore
Domain 1Maximum possible score = 4 × 3 × 2 = 24
Standardised domain score is: (11/24) × 100 = 46%
Domain 2Maximum possible score = 4 × 4 × 2 = 32
Standardised domain score is: (9/32) × 100 = 28%
Domain 3Maximum possible score = 4 × 7 × 2 = 56
Standardised domain score is: (17/56) × 100 = 30%
Domain 4Maximum possible score = 4 × 4 × 2 = 32
Standardised domain score is: (20/32) × 100 = 63%
Domain 5Maximum possible score = 4 × 3 × 2 = 24
Standardised domain score is: (6/24) × 100 = 25%
Domain 6Maximum possible score = 4 × 2 × 2 = 16
Standardised domain score is: (4/16) × 100 = 25%

D.5.4. Central venous catheterisation

Table 21Centres for Disease Control & Prevention. Guidelines for the Prevention of Intravascular Catheter Related Infections. 2002

Domain1total2total3total4total5total6total
Item1234567891011121314151617181920212223
Appraiser 14441241431211234321644441633410145 (71)
Appraiser 2434114131911444111643441533410415 (66)
Appraiser 34441243421344444442844431544412448 (88)
Total12111235125116346610111288601211121146101012329918 (225)

Table 22Domain scores

DomainScore
Domain 1Maximum possible score = 4 × 3 × 3 = 36
Standardised domain score is: (35/36) × 100 = 97%
Domain 2Maximum possible score = 4 × 4 × 3 = 48
Standardised domain score is: (34/48) × 100 = 90%
Domain 3Maximum possible score = 4 × 7 × 3 = 84
Standardised domain score is: (60/84) × 100 = 71%
Domain 4Maximum possible score = 4 × 4 × 3 = 48
Standardised domain score is: (46/48) × 100 = 96%
Domain 5Maximum possible score = 4 × 3 × 3 = 36
Standardised domain score is: (32/36) × 100 = 89%
Domain 6Maximum possible score = 4 × 2 × 3 = 24
Standardised domain score is: (18/24) × 100 = 75%

D.7. Rejected studies (2003)

D.7.1. Hand hygiene (PDF, 394K)

D.7.2. Urinary catheter (PDF, 711K)

D.7.3. Enteral feeding (PDF, 473K)

D.7.4. Central venous catheters (PDF, 422K)

D.8. Summary of recommendations (2003)

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.

D.8.1. 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:

D.8.1.1. 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]

D.8.1.2. 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]

D.8.1.3. 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]

D.8.2. 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.

D.8.2.1. 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]

D.8.2.2. 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]

D.8.2.3. 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]

D.8.2.4. 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]

D.8.2.5. 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. *A+

D.8.3. 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.

D.8.3.1. 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]

D.8.3.2. 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]

D.8.3.3. 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]

D.8.3.4. 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]

D.8.4. 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.

D.8.4.1. 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]

D.8.4.2. 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]

D.8.4.3. 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+

D.8.4.4. 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]

D.9. Text removed from previous guideline (2003)

D.9.1. Scope and Purpose of the Guidelines

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.

D.9.2. 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)116 and reproduced below:

Categories of evidence

IaEvidence from 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 grading scheme suggested by Eccles and Mason (2001)116 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

D.9.2.1. 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).

D.9.3. Standard Precautions

The recommendations are divided into four distinct interventions:

  1. The use and disposal of sharps;
  2. Education of patients, their carers and healthcare personnel.

The systematic review process is detailed in appendix D.1.2.

Following our reviews, guidelines were drafted which described 26 recommendations within the below 4 intervention categories:

  1. Standard Principles for Hand Hygiene;
  2. Standard Principles for the Use of Personal Protective Clothing;
  3. Standard Principles for the Safe Use and Disposal of Sharps;
  4. Education of patients, carers and their healthcare personnel

D.9.3.1. Areas for Further Research

Given the poor data available on community healthcare personnel practice, qualitative and quantitative studies are required to map the current situation. This should include:

  • the availability of hand decontamination equipment;
  • gloves and protective equipment in community and primary care settings and;
  • their use by different healthcare personnel and compliance with current guidance.

D.9.4. Hand hygiene

D.9.4.1. When must you decontaminate your hands in relation to patient care?

Decontamination refers to the process for the physical removal of blood, body fluids, and transient microorganisms from the hands, i.e., handwashing, and/or the destruction of microorganisms, i.e., hand antisepsis44.

Guidance suggests that, in deciding when it is necessary to decontaminate hands, four key factors need to be considered380:

  • the level of the anticipated contact with patients or objects;
  • the extent of the contamination that may occur with that contact;
  • the patient care activities being performed;
  • the susceptibility of the patient.

Patients are put at potential risk of developing a healthcare-associated infection when informal carers or healthcare personnel caring for them have contaminated hands. Hands must be decontaminated before every episode of care that involves direct contact with patients’ skin, their food, invasive devices or dressings. Current expert opinion consistently recommends that hands need to be decontaminated after completing an episode of patient care and following the removal of gloves to minimise cross contamination of the environment44,203,242.

Recommendation

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.

D.9.4.2. Is any one hand cleaning preparation better than another?

Our previous systematic review 380 identified no compelling evidence to favour the general use of antimicrobial handwashing agents over soap, or one antimicrobial agent over another. The current review has identified no new evidence that alters this analysis.

Our systematic review identified seventeen acceptable studies that compared hand hygiene preparations including alcohol based hand rubs and gels, antimicrobial handwashes and liquid soap. Five of the studies were randomised controlled trials (RCT) conducted in clinical settings comparing the use of alcohol-based preparations with other agents154,250,274,507,528. Four RCTs demonstrated alcohol to be a more effective hand hygiene agent than non-medicated soap and antimicrobial handwash,154,250,274,507 while a fifth study found no statistical difference between the use of alcohol and antiseptic soap528. These studies underpin a growing trend to adopt the use of alcohol-based hand rinses and gels in clinical practice. Three clinically based, quasi-experimental studies189,190,249 and seven controlled laboratory experiments60,114,169,214,235,300,352 also demonstrated an association between reductions in microbiological flora and the use of alcohol-based preparations. One clinically-based quasi-experimental study compared the use of two antimicrobial handwash preparations in reducing MRSA128. One descriptive study of the use of an antiseptic hand cream by community nurses showed sustained residual effect in reducing microbiological flora162.

When deciding which hand decontamination preparation to use, the practitioner must consider the need to remove transient and/or resident hand flora*. Preparations with a residual effect contain antimicrobial agents and are not normally necessary for everyday clinical practice but may be used for some invasive procedures and in outbreak situations. What is important is that healthcare practitioners use an appropriate preparation to decontaminate their hands. National and international guidelines44,380 suggest that the acceptability of agents and techniques is an essential criterion for the selection of preparations for hand hygiene. Acceptability of preparations is dependent upon the ease with which the preparation can be used in terms of time and access together with their dermatological effects44,380.

Economic analysis of cost effectiveness is based on the assumption that the rate of infection in primary and community care is 4 percent, i.e., half that in hospital,377,380 and that alcohol gel reduces infection rate by 30%130 or 25%154 i.e. to 2.8% or 3.0% compared to not washing. For every 1000 patients, between 10 and 12 infections would be avoided. If each infection resulted in a nurse visit (estimated cost £25320) then between £250 and £300 would be saved in avoided costs. This is without the possibility of Accident and Emergency Department attendances and/or inpatient stays. Therefore, if the cost of an alcoholic handrub* is within 25 pence of the cost of conventional handwashing, it will be cost saving. If one were to include patient outcomes (i.e. of avoiding infection with the associated morbidity and mortality) and hospital attendance, the cost effectiveness of hand hygiene with alcohol rubs would increase.

The cost of a single hospital acquired infection is estimated to be over £3000 453. The author concludes that even a very low reduction in infections through the use of alcohol handrubs, would be cost saving. It is felt that although the above analysis is in a different setting, it represents a conservative analysis.

Choice of decontamination: is it always necessary to wash hands to achieve decontamination?

In the community and home setting, choosing a method of hand decontamination will be heavily influenced by the assessment of what is practically possible, the available resources in the care setting (particularly patients’ own homes), what is appropriate for the episode of care, and, to some degree, personal preferences based on the acceptability of preparations or materials.

  • In general, effective handwashing with a non-medicated liquid soap will remove transient microorganisms and render the hands socially clean. This level of decontamination is sufficient for general social contact and most clinical care activities380.
  • Using an antimicrobial liquid soap preparation will reduce transient microorganisms and resident flora, and result in hand antisepsis44,380.
  • Although alcohol does not remove dirt and organic material, the effective use of alcohol-based handrubs on contaminated hands will result in substantial reductions of transient microorganisms44, Alcohol handrubs offer a practical and highly acceptable alternative to handwashing when the hands are not grossly soiled and are recommended for routine use44,154,250,274,507,528.
Recommendations

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

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.

D.9.5. Personal protective equipment

D.9.5.1. Do gloves leak?

Gloves must be disposed of as clinical waste and hands decontaminated after the gloves have been removed.

D.9.5.2. Making choices

Expert opinion is quite clear about when gloves must be used by healthcare practitioners in general clinical practice2,76,414. Having decided that gloves should be used for a healthcare activity, the practitioner must make a choice between the use of:

  • sterile or non-sterile gloves, based on contact with susceptible sites or clinical devices;
  • surgical or examination gloves, based on the aspect of care or treatment to be undertaken.

NHS Trusts need to provide gloves that conform to European Community Standard (CE), and which are acceptable to healthcare practitioners76,381. Gloves are available in a variety of materials, the most common being natural rubber latex (NRL) and synthetic materials. NRL remains the material of choice due to its efficacy in protecting against bloodborne viruses and properties that enable the wearer to maintain dexterity76,381. A pilot study of dentists using nitrile gloves in place of NRL found that they compared favourably in terms of puncture resistance312. The problem of patient or healthcare practitioner sensitivity to NRL proteins must be considered when deciding on glove materials. As a consequence, expert opinion strongly advises that powdered gloves should not be used in healthcare2,76,381,414.

Synthetic materials are generally more expensive than NRL and due to certain properties may not be suitable for all purposes76. Nitrile gloves have the same chemical range as NRL and may also lead to sensitivity problems. Vinyl gloves made to European Community standards provide the same level of protection as NRL381. Polythene gloves are not suitable for clinical use due to their permeability and tendency to damage easily76,381.

The following table highlights the cost comparison of the various gloves materials. Healthcare personnel should be aware of the cost differential in gloves and should select the most appropriate for the activity.

ProductPack Size (largest where more than one pack size)Cost per packCost per individual glove
Lightly powdered protector latex examination gloves1000£19.97£0.02
Lightly powdered vinyl seamless examination gloves1000£19.95£0.02
Nitrile gloves1000£54.95£0.05
Powder free latex examination gloves (non-sterile)1000£24.97£0.02
Powder free sterile latex gloves100£13.99£0.14

Web address: http://www.medisave.co.uk/acatalog/

Recommendations

Gloves that are acceptable to healthcare personnel and that conform to European Community (CE) standards must be available.

Sensitivity to natural rubber latex in patients, carers and healthcare personnel must be documented, and alternatives to natural rubber latex gloves must be available.

Neither powdered gloves nor polythene gloves should be used in healthcare activities.

D.9.5.3. Aprons or gowns?

In our systematic review, three studies were identified that highlighted the potential for uniforms to become contaminated57,200,360. These studies considered the uniforms of nurses and healthcare assistants in hospital and dentists in an out patient department. All found evidence of contamination of clothing during the shift, though no link was made to any adverse clinical outcome. However, two studies commented on the need for a clean uniform to be worn for each shift and recommended that they should be supplied on the basis of the number of days worked per week rather than hours57,360.

Our previous systematic review identified a variety of studies, none of which supported the routine use of gowns in general or specialist clinical settings380. However, expert opinion suggests that protective clothing should be worn by all healthcare practitioners when contamination with blood, body fluids, secretions, or excretions (with the exception of sweat), or when close contact with the patient, materials or equipment may lead to contamination of the clothing with microorganisms76,381.

Plastic aprons are recommended for general use, 76,381 but unused aprons need to be stored carefully, i.e., away from potential contamination57,381. Full body gowns need only be used where there is the possibility of extensive splashing of blood, body fluids, secretions or excretions and should be fluid repellent76,381.

D.9.5.4. Recommendations

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. 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).

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.9.6. Sharps

D.9.6.1. Sharps injuries – what’s the problem?

National and international guidelines, are consistent in their recommendations for the safe use and disposal of sharp instruments and needles65,126,336. As with many infection prevention and control policies, the assessment and management of the risks associated with the use of sharps is paramount and safe systems of work and engineering controls must be in place to minimise any identified risks, e.g., positioning the sharps bin as close as possible to the site of the intended clinical procedure.178 Any healthcare worker experiencing an occupational exposure to blood or body fluids needs to be assessed for the potential risk of infection by a specialist practitioner, e.g., physician, occupational health nurse and offered before testing, immunisation and post-exposure prophylaxis if appropriate125.

D.9.6.2. Do needle safety devices reduce avoidable injuries?

Expert advice encourages healthcare providers and their employees to pursue safer methods of working through considering the benefits of new safety devices126. The incidence of injuries related to needle devices has led to the development of prevention devices in eleven different product groups179. They are designed to minimise the risk of operator injury during venepuncture, intravenous therapy and injections, and so-called “downstream” injuries occurring following the disposal of sharps and often involving housekeeping or portering staff responsible for the collection of sharps disposal units. People with insulin dependent diabetes frequently use needle clipping devices.

It would seem to be logical that where needle safety or other protective devices are used, there should be a resulting reduction in sharps injuries. Our systematic review identified four studies that involved the introduction of needle safety devices to reduce reported needlestick injuries.145,356,394,527 All of the studies were descriptive and involved the implementation of other interventions at the same time as the introduction of the needle safety devices. Only two of these studies produced statistically significant reductions in needlestick injuries.145,356

A comprehensive report and product review conducted in the US provides background information and guidance on the need for and use of needlestick prevention devices in four clinical applications:179

The report identifies that none of the devices evaluated is without limitations in relation to cost, applicability and effectiveness. Some of the devices available are more expensive, may not be compatible with existing equipment, and paradoxically, may be associated with an increase in bloodstream infection rates.66

National Guidelines and the National Health Service Purchasing and Supply Agency identify that meaningful evaluations are paramount in assessing user acceptability and clinical applicability of needle safety devices.324,381 The evaluation should ensure that the safety feature works effectively and reliably, that the device is acceptable to healthcare practitioners and that it does not adversely affect patient care.

Recommendations

Needle safety devices must be used where there are clear indications that they will provide safer systems of working for healthcare personnel.

D.9.7. Urinary catheterisation

D.9.7.1. Is one catheter better than another?

A systematic review identified three experimental studies that compared the use of coated latex with silicone catheters.381 No significant difference in the incidence of bacteriuria was found. Our systematic review identified one laboratory study which indicated that bacteria were less likely to adhere to hydrophilic coated catheters than silicone coated catheters.402 However, many practitioners have strong preferences for one type of catheter over another. This preference is often based on clinical experience, patient assessment and which materials induce the least allergic response.

D.9.7.2. Instillation and washouts do not prevent infection

Our systematic review suggests that more than 50% of patients with long-term catheters will experience catheter encrustation and blockage.146,405 A tendency to encrustation is multifactorial and includes patient factors, catheter materials and bacterial organisms. Several studies identified an association between high urinary pH (alkaline) and encrustation and blocking but there is no evidence that monitoring urinary pH can be used to predict blocking.55,56,72,147,238,239

Systematic review381 evidence and further evidence from one controlled trial220 failed to demonstrate any beneficial effect of bladder instillation or washout with a variety of antiseptic or antimicrobial agents in preventing catheter-associated infection. A laboratory study demonstrated that any effect was only temporary.450 Study investigators commented that these agents may prove detrimental to patients with dehydration or low urine output. A study using a model bladder identified that whilst saline had no effect on encrustation. Suby G and mandelic acid washouts both made it more difficult for P.Mirabilis to adhere to catheters.148

Evidence from best practice supports the above and indicates that the introduction of such agents may have local toxic effects and contribute to the development of resistant microorganisms.240

Recommendations

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.

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

D.9.7.3. Changing catheters

Our systematic review suggests that antibiotic prophylaxis to prevent bacteraemia* at primary catheter insertion for acute retention is of proven value.407 In the community setting however, a prospective survey of 120 catheter changes without chemoprophylaxsis found zero incidence of clinical complications, despite a 5.6 percent incidence of sub clinical bacteraemia detected by blood culture.50 This descriptive finding is matched by the result of an experimental study of residents in a geriatric care centre.132 Antibiotic prophylaxis was of no benefit in preventing or delaying bacteriuria following long-term catheter placement. A systematic review419 and expert opinion92,293 suggest antibiotic prophylaxis at catheter change should be reserved for those with a history of symptomatic UTI following catheter change, for patients catheterised between 3–14 days or to prevent endocarditis in patients with heart valve lesion, septal defect, patent ductus or prosthetic valve.

Recommendations

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.

D.9.7.4. Re-use of intermittent catheters

Many people use disposable single-use catheters for intermittent catheterisation. Reusable single patient use catheters need to be cleaned after use. Our systematic review identified two crossover studies of young people with neurogenic bladders which indicated that cleaning catheters with soap and water results in acceptably low rates of bacteriuria when compared with the use of sterile catheters304,306 However, manufacturer’s recommendations advise against using soap as soap residues may cause urethral irritation. Catheters should be stored in a clean and dry condition, which is least likely to promote the growth of contaminating microorganisms.

Recommendation

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

D.9.8. Enteral Feeding

D.9.8.1. Care of insertion site and enteral feeding tube

Keep the tube clear

To help minimise the potential risk of microbial colonisation of the internal and external surfaces of enteral feeding tubes, expert opinion suggests that the tube should be flushed with either cooled boiled water or freshly opened sterile water before and after each change of feed, aspiration or drug administration.16,137 However, expert advice from specialist members of the Guideline Development Group suggests that fresh tap water may be safely used for flushing enteral feeding tubes in immuncompetent patients.4,457

Recommendations

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

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.9.9. Central venous catheters

D.9.9.1. General Asepsis

Good standards of hand hygiene and antiseptic technique can reduce the risk of infection

Because the potential consequences of CRBSI are so serious, enhanced efforts are needed to reduce the risk of infection to the absolute minimum. For this reason, hand antisepsis and proper aseptic technique are required for changing catheter dressings and for accessing the system.44,334

Hand antisepsis can be achieved by washing hands with an antimicrobial liquid soap and water or by using an alcohol-based hand rub. When hands are visibly dirty or contaminated with organic material, such as blood and other body fluids or excretions, they must first be washed with soap and water if alcohol-based hand rubs are going to be used to achieve hand antisepsis. In community and primary care settings, alcohol-based hand rubs are the most consistently accessible and appropriate agent to use for hand antisepsis.

Appropriate aseptic technique does not necessarily require sterile gloves; a new pair of disposable nonsterile gloves can be used in conjunction with a ‘no-touch’ technique, for example, in changing catheter site dressings.334 The ‘Standard Principles for Preventing HAI’ previously described in these guidelines gives additional advice on hand decontamination and the use of gloves and other protective equipment.

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

D.9.9.2. Use the right dressing regimen to protect the catheter site

Following CVC placement, one of two types of dressings is used to protect the catheter site; sterile gauze and tape or sterile transparent semipermeable polyurethane dressings.

HICPAC reviewed the evidence up to the end of 1999 related to which type of dressing provided the greatest protection against infection and found little difference.334 They concluded that the choice of dressing can be a matter of preference. If blood is oozing from the catheter insertion site, a gauze dressing might be preferred. Our systematic review did not identify any additional evidence which conflicted with HICPAC’s conclusions.

Gauze dressings are not waterproof and require frequent changing in order to inspect the catheter site. They are rarely useful in patients with long-term CVC. Sterile transparent, semipermeable polyurethane dressings have become a popular means of dressing catheter insertion sites. These reliably anchor the CVC, permit continuous visual inspection of the catheter site, allow patients to bathe and shower without saturating the dressing, and require less frequent changes than do standard gauze and tape dressings, saving healthcare personnel time.

Recommendations

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

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.

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.

Transparent dressings should be changed every 7 days, or when they are no longer intact or moisture collects under the dressing.

D.9.9.3. Use an appropriate antiseptic agent for disinfecting the catheter insertion site during dressing changes

HICPAC described compelling evidence that aqueous chlorhexidine 2 percent was superior to either 10% povidone iodine or 70% alcohol in lowering CRBSI rates when used for skin antisepsis prior to CVC insertion. They made no recommendation for the use of any disinfectant agent for cleaning the insertion site during dressing changes.334

A recent meta-analysis assessed studies that compared the risk for CRBSI following insertion-site skin care with either any type of chlorhexidine gluconate (CHG) solution vs. povodine iodine (PI) solution.67 This analysis indicated that the use of CHG rather than PI can reduce the risk for CRBSI by approximately 49% (risk ratio, 0.51 [CI, 0.27 to 0.97]) in hospitalised patients who require short-term catheterisation, i.e., for every 1000 catheter sites disinfected with CHG rather than PI, 71 episodes of catheter colonization and 11 episodes of CRBSI would be prevented. In this analysis, several types of CHG solutions were used in the individual trials, including 0.5 percent or 1 percent CHG alcohol solution and 0.5 percent or 2 percent CHG aqueous solution. All of these solutions provided a concentration of CHG that is higher than the minimal inhibitory concentration (MIC) for most nosocomial bacteria and yeasts. Subset analysis of aqueous and non-aqueous solutions showed similar effect sizes, but only the subset analysis of the five studies that used alcoholic CHG solution produced a statistically significant reduction in CRBSI. Because few studies used CHG aqueous solution, the lack of a significant difference seen for this solution compared with PI solution may be a result of inadequate statistical power.

Alcohol and other organic solvents and oil-based ointments and creams may damage some types of polyurethane and silicon CVC tubing. The manufacturer’s recommendations for only using disinfectants that are compatible with specific catheter materials must be followed.

Recommendations

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.

D.9.9.4. Aseptic technique is important when accessing the system

Following their review of the evidence, HICPAC stressed the importance of minimising the risk of introducing infection by using an appropriate antiseptic to decontaminate the access port before accessing the system with sterile devices. As most modern catheter hubs, luer connectors and other access ports are made from alcohol-resistant materials, the use of alcohol wipes, chlorhexidine gluconate or an iodophor for this purpose are recommended by HICPAC. However, they stress the importance of ensuring that any antiseptic agent used is chemically compatible with catheter hubs, ports and connectors.334

Recommendation

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

D.10. Deleted and amended recommendations (2003)

D.10.1. Deleted recommendations from from NICE clinical guideline 2

Recommendation in 2003 guidelineComment
Hands that are visibly soiled, or potentially grossly contaminated with dirt or organic material, must be washed with liquid soap and water
(Recommendation 1.1.2.2 in 2003 guideline)
Replaced by:
1.1.2.2 Decontaminate hands preferably with a handrub (conforming to current British standardsa), except in the following circumstances, when liquid soap and water must be used:
Hands must be decontaminated, preferably with an alcohol-based handrub unless hands are visibly soiled, between caring for different patients and between different care activities for the same patient
(Recommendation 1.1.2.3 in 2003 guideline)
Replaced by:
1.1.2.2 Decontaminate hands preferably with a handrub (conforming to current British standardsa), except in the following circumstances, when liquid soap and water must be used:
Reusable intermittent catheters should be cleaned with water and stored dry in accordance with the manufacturer’s instructions.
(Recommendation 1.2.5.14 in 2003 guideline)
Removed to avoid confusion as single-use intermittent urinary catheters have been recommended:
1.2.3.3 Offer a choice of either single-use hydrophilic or gel reservoir catheters for intermittent urinary self catheterisation.
Hands that are visibly soiled or contaminated with dirt or organic material must be washed with soap and water before using an alcohol handrub
(Recommendation 1.4.2.3 in 2003 guideline)
Replaced by:
1.1.2.2 Decontaminate hands preferably with a handrub (conforming to current British standardsa), except in the following circumstances, when liquid soap and water must be used:
  • when hands are visibly soiled or potentially contaminated with body fluids or
  • in clinical situations where there is potential for the spread of alcohol-resistant organisms (such as Clostridium difficile, or organisms that cause diarrhoeal illness).
The GDG did not consider it necessary to repeat this hand decontamination recommendation in the vascular access device chapter.
Following hand antisepsis, clean gloves and a no-touch technique or sterile gloves should be used when changing the insertion site dressing
(Recommendation 1.4.2.4 in 2003 guideline)
Replaced by:
1.4.2.1 Hands must be decontaminated (see section 1.1.2) before accessing or dressing a vascular access device.
1.4.2.2 An aseptic technique, such as Aseptic Non Touch Technique (ANTT), must be used for vascular access device catheter site care and when accessing the system.
a

At the time of publication of the guideline (March 2012): BS EN 1500: 1997

D.10.2. Amended recommendations (change to meaning)

Recommendations have been labelled [2003, amended 2012] if the evidence has not been reviewed but changes have been made that change the meaning of the recommendation.

Recommendation in 2003 guidelineRecommendation in current guidelineComment
1.1.4.1 Sharps must not be passed directly from hand to hand, and handling should be kept to a minimum.1.1.4.1 Sharps should not be passed directly from hand to hand, and handling should be kept to a minimum.The updated recommendation contains ‘should’ rather than ‘must’ because the GDG considered that the use of ‘must’ in the 2003 version is not covered by legislation (in accordance with the NICE guidelines manual, 2009).
1.2.5.4 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 1.1).1.2.5.4 Patients managing their own catheters, and their carers, must be educated about the need for hand decontamination before and after manipulation of the catheter, in accordance with the recommendations in the standard principles section (section 1.1.).This recommendation has been amended to reflect input from the NICE Patient and Public Involvement Programme: recommendations cannot be made directly about what patients and carers must do.
1.4.1.1 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.
1.4.1.2 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.
1.4.1.3 Follow-up training and support should be available to patients with central venous catheters and their carers.
1.4.1.1 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 vascular access device.
1.4.1.2 Healthcare workers caring for a patient with a vascular access device should be trained, and assessed as competent, in using and consistently adhering to the infection prevention practices described in this guideline.
1.4.1.3 Follow-up training and support should be available to patients with a vascular access device and their carers.
The updated recommendations contain ‘vascular access device’ rather than ‘central venous catheter’. This change has been made because peripherally inserted catheters were included in the scope of the guideline update.

D.10.3. Amended recommendations (no change to meaning)

Recommendation in current guidelineComment
1.1.3.1 Selection of protective equipment musta be based on an assessment of the risk of transmission of microorganisms to the patient, and the risk of contamination of the healthcare worker’s clothing and skin by patients’ blood, body fluids, secretions or excretions.
1.2.1.2 Community and primary healthcare workers must be trained in catheter insertion, including suprapubic catheter replacement and catheter maintenance.
1.2.4.1 All catheterisations carried out by healthcare workers should be aseptic procedures. After training, healthcare workers should be assessed for their competence to carry out these types of procedures.
1.2.5.2 Healthcare workers 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 the manufacturer’s recommendations).
1.2.5.3 Healthcare workers 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.
1.3.1.2 Healthcare workers should be trained in enteral feeding and management of the administration system.
1.4.1.2 Healthcare workers caring for a patient with a vascular access device should be trained, and assessed as competent, in using and consistently adhering to the infection prevention practices described in this guideline.
1.4.3.7 Healthcare workers 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.
1.4.4.10 When needleless devices are used, healthcare workers should ensure that all components of the system are compatible and secured, to minimise leaks and breaks in the system.
All instances of ‘healthcare personnel’ have been changed to ‘healthcare worker’. This is for consistency with other NICE clinical guidelines and is considered a more modern term. The GDG considered the term ‘healthcare workers’ to include a wider group of people than healthcare professionals, which they considered to be only those staff with professional qualifications.
In recommendation 1.3.1.2, ‘community staff’ has been changed to ‘healthcare workers’, for consistency with this terminology.
In recommendation 1.4.1.2, ‘community healthcare personnel’ has been changed to ‘healthcare workers’, for consistency with this terminology.
Copyright © 2012, National Clinical Guideline Centre.

Apart from any fair dealing for the purposes of research or private study, criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, no part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

The rights of National Clinical Guideline Centre to be identified as Author of this work have been asserted by them in accordance with the Copyright, Designs and Patents Act, 1988.

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.
NICE Clinical Guidelines, No. 139.
National Clinical Guideline Centre (UK).

NICE (National Institute for Health and Care Excellence)

PubMed Health Blog...

read all...

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...