Epic2: Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals

1. epic2:National evidence-based guidelinesfor preventing healthcare-associated infections in NHS hospitals in England Funded and endorsed by the Department of Health

2. Main menu Background information Standard principles for preventing healthcare associated infections in hospital and other acute care settings Guidelines for preventing infections associated with the use of short-term indwelling urethral catheters Guidelines for preventing infections associated with the use of central venous access devices (CVAD) Class A recommendations Next Back

3. Background information • Introduction • Guideline development team • Guideline advisory group • Guideline development methodology • Consultation process • Definitions Next Back Main Menu

4. Introduction to the epic 2 guidelines • Health care associated infections (HCAI) have become a significant threat to patient safety • While not all HCAI is avoidable, a significant proportion can be prevented by better application of existing knowledge and adherence to best practice • The epic2 guidelines: – describe HCAI prevention measures that are based on reliable evidence of efficacy – funded and endorsed by the Department of Health – developed by a nurse-led, multi-professional team of researchers and specialist clinicians – supercede the first epic guidelines published in January 2001 • There are over 100 recommendations in epic2; all are endorsed equally and none is regarded as optional Next Back Section Menu Main Menu

5. Guideline development team • Richard Wells Research Centre, Thames Valley University: • – Professor Robert J Pratt (Project Director) – Professor of Nursing and Director • – Dr Carol M Pellowe (Project Manger) – Deputy Director • – Heather P Loveday, Principal Lecturer (Research) • – Dr Peter J Harper, Senior Lecturer (Research) • – Simon RLJ Jones, Lecturer (Research) • – Jennie A Wilson, Research Fellow* • Health Protection Agency: • – Christine McDougall, Surveillance Manager • University of Leeds: • – Professor Mark H Wilcox, Professor of Medical Microbiology • *and HPA Next Back Section Menu Main Menu

6. Guideline advisory group • University College Hospitals NHS Foundation Trust: • – Daphne Colpman - Continence Advisor • – Liz Simcock – Clinical Nurse Specialist for Central venous Access, Cancer Services • Rotherham District General Hospital: • – Andrew Jackson – Nurse consultant (intravenous therapy) • Royal Liverpool and University of Liverpool: • – Dr. Godfrey W Smith, Consultant, Department of Medical Microbiology. • Royal College of Nursing Intravenous Therapy Forum Next Back Section Menu Main Menu

7. Guideline development methodology • The guidelines were developed using a systematic review process • An initial search was made for national and international guidelines and research studies published during the period 01 January 1999 to 31 August 2005 • All articles describing primary research, a systematic review or, a meta-analysis were critically appraised by two experienced appraisers • Evidence tables were constructed from the quality assessments and the studies summarised in the evidence reports • Following extensive discussion, the guidelines were drafted • The classification scheme adapted by NICE from SIGN was used to define the strength of recommendation Next Back Section Menu Main Menu

8. Consultation process • These guidelines were subject to extensive external consultation with key stakeholders: • AgenciesBNF, DoH, GMC, HPA, HSE, MHRA, NMC, SIGN, Welsh Assembly • AssociationsMedical Microbiologists, Healthcare Industries, Critical Care Nurses, Infection Control Nurses, Urological Nurses, Urological Surgeons, Health Care Trades, BMA • Employee organisationsUnison (public services trade union), Safer Needles Network • Patient groupsCarers UK, Patient Concern • Royal CollegesAnaesthetists, Midwives, Nursing, Pathologists, Physicians, Surgeons • SocietiesAntimicrobial Chemotherapy, Hospital Infection, Intensive Care, Royal Pharmaceutical Society, Royal Society of Medicine • Comments were also received from NHS Trusts, clinicians and practitioners throughout the country Next Back Section Menu Main Menu

9. Definitions Next Back Section Menu Main Menu

10. Definitions Next Back Section Menu Main Menu

11. Definitions Next Back Section Menu Main Menu

12. Definitions Next Back Section Menu Main Menu

13. Standard principles for preventing healthcare-associated infections in hospital and other acute care settings • Hospital environmental hygiene • Hand hygiene • The use of personal protective equipment • The safe use and disposal of sharps Next Back Main Menu

14. Hospital environmental hygiene • The hospital environment can become contaminated with microorganisms responsible for HCAI • Transmission of microorganisms from the environment to patients may occur through direct contact with contaminated equipment, or indirectly as a result of touching by hands • Cleaning will not completely eliminate microorganisms from environmental surfaces and reductions in their numbers will be transient • Staff education may be lacking on optimal cleaning practices in the clinical areas Next Back Section Menu Main Menu

15. Hospital environmental hygiene Next Back Section Menu Main Menu

16. Hospital environmental hygiene Next Back Section Menu Main Menu

17. Hand hygiene • Hand-mediated cross-transmission is a major contributing factor in the current infection threat to hospital in-patients • Serious life threatening infections can arise when organisms are cross transmitted onto susceptible sites, such as:– surgical wounds– endo-tracheal tubes during pulmonary ventilation– intravascular cannulation sites– enteral feeding systems– urinary catheter drainage systems • Cross-transmission to non-vulnerable sites can still leave a patient colonised with more pathogenic and resistant hospital organisms • Effective hand decontamination results in significant reductions in the carriage of potential pathogens Next Back Section Menu Main Menu

18. Hand hygiene Next Back Section Menu Main Menu

19. Hand hygiene Next Back Section Menu Main Menu

20. Hand hygiene Next Back Section Menu Main Menu

21. Hand hygiene Next Back Section Menu Main Menu

22. The use of personal protection equipment (PPE) • The primary uses of PPE are to protect staff and reduce opportunities for transmission of microorganisms in hospitals • The decision to use or wear PPE must be based upon an assessment of the level of risk associated with a specific patient care activity or intervention and take account of current health and safety legislation • A lack of knowledge and non-adherence to guideline recommendations is widespread and on going in-service education and training is required Next Back Section Menu Main Menu

23. The use of personal protection equipment Next Back Section Menu Main Menu

24. The use of personal protection equipment Next Back Section Menu Main Menu

25. The use of personal protection equipment Next Back Section Menu Main Menu

26. The use of personal protection equipment Next Back Section Menu Main Menu

27. The safe use and disposal of sharps • In 2003 the National Audit Office found that needlestick injuries ranked alongside moving and handling, falls, trips and exposure to hazardous substances as the main types of accidents experienced by NHS staff • Nurses are the group with the highest proportion of sharps injuries, accounting for 41.2% of all reported injuries in a 2002 survey • The number of reported occupational exposures to blood borne virus infections increased by 49% in three years from 206 in 2002 to 306 in 2005 • The average risk of transmission of blood borne viruses following a single percutaneous exposure in the absence of appropriate post exposure prophylaxis has been estimated to be: • Hepatitis B virus 1 in 3 • Hepatitis C virus 1 in 50 • Human immunodeficiency virus 1 in 300 Next Back Section Menu Main Menu

28. The safe use and disposal of sharps Next Back Section Menu Main Menu

29. The safe use and disposal of sharps Next Back Section Menu Main Menu

30. Guidelines for preventing infections associated with the use of short-term indwelling urethral catheters • Assessing the need for catheterisation • Selection of catheter type and system • Catheter insertion • Catheter maintenance • Education of patients, relatives and healthcare workers Next Back Main Menu

31. Assessing the need for catheterisation • Catheterising patients places them in significant danger acquiring a urinary tract infection • The per day risk of the development of bacteriuria appears comparable throughout catheterisation (3-6%) but the cumulative risk increases with duration of catheterisation • Around 50% of hospitalised patients catheterised longer than 7-10 days contact bacteriuria • 20-30% of these patients will develop symptoms of catheter-associated urinary tract infection • Many of these infections are serious and lead to significant morbidity and mortality Next Back Section Menu Main Menu

32. Assessing the need for catheterisation Next Back Section Menu Main Menu

33. Selection of catheter type • Several reviews suggest antiseptic impregnated or antimicrobial-coated urinary catheters can significantly prevent or delay the onset of catheter-associated urinary tract infection (CAUTI) when compared to standard untreated urine catheters. • The consensus, however, is that the individual studies reviewed are generally of poor quality • Evidence from best practice indicates that the incidence of CAUTI in patients catheterised for a short time (up to one week) is not influenced by any particular type of catheter material Next Back Section Menu Main Menu

34. Selection of catheter type Next Back Section Menu Main Menu

35. Catheter insertion • Principles of good practice, clinical guidance and expert opinion agree that urinary catheters must be inserted using sterile equipment and an aseptic technique • Ensuring healthcare practitioners are competent in the insertion of urinary catheters will minimise trauma, discomfort and the potential for CAUTI Next Back Section Menu Main Menu

36. Catheter insertion Next Back Section Menu Main Menu

37. Catheter maintenance • Maintaining a sterile, continuously closed urinary drainage system is central to the prevention of CAUTI • The risk of infection reduces from 97% with an open system to 8-15% when a sterile closed system is employed • Breaches in the closed system, such as unnecessary emptying of the urinary drainage bag or taking a urine sample, will increase the risk of catheter-related infection Next Back Section Menu Main Menu

38. Catheter maintenance Next Back Section Menu Main Menu

39. Catheter maintenance Next Back Section Menu Main Menu

40. Education of patients, relatives and healthcare workers • Patients, their relatives and healthcare workers responsible for catheter insertion and management should be educated about infection prevention • All those involved must be aware of the signs and symptoms of urinary tract infection and how to access expert help when difficulties arise Next Back Section Menu Main Menu

41. Education of patients, relatives and healthcare workers Next Back Section Menu Main Menu

42. Guidelines for preventing infections associated with the use of central venous access devices (CVAD) • Bloodstream infections associated with the insertion and maintenance of CVAD are among the most dangerous of complications • Approximately 3 in every 1000 patients admitted to hospital in the UK acquires a bloodstream infection, and nearly one third of these infections are related to CVAD • CR-BSI is generally caused either by skin microorganisms at the insertion site or microorganisms from the hands of healthcare workers that contaminate and colonise the catheter hub Next Back Section Menu Main Menu

43. Guidelines for preventing infections associated with the use of central venous access devices (CVAD) • Education of healthcare workers and patients • General asepsis • Selection of catheter type • Selection of catheter insertion site • Maximal sterile barrier precautions during catheter insertion • Cutaneous antisepsis • Catheter and catheter site care • Catheter replacement strategies; and • General principles for catheter management Next Back Main Menu

44. Education of healthcare workers and patients • It is essential that everyone involved in caring for patients with CVAD is educated about infection prevention • Educational programmes that enable healthcare workers to provide, monitor and evaluate care and to continually increase their competence are critical to the success of any infection prevention strategy • The risk of infection declines following the standardisation of aseptic care and increases when the maintenance of intravascular catheters is undertaken by inexperienced healthcare workers Next Back Section Menu Main Menu

45. Education of healthcare workers and patients Next Back Section Menu Main Menu

46. General asepsis • Good standards of hand hygiene and antiseptic technique can reduce the risk of infection • Because the potential consequences of catheter-related infections are so serious, enhanced efforts are needed to reduce the risk of infection to the absolute minimum Next Back Section Menu Main Menu

47. General asepsis Next Back Section Menu Main Menu

48. Selection of catheter type • Different types of CVAD are available: • – made of different materials • – have one or more lumens • – coated or impregnated with antimicrobial or antiseptic agents or heparin-bonded • – cuffed and designed to be tunnelled • – having totally implantable ports • Selection of the most appropriate CVAD for each individual patients can reduce the risk of subsequent catheter-related infection Next Back Section Menu Main Menu

49. Selection of catheter type Next Back Section Menu Main Menu

50. Selection of catheter insertion site • Selecting the best insertion site for the patient can minimise the risk of infection • Several factors need to be assessed when determining the site of CVAD placement, including: • – patient specific factors (e.g. pre-existing CVAD, anatomic deformity, bleeding diathesis, some types of positive pressure ventilation) • – relative risk of mechanical complications (e.g. bleeding, pneumothorax, thrombosis) • – the risk of infection Next Back Section Menu Main Menu