National evidence-based guidelines for preventing hospital-acquired infections were commissioned recently by the Department of Health (Pratt et al, 2001). These guidelines impact on the activities of all health care practitioners working in hospitals.
VOL: 97, ISSUE: 13, PAGE NO: 34
Peter Harper, BSc, DipN, RN, RNT, CertEd, is senior lecturer (research)
Carol Pellowe, MA Ed, BA, RN, RNT, is deputy director and principal lecturer at the Richard Wells Research Centre, Thames Valley University, LondonHeather Loveday, MA, RN, RNT, is principal lecturer;Nicola Robinson, PhD, BSc, is reader; andRobert Pratt, MSc, BA, RN, RNT, DN, is professor of nursing; all at the Richard Wells Research Centre, Thames Valley University, London
This article, which outlines the origins, development and focus of the guidelines, is the first in a series of four. The second, with the poster in this week’s issue, focuses on standard principles. The third and fourth articles will introduce the guidelines directed at preventing infections in relation to two specific areas of practice: the use of short-term indwelling urethral catheters and central venous catheters (CVCs). It is important that these specific guidelines are used in conjunction with standard principles.
Why do we need national guidelines for preventing HAIs?
At any one time, 9% of inpatients will have an infection acquired during their stay in hospital (Meers et al, 1981; Emmerson et al, 1996). A study conducted between August 1994 and September 1995 on the control of HAIs in 19 hospitals in England and Wales suggested that there might be at least 100,000 infections each year (Glynn et al, 1997). The financial cost of HAIs to one trust has been estimated at £3.6m a year (Plowman et al, 2000). It is clear that preventing these infections would result in significant social and economic benefits. The Department of Health has estimated that 30% of HAIs are preventable (Hospital Infection Working Group of the DoH and Public Health Laboratory Service, 1995).
Who developed the guidelines?
The Richard Wells Research Centre at the Wolfson Institute of Health Sciences, Thames Valley University, was commissioned to develop the guidelines in 1998. A nurse-led multidisciplinary team of researchers, senior infection-control nurses and doctors was set up to carry out the work in consultation with many different professional organisations, learned societies and royal colleges. This activity was designated the epic project (evidence-based practice in infection control).
At all stages of their development, the guidelines were subject to extensive consultation. A multidisciplinary project advisory group served as the primary internal mechanism and was formally consulted throughout. External consultation included the use of focus groups, questionnaires sent to a representative group of specialist practitioners and draft documents posted on the epic website for comment. The final stage of consultation involved the presentation of final drafts for comment by relevant institutions and organisations.
What is the evidence for these guidelines?
The evidence for these guidelines is primarily of two types:
- Evidence derived from systematic review of infection-control literature;
- Evidence derived from published professional, national and international guidelines.
- Evidence derived from systematic review of infection-control literature
Systematic review of research literature is now generally accepted as the method of choice for developing a knowledge base that can be used to inform the way in which specific health care interventions should be undertaken. Systematic review has two broad components: the way in which the literature is identified and the way in which the quality of the literature is established.
The epic project team used accepted, published and standardised methodological strategies to search the main health care databases. Retrieved articles were reviewed against specific inclusion/exclusion criteria and those included were then appraised to judge both their clinical usefulness and their methodological quality. A precise account of the review process, and all other processes, can be found in the project technical reports. These are available on the epic project website.
Evidence derived from published professional, national and international guidelines
For standard precautions and indwelling urethral catheters, where evidence from the systematic review was either not available or not of sufficient quality or quantity, additional evidence was sought from other professional, national and international guidelines. What was important in this process was to establish that the guidelines used had, in turn, been developed in a systematic and objective way. The development processes of retrieved guidelines were appraised using a validated appraisal instrument (Cluzeau et al, 1997).
Expert review of guidelines
Recommendations for preventing infections associated with the use of CVCs are based on an ‘expert review’ of evidence-linked guidelines for preventing intravascular device-related infections, developed in the mid-1990s at the Centers for Disease Control and Prevention (CDC) by the Hospital (now Healthcare) Infection Control Practices Advisory Committee (HICPAC) (Pearson, 1996). A two-stage appraisal process was used to formally review these guidelines:
Structured appraisal of the methods used to develop these guidelines
In the first stage, three dimensions of guideline development were assessed (Box 2). An appraisal process and associated instrument, developed in England (Cluzeau et al, 1997) and based on guideline appraisal recommendations published by the CDC, was used for the review (Centers for Disease Control and Prevention, 1996).
Updating the evidence base
During the second stage of the expert review, we examined the detailed content and evidence base of those recommendations in the HICPAC guidelines that were specifically relevant to preventing HAIs associated with the insertion and maintenance of CVCs. To update the evidence base, we also systematically searched, retrieved and appraised additional supporting evidence produced since the HICPAC guidelines were developed in 1994-1995. This search was confined to elements of infection prevention where expert advisers indicated new developments or changes in technology had occurred, or where pertinent new experimental trials or systematic reviews had been published.
How is the evidence graded?
The process of grading the evidence from systematic review represents perhaps one of the more challenging aspects of development. Having appraised each individual piece of evidence, a collective grade was established. All the individual pieces of evidence, when combined, form the evidence base for a particular intervention.
In the guidelines, the type of supporting evidence is explicitly linked to each recommendation. There is a natural tendency to view this grading system as hierarchical, which is not the intention. This tendency is probably due to the traditional perception that the ‘best’ type of evidence is that which is derived from experimental research and, in many grading systems, ‘Category 1’ evidence is synonymous with ‘randomised control trials’. Many aspects of infection prevention, however, involve so many variables that they are extremely difficult to control with any certainty. Consequently, we have to rely on different types of evidence. The evidence category used in these guidelines indicates the best evidence available for each of the recommendations, not the best evidence possible. In line with other UK guidelines, the evidence grade alerts the practitioner to the type of evidence that underpins each recommendation but does not imply that one recommendation is more or less important than others. When reading the guidelines, note that the recommendations are endorsed equally and none is regarded as optional. The evidence for these guidelines will be updated in 2002.
How can these guidelines be used to improve your clinical effectiveness?
The guidelines do not include procedural details. These are for practitioners to define locally in the context of their own clinical environment. The guidelines are intended to inform the development of detailed local operational protocols, but can also be used as a benchmark to determine appropriate infection-prevention decisions and, as part of reflective practice, to assess clinical effectiveness. They also provide a baseline for clinical audit, evaluation and education, and facilitate ongoing quality improvements.
The concluding section of the guidelines focuses on important issues for clinical governance and includes a discussion of:
- Issues associated with implementation, audit and education;
- Quality standards;
- Avenues for further research.
The guidelines do not address the fundamental issue of implementation in any detail, but that does not mean that the project team does not recognise its importance. It could be argued that the most important factor in preventing HAIs is not the recommendations themselves but the degree to which practitioners internalise them and, in so doing, change their practice. For example, no matter how ‘evidence-based’ or ‘well-presented’ the guidelines on hand-washing are, they cannot make practitioners wash their hands. The only way that such an outcome can be achieved is through a change in behaviour. How this change in behaviour is achieved is the challenge that faces all health care practitioners.
The guidelines are available on the DoH website at: www.doh.gov.uk/hai/epic.htm
The technical reports that detail the development process can be found on the epic project website at: www.epic.tvu.ac.uk
The Richard Wells Research Centre website is at: www.richardwellsresearch.com