New NICE guidelines extend infection control measures to primary and community care settings

Following a crackdown on HCAIs in hospitals over recent years, the new report, commissioned by the Department of Health, aims to improve standards in a wide range of community and primary care facilities.

Updated from earlier guidance published in 2003, the document makes a number of suggestions for widespread improvements, covering issues including hand hygiene, personal protective equipment, the safe disposal of sharps and the use of urinary catheters and vascular access devices.

The recommendations have been put forward by a team of professionals including Dr Carole Pellowe, a senior lecturer in infection control at the Florence Nightingale School of Nursing and Midwifery at King's College, London; Dr Godfrey Smith, a consultant medical microbiologist and infection prevention doctor at Royal Liverpool and Broadgreen University Hospitals NHS Trust; Dr Julian Spinks, a GP from Kent; and Dr Eugenia Lee, a London GP and associate in public health at Greenwich Teaching Primary Care Trust.

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

"Since the publication of the NICE clinical guideline on the prevention of healthcare-associated infections in primary and community care in 2003, many changes have occurred within the NHS which place the patient firmly at the centre of all activities. First the NHS Constitution for England defines the rights and pledges regarding the care every patient can expect. To support this the Care Quality Commission, the independent regulator of all health and adult social care in England, ensures that health and social care is safe and monitors how providers comply with established standards.

"New guidance is needed to reflect the fact that increasingly, as a result of the rapid turnover of patients in acute care settings, complex care is now being delivered in the community. New standards are required in relation to the care of patients and management of devices to prevent related HCAIs, which will also reinforce the principles of asepsis."

New guidance is needed to reflect the fact that increasingly, as a result of the rapid turnover of patients in acute care settings, complex care is now being delivered in the community

It is estimated that 300,000 patients a year in England acquire an HCAI as a result of care within the NHS and, in 2007, MRSA bloodstream infections and C. difficile infections were recorded as the underlying cause of, or a contributory factor in, approximately 9,000 deaths in hospital and primary care settings in England. This costs the NHS £1billion, £56m of which is incurred after patients are discharged from hospitals.

Expert opinion is consistent in its assertion that effective hand decontamination results in significant reductions in the carriage of potential pathogens on the hands and logically decreases the incidence of preventable HCAI leading to a reduction in patient morbidity and mortality

The new guidelines cover all adults and children receiving healthcare in primary or community care settings, including GP surgeries, dental surgeries, prisons, schools and in the home. They also cover ambulance services. The measures are aimed at healthcare workers in the community as well as family members and carers.

While there are a large number of new and reinforced recommendations contained in the report, which was overseen by researchers at Thames Valley University, there is a proposed top 10 checklist of the most-important measures. They are:

1. Everyone involved in providing care should be: Educated about the standard principles of infection prevention and control and trained in hand decontamination, the use of personal protective equipment and the safe use and disposal of sharps
2. Whatever care is delivered, healthcare workers must have available appropriate supplies of materials for hand decontamination, sharps containers, and personal protective equipment
3. Patients and carers should be educated about the benefits of hand hygiene, the correct techniques and timing of hand hygiene, when it is appropriate to use liquid soap and water or a handrub, the availability of hand decontamination facilities, and their role in maintaining standards of healthcare workers' hand hygiene
4. Hands must be decontaminated immediately before and after every episode of direct patient contact or care, immediately after any exposure to body fluids, immediately after any other contact with a patient's surroundings that could result in hands becoming contaminated, and after the removal of gloves
5. When inserting long-term urinary catheters, the type and gauge of catheter should be selected based on age, any allergy or sensitivity, gender, history of urinary tract infection, patient preference and comfort, previous catheter history, and the reason for catheterisation
6. Offer non-coated intermittent catheters for multiple use except in the following circumstances when a choice of single-use hydrophilic or gel reservoir catheters should be offered: If the patient is unable to wash and dry the catheter, if no suitable facilities to wash and dry the catheter are available, or if catheterisation is performed by a healthcare worker or anyone else other than the patient or close family member
7. All catheterisations carried out by healthcare works should be aseptic procedures. After training healthcare workers should be assessed for their competence to carry out these types of procedure
8. When changing catheters in patients with a long-term indwelling catheter only consider antibiotic prophylaxis where there is a history of symptomatic urinary tract infection after catheter change or where the patient has experienced trauma during catheterisation
9. When inserting vascular access devices, healthcare workers should be trained and assessed as competent in consistently adhering to infection prevention practices
10. Decontaminate the skin at the insertion site with chlorhexidine gluconate in 70% alcohol before inserting a peripheral vascular access device or peripherally inserted central catheter

Other areas altered or updated for 2011 include advice on glove and apron use, the location and upkeep of sharps containers, and adherence to the bare-below-the-elbows policy.

Commenting on the impact of proper handwashing techniques, the report states: "Expert opinion is consistent in its assertion that effective hand decontamination results in significant reductions in the carriage of potential pathogens on the hands and logically decreases the incidence of preventable HCAI leading to a reduction in patient morbidity and mortality."

Since the publication of the NICE clinical guideline on the prevention of healthcare-associated infections in primary and community care in 2003, many changes have occurred within the NHS which place the patient firmly at the centre of all activities

The report goes on to make a number of recommendations for further research in certain areas, including the clinical and cost effectiveness of chlorhexidine 2% in alcohol versus chlorhexidine 0.5% in alcohol versus chlorhexidine 2% aqueous solution versus chlorhexidine 0.5% aqueous solution for cleansing the skin before insertion of peripheral vascular access devices (VADs) and during dressing changes of all VADs on reducing VAD-related bacteraemia and VAD site infections.

It states: "In the community, compliance is improved when a single solution is used for all aspects of VAD-related skin care. There is no direct evidence comparing different percentages of chlorhexidine in aqueous and alcohol solutions, and little evidence on the use of such solutions in the community. A randomised controlled trial is required to compare the clinical and cost effectiveness of the different solutions available. The trial should enrol patients in the community with a VAD and the protocol would need to use the same skin preparation technique regardless of solution, and could also investigate decontamination technique and drying time. The primary outcome measures should be rate of VAD-related bacteraemia, rate of VAD site infections, mortality, cost and quality of life. Secondary outcomes measures should include visual infusion phlebitis (VIP) score, insertion times, and skin irritation."

It also calls for greater research into a number of areas, including what are the barriers to compliance with standard infection prevention principles and what is the clinical and cost-effectiveness of using wipes and handrubs to remove visible contamination.