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Mong I, Ramoo V, Ponnampalavanar S, Chong MC, Wan Nawawi WNF. Knowledge, attitude and practice in relation to catheter-associated urinary tract infection (CAUTI) prevention: A cross-sectional study. J Clin Nurs 2021; 31:209-219. [PMID: 34105196 DOI: 10.1111/jocn.15899] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 05/17/2021] [Accepted: 05/20/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Healthcare-associated infection (HAI) is one of the major threats to patients' safety besides being among the principal causes of patient morbidity and mortality. Catheter-associated urinary tract infection (CAUTI) is reported to be the most common HAI worldwide. CAUTI can be prevented with appropriate practice and care by healthcare personnel, especially nurses, who play the main role in urinary catheter care. Nurses' knowledge and attitude are considered to be important factors that influence their practice. OBJECTIVES To assess nurses' level of knowledge, attitude and perceived practice regarding CAUTI and its preventive measures. METHODS A cross-sectional design was adopted, and a self-administered questionnaire was used to collect data. Nurses from the medical and surgical inpatient wards of a tertiary teaching hospital in Malaysia were recruited in two stages using the stratified and simple random sampling methods. A total of 301 nurses participated. Descriptive analysis, an independent t test, ANOVA and hierarchical multiple regression were employed to analyse the data using SPSS software version 25. In addition, a STROBE checklist was used to report the results of this study. RESULTS Nurses were found to have good knowledge, a positive attitude and good perceived practice regarding CAUTI prevention. Nurses aged above 30 and who had more than ten years of experience reported higher knowledge levels. Knowledge was found to be positively correlated with attitude and perceived practice; however, attitude explained a higher variance in perceived practice of CAUTI prevention compared with knowledge. CONCLUSION Attitude was found to have a higher significant influence on perceived practice in this study. Educators need to emphasise the inculcation of a positive attitude among nurses rather than just knowledge for CAUTI prevention. Since this study assessed perceived practice, examining nurses' actual practice and its impact on patient outcomes is recommended in future studies.
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Affiliation(s)
- Ivy Mong
- Department of Nursing Science, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Vimala Ramoo
- Department of Nursing Science, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Mei Chan Chong
- Department of Nursing Science, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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2
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Gyesi-Appiah E, Brown J, Clifton A. Short-term urinary catheters and their risks: an integrated systematic review. Br J Community Nurs 2020; 25:538-544. [PMID: 33161748 DOI: 10.12968/bjcn.2020.25.11.538] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
This thematic review was part of a bigger literature review into the effects of short-term urinary catheters on patients who are discharged home from an acute hospital. This integrated review examined the risks associated with short-term urinary catheters. The MEDLINE, British Nursing Index and CINAHL databases were searched for studies published between 2013 and 2018 that researched the effects of short-term urinary catheters on patients. Twelve research studies were included, which showed the presence of short-term indwelling urinary catheters increased the risk of infection, length of hospital stay and mortality rates. Short-term urinary catheters should be strictly monitored and removed as soon as they are not required.
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Affiliation(s)
- Evelyn Gyesi-Appiah
- Research Student, De Montfort University, Leicester, and Nurse, University Hospitals of Leicester NHS Trust
| | - Jayne Brown
- Professor of Nursing (Older People), School of Nursing and Midwifery, De Montfort University, Leicester
| | - Andrew Clifton
- Associate Professor, Mental Health Nursing, School of Nursing and Midwifery, De Montfort University, Leicester
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3
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Prieto J, Wilson J, Bak A, Denton A, Flores A, Lusardi G, Reid M, Shepherd L, Whittome N, Loveday H. A prevalence survey of patients with indwelling urinary catheters on district nursing caseloads in the United Kingdom: The Community Urinary Catheter Management (CCaMa) Study. J Infect Prev 2020; 21:129-135. [PMID: 32655693 DOI: 10.1177/1757177420901550] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 12/07/2019] [Indexed: 11/16/2022] Open
Abstract
Background Catheter-associated urinary tract infection (CAUTI) is common in both hospitals and the community. Aim To investigate the prevalence of indwelling urinary catheters on district nursing caseloads in the UK. Methods Participants were recruited through the Infection Prevention Society (IPS). An electronic survey was undertaken on a single day between November 2017 and January 2018. Data were analysed using descriptive statistics. Findings A total of 49,575 patients were included in the survey, of whom 5352 had an indwelling urinary catheter. This gave a point prevalence of 10.8% (95% confidence interval [CI] = 10.53-11.07), which varied between organisations, ranging from 2.36% (95% CI = 2.05-2.73) to 22.02% (95% CI = 20.12-24.05). Of catheters, 5% were newly placed (within four weeks). Of these, most (77%) had a documented indication for insertion. Only half of patients with a newly placed catheter had a plan for its removal. This varied between organisations in the range of 20%-96%. Only 13% of patients had a patient-held management plan or 'catheter passport' but these patients were significantly more likely to also have an active removal plan (28/36 [78%] vs. 106/231 [46%]; P < 0.0001). Alternative bladder management strategies had been considered for 70/267 (26%) patients. Discussion The management of patients with an indwelling urinary catheter represents a significant component of district nursing caseloads. Given the high proportion of newly catheterised patients without an active management plan for removal of the catheter, the establishment of an optimal management pathway should be the focus of future prevention efforts.
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Affiliation(s)
| | - Jennie Wilson
- Richard Wells Research Centre, University of West London, London, UK
| | - Aggie Bak
- Richard Wells Research Centre, University of West London, London, UK
| | | | | | | | - Matthew Reid
- Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | | | | | - Heather Loveday
- Richard Wells Research Centre, University of West London, London, UK
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4
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Gyesi-Appiah E, Brown J, Clifton A. Short-term urinary catheters and their risks: an integrated systematic review. ACTA ACUST UNITED AC 2020; 29:S16-S22. [DOI: 10.12968/bjon.2020.29.9.s16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background:This thematic review was part of a bigger literature review into the effects of short-term urinary catheters on patients who are discharged home from an acute hospital.Aims:This integrated review examined the risks associated with short-term urinary catheters.Methods:The MEDLINE, British Nursing Index and CINAHL databases were searched for studies published between 2013 and 2018 that researched the effects of short-term urinary catheters on patients.Findings:Twelve research studies were included, which showed the presence of short-term indwelling urinary catheters increased the risk of infection, length of hospital stay and mortality rates.Conclusion:Short-term urinary catheters should be strictly monitored and removed as soon as they are not required.
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Affiliation(s)
- Evelyn Gyesi-Appiah
- Research Student, De Montfort University, Leicester, and Nurse, University Hospitals of Leicester NHS Trust
| | - Jayne Brown
- Professor of Nursing (Older People), School of Nursing and Midwifery, De Montfort University, Leicester
| | - Andrew Clifton
- Associate Professor, Mental Health Nursing, School of Nursing and Midwifery, De Montfort University, Leicester
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Giles M, Graham L, Ball J, Watts W, King J, Bantawa K, Paul M, Harris A, Paul O'Brien A, Parker V. Variations in indwelling urinary catheter use in four Australian acute care hospitals. J Clin Nurs 2019; 28:4572-4581. [PMID: 31469471 DOI: 10.1111/jocn.15048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 07/25/2019] [Accepted: 08/18/2019] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To identify the point prevalence of indwelling urinary catheters (IDCs) in adult inpatients in acute care hospitals, and to describe the indications for IDC insertion based on patient age, gender, specialty and hospital. BACKGROUND Catheter-associated urinary tract infections (CAUTIs) are preventable healthcare-associated infections. IDC duration is the strongest predictor of CAUTI, and little is known about characteristics of patients who receive an IDC. DESIGN Two single-day point prevalence surveys collected baseline patient data as part of a larger pre-post control-intervention study. METHODS Surveys were conducted at four acute care hospitals in NSW, Australia, for all adult patients. Data collection included IDC presence, insertion details and urine culture collection. Point prevalence data were linked with electronically extracted patient demographic data. This study is presented in line with STROBE checklist (See Supplementary File 1). RESULT Data from 1,630 patients were analysed, with 196 patients (12%) identified as having an IDC on the survey dates. IDC prevalence rates were higher in males (13%) than in females (11%). Critical care had the highest rate of patients with IDCs (42%). Urine cultures were collected in 70 patients with an IDC (43%). CONCLUSIONS Findings indicated similar rates of IDC use in males and females, and there was no significant difference in age between patients with or without an IDC. However, indication for IDC varied by patient age and gender. High rates of urine culture collection may represent routine collection. RELEVANCE TO CLINICAL PRACTICE IDC use is found across genders, all age groups and specialties. Nurses should be aware that any of their patients may have an IDC and be particularly aware of certain indications based on patient age and gender. Routine urine culture collection is not advised, and instead, nurses should be guided by clinical decision-making tools.
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Affiliation(s)
- Michelle Giles
- Hunter New England Local Health District, Newcastle, New South Wales, Australia.,University of Newcastle, Newcastle, New South Wales, Australia
| | - Laura Graham
- Hunter New England Local Health District, Newcastle, New South Wales, Australia
| | - Jean Ball
- Hunter New England Local Health District, Newcastle, New South Wales, Australia
| | - Wendy Watts
- Hunter New England Local Health District, Newcastle, New South Wales, Australia
| | - Jennie King
- University of Newcastle, Newcastle, New South Wales, Australia.,Central Coast Local Health District, Gosford, New South Wales, Australia
| | - Kamana Bantawa
- Hunter New England Local Health District, Newcastle, New South Wales, Australia
| | - Michelle Paul
- Hunter New England Local Health District, Newcastle, New South Wales, Australia
| | - Alison Harris
- Central Coast Local Health District, Gosford, New South Wales, Australia
| | | | - Vicki Parker
- Hunter New England Local Health District, Newcastle, New South Wales, Australia
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Effectiveness of behavioural interventions to reduce urinary tract infections and Escherichia coli bacteraemia for older adults across all care settings: a systematic review. J Hosp Infect 2019; 102:200-218. [DOI: 10.1016/j.jhin.2018.10.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 10/15/2018] [Indexed: 11/23/2022]
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7
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Nurses’ and Physicians’ Perceptions of Indwelling Urinary Catheter Practices and Culture in Their Institutions. J Patient Saf 2018; 16:e82-e89. [DOI: 10.1097/pts.0000000000000502] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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8
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Hu FW, Shih HI, Hsu HC, Chen CH, Chang CM. Dynamic changes in the appropriateness of urinary catheter use among hospitalized older patients in the emergency department. PLoS One 2018; 13:e0193905. [PMID: 29565991 PMCID: PMC5863961 DOI: 10.1371/journal.pone.0193905] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 02/05/2018] [Indexed: 11/18/2022] Open
Abstract
Objectives To investigate incidence, rationales, related factors and outcomes for changing from appropriate catheter placement to inappropriate use among hospitalized older patients in the emergency department. Methods A secondary analysis was adopted from a longitudinal study that was designed to follow the lifecycle of the urinary catheter among hospitalized older patients. Patients aged 65 and older with a urinary catheter that had been placed in the emergency department were included. Demographic factors, present health conditions, conditional factors of catheter placement, and rationales for daily urinary catheter use were collected from the original data. Inappropriate urinary catheter days were evaluated as an outcome. Results Appropriate urinary catheters were placed in the emergency department in 117 of the 156 patients (75%). Of these patients, 77 patients (65.8%) experienced a change from appropriate placement to inappropriate use, with a mean duration of 2.88±1.56 days. The common rationales were post-operation for hip fracture (36.3%) and no longer needing to monitor urine output (27.2%). A hierarchical regression model shows that a change from appropriate catheter placement to inappropriate use was associated with a diagnosis of urinary tract infection (OR = 0.15; 95% CI = 0.03–0.77; p = 0.02) and no record of the indication for catheter placement (OR = 4.76; 95% CI = 1.20–18.90; p = 0.02), and all variables together explained 35.9% of the variance. In addition, a change from appropriate placement to inappropriate use was further associated with prolonging inappropriate catheter-days (β = 5.34; 95% CI: 3.72–6.97; p <0.001). Conclusions The study highlights a considerable percentage of change from appropriate placement to inappropriate use. Efforts to construct reminder intervention, to improve the record of catheter placement and continued attention to catheter use are necessary to reduce inappropriate urinary catheter use.
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Affiliation(s)
- Fang-Wen Hu
- Department of Nursing, National Cheng Kung University Hospital, Tainan City, Taiwan
| | - Hsin-I Shih
- Department of Emergency Medicine, National Cheng Kung University Hospital, Tainan City, Taiwan.,Department of Medicine, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Hsiang-Chin Hsu
- Department of Emergency Medicine, National Cheng Kung University Hospital, Tainan City, Taiwan
| | - Ching-Huey Chen
- Department of Nursing, College of Health Sciences, Chang Jung Christian University, Tainan City, Taiwan
| | - Chia-Ming Chang
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan City, Taiwan.,Division of Geriatrics and Gerontology, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan City, Taiwan
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9
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Assessment of a multi-modal intervention for the prevention of catheter-associated urinary tract infections. J Hosp Infect 2016; 94:175-81. [DOI: 10.1016/j.jhin.2016.07.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 07/19/2016] [Indexed: 01/08/2023]
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10
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Murphy C, Prieto J, Fader M. "It's easier to stick a tube in": a qualitative study to understand clinicians' individual decisions to place urinary catheters in acute medical care. BMJ Qual Saf 2015; 24:444-50. [PMID: 26065467 DOI: 10.1136/bmjqs-2015-004114] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 04/30/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Indwelling urinary catheters (IUCs) placed in acute care are a leading cause of healthcare-associated urinary tract infection. Despite initiatives to minimise the placement of IUCs, levels of inappropriate use are still considered unacceptable. IUC practice is difficult to change, and factors influencing clinicians' decisions need to be better understood. OBJECTIVE To explore why clinicians decide to place IUCs in acute medical care. METHODS We conducted a qualitative study in the emergency department and acute medical wards of a 1200+ bed hospital, undertaking 30 retrospective think aloud and 20 semistructured interviews with nurses and physicians who made the decision to place an IUC. A purposive sample and thematic analysis were used. RESULTS Opinions on when an IUC was warranted varied considerably. Inconsistency in decision-making was caused by differing beliefs on when an IUC was appropriate for each clinical indication. Numerous patient and non-patient factors, including clinical setting, resources, patient age and gender and staff workload, also impacted on each decision. Assessing when the benefit of an IUC outweighed the risk could be problematic due to conflicting goals. CONCLUSIONS These findings help to explain why clinicians sometimes deviate from IUC best practice guidance and resist interventions to modify practice. In order to engage nurses and physicians in change, interventions to reduce IUC use should acknowledge and respond to the complexity and lack of clarity often faced by clinicians making the decision to place an IUC. However, it is equally important that inconsistencies in IUC-related beliefs are recognised, investigated and, where appropriate, challenged.
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Affiliation(s)
- Catherine Murphy
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Jacqui Prieto
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Mandy Fader
- Faculty of Health Sciences, University of Southampton, Southampton, UK
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11
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Giles M, Watts W, O’Brien A, Berenger S, Paul M, McNeil K, Bantawa K. Does our bundle stack up! Innovative nurse-led changes for preventing catheter-associated urinary tract infection (CAUTI). ACTA ACUST UNITED AC 2015. [DOI: 10.1071/hi14035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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12
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Hanafin S, Roe S, O'Dowd M, Barry C. Supporting the use of evidence in community nursing: a national strategic approach. Br J Community Nurs 2014; 19:496-501. [PMID: 25284186 DOI: 10.12968/bjcn.2014.19.10.496] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
While there is an acceptance across all stakeholders that nursing practice should be informed by evidence, there is a substantial literature on the challenges this creates for nurses in the delivery of services. These challenges are accentuated for nurses in community settings, where accessible, up-to-date research evidence is more problematic because of the decentralised organisation and delivery of these services. Recognising this gap, and the consequent needs of its members, the Institute of Community Health Nursing (ICHN) in Ireland has commenced a national strategic development in this area. The purpose of the strategy is to actively support and facilitate public health and community nurses to provide services to individuals, families and communities that are based on the best available research evidence. This article provides a brief overview of the development and key components of the ICHN strategy.
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Affiliation(s)
- Sinéad Hanafin
- Visiting Research Fellow, School of Nursing and Midwifery, Trinity College Dublin
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McNulty C, Verlander NQ, Turner K, Fry C. Point prevalence survey of urinary catheterisation in care homes and where they were inserted, 2012. J Infect Prev 2014; 15:122-126. [PMID: 28989371 DOI: 10.1177/1757177414532507] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2014] [Indexed: 11/15/2022] Open
Abstract
The extent to which the use of catheter care bundles and other interventions has led to a reduction in urinary catheterisation rates is unknown. We aimed to determine current urinary catheterisation rates in care homes with residents over 65 years old, and determine the extent to which residents are discharged from the hospital setting with urinary catheters. A point prevalence questionnaire survey was used in care homes that looked after residents over 65 years in six UK health boards or primary care trusts, to determine urinary catheterisation rates, and where these catheters were inserted. Questionnaires for 445 of 461 care homes (96.5%) were completed, 425 of 445 care homes cared for residents over 65 years; 888 (6.9%) of 12,827 residents had a urethral (82.5%) or supra-pubic (17.5%) urinary catheter. Over half of all catheters (both urethral and suprapubic, 57.4%, 509 of 888 catheters), and 3.1% of all residents had a catheter inserted while the residents were hospital inpatients, and then discharged back to the care home still catheterised. There was a significant variation in urinary catheterisation rates in the care homes surveyed, and rates remain similar to previous English surveys in 2003 and 2009. More still needs to be done to understand the variation in urinary catheterisation rates in care homes and reduce these rates, including the numbers of residents that are discharged from hospital with a urinary catheter.
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Affiliation(s)
- Cam McNulty
- Public Health England Primary Care Unit, and Cardiff University, UK
| | | | - K Turner
- Public Health England Primary Care Unit, UK
| | - C Fry
- Department of Health, London, UK
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Loveday HP, Wilson JA, Pratt RJ, Golsorkhi M, Tingle A, Bak A, Browne J, Prieto J, Wilcox M, UK Department of Health. epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 2014; 86 Suppl 1:S1-70. [PMID: 24330862 PMCID: PMC7114876 DOI: 10.1016/s0195-6701(13)60012-2] [Citation(s) in RCA: 660] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were originally commissioned by the Department of Health and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were first published in January 2001(1) and updated in 2007.(2) A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective for the prevention of HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. The Department of Health commissioned a review of new evidence and we have updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the epic2 guidelines published in 2007 remain robust, relevant and appropriate, but some guideline recommendations required adjustments to enhance clarity and a number of new recommendations were required. These have been clearly identified in the text. In addition, the synopses of evidence underpinning the guideline recommendations have been updated. These guidelines (epic3) provide comprehensive recommendations for preventing HCAI in hospital and other acute care settings based on the best currently available evidence. National evidence-based guidelines are broad principles of best practice that need to be integrated into local practice guidelines and audited to reduce variation in practice and maintain patient safety. Clinically effective infection prevention and control practice is an essential feature of patient protection. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of health care in NHS hospitals in England can be minimised.
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Affiliation(s)
- H P Loveday
- Richard Wells Research Centre, College of Nursing, Midwifery and Healthcare, University of West London (London).
| | - J A Wilson
- Richard Wells Research Centre, College of Nursing, Midwifery and Healthcare, University of West London (London)
| | - R J Pratt
- Richard Wells Research Centre, College of Nursing, Midwifery and Healthcare, University of West London (London)
| | - M Golsorkhi
- Richard Wells Research Centre, College of Nursing, Midwifery and Healthcare, University of West London (London)
| | - A Tingle
- Richard Wells Research Centre, College of Nursing, Midwifery and Healthcare, University of West London (London)
| | - A Bak
- Richard Wells Research Centre, College of Nursing, Midwifery and Healthcare, University of West London (London)
| | - J Browne
- Richard Wells Research Centre, College of Nursing, Midwifery and Healthcare, University of West London (London)
| | - J Prieto
- Faculty of Health Sciences, University of Southampton (Southampton)
| | - M Wilcox
- Microbiology and Infection Control, Leeds Teaching Hospitals and University of Leeds (Leeds)
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