Epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England
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Journal of Hospital Infection 86S1 (2014) S1–S70
Available online at www.sciencedirect.com
Journal of Hospital Infection
j o u r n a l h o m e p a g e : w w w. e l s ev i e r h e a l t h . c o m / j o u r n a l s / j h i n
epic3: National Evidence-Based Guidelines for
Preventing Healthcare-Associated Infections in
NHS Hospitals in England
H.P. Lovedaya*, J.A. Wilsona, R.J. Pratta, M. Golsorkhia, A. Tinglea, A. Baka,
J. Brownea, J. Prietob, M. Wilcoxc
a
Richard Wells Research Centre, College of Nursing, Midwifery and Healthcare, University of West London (London).
b
Faculty of Health Sciences, University of Southampton (Southampton).
c
Microbiology and Infection Control, Leeds Teaching Hospitals and University of Leeds (Leeds).
Executive Summary
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 rst published in January 20011 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 identied, 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 identied 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.
NICE has accredited the process used by the University of West London to produce
its epic3 guidance. Accreditation is valid for 5 years from December 2013.
More information on accreditation can be viewed at: www.nice.org.uk/accreditation
For full details on our accreditation visit:
www.nice.uk/accreditation
* Corresponding author. Address: Richard Wells Research Centre, College of Nursing, Midwifery and Healthcare, University of West London,
Paragon House, Boston Manor Road, Brentford TW8 9GB, UK. Tel.: +44 (0) 20 8209 4110
E-mail address: heather.loveday@uwl.ac.uk (Heather Loveday)
0195-6701/$ e see front matter ª 2013 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.S2 H. P. Loveday et al. / Journal of Hospital Infection 86S1 (2014) S1–S70
1 Introductory Section 1.3 Acknowledgements
1.1 Guideline Development Team We would like to acknowledge the assistance of the
Infection Prevention Society, British Infection Association
• Professor Heather P. Loveday (Project Lead), Professor of and the Healthcare Infection Society for their input into the
Evidence-based Healthcare, College of Nursing, Midwifery development of these guidelines; and other associations,
and Healthcare, University of West London (London) (HL). learned societies, professional organisations, Royal Colleges
• Ms Jennie A. Wilson, Reader, Healthcare Epidemiology, and patient groups who took an active role in the external
University of West London (London) (JW). review of the guidelines. We would also like to acknowledge the
• Dr Jacqui Prieto, Senior Clinical Academic Research Fellow, support received from Professor Brian Duerden CBE in chairing
University of Southampton (Southampton). the Guideline Development Advisory Group, and Carole Fry in
• Professor Mark Wilcox, Professor of Medical Microbiology, the Chief Medical Ofcer’s Team at the Department of Health
University of Leeds (Leeds) (MW). (England).
• Professor Robert J. Pratt CBE, Professor of Nursing,
University of West London (London).
• Ms Aggie Bak, Research Assistant, University of West London 1.4 Source of Funding
(London).
• Ms Jessica Browne, Research Assistant, University of West The Department of Health (England).
London (London).
• Ms Sharon Elliott, Senior Lecturer (Director Clinical
Simulation), University of West London (London). 1.5 Disclosure of Potential Conict of Interest
• Ms Mana Golsorkhi, Research Assistant, University of West
London (London). HL: Trustee and Director of the International Clinical Virology
• Mr Roger King, Lecturer (Operating Department Practice), Centre and the Infection Prevention Society; educational grant
University of West London (London). from Care Fusion to attend SHEA conference in April 2010 and
• Ms Caroline Smales, Senior Lecturer (Infectious Diseases), consultancy for GAMA Healthcare Ltd in January 2012.
University of West London (London). JW: Trustee of the Infection Prevention Society; consultancy
• Ms Alison Tingle, Principal Research Programme Ofcer, for Care Fusion and ICNet.
University of West London (London). MW: Research on the use of hydrogen peroxide decontamination
supported by Hygiene Solutions (Deprox).
JPh: Sponsored speaker/session chair for Cook Medical.
TC: Consultancy NIHR HTA Programme.
DA: Consultancy and commissioned publications from Sano,
BD, Smiths-Industry; consultancy from NHS Midlands and East;
PhD supported by an education grant from BD and Enturia.
1.2 Guideline Advisory Group TB: Advisor to Fresenius Medical Care Renal Services and
Nottingham Woodthorpe Hospital (Ramsay Healthcare);
• Dr Debra Adams, NHS Trust Development Authority (DA) sponsored speaker for Advanced Sterilisation Products.
• Ms Susan Bennett, Lay Member (SB) SB: Member of NICE Medical Technology Advisory Committee;
• Dr Tim Boswell, Nottingham University Hospitals NHS Trust (TB) former trustee of Bladder and Bowel Foundation; sponsorship
• Ms Maria Cann, Lay Member (MC) from a number of urinary catheter manufacturers; Urology Trade
• Ms Tracey Cooper, South London NHS Trust (TC) Association; Bladder and Bowel Foundation representative on
• Dr Peter Cowling, Northern Lincolnshire & Goole Hospitals the Urology User Group Coalition.
NHS Trust MC: Trustee of MRSA Action UK; conference attendances
• Ms Judith Hudson, Association of Healthcare Cleaning sponsored by Mölnlycke Healthcare.
Professionals All other authors: no conicts declared.
• Ms Theresa Neale, Urology Nurse Specialist, British
Association of Urological Nurses (Consultant)
• Dr Jeff Phillips, Consultant Intensivist and Clinical Lead 1.6 Relationship of Author(s) with Sponsor
for Anaesthetics (Consultant) (JPh), Princess Alexandra
Hospital Harlow The Department of Health (England) commissioned the
• Dr Jacqui Prieto, University of Southampton (Infection authors to update the evidence and guideline recommendations
Prevention Adviser) previously developed by them and published as the epic2
• Mr Julian Shah, Consultant Urologist (Consultant), King guidelines in the Journal of Hospital Infection in 2007.
Edward VII Hospital, London
• Professor Mark Wilcox, Leeds Teaching Hospitals and
University of Leeds 1.7 Responsibility for Guidelines
• Ms Carole Fry, Department of Health (Observer)
• Professor Brian I. Duerden CBE, Duerden Microbiology The views expressed in this publication are those of the
Consulting Ltd (Chair of Face-to-Face Meeting) authors and, following extensive consultation, have been
• Ms Meg Morse, Administrative Ofcer, University of West endorsed by the Department of Health (England).
LondonH. P. Loveday et al. / Journal of Hospital Infection 86S1 (2014) S1–S70 S3
1.8 Summary of Guidelines SP5 All healthcare workers need to be
educated about the importance of
Standard principles for preventing healthcare- maintaining a clean and safe care
associated infections in hospital and other acute environment for patients. Every
care settings healthcare worker needs to know their
specic responsibilities for cleaning
This guidance is based on the best critically appraised and decontaminating the clinical
evidence currently available. The type and class of supporting environment and the equipment used in patient care.
evidence explicitly linked to each recommendation is described. Class D/GPP
Some recommendations from the previous guidelines have been
revised to improve clarity; where a new recommendation has been
made, this is indicated in the text. These recommendations are
not detailed procedural protocols, and need to be incorporated Hand hygiene
into local guidelines. None are regarded as optional.
Standard infection control precautions need to be applied SP6 Hands must be decontaminated:
by all healthcare practitioners to the care of all patients (i.e. • immediately before each episode
adults, children and neonates). The recommendations are of direct patient contact or care,
divided into ve distinct interventions: including clean/aseptic procedures;
• hospital environmental hygiene; • immediately after each episode of
• hand hygiene; direct patient contact or care;
• use of personal protective equipment (PPE); • immediately after contact with body
• safe use and disposal of sharps; and uids, mucous membranes and non-intact skin;
• principles of asepsis. • immediately after other activities
These guidelines do not address the additional infection or contact with objects and
control requirements of specialist settings, such as the operat- equipment in the immediate patient
ing department or outbreak situations. environment that may result in the
hands becoming contaminated; and
• immediately after the removal of gloves.
Class C
Hospital environmental hygiene
SP7 Use an alcohol-based hand rub for
SP1 The hospital environment must be decontamination of hands before and
visibly clean; free from non-essential after direct patient contact and clinical
items and equipment, dust and dirt; and care, except in the following situations
acceptable to patients, visitors and staff. when soap and water must be used:
Class D/GPP • when hands are visibly soiled or
potentially contaminated with body uids; and
SP2 Levels of cleaning should be • when caring for patients with
increased in cases of infection and/ vomiting or diarrhoeal illness,
or colonisation when a suspected or regardless of whether or not gloves
known pathogen can survive in the have been worn.
environment, and environmental Class A
contamination may contribute to the
spread of infection. SP8 Healthcare workers should ensure that
Class D/GPP their hands can be decontaminated effectively by:
• removing all wrist and hand jewellery;
SP3 The use of disinfectants should be • wearing short-sleeved clothing when
considered for cases of infection and/ delivering patient care;
or colonisation when a suspected or • making sure that ngernails are
known pathogen can survive in the short, clean, and free from false
environment, and environmental nails and nail polish; and
contamination may contribute to the • covering cuts and abrasions with
spread of infection. waterproof dressings.
Class D/GPP Class D/GPP
SP4 Shared pieces of equipment used in
the delivery of patient care must be
cleaned and decontaminated after
each use with products recommended
by the manufacturer.
Class D/GPPS4 H. P. Loveday et al. / Journal of Hospital Infection 86S1 (2014) S1–S70
SP9 Effective handwashing technique SP14 Healthcare organisations must provide
involves three stages: preparation, regular training in risk assessment,
washing and rinsing, and drying. effective hand hygiene and glove use
• Preparation: wet hands under tepid for all healthcare workers.
running water before applying the Class D/GPP
recommended amount of liquid soap
or an antimicrobial preparation. SP15 Local programmes of education, social
• Washing: the handwash solution marketing, and audit and feedback
must come into contact with all of should be refreshed regularly and
the surfaces of the hand. The hands promoted by senior managers and
should be rubbed together vigorously clinicians to maintain focus, engage
for a minimum of 10–15 s, paying staff and produce sustainable levels of compliance.
particular attention to the tips of the New recommendation Class C
ngers, the thumbs and the areas
between the ngers. Hands should be SP16 Patients and relatives should be
rinsed thoroughly. provided with information about the
• Drying: use good-quality paper need for hand hygiene and how to keep
towels to dry the hands thoroughly. their own hands clean.
Class D/GPP New recommendation Class D/GPP
SP10 When decontaminating hands using an SP17 Patients should be offered the
alcohol-based hand rub, hands should opportunity to clean their hands before
be free of dirt and organic material, and: meals; after using the toilet, commode
• hand rub solution must come into or bedpan/urinal; and at other times as
contact with all surfaces of the hand; and appropriate. Products available should
• hands should be rubbed together be tailored to patient needs and may
vigorously, paying particular include alcohol-based hand rub, hand
attention to the tips of the ngers, wipes and access to handwash basins.
the thumbs and the areas between New recommendation Class D/GPP
the ngers, until the solution has
evaporated and the hands are dry.
Class D/GPP
Use of personal protective equipment
SP11 Clinical staff should be made aware
of the potentially damaging effects SP18 Selection of personal protective
of hand decontamination products, equipment must be based on an assessment of the:
and encouraged to use an emollient • risk of transmission of
hand cream regularly to maintain microorganisms to the patient or carer;
the integrity of the skin. Consult the • risk of contamination of healthcare
occupational health team or a general practitioners’ clothing and skin by
practitioner if a particular liquid soap, patients’ blood or body uids; and
antiseptic handwash or alcohol-based • suitability of the equipment for proposed use.
hand rub causes skin irritation. Class D/GPP/H&S
Class D/GPP
SP19 Healthcare workers should be educated
SP12 Alcohol-based hand rub should be made and their competence assessed in the:
available at the point of care in all • assessment of risk;
healthcare facilities. • selection and use of personal
Class C protective equipment; and
• use of standard precautions.
SP13 Hand hygiene resources and healthcare Class D/GPP/H&S
worker adherence to hand hygiene
guidelines should be audited at regular SP20 Supplies of personal protective
intervals, and the results should be fed equipment should be made available
back to healthcare workers to improve wherever care is delivered and risk
and sustain high levels of compliance. assessment indicates a requirement.
Class C Class D/GPP/H&SH. P. Loveday et al. / Journal of Hospital Infection 86S1 (2014) S1–S70 S5
SP21 Gloves must be worn for: SP29 Fluid-repellent surgical face masks and
• invasive procedures; eye protection must be worn where
• contact with sterile sites and non- there is a risk of blood or body uids
intact skin or mucous membranes; splashing into the face and eyes.
• all activities that have been assessed Class D/GPP H&S
as carrying a risk of exposure to
blood or body uids; and SP30 Appropriate respiratory protective
• when handling sharps or contaminated devices. equipment should be selected
Class D/GPP/H&S according to a risk assessment
that takes account of the infective
SP22 Gloves must be: microorganism, the anticipated activity
• worn as single-use items; and the duration of exposure.
• put on immediately before an Class D/GPP/H&S
episode of patient contact or treatment;
• removed as soon as the episode is completed; SP31 Respiratory protective equipment must
• changed between caring for different patients; and t the user correctly and they must be
• disposed of into the appropriate trained in how to use and adjust it in
waste stream in accordance with accordance with health and safety regulations.
local policies for waste management. Class D/GPP/H&S
Class D/GPP/H&S
SP32 Personal protective equipment should
SP23 Hands must be decontaminated be removed in the following sequence
immediately after gloves have been removed. to minimise the risk of cross/self-contamination:
Class D/GPP/H&S • gloves;
• apron;
SP24 A range of CE-marked medical and • eye protection (when worn); and
protective gloves that are acceptable • mask/respirator (when worn).
to healthcare personnel and suitable Hands must be decontaminated
for the task must be available in all clinical areas. following the removal of personal
Class D/GPP/H&S protective equipment.
New recommendation Class D/GPP/H&S
SP25 Sensitivity to natural rubber latex
in patients, carers and healthcare
workers must be documented, and
alternatives to natural rubber latex
gloves must be available. Safe use and disposal of sharps
Class D/GPP/H&S
SP33 Sharps must not be passed directly
SP26 Disposable plastic aprons must be worn from hand to hand, and handling
when close contact with the patient, should be kept to a minimum.
materials or equipment pose a risk that Class D/GPP/H&S
clothing may become contaminated
with pathogenic microorganisms, blood SP34 Needles must not be recapped, bent or
or body uids. disassembled after use.
Class D/GPP/H&S Class D/GPP/H&S
SP27 Full-body uid-repellent gowns must be SP35 Used sharps must be discarded at the
worn where there is a risk of extensive point of use by the person generating the waste.
splashing of blood or body uids on to Class D/GPP/H&S
the skin or clothing of healthcare workers.
Class D/GPP/H&S SP36 All sharps containers must:
• conform to current national and
SP28 Plastic aprons/uid-repellent gowns international standards;
should be worn as single-use items • be positioned safely, away from
for one procedure or episode of public areas and out of the reach
patient care, and disposed of into of children, and at a height that
the appropriate waste stream in enables safe disposal by all members of staff;
accordance with local policies for • be secured to avoid spillage;
waste management. When used, non- • be temporarily closed when not in use;
disposable protective clothing should • not be lled above the ll line; and
be sent for laundering. • be disposed of when the ll line is reached.
Class D/GPP/H&S Class D/GPP/H&SS6 H. P. Loveday et al. / Journal of Hospital Infection 86S1 (2014) S1–S70
SP37 All clinical and non-clinical staff must Assessing the need for catheterisation
be educated about the safe use and
disposal of sharps and the action to be UC1 Only use a short-term indwelling
taken in the event of an injury. urethral catheter in patients for whom
Class D/GPP/H&S it is clinically indicated, following
assessment of alternative methods and
SP38 Use safer sharps devices where discussion with the patient.
assessment indicates that they will Class D/GPP
provide safe systems of working for
healthcare workers. UC2 Document the clinical indication(s)
Class C/H&S for catheterisation, date of insertion,
expected duration, type of catheter
SP39 Organisations should involve end-users and drainage system, and planned date of removal.
in evaluating safer sharps devices Class D/GPP
to determine their effectiveness,
acceptability to practitioners, impact UC3 Assess and record the reasons for
on patient care and cost benet prior catheterisation every day. Remove the
to widespread introduction. catheter when no longer clinically indicated.
Class D/GPP/H&S Class D/GPP
Asepsis
SP40 Organisations should provide education Selection of catheter type
to ensure that healthcare workers are
trained and competent in performing UC4 Assess patient’s needs prior to
the aseptic technique. catheterisation in terms of:
New recommendation Class D/GPP • latex allergy;
• length of catheter (standard, female, paediatric);
SP41 The aseptic technique should be used • type of sterile drainage bag and
for any procedure that breeches the sampling port (urometer, 2-L bag, leg
body’s natural defences, including: bag) or catheter valve; and
• insertion and maintenance of invasive devices; • comfort and dignity.
• infusion of sterile uids and medication; and New recommendation Class D/GPP
• care of wounds and surgical incisions.
New recommendation Class D/GPP UC5 Select a catheter that minimises
urethral trauma, irritation and patient
discomfort, and is appropriate for the
anticipated duration of catheterisation.
Guidelines for preventing infections associated with Class D/GPP
the use of short-term indwelling urethral catheters
UC6 Select the smallest gauge catheter
This guidance is based on the best critically appraised that will allow urinary outow and use
evidence currently available. The type and class of supporting a 10-mL retention balloon in adults
evidence explicitly linked to each recommendation is des- (follow manufacturer’s instructions
cribed. Some recommendations from the previous guidelines for paediatric catheters). Urological
have been revised to improve clarity; where a new recom- patients may require larger gauge sizes and balloons.
mendation has been made, this is indicated in the text. These Class D/GPP
recommendations are not detailed procedural protocols,
and need to be incorporated into local guidelines. None are
regarded as optional.
These guidelines apply to adults and children aged 1 year Catheter insertion
who require a short-term indwelling urethral catheter (28
days), and should be read in conjunction with the guidance on UC7 Catheterisation is an aseptic procedure
Standard Principles. The recommendations are divided into six and should only be undertaken by
distinct interventions: healthcare workers trained and
• assessing the need for catheterisation; competent in this procedure.
• selection of catheter type and system; Class D/GPP
• catheter insertion;
• catheter maintenance; UC8 Clean the urethral meatus with sterile,
• education of patients, relatives and healthcare workers; normal saline prior to the insertion of the catheter.
and Class D/GPP
• system interventions for reducing the risk of infection.H. P. Loveday et al. / Journal of Hospital Infection 86S1 (2014) S1–S70 S7
UC9 Use lubricant from a sterile single- Education of patients, relatives and healthcare workers
use container to minimise urethral
discomfort, trauma and the risk of UC20 Do not use bladder maintenance
infection. Ensure the catheter is solutions to prevent catheter-associated infection.
secured comfortably. Class A
Class D/GPP
UC21 Healthcare workers should be trained
and competent in the appropriate use,
selection, insertion, maintenance and
Catheter maintenance removal of short-term indwelling urethral catheters.
Class D/GPP
UC10 Connect a short-term indwelling
urethral catheter to a sterile closed UC22 Ensure patients, relatives and carers
urinary drainage system with a sampling port. are given information regarding the
Class A reason for the catheter and the plan
for review and removal. If discharged
UC11 Do not break the connection between with a catheter, the patient should be
the catheter and the urinary drainage given written information and shown how to:
system unless clinically indicated. • manage the catheter and drainage system;
Class A • minimise the risk of urinary tract infection; and
• obtain additional supplies suitable
UC12 Change short-term indwelling urethral for individual needs.
catheters and/or drainage bags when Class D/GPP
clinically indicated and in line with the
manufacturer’s recommendations.
New recommendation Class D/GPP
System interventions for reducing the risk of infection
UC13 Decontaminate hands and wear a new
pair of clean non-sterile gloves before UC23 Use quality improvement systems
manipulating each patient’s catheter. to support the appropriate use and
Decontaminate hands immediately management of short-term urethral
following the removal of gloves. catheters and ensure their timely
Class D/GPP removal. These may include:
• protocols for catheter insertion;
UC14 Use the sampling port and the aseptic • use of bladder ultrasound scanners to
technique to obtain a catheter sample of urine. assess and manage urinary retention;
Class D/GPP • reminders to review the continuing
use or prompt the removal of catheters;
UC15 Position the urinary drainage bag below • audit and feedback of compliance
the level of the bladder on a stand that with practice guidelines; and
prevents contact with the oor. • continuing professional education
Class D/GPP New recommendation Class D/GPP
UC16 Do not allow the urinary drainage bag UC24 No patient should be discharged
to ll beyond three-quarters full. or transferred with a short-term
Class D/GPP indwelling urethral catheter without a
plan documenting the:
UC17 Use a separate, clean container for each • reason for the catheter;
patient and avoid contact between the • clinical indications for continuing
urinary drainage tap and the container catheterisation; and
when emptying the drainage bag. • date for removal or review by an
Class D/GPP appropriate clinician overseeing their care.
New recommendation Class D/GPP
UC18 Do not add antiseptic or antimicrobial
solutions to urinary drainage bags.
Class A
UC19 Routine daily personal hygiene is all
that is required for meatal cleansing.
Class AS8 H. P. Loveday et al. / Journal of Hospital Infection 86S1 (2014) S1–S70
Guidelines for preventing infections associated with Selection of catheter type
the use of intravascular access devices
IVAD6 Use a catheter with the minimum
This guidance is based on the best critically appraised number of ports or lumens essential for
evidence currently available. The type and class of supporting management of the patient.
evidence explicitly linked to each recommendation is des- Class A
cribed. Some recommendations from the previous guide-
lines have been revised to improve clarity; where a new IVAD7 Preferably use a designated single-
recommendation has been made, this is indicated in the text. lumen catheter to administer lipid-
These recommendations are not detailed procedural protocols, containing parenteral nutrition or other
and need to be incorporated into local guidelines. None are lipid-based solutions.
regarded as optional. Class D/GPP
IVAD8 Use a tunnelled or implanted
central venous access device with a
Education of healthcare workers and patients subcutaneous port for patients in whom
long-term vascular access is required.
IVAD1 Healthcare workers caring for patients Class A
with intravascular catheters should
be trained and assessed as competent IVAD9 Use a peripherally inserted central
in using and consistently adhering catheter for patients in whom medium-
to practices for the prevention of term intermittent access is required.
catheter-related bloodstream infection. New recommendation Class D/GPP
Class D/GPP
IVAD10 Use an antimicrobial-impregnated
IVAD2 Healthcare workers should be aware central venous access device for
of the manufacturer’s advice relating adult patients whose central venous
to individual catheters, connection catheter is expected to remain in
and administration set dwell time, place for >5 days if catheter-related
and compatibility with antiseptics and bloodstream infection rates remain
other uids to ensure the safe use of devices. above the locally agreed benchmark,
New recommendation Class D/GPP despite the implementation of a
comprehensive strategy to reduce
IVAD3 Before discharge from hospital, catheter-related bloodstream infection.
patients with intravascular catheters Class A
and their carers should be taught any
techniques they may need to use to
prevent infection and manage their device.
Class D/GPP Selection of catheter insertion site
IVAD11 In selecting an appropriate
intravascular insertion site, assess the
General asepsis risks for infection against the risks of
mechanical complications and patient comfort.
IVAD4 Hands must be decontaminated, Class D/GPP
with an alcohol-based hand rub or by
washing with liquid soap and water if IVAD12 Use the upper extremity for non-
soiled or potentially contaminated with tunnelled catheter placement unless
blood or body uids, before and after medically contraindicated.
any contact with the intravascular Class C
catheter or insertion site.
Class A
IVAD5 Use the aseptic technique for the Maximal sterile barrier precautions during catheter
insertion and care of an intravascular insertion
access device and when administering
intravenous medication. IVAD13 Use maximal sterile barrier precautions
Class B for the insertion of central venous access devices.
Class CH. P. Loveday et al. / Journal of Hospital Infection 86S1 (2014) S1–S70 S9
Cutaneous antisepsis IVAD21 Consider the use of daily cleansing with
chlorhexidine in adult patients with a
IVAD14 Decontaminate the skin at the insertion central venous catheter as a strategy
site with a single-use application of to reduce catheter-related bloodstream infection.
2% chlorhexidine gluconate in 70% New recommendation Class B
isopropyl alcohol (or povidone iodine in
alcohol for patients with sensitivity to IVAD22 Dressings used on tunnelled or
chlorhexidine) and allow to dry prior to implanted catheter insertion sites
the insertion of a central venous access device. should be replaced every 7 days until
Class A the insertion site has healed unless
there is an indication to change them
IVAD15 Decontaminate the skin at the insertion sooner. A dressing may no longer be
site with a single-use application of required once the insertion site has healed.
2% chlorhexidine gluconate in 70% Class D/GPP
isopropyl alcohol (or povidone iodine in
alcohol for patients with sensitivity to IVAD23 Use a single-use application of 2%
chlorhexidine) and allow to dry before chlorhexidine gluconate in 70%
inserting a peripheral vascular access device. isopropyl alcohol (or povidone iodine
New recommendation Class D/GPP in alcohol for patients with sensitivity
to chlorhexidine) to clean the central
IVAD16 Do not apply antimicrobial ointment catheter insertion site during dressing
routinely to the catheter placement changes, and allow to air dry.
site prior to insertion to prevent Class A
catheter-related bloodstream infection.
Class D/GPP IVAD24 Use a single-use application of 2%
chlorhexidine gluconate in 70%
isopropyl alcohol (or povidone iodine in
alcohol for patients with sensitivity to
Catheter and catheter site care chlorhexidine) to clean the peripheral
venous catheter insertion site during
IVAD17 Use a sterile, transparent, semi- dressing changes, and allow to air dry.
permeable polyurethane dressing to New recommendation Class D/GPP
cover the intravascular insertion site.
Class D/GPP IVAD25 Do not apply antimicrobial ointment
to catheter insertion sites as part of
IVAD18 Transparent, semi-permeable routine catheter site care.
polyurethane dressings should be Class D/GPP
changed every 7 days, or sooner, if
they are no longer intact or if moisture
collects under the dressing.
Class D/GPP Catheter replacement strategies
IVAD19 Use a sterile gauze dressing if a patient IVAD26 Do not routinely replace central venous
has profuse perspiration or if the access devices to prevent catheter-related infection.
insertion site is bleeding or leaking, Class A
and change when inspection of the
insertion site is necessary or when IVAD27 Do not use guidewire-assisted catheter
the dressing becomes damp, loosened exchange for patients with catheter-
or soiled. Replace with a transparent related bloodstream infection.
semi-permeable dressing as soon as possible. Class A
Class D/GPP
IVAD28 Peripheral vascular catheter insertion
IVAD20 Consider the use of a chlorhexidine- sites should be inspected at a minimum
impregnated sponge dressing in adult during each shift, and a Visual Infusion
patients with a central venous catheter Phlebitis score should be recorded.
as a strategy to reduce catheter- The catheter should be removed when
related bloodstream infection. complications occur or as soon as it is
New recommendation Class B no longer required.
New recommendation Class D/GPPS10 H. P. Loveday et al. / Journal of Hospital Infection 86S1 (2014) S1–S70
IVAD29 Peripheral vascular catheters should IVAD36 When safer sharps devices are used,
be re-sited when clinically indicated healthcare workers should ensure
and not routinely, unless device- that all components of the system are
specic recommendations from the compatible and secured to minimise
manufacturer indicate otherwise. leaks and breaks in the system.
New recommendation Class B Class D/GPP
IVAD37 Administration sets in continuous
use do not need to be replaced more
General principles for catheter management frequently than every 96 h, unless
device-specic recommendations from
IVAD30 A single-use application of 2% the manufacturer indicate otherwise,
chlorhexidine gluconate in 70% isopropyl they become disconnected or the
alcohol (or povidone iodine in alcohol for intravascular access device is replaced.
patients with sensitivity to chlorhexidine) Class A
should be used to decontaminate the
access port or catheter hub. The hub IVAD38 Administration sets for blood and blood
should be cleaned for a minimum of 15 s components should be changed when
and allowed to dry before accessing the system. the transfusion episode is complete or
Class D/GPP every 12 h (whichever is sooner).
Class D/GPP
IVAD31 Antimicrobial lock solutions should not
be used routinely to prevent catheter- IVAD39 Administration sets used for lipid-
related bloodstream infections. containing parenteral nutrition should
Class D/GPP be changed every 24 h.
Class D/GPP
IVAD32 Do not routinely administer intranasal
or systemic antimicrobials before IVAD40 Use quality improvement interventions
insertion or during the use of an to support the appropriate use and
intravascular device to prevent management of intravascular access
catheter colonisation or bloodstream infection. devices (central and peripheral venous
Class A catheters) and ensure their timely
removal. These may include:
IVAD33 Do not use systemic anticoagulants • protocols for device insertion and maintenance;
routinely to prevent catheter-related • reminders to review the continuing
bloodstream infection. use or prompt the removal of
Class D/GPP intravascular devices;
• audit and feedback of compliance
IVAD34 Use sterile normal saline for injection with practice guidelines; and
to ush and lock catheter lumens that • continuing professional education.
are accessed frequently. New recommendation Class C/GPP
Class A
IVAD35 The introduction of new intravascular
devices or components should be
monitored for an increase in the
occurrence of device-associated
infection. If an increase in infection
rates is suspected, this should be
reported to the Medicines and
Healthcare Products Regulatory Agency in the UK.
Class D/GPPH. P. Loveday et al. / Journal of Hospital Infection 86S1 (2014) S1–S70 S11
1.9 Introduction – the epic3 Guidelines What is the evidence for these guidelines?
National evidence-based guidelines for preventing HCAI The evidence for these guidelines was identied by multiple
in NHS hospitals were rst published in January 20011 and systematic reviews of peer-reviewed research. In addition,
updated in 2007.2 This second update was commissioned by the evidence from expert opinion as reected in systematically
Department of Health in 2012 for publication in 2013. identied professional, national and international guidelines
was considered following formal assessment using a validated
What are national evidence-based guidelines? appraisal tool.3 All evidence was critically appraised for its
methodological rigour and clinical practice applicability,
These are systematically developed broad statements and the best-available evidence inuenced the guideline
(principles) of good practice. They are driven by practice recommendations.
need, based on evidence and subject to multi-professional
debate, timely and frequent review, and modication. National Who developed these guidelines?
guidelines are intended to inform the development of detailed
operational protocols at local level, and can be used to ensure A team of specialist infection prevention and control
that these incorporate the most important principles for researchers and clinical specialists and a Guideline Development
preventing HCAI in the NHS and other acute healthcare settings. Advisory Group, comprising lay members and specialist clinical
practitioners, developed the epic3 guidelines (see Sections 1.1
Why do we need national guidelines for preventing and 1.2).
healthcare-associated infections?
Who are these guidelines for?
During the past two decades, HCAI have become a signicant
threat to patient safety. The technological advances made These guidelines can be appropriately adapted and
in the treatment of many diseases and disorders are often used by all hospital practitioners. This will inform the
undermined by the transmission of infections within healthcare development of more detailed local protocols and ensure
settings, particularly those caused by antimicrobial-resistant that important standard principles for infection prevention
strains of disease-causing microorganisms that are now are incorporated. Consequently, they are aimed at hospital
endemic in many healthcare environments. The nancial managers, members of hospital infection prevention and
and personal costs of these infections, in terms of the control teams, and individual healthcare practitioners.
economic consequences to the NHS and the physical, social At an individual level, they are intended to inuence the
and psychological costs to patients and their relatives, have quality and clinical effectiveness of infection prevention
increased both government and public awareness of the risks decision-making. The dissemination of these guidelines will
associated with healthcare interventions, especially the risk also help patients and carers/relatives to understand the
of acquiring a new infection. standard infection prevention precautions they can expect
Many, although not all, HCAI can be prevented. Clinical all healthcare workers to implement to protect them from
effectiveness (i.e. using prevention measures that are based HCAI.
on reliable evidence of efcacy) is a core component of an
effective strategy designed to protect patients from the risk How are these guidelines structured?
of infection, and when combined with quality improvement
methods can account for signicant reductions in HCAI such Each set of guidelines follows an identical format, which
as meticillin-resistant Staphylococcus aureus (MRSA) and consists of:
Clostridium difcile. • a brief introduction;
• the intervention heading;
What is the purpose of the guidelines? • a headline statement describing the key issues being
addressed;
These guidelines describe clinically effective measures that • a synthesis of the related evidence; and
are used by healthcare workers for preventing infections in • guideline recommendation(s) classied according to the
hospital and other acute healthcare settings. strength of the underpinning evidence.
What is the scope of the guidelines? How frequently are the guidelines reviewed and
updated?
Three sets of guidelines were developed originally and have
now been updated. They include: A cardinal feature of evidence-based guidelines is that
• standard infection control principles: including best practice they are subject to timely review in order that new research
recommendations for hospital environmental hygiene, evidence and technological advances can be identied,
effective hand hygiene, the appropriate use of PPE, the appraised and, if shown to be effective for the prevention of
safe use and disposal of sharps, and the principles of HCAI, incorporated into amended guidelines. The evidence
asepsis; base for these guidelines will be reviewed in 2 years (2015) and
• guidelines for preventing infections associated with the use the guidelines will be considered for updating approximately
of short-term indwelling urethral catheters; and 4 years after publication (2017). Following publication the
• guidelines for preventing infections associated with the use DH will ask the Advisory Group on Antimicrobial Resistance
of intravascular access devices. and Healthcare Associated Infection to advise whether theS12 H. P. Loveday et al. / Journal of Hospital Infection 86S1 (2014) S1–S70
evidence base has progressed signicantly to alter the guideline Searches were constructed using relevant MeSH (medical
recommendations and warrant an update. subject headings) and free-text terms. The following databases
were searched:
How can these guidelines be used to improve your • Medline;
clinical effectiveness? • Cumulated Index of Nursing and Allied Health Literature;
• Embase;
In addition to informing the development of detailed local • the Cochrane Library; and
operational protocols, these guidelines can be used as a • PsycINFO (only searched for hand hygiene).
benchmark for determining appropriate infection prevention
decisions and, as part of reective practice, to assess clinical Abstract review – identifying studies for appraisal
effectiveness. They also provide a baseline for clinical audit,
evaluation and education, and facilitate on-going quality Search results were downloaded into a Refworks™ database,
improvements. There are a number of audit tools available and titles and abstracts were printed for review. Titles and
locally, nationally and internationally that can be used to audit abstracts were assessed independently by two reviewers, and
compliance with guidance including high-impact intervention studies were retrieved where the title or abstract: addressed
tools for auditing care bundles. one or more of the review questions; identied primary
research or systematically conducted secondary research;
How much will it cost to implement these guidelines? or indicated a theoretical/clinical/in-use study. Where no
abstract was available and the title indicated one or more of
Signicant additional costs are not anticipated in imple- the above criteria, the study was retrieved. Due to the limited
menting these guidelines. However, where current equipment resources available for this review, foreign language studies
or resources do not facilitate the implementation of the were not identied for retrieval.
guidelines or where staff levels of adherence to current Full-text studies were retrieved and read in detail by two
guidance are poor, there may be an associated increase in costs. experienced reviewers; those meeting the study inclusion
Given the social and economic costs of HCAI, the consequences criteria were independently quality assessed for inclusion in
associated with not implementing these guidelines would be the systematic review.
unacceptable to both patients and healthcare professionals.
Quality assessment and data extraction
1.10 Guideline Development Methodology
Included studies were appraised using tools based on
The guidelines were developed using a systematic review systems developed by the Scottish Intercollegiate Guideline
process (Appendix A.1). In each set of guidelines, a summary of Network (SIGN) for study quality assessment.4 Studies were
the relevant guideline development methodology is provided. appraised independently by two reviewers and data were
extracted by one experienced reviewer. Any disagreement
Search process between reviewers was resolved through discussion. Evidence
tables were constructed from the quality assessments, and the
Electronic databases were searched for national and studies were summarised in adapted considered judgement
international guidelines and research studies published during forms. The evidence was classied using methods from SIGN,
the periods identied for each search question. A two-stage and adapted to include interrupted time series design and
search process was used. controlled before–after studies using criteria developed by the
Cochrane Effective Practice and Organisation of Care (EPOC)
Stage 1: Identication of systematic reviews and guidelines Group (Table 1).4,5 This system is similar that used in the
previous epic guidelines.2
For each set of epic guidelines, an electronic search was The evidence tables and considered judgement reports
conducted for systematic reviews of randomised controlled were presented to the Guideline Development Advisory Group
trials (RCTs) and current national and international guidelines. for discussion. The guidelines were drafted after extensive
International and national guidelines were retrieved and discussion.
subjected to critical appraisal using the AGREE II Instrument,3 Factors inuencing the guideline recommendations included:
an evaluation method used internationally for assessing the • the nature of the evidence;
methodological quality of clinical guidelines. • the applicability of the evidence to practice;
Following appraisal, accepted guidelines were included as • patient preference and acceptability; and
part of the evidence base supporting guideline development • costs and knowledge of healthcare systems.
and, where appropriate, for delineating search limits. They The classication scheme adopted by SIGN was used to
were also used to verify professional consensus and, in some dene the strength of recommendation (Table 2).4
instances, as the primary source of evidence.
Stage 2: Systematic search for additional evidence
Review questions for the systematic reviews of the literature
were developed for each set of epic guideline topics following
recommendations from scientic advisors and the Guideline
Development Advisory Group.H. P. Loveday et al. / Journal of Hospital Infection 86S1 (2014) S1–S70 S13
Table 1 1.11 Consultation Process
Levels of evidence for intervention studies5
1++ High-quality meta-analyses, systematic reviews of RCTs or These guidelines have been subject to extensive external
RCTs with a very low risk of bias consultation with key stakeholders, including Royal Colleges,
1+ Well-conducted meta-analyses, systematic reviews or professional societies and organisations, patients and trade
RCTs with a low risk of bias unions (Appendix A.2). Comments were requested on:
1- Meta-analyses, systematic reviews or RCTs with a high risk • format;
of bias* • content;
2++ High-quality systematic reviews of case–control or cohort • practice applicability of the guidelines;
studies. • patient preference and acceptability; and
High-quality case–control or cohort studies with a very • specic sections or recommendations.
low risk of confounding or bias and a high probability All the comments were collated and sent to the scientic
that the relationship is causal.
advisors and the Guideline Development Advisory Group for
Interrupted time series with a control group: (i) there is a
clearly dened point in time when the intervention
consideration prior to virtual meetings for discussion and
occurred; and (ii) at least three data points before and agreement on any changes in the light of comments. Final
three data points after the intervention agreement was sought from the scientic advisors and the
2+ Well-conducted case–control or cohort studies with a low Guideline Development Advisory Group following revision.
risk of confounding or bias and a moderate probability
that the relationship is causal.
Controlled before–after studies with two or more
intervention and control sites
2- Case–control or cohort studies with a high risk of
confounding or bias and a signicant risk that the
relationship is not causal.
Interrupted time series without a parallel control group:
(i) there is a clearly dened point in time when the
intervention occurred; and (ii) at least three data points
before and three data points after the intervention.
Controlled before–after studies with one intervention and
one control site
3 Non-analytic studies (e.g. uncontrolled before–after
studies, case reports, case series)
4 Expert opinion.
Legislation
*Studies with an evidence level of ‘1-‘ and ‘2-‘ should not be
used as a basis for making a recommendation.
RCT, randomised controlled trial.
Table 2
Classication of recommendations4
A At least one meta-analysis, systematic review or RCT
rated as 1++, and directly applicable to the target
population; or
A body of evidence consisting principally of studies
rated as 1+, directly applicable to the target
population, and demonstrating overall consistency of
results
B A body of evidence including studies rated as 2++,
directly applicable to the target population, and
demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C A body of evidence including studies rated as 2+,
directly applicable to the target population and
demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Recommended best practice based on the clinical
Practice experience of the Guideline Development Advisory
Points Group and patient preference and experience
IP Recommendation from NICE Interventional Procedures
guidance
RCT, randomised controlled trial; NICE, National Institute for
Health and Clinical Excellence.S14 H. P. Loveday et al. / Journal of Hospital Infection 86S1 (2014) S1–S70
2 Standard Principles for Preventing Enhanced cleaning describes the use of methods in addition
Healthcare-Associated Infections in Hospital and to standard cleaning specications. These may include
increased cleaning frequency for all or some surfaces, or the
Other Acute Care Settings use of additional cleaning equipment. Enhanced cleaning
may be applied to all areas of the healthcare environment or
2.1 Introduction in specic circumstances, such as cleaning of rooms or bed
spaces following the transfer or discharge of patients who are
This guidance is based on the best critically appraised colonised or infected with a pathogenic microorganism. This is
evidence currently available. The type and class of supporting sometimes referred to as ‘terminal cleaning’.
evidence explicitly linked to each recommendation is Disinfection is the use of chemical or physical methods to
described. Some recommendations from the previous guide- reduce the number of pathogenic microorganisms on surfaces.
lines have been revised to improve clarity; where a new These methods need to be used in combination with cleaning
recommendation has been made, this is indicated in the text. as they have limited ability to penetrate organic material. The
These recommendations are not detailed procedural protocols, term ‘decontamination’ is used for the process that results in
and need to be incorporated into local guidelines. None are the removal of hazardous substances (e.g. microorganisms,
regarded as optional. chemicals) and therefore may apply to cleaning or disinfection.
Standard infection control precautions need to be applied Research evidence in this eld remains largely limited
by all healthcare practitioners to the care of all patients (i.e. to ecological studies and weak quasi-experimental and
adults, children and neonates). The recommendations are observational study designs. There is evidence from outbreak
divided into ve distinct interventions: reports and observational research which demonstrates
• hospital environmental hygiene; that the hospital environment becomes contaminated with
• hand hygiene; microorganisms responsible for HCAI. Pathogens may be
• use of PPE; recovered from a variety of surfaces in clinical environments,
• safe use and disposal of sharps; and including those near to the patient that are touched frequently
• principles of asepsis. by healthcare workers.11–20 However, no studies have provided
These guidelines do not address the additional infection high-quality evidence of direct transmission of the same strain
control requirements of specialist settings, such as the of microorganisms found in the environment to those found in
operating department or outbreak situations. colonised or infected patients.
We identied one prospective cohort study that found a
signicant independent association between acquisition of
2.2 Hospital Environmental Hygiene two multi-drug-resistant pathogens and a prior room occupant
with the same organism [multi-drug-resistant Pseudomonas
Hospital hygiene is important for the prevention of aeruginosa odds ratio (OR) 2.3, 95% condence interval (CI)
healthcare-associated infections in hospitals 1.2–4.3, p=0.012; multi-drug-resistant Acinetobacter baumanii
OR 4.2, 95% CI 1.1–1.3, p=0.04] after adjustment for severity of
This section discusses the evidence upon which recom- underlying illness, comorbidities, antimicrobial exposure and
mendations for hospital environmental hygiene are based. some other risk factors.21 A further study reported an association
The evidence identied in the previous systematic review was between MRSA and vancomycin-resistant enterococcus (VRE),22
used as the basis for updating the searches, and searches were but conclusions that can be drawn from the ndings are limited
conducted for new evidence published since 2006.2 Hospital by the retrospective study design and lack of adjustment
environmental hygiene encompasses a wide range of routine for severity of underlying illness, colonisation pressure and
activities. Guidelines are provided here for: antibiotic exposure. Similarly, another retrospective cohort
• cleaning the general hospital environment; study found an association between acquisition of C. difcile
• cleaning items of shared equipment; and and prior room occupant with the same infection; however,
• education and training of staff. this was based solely on clinical diagnosis rather than active
surveillance.23
Maintain a clean hospital environment Many microorganisms recovered from the hospital
environment do not cause HCAI. Cleaning will not completely
Current legislation, regulatory frameworks and quality eliminate microorganisms from environmental surfaces, and
standards emphasise the importance of the healthcare reductions in their numbers will be transient.15 There is some
environment and shared clinical equipment being clean and evidence that enhanced cleaning regimens are associated
properly decontaminated to minimise the risk of transmission with the control of outbreaks of HCAI;24 however, these study
of HCAI and to maintain public condence.6–10 Patients and designs do not provide robust evidence of cause and effect.
their relatives expect the healthcare environment to be clean Enhanced cleaning has been recommended, particularly
and infection hazards to be controlled adequately.9 ‘terminal cleaning’, after a bed area has been used by a
The term ‘cleaning’ is used to describe the physical removal patient colonised or infected with an HCAI. We searched for
of soil, dirt or dust from surfaces. Conventionally, this is robust evidence from studies conducted in the healthcare
achieved in healthcare settings using cloths and mops. Dust may environment which demonstrated cleaning interventions
be removed using dry dust-control mops/cloths. Detergent and that were associated with reductions in both environmental
water is used for cleaning of soiled or contaminated surfaces, contamination and HCAI. A randomised crossover study of daily
although microbre cloths and water can also be used for enhanced cleaning of high-touch surfaces in an intensive care
surface cleaning.9 unit (ICU) demonstrated a reduction in the daily number ofYou can also read
