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epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England

      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 first published in January 2001
      • Pratt RJ
      • Pellowe C
      • Loveday HP
      • Department of Health (England)
      • et al.
      The epic project: developing national evidence-based guidelines for preventing healthcare associated infections. Phase I: Guidelines for preventing hospital-acquired infections.
      and updated in 2007.
      • Pratt RJ
      • Pellowe CM
      • Wilson JA
      • et al.
      epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
      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.
      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

      1. Introductory Section

      1.1 Guideline Development Team

      • Professor Heather P. Loveday (Project Lead), Professor of Evidence-based Healthcare, College of Nursing, Midwifery and Healthcare, University of West London (London) (HL).
      • Ms Jennie A. Wilson, Reader, Healthcare Epidemiology, University of West London (London) (JW).
      • Dr Jacqui Prieto, Senior Clinical Academic Research Fellow, University of Southampton (Southampton).
      • Professor Mark Wilcox, Professor of Medical Microbiology, University of Leeds (Leeds) (MW).
      • Professor Robert J. Pratt CBE, Professor of Nursing, University of West London (London).
      • Ms Aggie Bak, Research Assistant, University of West London (London).
      • Ms Jessica Browne, Research Assistant, University of West London (London).
      • Ms Sharon Elliott, Senior Lecturer (Director Clinical Simulation), University of West London (London).
      • Ms Mana Golsorkhi, Research Assistant, University of West London (London).
      • Mr Roger King, Lecturer (Operating Department Practice), University of West London (London).
      • Ms Caroline Smales, Senior Lecturer (Infectious Diseases), University of West London (London).
      • Ms Alison Tingle, Principal Research Programme Officer, University of West London (London).

      1.2 Guideline Advisory Group

      • Dr Debra Adams, NHS Trust Development Authority (DA)
      • Ms Susan Bennett, Lay Member (SB)
      • Dr Tim Boswell, Nottingham University Hospitals NHS Trust (TB)
      • Ms Maria Cann, Lay Member (MC)
      • Ms Tracey Cooper, South London NHS Trust (TC)
      • Dr Peter Cowling, Northern Lincolnshire & Goole Hospitals NHS Trust
      • Ms Judith Hudson, Association of Healthcare Cleaning Professionals
      • Ms Theresa Neale, Urology Nurse Specialist, British Association of Urological Nurses (Consultant)
      • Dr Jeff Phillips, Consultant Intensivist and Clinical Lead for Anaesthetics (Consultant) (JPh), Princess Alexandra Hospital Harlow
      • Dr Jacqui Prieto, University of Southampton (Infection Prevention Adviser)
      • Mr Julian Shah, Consultant Urologist (Consultant), King Edward VII Hospital, London
      • Professor Mark Wilcox, Leeds Teaching Hospitals and University of Leeds
      • Ms Carole Fry, Department of Health (Observer)
      • Professor Brian I. Duerden CBE, Duerden Microbiology Consulting Ltd (Chair of Face-to-Face Meeting)
      • Ms Meg Morse, Administrative Officer, University of West London

      1.3 Acknowledgements

      We would like to acknowledge the assistance of the Infection Prevention Society, British Infection Association and the Healthcare Infection Society for their input into the development of these guidelines; and other associations, learned societies, professional organisations, Royal Colleges and patient groups who took an active role in the external review of the guidelines. We would also like to acknowledge the support received from Professor Brian Duerden CBE in chairing the Guideline Development Advisory Group, and Carole Fry in the Chief Medical Officer's Team at the Department of Health (England).

      1.4 Source of Funding

      The Department of Health (England).

      1.5 Disclosure of Potential Conflict of Interest

      HL: Trustee and Director of the International Clinical Virology Centre and the Infection Prevention Society; educational grant from Care Fusion to attend SHEA conference in April 2010 and consultancy for GAMA Healthcare Ltd in January 2012.
      JW: Trustee of the Infection Prevention Society; consultancy for Care Fusion and ICNet.
      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 Sanofi, BD, Smiths-Industry; consultancy from NHS Midlands and East; PhD supported by an education grant from BD and Enturia.
      TB: Advisor to Fresenius Medical Care Renal Services and Nottingham Woodthorpe Hospital (Ramsay Healthcare); sponsored speaker for Advanced Sterilisation Products.
      SB: Member of NICE Medical Technology Advisory Committee; former trustee of Bladder and Bowel Foundation; sponsorship from a number of urinary catheter manufacturers; Urology Trade Association; Bladder and Bowel Foundation representative on the Urology User Group Coalition.
      MC: Trustee of MRSA Action UK; conference attendances sponsored by Mölnlycke Healthcare.
      All other authors: no conflicts declared.

      1.6 Relationship of Author(s) with Sponsor

      The Department of Health (England) commissioned the authors to update the evidence and guideline recommendations previously developed by them and published as the epic2 guidelines in the Journal of Hospital Infection in 2007.

      1.7 Responsibility for Guidelines

      The views expressed in this publication are those of the authors and, following extensive consultation, have been endorsed by the Department of Health (England).

      1.8 Summary of Guidelines

      Standard principles for preventing healthcare-associated infections in hospital and other acute care settings

      This guidance is based on the best critically appraised evidence currently available. The type and class of supporting evidence explicitly linked to each recommendation is described. 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 into local guidelines. None are regarded as optional.
      Standard infection control precautions need to be applied by all healthcare practitioners to the care of all patients (i.e. adults, children and neonates). The recommendations are divided into five distinct interventions:
      • hospital environmental hygiene;
      • hand hygiene;
      • use of personal protective equipment (PPE);
      • safe use and disposal of sharps; and
      • principles of asepsis.
      These guidelines do not address the additional infection control requirements of specialist settings, such as the operating department or outbreak situations.

      Hospital environmental hygiene

      • SP1
        The hospital environment must be visibly clean; free from non-essential items and equipment, dust and dirt; and acceptable to patients, visitors and staff.
        Class D/GPP
      • SP2
        Levels of cleaning should be increased in cases of infection and/or colonisation when a suspected or known pathogen can survive in the environment, and environmental contamination may contribute to the spread of infection.
        Class D/GPP
      • SP3
        The use of disinfectants should be considered for cases of infection and/or colonisation when a suspected or known pathogen can survive in the environment, and environmental contamination may contribute to the spread of infection.
        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/GPP
      • SP5
        All healthcare workers need to be educated about the importance of maintaining a clean and safe care environment for patients. Every healthcare worker needs to know their specific responsibilities for cleaning and decontaminating the clinical environment and the equipment used in patient care.
        Class D/GPP

      Hand hygiene

      • SP6
        Hands must be decontaminated:
        • immediately before each episode of direct patient contact or care, including clean/aseptic procedures;
        • immediately after each episode of direct patient contact or care;
        • immediately after contact with body fluids, mucous membranes and non-intact skin;
        • immediately after other activities or contact with objects and equipment in the immediate patient environment that may result in the hands becoming contaminated; and
        • immediately after the removal of gloves.
        Class C
      • SP7
        Use an alcohol-based hand rub for decontamination of hands before and after direct patient contact and clinical care, except in the following situations when soap and water must be used:
        • when hands are visibly soiled or potentially contaminated with body fluids; and
        • when caring for patients with vomiting or diarrhoeal illness, regardless of whether or not gloves have been worn.
        Class A
      • SP8
        Healthcare workers should ensure that their hands can be decontaminated effectively by:
        • removing all wrist and hand jewellery;
        • wearing short-sleeved clothing when delivering patient care;
        • making sure that fingernails are short, clean, and free from false nails and nail polish; and
        • covering cuts and abrasions with waterproof dressings.
        Class D/GPP
      • SP9
        Effective handwashing technique involves three stages: preparation, washing and rinsing, and drying.
        • Preparation: wet hands under tepid running water before applying the recommended amount of liquid soap or an antimicrobial preparation.
        • Washing: the handwash solution must come into contact with all of the surfaces of the hand. The hands should be rubbed together vigorously for a minimum of 10–15 s, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers. Hands should be rinsed thoroughly.
        • Drying: use good-quality paper towels to dry the hands thoroughly.
        Class D/GPP
      • SP10
        When decontaminating hands using an alcohol-based hand rub, hands should be free of dirt and organic material, and:
        • hand rub solution must come into contact with all surfaces of the hand; and
        • hands should be rubbed together vigorously, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers, until the solution has evaporated and the hands are dry.
        Class D/GPP
      • SP11
        Clinical staff should be made aware of the potentially damaging effects of hand decontamination products, and encouraged to use an emollient hand cream regularly to maintain the integrity of the skin. Consult the occupational health team or a general practitioner if a particular liquid soap, antiseptic handwash or alcohol-based hand rub causes skin irritation.
        Class D/GPP
      • SP12
        Alcohol-based hand rub should be made available at the point of care in all healthcare facilities.
        Class C
      • SP13
        Hand hygiene resources and healthcare worker adherence to hand hygiene guidelines should be audited at regular intervals, and the results should be fed back to healthcare workers to improve and sustain high levels of compliance.
        Class C
      • SP14
        Healthcare organisations must provide regular training in risk assessment, effective hand hygiene and glove use for all healthcare workers.
        Class D/GPP
      • SP15
        Local programmes of education, social marketing, and audit and feedback should be refreshed regularly and promoted by senior managers and clinicians to maintain focus, engage staff and produce sustainable levels of compliance.
        New recommendation Class C
      • SP16
        Patients and relatives should be provided with information about the need for hand hygiene and how to keep their own hands clean.
        New recommendation Class D/GPP
      • SP17
        Patients should be offered the opportunity to clean their hands before meals; after using the toilet, commode or bedpan/urinal; and at other times as appropriate. Products available should be tailored to patient needs and may include alcohol-based hand rub, hand wipes and access to handwash basins.
        New recommendation Class D/GPP

      Use of personal protective equipment

      • SP18
        Selection of personal protective equipment must be based on an assessment of the:
        • risk of transmission of microorganisms to the patient or carer;
        • risk of contamination of healthcare practitioners' clothing and skin by patients' blood or body fluids; and
        • suitability of the equipment for proposed use.
        Class D/GPP/H&S
      • SP19
        Healthcare workers should be educated and their competence assessed in the:
        • assessment of risk;
        • selection and use of personal protective equipment; and
        • use of standard precautions.
        Class D/GPP/H&S
      • SP20
        Supplies of personal protective equipment should be made available wherever care is delivered and risk assessment indicates a requirement.
        Class D/GPP/H&S
      • SP21
        Gloves must be worn for:
        • invasive procedures;
        • contact with sterile sites and non-intact skin or mucous membranes;
        • all activities that have been assessed as carrying a risk of exposure to blood or body fluids; and
        • when handling sharps or contaminated devices.
        Class D/GPP/H&S
      • SP22
        Gloves must be:
        • worn as single-use items;
        • put on immediately before an episode of patient contact or treatment;
        • removed as soon as the episode is completed;
        • changed between caring for different patients; and
        • disposed of into the appropriate waste stream in accordance with local policies for waste management.
        Class D/GPP/H&S
      • SP23
        Hands must be decontaminated immediately after gloves have been removed.
        Class D/GPP/H&S
      • SP24
        A range of CE-marked medical and protective gloves that are acceptable to healthcare personnel and suitable for the task must be available in all clinical areas.
        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.
        Class D/GPP/H&S
      • SP26
        Disposable plastic aprons must be worn when close contact with the patient, materials or equipment pose a risk that clothing may become contaminated with pathogenic microorganisms, blood or body fluids.
        Class D/GPP/H&S
      • SP27
        Full-body fluid-repellent gowns must be worn where there is a risk of extensive splashing of blood or body fluids on to the skin or clothing of healthcare workers.
        Class D/GPP/H&S
      • SP28
        Plastic aprons/fluid-repellent gowns should be worn as single-use items for one procedure or episode of patient care, and disposed of into the appropriate waste stream in accordance with local policies for waste management. When used, non-disposable protective clothing should be sent for laundering.
        Class D/GPP/H&S
      • SP29
        Fluid-repellent surgical face masks and eye protection must be worn where there is a risk of blood or body fluids splashing into the face and eyes.
        Class D/GPP H&S
      • SP30
        Appropriate respiratory protective equipment should be selected according to a risk assessment that takes account of the infective microorganism, the anticipated activity and the duration of exposure.
        Class D/GPP/H&S
      • SP31
        Respiratory protective equipment must fit the user correctly and they must be trained in how to use and adjust it in accordance with health and safety regulations.
        Class D/GPP/H&S
      • SP32
        Personal protective equipment should be removed in the following sequence to minimise the risk of cross/self-contamination:
        • gloves;
        • apron;
        • eye protection (when worn); and
        • mask/respirator (when worn). Hands must be decontaminated following the removal of personal protective equipment.
        New recommendation Class D/GPP/H&S

      Safe use and disposal of sharps

      • SP33
        Sharps must not be passed directly from hand to hand, and handling should be kept to a minimum.
        Class D/GPP/H&S
      • SP34
        Needles must not be recapped, bent or disassembled after use.
        Class D/GPP/H&S
      • SP35
        Used sharps must be discarded at the point of use by the person generating the waste.
        Class D/GPP/H&S
      • SP36
        All sharps containers must:
        • conform to current national and international standards;
        • be positioned safely, away from public areas and out of the reach of children, and at a height that enables safe disposal by all members of staff;
        • be secured to avoid spillage;
        • be temporarily closed when not in use;
        • not be filled above the fill line; and
        • be disposed of when the fill line is reached.
        Class D/GPP/H&S
      • SP37
        All clinical and non-clinical staff must be educated about the safe use and disposal of sharps and the action to be taken in the event of an injury.
        Class D/GPP/H&S
      • SP38
        Use safer sharps devices where assessment indicates that they will provide safe systems of working for healthcare workers.
        Class C/H&S
      • SP39
        Organisations should involve end-users in evaluating safer sharps devices to determine their effectiveness, acceptability to practitioners, impact on patient care and cost benefit prior to widespread introduction.
        Class D/GPP/H&S

      Asepsis

      • SP40
        Organisations should provide education to ensure that healthcare workers are trained and competent in performing the aseptic technique.
        New recommendation Class D/GPP
      • SP41
        The aseptic technique should be used for any procedure that breaches the body's natural defences, including:
        • insertion and maintenance of invasive devices;
        • infusion of sterile fluids and medication; and
        • care of wounds and surgical incisions.
        New recommendation Class D/GPP

      Guidelines for preventing infections associated with the use of short-term indwelling urethral catheters

      This guidance is based on the best critically appraised evidence currently available. The type and class of supporting evidence explicitly linked to each recommendation is described. 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 into local guidelines. None are regarded as optional.
      These guidelines apply to adults and children aged ≥1 year who require a short-term indwelling urethral catheter (≤28 days), and should be read in conjunction with the guidance on Standard Principles. The recommendations are divided into six distinct interventions:
      • assessing the need for catheterisation;
      • selection of catheter type and system;
      • catheter insertion;
      • catheter maintenance;
      • education of patients, relatives and healthcare workers; and
      • system interventions for reducing the risk of infection.

      Assessing the need for catheterisation

      • UC1
        Only use a short-term indwelling urethral catheter in patients for whom it is clinically indicated, following assessment of alternative methods and discussion with the patient.
        Class D/GPP
      • UC2
        Document the clinical indication(s) for catheterisation, date of insertion, expected duration, type of catheter and drainage system, and planned date of removal.
        Class D/GPP
      • UC3
        Assess and record the reasons for catheterisation every day. Remove the catheter when no longer clinically indicated.
        Class D/GPP

      Selection of catheter type

      • UC4
        Assess patient's needs prior to catheterisation in terms of:
        • latex allergy;
        • length of catheter (standard, female, paediatric);
        • type of sterile drainage bag and sampling port (urometer, 2-L bag, leg bag) or catheter valve; and
        • comfort and dignity.
        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.
        Class D/GPP
      • UC6
        Select the smallest gauge catheter that will allow urinary outflow and use a 10-mL retention balloon in adults (follow manufacturer's instructions for paediatric catheters). Urological patients may require larger gauge sizes and balloons.
        Class D/GPP

      Catheter insertion

      • UC7
        Catheterisation is an aseptic procedure and should only be undertaken by healthcare workers trained and competent in this procedure.
        Class D/GPP
      • UC8
        Clean the urethral meatus with sterile, normal saline prior to the insertion of the catheter.
        Class D/GPP
      • UC9
        Use lubricant from a sterile single-use container to minimise urethral discomfort, trauma and the risk of infection. Ensure the catheter is secured comfortably.
        Class D/GPP

      Catheter maintenance

      • UC10
        Connect a short-term indwelling urethral catheter to a sterile closed urinary drainage system with a sampling port.
        Class A
      • UC11
        Do not break the connection between the catheter and the urinary drainage system unless clinically indicated.
        Class A
      • UC12
        Change short-term indwelling urethral catheters and/or drainage bags when clinically indicated and in line with the manufacturer's recommendations.
        New recommendation Class D/GPP
      • UC13
        Decontaminate hands and wear a new pair of clean non-sterile gloves before manipulating each patient's catheter. Decontaminate hands immediately following the removal of gloves.
        Class D/GPP
      • UC14
        Use the sampling port and the aseptic technique to obtain a catheter sample of urine.
        Class D/GPP
      • UC15
        Position the urinary drainage bag below the level of the bladder on a stand that prevents contact with the floor.
        Class D/GPP
      • UC16
        Do not allow the urinary drainage bag to fill beyond three-quarters full.
        Class D/GPP
      • UC17
        Use a separate, clean container for each patient and avoid contact between the urinary drainage tap and the container when emptying the drainage bag.
        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 A

      Education of patients, relatives and healthcare workers

      • UC20
        Do not use bladder maintenance solutions to prevent catheter-associated infection.
        Class A
      • UC21
        Healthcare workers should be trained and competent in the appropriate use, selection, insertion, maintenance and removal of short-term indwelling urethral catheters.
        Class D/GPP
      • UC22
        Ensure patients, relatives and carers are given information regarding the reason for the catheter and the plan for review and removal. If discharged with a catheter, the patient should be given written information and shown how to:
        • manage the catheter and drainage system;
        • minimise the risk of urinary tract infection; and
        • obtain additional supplies suitable for individual needs.
        Class D/GPP

      System interventions for reducing the risk of infection

      • UC23
        Use quality improvement systems to support the appropriate use and management of short-term urethral catheters and ensure their timely removal. These may include:
        • protocols for catheter insertion;
        • use of bladder ultrasound scanners to assess and manage urinary retention;
        • reminders to review the continuing use or prompt the removal of catheters;
        • audit and feedback of compliance with practice guidelines; and
        • continuing professional education
        New recommendation Class D/GPP
      • UC24
        No patient should be discharged or transferred with a short-term indwelling urethral catheter without a plan documenting the:
        • reason for the catheter;
        • clinical indications for continuing catheterisation; and
        • date for removal or review by an appropriate clinician overseeing their care.
        New recommendation Class D/GPP

      Guidelines for preventing infections associated with the use of intravascular access devices

      This guidance is based on the best critically appraised evidence currently available. The type and class of supporting evidence explicitly linked to each recommendation is described. 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 into local guidelines. None are regarded as optional.

      Education of healthcare workers and patients

      • IVAD1
        Healthcare workers caring for patients with intravascular catheters should be trained and assessed as competent in using and consistently adhering to practices for the prevention of catheter-related bloodstream infection.
        Class D/GPP
      • IVAD2
        Healthcare workers should be aware of the manufacturer's advice relating to individual catheters, connection and administration set dwell time, and compatibility with antiseptics and other fluids to ensure the safe use of devices.
        New recommendation Class D/GPP
      • IVAD3
        Before discharge from hospital, patients with intravascular catheters and their carers should be taught any techniques they may need to use to prevent infection and manage their device.
        Class D/GPP

      General asepsis

      • IVAD4
        Hands must be decontaminated, with an alcohol-based hand rub or by washing with liquid soap and water if soiled or potentially contaminated with blood or body fluids, before and after any contact with the intravascular catheter or insertion site.
        Class A
      • IVAD5
        Use the aseptic technique for the insertion and care of an intravascular access device and when administering intravenous medication.
        Class B

      Selection of catheter type

      • IVAD6
        Use a catheter with the minimum number of ports or lumens essential for management of the patient.
        Class A
      • IVAD7
        Preferably use a designated single-lumen catheter to administer lipid-containing parenteral nutrition or other lipid-based solutions.
        Class D/GPP
      • IVAD8
        Use a tunnelled or implanted central venous access device with a subcutaneous port for patients in whom long-term vascular access is required.
        Class A
      • IVAD9
        Use a peripherally inserted central catheter for patients in whom medium-term intermittent access is required.
        New recommendation Class D/GPP
      • IVAD10
        Use an antimicrobial-impregnated central venous access device for adult patients whose central venous catheter is expected to remain in place for >5 days if catheter-related bloodstream infection rates remain above the locally agreed benchmark, despite the implementation of a comprehensive strategy to reduce catheter-related bloodstream infection.
        Class A

      Selection of catheter insertion site

      • IVAD11
        In selecting an appropriate intravascular insertion site, assess the risks for infection against the risks of mechanical complications and patient comfort.
        Class D/GPP
      • IVAD12
        Use the upper extremity for non-tunnelled catheter placement unless medically contraindicated.
        Class C

      Maximal sterile barrier precautions during catheter insertion

      • IVAD13
        Use maximal sterile barrier precautions for the insertion of central venous access devices.
        Class C

      Cutaneous antisepsis

      • IVAD14
        Decontaminate the skin at the insertion site with a single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol (or povidone iodine in alcohol for patients with sensitivity to chlorhexidine) and allow to dry prior to the insertion of a central venous access device.
        Class A
      • IVAD15
        Decontaminate the skin at the insertion site with a single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol (or povidone iodine in alcohol for patients with sensitivity to chlorhexidine) and allow to dry before inserting a peripheral vascular access device.
        New recommendation Class D/GPP
      • IVAD16
        Do not apply antimicrobial ointment routinely to the catheter placement site prior to insertion to prevent catheter-related bloodstream infection.
        Class D/GPP

      Catheter and catheter site care

      • IVAD17
        Use a sterile, transparent, semi-permeable polyurethane dressing to cover the intravascular insertion site.
        Class D/GPP
      • IVAD18
        Transparent, semi-permeable polyurethane dressings should be changed every 7 days, or sooner, if they are no longer intact or if moisture collects under the dressing.
        Class D/GPP
      • IVAD19
        Use a sterile gauze dressing if a patient has profuse perspiration or if the insertion site is bleeding or leaking, and change when inspection of the insertion site is necessary or when the dressing becomes damp, loosened or soiled. Replace with a transparent semi-permeable dressing as soon as possible.
        Class D/GPP
      • IVAD20
        Consider the use of a chlorhexidine-impregnated sponge dressing in adult patients with a central venous catheter as a strategy to reduce catheter-related bloodstream infection.
        New recommendation Class B
      • IVAD21
        Consider the use of daily cleansing with chlorhexidine in adult patients with a central venous catheter as a strategy to reduce catheter-related bloodstream infection.
        New recommendation Class B
      • IVAD22
        Dressings used on tunnelled or implanted catheter insertion sites should be replaced every 7 days until the insertion site has healed unless there is an indication to change them sooner. A dressing may no longer be required once the insertion site has healed.
        Class D/GPP
      • IVAD23
        Use a single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol (or povidone iodine in alcohol for patients with sensitivity to chlorhexidine) to clean the central catheter insertion site during dressing changes, and allow to air dry.
        Class A
      • IVAD24
        Use a single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol (or povidone iodine in alcohol for patients with sensitivity to chlorhexidine) to clean the peripheral venous catheter insertion site during dressing changes, and allow to air dry.
        New recommendation Class D/GPP
      • IVAD25
        Do not apply antimicrobial ointment to catheter insertion sites as part of routine catheter site care.
        Class D/GPP

      Catheter replacement strategies

      • IVAD26
        Do not routinely replace central venous access devices to prevent catheter-related infection.
        Class A
      • IVAD27
        Do not use guidewire-assisted catheter exchange for patients with catheter-related bloodstream infection.
        Class A
      • IVAD28
        Peripheral vascular catheter insertion sites should be inspected at a minimum during each shift, and a Visual Infusion Phlebitis score should be recorded. The catheter should be removed when complications occur or as soon as it is no longer required.
        New recommendation Class D/GPP
      • IVAD29
        Peripheral vascular catheters should be re-sited when clinically indicated and not routinely, unless device-specific recommendations from the manufacturer indicate otherwise.
        New recommendation Class B

      General principles for catheter management

      • IVAD30
        A single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol (or povidone iodine in alcohol for patients with sensitivity to chlorhexidine) should be used to decontaminate the access port or catheter hub. The hub should be cleaned for a minimum of 15 s and allowed to dry before accessing the system.
        Class D/GPP
      • IVAD31
        Antimicrobial lock solutions should not be used routinely to prevent catheter-related bloodstream infections.
        Class D/GPP
      • IVAD32
        Do not routinely administer intranasal or systemic antimicrobials before insertion or during the use of an intravascular device to prevent catheter colonisation or bloodstream infection.
        Class A
      • IVAD33
        Do not use systemic anticoagulants routinely to prevent catheter-related bloodstream infection.
        Class D/GPP
      • IVAD34
        Use sterile normal saline for injection to flush and lock catheter lumens that are accessed frequently.
        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/GPP
      • IVAD36
        When safer sharps devices are used, healthcare workers should ensure that all components of the system are compatible and secured to minimise leaks and breaks in the system.
        Class D/GPP
      • IVAD37
        Administration sets in continuous use do not need to be replaced more frequently than every 96 h, unless device-specific recommendations from the manufacturer indicate otherwise, they become disconnected or the intravascular access device is replaced.
        Class A
      • IVAD38
        Administration sets for blood and blood components should be changed when the transfusion episode is complete or every 12 h (whichever is sooner).
        Class D/GPP
      • IVAD39
        Administration sets used for lipid-containing parenteral nutrition should be changed every 24 h.
        Class D/GPP
      • IVAD40
        Use quality improvement interventions to support the appropriate use and management of intravascular access devices (central and peripheral venous catheters) and ensure their timely removal. These may include:
        • protocols for device insertion and maintenance;
        • reminders to review the continuing use or prompt the removal of intravascular devices;
        • audit and feedback of compliance with practice guidelines; and
        • continuing professional education.
        New recommendation Class C/GPP

      1.9 Introduction – the epic3 Guidelines

      National evidence-based guidelines for preventing HCAI in NHS hospitals were first published in January 2001
      • Pratt RJ
      • Pellowe C
      • Loveday HP
      • Department of Health (England)
      • et al.
      The epic project: developing national evidence-based guidelines for preventing healthcare associated infections. Phase I: Guidelines for preventing hospital-acquired infections.
      and updated in 2007.
      • Pratt RJ
      • Pellowe CM
      • Wilson JA
      • et al.
      epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
      This second update was commissioned by the Department of Health in 2012 for publication in 2013.

      What are national evidence-based guidelines?

      These are systematically developed broad statements (principles) of good practice. They are driven by practice need, based on evidence and subject to multi-professional debate, timely and frequent review, and modification. National guidelines are intended to inform the development of detailed operational protocols at local level, and can be used to ensure that these incorporate the most important principles for preventing HCAI in the NHS and other acute healthcare settings.

      Why do we need national guidelines for preventing healthcare-associated infections?

      During the past two decades, HCAI have become a significant threat to patient safety. The technological advances made in the treatment of many diseases and disorders are often undermined by the transmission of infections within healthcare settings, particularly those caused by antimicrobial-resistant strains of disease-causing microorganisms that are now endemic in many healthcare environments. The financial and personal costs of these infections, in terms of the economic consequences to the NHS and the physical, social and psychological costs to patients and their relatives, have increased both government and public awareness of the risks associated with healthcare interventions, especially the risk of acquiring a new infection.
      Many, although not all, HCAI can be prevented. Clinical effectiveness (i.e. using prevention measures that are based on reliable evidence of efficacy) is a core component of an effective strategy designed to protect patients from the risk of infection, and when combined with quality improvement methods can account for significant reductions in HCAI such as meticillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile.

      What is the purpose of the guidelines?

      These guidelines describe clinically effective measures that are used by healthcare workers for preventing infections in hospital and other acute healthcare settings.

      What is the scope of the guidelines?

      Three sets of guidelines were developed originally and have now been updated. They include:
      • standard infection control principles: including best practice recommendations for hospital environmental hygiene, effective hand hygiene, the appropriate use of PPE, the safe use and disposal of sharps, and the principles of asepsis;
      • guidelines for preventing infections associated with the use of short-term indwelling urethral catheters; and
      • guidelines for preventing infections associated with the use of intravascular access devices.

      What is the evidence for these guidelines?

      The evidence for these guidelines was identified by multiple systematic reviews of peer-reviewed research. In addition, evidence from expert opinion as reflected in systematically identified professional, national and international guidelines was considered following formal assessment using a validated appraisal tool.
      • AGREE II Instrument
      Appraisal of guidelines for research and evaluation Il.
      All evidence was critically appraised for its methodological rigour and clinical practice applicability, and the best-available evidence influenced the guideline recommendations.

      Who developed these guidelines?

      A team of specialist infection prevention and control researchers and clinical specialists and a Guideline Development Advisory Group, comprising lay members and specialist clinical practitioners, developed the epic3 guidelines (see Sections 1.1 and 1.2).

      Who are these guidelines for?

      These guidelines can be appropriately adapted and used by all hospital practitioners. This will inform the development of more detailed local protocols and ensure that important standard principles for infection prevention are incorporated. Consequently, they are aimed at hospital managers, members of hospital infection prevention and control teams, and individual healthcare practitioners. At an individual level, they are intended to influence the quality and clinical effectiveness of infection prevention decision-making. The dissemination of these guidelines will also help patients and carers/relatives to understand the standard infection prevention precautions they can expect all healthcare workers to implement to protect them from HCAI.

      How are these guidelines structured?

      Each set of guidelines follows an identical format, which consists of:
      • a brief introduction;
      • the intervention heading;
      • a headline statement describing the key issues being addressed;
      • a synthesis of the related evidence; and
      • guideline recommendation(s) classified according to the strength of the underpinning evidence.

      How frequently are the guidelines reviewed and updated?

      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. The evidence base for these guidelines will be reviewed in 2 years (2015) and the guidelines will be considered for updating approximately 4 years after publication (2017). Following publication the DH will ask the Advisory Group on Antimicrobial Resistance and Healthcare Associated Infection to advise whether the evidence base has progressed significantly to alter the guideline recommendations and warrant an update.

      How can these guidelines be used to improve your clinical effectiveness?

      In addition to informing the development of detailed local operational protocols, these guidelines can be used as a benchmark for determining appropriate infection prevention decisions and, as part of reflective practice, to assess clinical effectiveness. They also provide a baseline for clinical audit, evaluation and education, and facilitate on-going quality improvements. There are a number of audit tools available locally, nationally and internationally that can be used to audit compliance with guidance including high-impact intervention tools for auditing care bundles.

      How much will it cost to implement these guidelines?

      Significant additional costs are not anticipated in implementing these guidelines. However, where current equipment or resources do not facilitate the implementation of the guidelines or where staff levels of adherence to current guidance are poor, there may be an associated increase in costs. Given the social and economic costs of HCAI, the consequences associated with not implementing these guidelines would be unacceptable to both patients and healthcare professionals.

      1.10 Guideline Development Methodology

      The guidelines were developed using a systematic review process (Appendix A.1). In each set of guidelines, a summary of the relevant guideline development methodology is provided.

      Search process

      Electronic databases were searched for national and international guidelines and research studies published during the periods identified for each search question. A two-stage search process was used.

      Stage 1: Identification of systematic reviews and guidelines

      For each set of epic guidelines, an electronic search was conducted for systematic reviews of randomised controlled trials (RCTs) and current national and international guidelines. International and national guidelines were retrieved and subjected to critical appraisal using the AGREE II Instrument,
      • AGREE II Instrument
      Appraisal of guidelines for research and evaluation Il.
      an evaluation method used internationally for assessing the methodological quality of clinical guidelines.
      Following appraisal, accepted guidelines were included as part of the evidence base supporting guideline development and, where appropriate, for delineating search limits. They were also used to verify professional consensus and, in some 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 scientific advisors and the Guideline Development Advisory Group.
      Searches were constructed using relevant MeSH (medical subject headings) and free-text terms. The following databases were searched:
      • Medline;
      • Cumulated Index of Nursing and Allied Health Literature;
      • Embase;
      • the Cochrane Library; and
      • PsycINFO (only searched for hand hygiene).

      Abstract review – identifying studies for appraisal

      Search results were downloaded into a Refworks™ database, and titles and abstracts were printed for review. Titles and abstracts were assessed independently by two reviewers, and studies were retrieved where the title or abstract: addressed one or more of the review questions; identified primary research or systematically conducted secondary research; or indicated a theoretical/clinical/in-use study. Where no abstract was available and the title indicated one or more of the above criteria, the study was retrieved. Due to the limited resources available for this review, foreign language studies were not identified for retrieval.
      Full-text studies were retrieved and read in detail by two experienced reviewers; those meeting the study inclusion criteria were independently quality assessed for inclusion in the systematic review.

      Quality assessment and data extraction

      Included studies were appraised using tools based on systems developed by the Scottish Intercollegiate Guideline Network (SIGN) for study quality assessment.
      • Scottish Intercollegiate Guidelines Network
      Studies were appraised independently by two reviewers and data were extracted by one experienced reviewer. Any disagreement between reviewers was resolved through discussion. Evidence tables were constructed from the quality assessments, and the studies were summarized in adapted considered judgement forms. The evidence was classified using methods from SIGN, and adapted to include interrupted time series design and controlled before-after studies using criteria developed by the Cochrane Effective Practice and Organisation of Care (EPOC) Group (Table 1).
      • Scottish Intercollegiate Guidelines Network
      • Cochrane Effective Practice and Organisation of Care Review Group
      This system is similar that used in the previous epic guidelines.
      • Pratt RJ
      • Pellowe CM
      • Wilson JA
      • et al.
      epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
      Table 1Levels of evidence for intervention studies
      • Cochrane Effective Practice and Organisation of Care Review Group
      1++High-quality meta-analyses, systematic reviews of RCTs or RCTs with a very low risk of bias
      1+Well-conducted meta-analyses, systematic reviews or RCTs with a low risk of bias
      1-Meta-analyses, systematic reviews or RCTs with a high risk of bias
      Studies with an evidence level of ‘1-’ and ‘2-’ should not be used as a basis for making a recommendation.
      2++
      • High-quality systematic reviews of case-control or cohort studies.
      • High-quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal.
      • Interrupted time series with a control group: (i) there is a clearly defined point in time when the intervention occurred; and (ii) at least three data points before and three data points after the intervention
      2+
      • Well-conducted case-control or cohort studies with a low 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 significant risk that the relationship is not causal.
      • Interrupted time series without a parallel control group: (i) there is a clearly defined 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
      3Non-analytic studies (e.g. uncontrolled before-after studies, case reports, case series)
      4Expert opinion. Legislation
      RCT, randomised controlled trial.
      * Studies with an evidence level of ‘1-’ and ‘2-’ should not be used as a basis for making a recommendation.
      The evidence tables and considered judgement reports were presented to the Guideline Development Advisory Group for discussion. The guidelines were drafted after extensive discussion.
      Factors influencing the guideline recommendations included:
      • the nature of the evidence;
      • the applicability of the evidence to practice;
      • patient preference and acceptability; and
      • costs and knowledge of healthcare systems.
      The classification scheme adopted by SIGN was used to define the strength of recommendation (Table 2).
      • Scottish Intercollegiate Guidelines Network
      Table 2Classification of recommendations
      • Scottish Intercollegiate Guidelines Network
      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 Practice Points IP
      • Recommended best practice based on the clinical experience of the Guideline Development Advisory Group and patient preference and experience
      • Recommendation from NICE Interventional Procedures guidance
      RCT, randomised controlled trial; NICE, National Institute for Health and Clinical Excellence.

      1.11 Consultation Process

      These guidelines have been subject to extensive external consultation with key stakeholders, including Royal Colleges, professional societies and organisations, patients and trade unions (Appendix A.2). Comments were requested on:
      • format;
      • content;
      • practice applicability of the guidelines;
      • patient preference and acceptability; and
      • specific sections or recommendations.
      All the comments were collated and sent to the scientific advisors and the Guideline Development Advisory Group for consideration prior to virtual meetings for discussion and agreement on any changes in the light of comments. Final agreement was sought from the scientific advisors and the Guideline Development Advisory Group following revision.

      2. Standard Principles for Preventing Healthcare-Associated Infections in Hospital and Other Acute Care Settings

      2.1 Introduction

      This guidance is based on the best critically appraised evidence currently available. The type and class of supporting evidence explicitly linked to each recommendation is described. 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 into local guidelines. None are regarded as optional.
      Standard infection control precautions need to be applied by all healthcare practitioners to the care of all patients (i.e. adults, children and neonates). The recommendations are divided into five distinct interventions:
      • hospital environmental hygiene;
      • hand hygiene;
      • use of PPE;
      • safe use and disposal of sharps; and
      • principles of asepsis.
      These guidelines do not address the additional infection control requirements of specialist settings, such as the operating department or outbreak situations.

      2.2 Hospital Environmental Hygiene

      Hospital hygiene is important for the prevention of healthcare-associated infections in hospitals

      This section discusses the evidence upon which recommendations for hospital environmental hygiene are based. The evidence identified in the previous systematic review was used as the basis for updating the searches, and searches were conducted for new evidence published since 2006.
      • Pratt RJ
      • Pellowe CM
      • Wilson JA
      • et al.
      epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
      Hospital environmental hygiene encompasses a wide range of routine activities. Guidelines are provided here for:
      • cleaning the general hospital environment;
      • cleaning items of shared equipment; and
      • education and training of staff.

      Maintain a clean hospital environment

      Current legislation, regulatory frameworks and quality standards emphasise the importance of the healthcare environment and shared clinical equipment being clean and properly decontaminated to minimise the risk of transmission of HCAI and to maintain public confidence.
      • Department of Health
      • Department of Health
      • Care Quality Commission
      • National Patient Safety Agency
      • National Institute for Health and Care Excellence
      Patients and their relatives expect the healthcare environment to be clean and infection hazards to be controlled adequately.
      • National Patient Safety Agency
      The term ‘cleaning’ is used to describe the physical removal of soil, dirt or dust from surfaces. Conventionally, this is achieved in healthcare settings using cloths and mops. Dust may be removed using dry dust-control mops/cloths. Detergent and water is used for cleaning of soiled or contaminated surfaces, although microfibre cloths and water can also be used for surface cleaning.
      • National Patient Safety Agency
      Enhanced cleaning describes the use of methods in addition to standard cleaning specifications. These may include increased cleaning frequency for all or some surfaces, or the use of additional cleaning equipment. Enhanced cleaning may be applied to all areas of the healthcare environment or in specific circumstances, such as cleaning of rooms or bed spaces following the transfer or discharge of patients who are colonised or infected with a pathogenic microorganism. This is sometimes referred to as ‘terminal cleaning’.
      Disinfection is the use of chemical or physical methods to reduce the number of pathogenic microorganisms on surfaces. These methods need to be used in combination with cleaning as they have limited ability to penetrate organic material. The term ‘decontamination’ is used for the process that results in the removal of hazardous substances (e.g. microorganisms, chemicals) and therefore may apply to cleaning or disinfection.
      Research evidence in this field remains largely limited to ecological studies and weak quasi-experimental and observational study designs. There is evidence from outbreak reports and observational research which demonstrates that the hospital environment becomes contaminated with microorganisms responsible for HCAI. Pathogens may be recovered from a variety of surfaces in clinical environments, including those near to the patient that are touched frequently by healthcare workers.
      • Boyce JM
      • Havill NL
      • Otter JA
      • Adams NMT
      Widespread environmental contamination associated with patients with diarrhea and methicillin-resistant Staphylococcus aureus colonization of the gastrointestinal tract.
      • Dancer SJ
      Importance of the environment in meticillin-resistant Staphylococcus aureus acquisition: the case for hospital cleaning.
      • Griffiths R
      • Fernandez R
      • Halcomb E
      Reservoirs of MRSA in the acute hospital setting: a systematic review.
      • Barker J
      • Vipond IB
      • Bloomfield SF
      Effects of cleaning and disinfection in reducing the spread of Norovirus contamination via environmental surfaces.
      • Denton M
      • Wilcox MH
      • Parnell P
      • et al.
      Role of environmental cleaning in controlling an outbreak of Acinetobacter baumannii on a neurosurgical intensive care unit.
      • Wilcox MH
      • Fawley WN
      • Wigglesworth N
      • Parnell P
      • Verity P
      • Freeman J
      Comparison of the effect of detergent versus hypochlorite cleaning on environmental contamination and incidence of Clostridium difficile infection.
      • Boyce JM
      • Potter-Bynoe G
      • Chenevert C
      • King T
      Environmental contamination due to methicillin-resistant Staphylococcus aureus: possible infection control implications.
      • Oie S
      • Hosokawa I
      • Kamiya A
      Contamination of room door handles by methicillin-sensitive/methicillin-resistant Staphylococcus aureus.
      • Schultz M
      • Gill J
      • Zubairi S
      • Huber R
      • Gordin F
      Bacterial contamination of computer keyboards in a teaching hospital.
      • Brooks SE
      • Walczak MA
      • Hameed R
      • Coonan P
      Chlorhexidine resistance in antibiotic-resistant bacteria isolated from the surfaces of dispensers of soap containing chlorhexidine.
      However, no studies have provided high-quality evidence of direct transmission of the same strain of microorganisms found in the environment to those found in colonised or infected patients.
      We identified one prospective cohort study that found a significant independent association between acquisition of two multi-drug-resistant pathogens and a prior room occupant with the same organism [multi-drug-resistant Pseudomonas aeruginosa odds ratio (OR) 2.3, 95% confidence interval (CI) 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 underlying illness, comorbidities, antimicrobial exposure and some other risk factors.
      • Nseir S
      • Blazejewski C
      • Lubret R
      • Wallet F
      • Courcol R
      • Durocher A
      Risk of acquiring multidrug-resistant Gram-negative bacilli from prior room occupants in the intensive care unit.
      A further study reported an association between MRSA and vancomycin-resistant enterococcus (VRE),
      • Huang SS
      • Datta R
      • Platt R
      Risk of acquiring antibiotic-resistant bacteria from prior room occupants.
      but conclusions that can be drawn from the findings are limited by the retrospective study design and lack of adjustment for severity of underlying illness, colonisation pressure and antibiotic exposure. Similarly, another retrospective cohort study found an association between acquisition of C. difficile and prior room occupant with the same infection; however, this was based solely on clinical diagnosis rather than active surveillance.
      • Shaughnessy MK
      • Micielli RL
      • DePestel DD
      • et al.
      Evaluation of hospital room assignment and acquisition of Clostridium difficile infection.
      Many microorganisms recovered from the hospital environment do not cause HCAI. Cleaning will not completely eliminate microorganisms from environmental surfaces, and reductions in their numbers will be transient.
      • Denton M
      • Wilcox MH
      • Parnell P
      • et al.
      Role of environmental cleaning in controlling an outbreak of Acinetobacter baumannii on a neurosurgical intensive care unit.
      There is some evidence that enhanced cleaning regimens are associated with the control of outbreaks of HCAI;
      • Rampling A
      • Wiseman S
      • Davis L
      • et al.
      Evidence that hospital hygiene is important in the control of methicillin-resistant Staphylococcus aureus.
      however, these study designs do not provide robust evidence of cause and effect.
      Enhanced cleaning has been recommended, particularly ‘terminal cleaning’, after a bed area has been used by a patient colonised or infected with an HCAI. We searched for robust evidence from studies conducted in the healthcare environment which demonstrated cleaning interventions that were associated with reductions in both environmental contamination and HCAI. A randomised crossover study of daily enhanced cleaning of high-touch surfaces in an intensive care unit (ICU) demonstrated a reduction in the daily number of sites in a bed area contaminated with MRSA (OR 0.59, 95% CI 0.4–0.86, p=0.006), and the aerobic colony count in communal areas (OR 0.65, 95% CI 0.47–0.92, p=0.013). Although the reduction in MRSA in the environment was associated with a large reduction in MRSA contaminating doctors' hands (OR 0.26, 95% CI 0.07–0.95, p=0.025), there was no effect on the incidence of MRSA acquisition by patients (OR 0.98, 95% CI 0.58–1.65, p=0.93).
      • Wilson AP
      • Smyth D
      • Moore G
      • et al.
      The impact of enhanced cleaning within the intensive care unit on contamination of the near-patient environment with hospital pathogens: a randomized crossover study in critical care units in two hospitals.
      Disinfectants have been recommended for cleaning the hospital environment;
      • Pratt RJ
      • Pellowe C
      • Loveday HP
      • Department of Health (England)
      • et al.
      The epic project: developing national evidence-based guidelines for preventing healthcare associated infections. Phase I: Guidelines for preventing hospital-acquired infections.
      • Pratt RJ
      • Pellowe CM
      • Wilson JA
      • et al.
      epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
      however, a systematic review failed to confirm a link between disinfection and the prevention of HCAI, although contamination of detergent and inadequate disinfection strength could have been an important confounder.
      • Dettenkofer M
      • Wenzler S
      • Amthor S
      • Antes G
      • Motschall E
      • Daschner FD
      Does disinfection of environmental surfaces influence nosocomial infection rates? A systematic review.
      Whilst subsequent studies may have demonstrated a link between disinfection and reduced environmental contamination, and sometimes the acquisition of HCAI, the study designs are weak with no control groups or randomisation of intervention, and/or the introduction of multiple interventions at the same time. This makes it difficult to draw definitive conclusions about the specific effect of disinfection or cleaning.

      Emerging technology

      New technologies for cleaning and decontaminating the healthcare environment have become available over the past 10 years, including hydrogen peroxide, and others are in the early stages of development. Whilst hydrogen peroxide has been used for decontamination of selected rooms in a US hospital following use by patients with a multi-drug-resistant organism or C. difficile, this study found that it was not possible to use hydrogen peroxide routinely for this purpose.
      • Otter JA
      • Puchowicz M
      • Ryan D
      • et al.
      Feasibility of routinely using hydrogen peroxide vapor to decontaminate rooms in a busy United States hospital.
      The effectiveness, cost-effectiveness and practicality of this and other new technologies in terms of reducing HCAI and routine use in the variety of facilities in UK hospitals has yet to be demonstrated.
      We identified three studies conducted in patient care environments that provided evidence for the effectiveness of different products, containing chemical or other disinfection agents, on environmental contamination but not reductions in HCAI. A prospective randomised crossover study provided evidence for the effectiveness of daily cleaning of high-touch surfaces with microfibre/copper-impregnated cloths on the reduction of MRSA, as discussed above.
      • Wilson AP
      • Smyth D
      • Moore G
      • et al.
      The impact of enhanced cleaning within the intensive care unit on contamination of the near-patient environment with hospital pathogens: a randomized crossover study in critical care units in two hospitals.
      An RCT demonstrated the efficacy of daily high-touch surface cleaning with peracetic acid on MRSA and C. difficile contamination of the environment, with a significant reduction in MRSA and C. difficile isolated from samples taken from surfaces with gloved hands (p<0.001) and the hands of healthcare workers (3/27 in peractic acid group vs 15/38 in standard cleaning group, p=0.13).
      • Kundrapu S
      • Sunkesula V
      • Jury LA
      • Sitzlar BM
      • Donskey CJ
      Daily disinfection of high-touch surfaces in isolation rooms to reduce contamination of healthcare workers' hands.
      A non-randomised controlled trial (NRCT) in two wards at a single hospital provided evidence that an additional cleaner was associated with a 32.5% reduction in environmental microbial contamination of hand-touch sites (95% CI 20.2–42.9, p<0.0001) and 26.6% reduction in acquisition of MRSA infection (95% CI 7.7–92.3, p=0.032), although the infection types were not specified.
      • Dancer S
      • White L
      • Lamb J
      • Girvan EK
      • Robertson C
      Measuring the effect of enhanced cleaning in a UK hospital: a prospective cross-over study.
      Hydrogen peroxide has been used as a method of decontamination of the environment in situations where wards/beds can be closed or left unused for the required period of time
      • French GL
      • Otter JA
      • Shannon KP
      • Adams NMT
      • Watling D
      • Parks MJ
      Tackling contamination of the hospital environment by methicillin-resistant Staphylococcus aureus (MRSA): a comparison between conventional terminal cleaning and hydrogen peroxide vapour decontamination.
      • Otter JA
      • Yezli S
      • Perl TM
      • Barbut F
      • French GL
      The role of ‘no-touch’ automated room disinfection systems in infection prevention and control.
      • Fu TY
      • Gent P
      • Kumar V
      Efficacy, efficiency and safety aspects of hydrogen peroxide vapour and aerosolized hydrogen peroxide room disinfection systems.
      We identified a prospective, randomised before-after study that compared the efficacy of hypochlorite and a hydrogen peroxide decontamination system for terminal cleaning of rooms used by a patient with C. difficile infection in reducing environmental contamination with C. difficile. Although both methods reduced environmental contamination significantly compared with cleaning alone, hydrogen peroxide achieved a significantly greater reduction (91% vs 30% decrease in proportion of samples with C. difficile, p<0.005).
      • Barbut F
      • Menuet D
      • Verachten M
      • Girou E
      Comparison of the efficacy of a hydrogen peroxide dry-mist disinfection system and sodium hypochlorite solution for eradication of Clostridium difficile spores.
      A prospective cohort study provided evidence for the efficacy of hydrogen peroxide when used for terminal decontamination after standard cleaning in significantly reducing the acquisition of multi-drug-resistant organisms in patients subsequently admitted to the rooms (adjusted incidence rate ratio 0.36, 95% CI 0.19–0.7). However, the effect was mainly driven by reduction in acquisition of VRE, and the results could have been confounded by the concurrent implementation of chlorhexidine baths, incomplete surveillance data and non-random assignment of rooms to the intervention.
      • Passaretti CL
      • Otter JA
      • Reich NG
      • et al.
      An evaluation of environmental decontamination with hydrogen peroxide vapor for reducing the risk of patient acquisition of multidrug-resistant organisms.
      The efficacy of antimicrobial surfaces in the clinical environment in reducing surface contamination and HCAI is an area of emerging research. Four non-randomised, experimental studies, conducted in clinical environments, demonstrated significant reductions in microbial burden of between 80% and 90% on high-touch surfaces coated with metallic copper and/or its alloys compared with similar non-copper surfaces.
      • Schmidt MG
      • Cantey JR
      • Freeman KD
      • et al.
      Sustained reduction of microbial burden on common hospital surfaces through introduction of copper.
      • Schmidt MG
      • Attaway III, HH
      • Fairey SE
      • Steed LL
      • Michels HT
      • Salgado CD
      Copper continuously limits the concentration of bacteria resident on bed rails within the intensive care unit.
      • Casey AL
      • Elliott TSJ
      • Adams D
      • et al.
      Role of copper in reducing hospital environment contamination.
      • Karpanen TJ
      • Casey AL
      • Lambert PA
      • et al.
      The antimicrobial efficacy of copper alloy furnishing in the clinical environment: a crossover study.
      One RCT conducted in three ICUs reported a significantly lower acquisition of HCAI in patients allocated to rooms with six high-touch copper-coated surfaces (3.4% vs 8.1%, p=0.013). A multi-variate analysis suggested that both severity of underlying illness and room assignment were independently associated with the acquisition of HCAI or colonisation. However, these findings may have been biased by poor discrimination of patients colonised on admission because of limited surveillance cultures, poor agreement in defining cases of HCAI, and incomplete adjustment for confounders in the multi-variate analysis.
      • Salgado CD
      • Sepkowitz KA
      • John JF
      • et al.
      Copper surfaces reduce the rate of healthcare-acquired infections in the intensive care unit.
      Evidence of the effectiveness and cost-effectiveness of these technologies and their contribution to reductions in HCAI is therefore not currently available.

      Assessing environmental cleanliness

      Indicators of cleanliness based on levels of microbial or adenosine triphosphate (ATP) contamination have been recommended; however, relationships between ATP and aerobic colony counts are not consistent, and neither method distinguishes normal environmental flora and pathogens responsible for HCAI.
      • Mulvey D
      • Redding P
      • Robertson C
      • et al.
      Finding a benchmark for monitoring hospital cleanliness.
      • Boyce JM
      • Havill NL
      • Dumigan DG
      • Golebiewski M
      • Balogun O
      • Rizvani R
      Monitoring the effectiveness of hospital cleaning practices by use of an adenosine triphosphate bioluminescence assay.
      Benchmark values of between 250 and 500 relative light units have been proposed as a more objective measure of assessing the efficacy of cleaning than visual assessment, although these are based on arbitrary standards of acceptable contamination that have not been shown to be associated with reductions in HCAI.
      • Lewis T
      • Griffith C
      • Gallo M
      • Weinbren M
      A modified ATP benchmark for evaluating the cleaning of some hospital environmental surfaces.
      • Griffith CJ
      • Obee P
      • Cooper RA
      • Burton NF
      • Lewis M
      The effectiveness of existing and modified cleaning regimens in a Welsh hospital.
      • Malik RE
      • Cooper RA
      • Griffith CJ
      Use of audit tools to evaluate the efficacy of cleaning systems in hospitals.
      We identified a number of uncontrolled before-after studies that used ATP in various forms to highlight the extent of contamination of the healthcare environment. In addition, some studies described the use of ATP monitoring as an intervention to improve cleaning, but the lack of a control group in the study design precluded their inclusion in this review. As cleaning will only have a transient effect on the numbers of microorganisms, regular cleaning or disinfection of hospital surfaces will not guarantee a pathogen-free environment. Preventing the transfer of pathogens from the environment to patients therefore still depends on ensuring that hands are decontaminated prior to patient contact.
      • SP1
        The hospital environment must be visibly clean; free from non-essential items and equipment, dust and dirt; and acceptable to patients, visitors and staff.
        Class D/GPP
      • SP2
        Levels of cleaning should be increased in cases of infection and/or colonisation when a suspected or known pathogen can survive in the environment, and environmental contamination may contribute to the spread of infection.
        Class D/GPP
      • SP3
        The use of disinfectants should be considered for cases of infection and/or colonisation when a suspected or known pathogen can survive in the environment, and environmental contamination may contribute to the spread of infection.
        Class D/GPP

      Decontamination of equipment

      Shared clinical equipment used to deliver care in the clinical environment comes into contact with intact skin and is therefore unlikely to introduce infection directly. However, it can act as a vehicle by which microorganisms are transferred between patients, which may subsequently result in infection. Equipment should therefore be cleaned and decontaminated after each use with cleaning agents compatible with the piece of equipment being cleaned. In some outbreak situations, the use of chlorine-releasing agents and detergent should be considered.
      • Department of Health
      • Department of Health
      • Care Quality Commission
      • National Patient Safety Agency
      • 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/GPP

      Healthcare workers' role in maintaining a clean environment

      In a systematic review of healthcare workers' knowledge about MRSA and/or frequency of cleaning practices, three studies indicated that staff were not using appropriate cleaning practices with sufficient frequency to ensure minimisation of MRSA contamination of personal equipment.
      • Griffiths R
      • Fernandez R
      • Halcomb E
      Reservoirs of MRSA in the acute hospital setting: a systematic review.
      Staff education was lacking on optimal cleaning practices in the clinical areas. The finding of the review is reinforced by a later observational study, which noted that lapses in adherence to the cleaning protocol were linked with an increase in environmental contamination with isolates of A. baumannii.
      • Denton M
      • Wilcox MH
      • Parnell P
      • et al.
      Role of environmental cleaning in controlling an outbreak of Acinetobacter baumannii on a neurosurgical intensive care unit.
      A second systematic review of four cohort studies that compared the use of detergents and disinfectants on microbial-contaminated hospital environmental surfaces suggested that a lack of effectiveness was, in many instances, due to inadequate strengths of disinfectants, probably resulting from a lack of knowledge.
      • Dettenkofer M
      • Wenzler S
      • Amthor S
      • Antes G
      • Motschall E
      • Daschner FD
      Does disinfection of environmental surfaces influence nosocomial infection rates? A systematic review.
      We identified no new, robust research studies of education or system interventions for this review. However, creating a culture of responsibility for maintaining a clean environment and increasing knowledge about how to decontaminate equipment and high-touch surfaces effectively requires education and training of both healthcare cleaning professionals and clinical staff.
      • SP5
        All healthcare workers need to be educated about the importance of maintaining a clean and safe care environment for patients. Every healthcare worker needs to know their specific responsibilities for cleaning and decontaminating the clinical environment and the equipment used in patient care.
        Class D/GPP

      Hospital Hygiene – Systematic Review Process

      Systematic Review Questions

      • 1.
        What is the evidence that the patient environment (including clinical equipment) is a significant factor in the transmission of HCAI?
      • 2.
        What is the effectiveness and cost-effectiveness of conventional cleaning vs enhanced cleaning of the patient bed space in reducing environmental contamination and HCAI?
      • 3.
        What is the effectiveness and cost-effectiveness of antimicrobial surfaces (e.g. silver, copper) in the patient environment in reducing environmental contamination and HCAI?
      • 4.
        What is the effectiveness of education interventions in improving healthcare workers' knowledge and behaviour in maintaining a clean patient environment (including clinical equipment) and in reducing environmental contamination and HCAI?
      • 5.
        What is the effectiveness of system interventions in driving improvements in hospital environmental hygiene and in reducing environmental contamination and HCAI?

      Databases and Search Terms Used

      Databases

      Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, NEHL Guideline Finder, National Institute for Health and Clinical Excellence, the Cochrane Library (CDSR, CCRCT, CMR), US Guideline Clearing House, DARE (NHS Evidence, HTA), Prospero

      MeSH Terms

      Infection control; cross infection; equipment contamination; disease transmission; disinfection; disinfectants; soaps; anti-infective agents; surface-active agents; hospital housekeeping; hydrogen peroxide; silver

      Thesaurus and Free-Text Terms

      Hospital hygiene; hospital housekeeper; blood spill; blood exposure; blood splash

      Search Date

      Jan 2005-Nov 2012

      Search Results

      Total number of articles located = 5944

      Sift 1 Criteria

      Abstract indicates that the article: relates to infections associated with hospital hygiene; is written in English; is primary research, a systematic review or a meta-analysis; and appears to inform one or more of the review questions.

      Articles Retrieved

      Total number of articles retrieved from Sift 1 = 164

      Sift 2 Criteria

      Full text confirms that the article: relates to infections associated with hospital hygiene; is written in English; is primary research (randomised controlled trials, prospective cohort, interrupted time series, controlled before-after, quasi-experimental, experimental studies answering specific questions), a systematic review or a meta-analysis including the above designs; and informs one or more of the review questions.

      Articles Selected for Appraisal

      Total number of studies selected for appraisal during Sift 2 = 26

      Critical Appraisal

      All articles that described primary research, a systematic review or a meta-analysis and met the Sift 2 criteria were independently critically appraised by two appraisers using SIGN and EPOC criteria. Consensus and grading was achieved through discussion.

      Accepted and Rejected Evidence

      Total number of studies accepted after critical appraisal = 12
      Total number of studies rejected after critical appraisal = 14

      2.3 Hand Hygiene

      This section discusses the evidence for recommendations concerning hand hygiene practice. Designing and conducting robust, ethical RCTs in the field of hand hygiene is challenging, meaning that recommendations are based on evidence from NRCTs, quasi-experimental studies, observational studies and laboratory studies with volunteers. In addition, expert opinion derived from systematically retrieved and appraised professional, national and international guidelines is used. The areas discussed in this section include:
      • assessment of the need to decontaminate hands;
      • efficacy of hand decontamination agents and preparations;
      • rationale for choice of hand decontamination practice;
      • technique for hand decontamination;
      • care required to protect hands from the adverse effects of hand decontamination practice;
      • promoting adherence to hand hygiene guidelines; and
      • involving patients and carers in hand hygiene.

      Why is hand decontamination crucial to the prevention of healthcare-associated infection?

      The transfer of organisms between humans can occur directly via hands, or indirectly via an environmental source (e.g. commode or wash basin). Epidemiological evidence indicates that hand-mediated transmission is a major contributing factor in the acquisition and spread of infection in hospitals.
      • Pratt RJ
      • Pellowe C
      • Loveday HP
      • Department of Health (England)
      • et al.
      The epic project: developing national evidence-based guidelines for preventing healthcare associated infections. Phase I: Guidelines for preventing hospital-acquired infections.
      • Pratt RJ
      • Pellowe CM
      • Wilson JA
      • et al.
      epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
      • World Health Organization
      The hands are colonised by two categories of microbial flora. The resident flora are found on the surface, just below the uppermost layer of skin, are adapted to survive in the local conditions and are generally of low pathogenicity, although some, such as Stapylococcus epidermidis, may cause infection if transferred on to a susceptible site such as an invasive device. The transient flora are made up of microorganisms acquired by touching contaminated surfaces such as the environment, patients or other people, and are readily transferred to the next person or object touched. They may include a range of antimicrobial-resistant pathogens such as MRSA, Acinetobacter or other multi-resistant Gram-negative bacteria.
      • Pratt RJ
      • Pellowe C
      • Loveday HP
      • Department of Health (England)
      • et al.
      The epic project: developing national evidence-based guidelines for preventing healthcare associated infections. Phase I: Guidelines for preventing hospital-acquired infections.
      If transferred into susceptible sites such as invasive devices or wounds, these microorganisms can cause life-threatening infections. Transmission to non-vulnerable sites may leave a patient colonised with pathogenic and antibiotic-resistant organisms, which may result in an HCAI at some point in the future.
      Outbreak reports and observational studies of the dynamics of bacterial hand contamination have demonstrated an association between patient care activities that involve direct patient contact and hand contamination.
      • Pratt RJ
      • Pellowe CM
      • Wilson JA
      • et al.
      epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
      • World Health Organization
      • Gupta A
      • Della-Latta P
      • Todd B
      • et al.
      Outbreak of extended-spectrum beta-lactamase-producing Klebsiella pneumoniae in a neonatal intensive care unit linked to artificial nails.
      • Pittet D
      • Dharan S
      • Touveneau S
      • Sauvan V
      • Perneger TV
      Bacterial contamination of the hands of hospital staff during routine patient care.
      • Pessoa-Silva CL
      • Dharan S
      • Hugonnet S
      • et al.
      Dynamics of bacterial hand contamination during routine neonatal care.
      The association between hand decontamination, using liquid soap and water and waterless alcohol-base hand rub (ABHR), and reductions in infection have been confirmed by clinically-based non-randomised trials
      • Fendler EJ
      • Ali Y
      • Hammond BS
      • Lyons MK
      • Kelley MB
      • Vowell NA
      The impact of alcohol hand sanitizer use on infection rates in an extended care facility.
      • Ryan MA
      • Christian RS
      • Wohlrabe J
      Handwashing and respiratory illness among young adults in military training.
      and observational studies.
      • Pittet D
      • Hugonnet S
      • Harbarth S
      • et al.
      Effectiveness of a hospital-wide programme to improve compliance with hand hygiene.
      • Gordin FM
      • Schultz ME
      • Huber RA
      • Gill JA
      Reduction in nosocomial transmission of drug-resistant bacteria after introduction of an alcohol-based handrub.
      Current national and international guidance has consistently identified that effective hand decontamination results in significant reductions in the carriage of potential pathogens on the hands, and therefore it is logical that the incidence of preventable HCAI is decreased, leading to a reduction in patient morbidity and mortality.
      • Pratt RJ
      • Pellowe CM
      • Wilson JA
      • et al.
      epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
      • World Health Organization
      • Boyce JM
      • Pittet D
      • Healthcare Infection Control Practices Advisory Committee
      • Society for Healthcare Epidemiology of America
      • Association for Professionals in Infection Control
      • Infectious Diseases Society of America Hand Hygiene Task Force
      Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.

      When must you decontaminate your hands in relation to patient care?

      Patients are put at risk of developing an HCAI when informal carers or healthcare workers caring for them have contaminated hands. Decontamination refers to a process for the physical removal of dirt, blood and body fluids, and the removal or destruction of microorganisms from the hands.
      • World Health Organization
      The World Health Organization's (WHO) ‘Five Moments for Hand Hygiene’
      • Boyce JM
      • Pittet D
      • Healthcare Infection Control Practices Advisory Committee
      • Society for Healthcare Epidemiology of America
      • Association for Professionals in Infection Control
      • Infectious Diseases Society of America Hand Hygiene Task Force
      Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
      provides a framework for training healthcare workers, audit and feedback of hand hygiene practice, and has been adopted without modification in many countries and adapted in others (e.g. Canada).
      • Provincial Infectious Diseases Advisory Committee
      Hands must be decontaminated at critical points before, during and after patient care activity to prevent cross-transmission of microorganisms.
      • Pratt RJ
      • Pellowe C
      • Loveday HP
      • Department of Health (England)
      • et al.
      The epic project: developing national evidence-based guidelines for preventing healthcare associated infections. Phase I: Guidelines for preventing hospital-acquired infections.
      • Pratt RJ
      • Pellowe CM
      • Wilson JA
      • et al.
      epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
      • World Health Organization
      • Sax H
      • Allegranzi B
      • Uçkay I
      • Larson E
      • Boyce J
      • Pittet D
      ‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene.
      Evidence considered by the National Institute for Health and Clinical Excellence (NICE)
      • National Clinical Guideline Centre
      indicated increases in hand decontamination compliance before and after patient contact associated with implementation of the WHO ‘Five Moments’ and US Centers for Disease Control and Prevention 2002 guidelines, but no difference in compliance after contact with patient surroundings. The following recommendations are derived from the WHO framework and NICE guidelines,
      • National Clinical Guideline Centre
      and include additional points of emphasis.
      • SP6
        Hands must be decontaminated:
        • immediately before each episode of direct patient contact or care, including clean/aseptic procedures;
        • immediately after each episode of direct patient contact or care;
        • immediately after contact with body fluids, mucous membranes and non-intact skin;
        • immediately after other activities or contact with objects and equipment in the immediate patient environment that may result in the hands becoming contaminated; and
        • immediately after the removal of gloves.
        Class C

      Is any one hand-cleaning preparation better than another?

      Current national and international guidelines
      • Pratt RJ
      • Pellowe CM
      • Wilson JA
      • et al.
      epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
      • World Health Organization
      • Boyce JM
      • Pittet D
      • Healthcare Infection Control Practices Advisory Committee
      • Society for Healthcare Epidemiology of America
      • Association for Professionals in Infection Control
      • Infectious Diseases Society of America Hand Hygiene Task Force
      Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
      consider the efficacy of various preparations for the decontamination of hands using liquid soap and water, antiseptic handwash agents and ABHR in laboratory studies and their effectiveness in clinical use. Overall, there is no compelling evidence to favour the general use of antiseptic handwashing agents over liquid soap or one antiseptic agent over another.
      • Pratt RJ
      • Pellowe CM
      • Wilson JA
      • et al.
      epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
      • World Health Organization
      • Boyce JM
      • Pittet D
      • Healthcare Infection Control Practices Advisory Committee
      • Society for Healthcare Epidemiology of America
      • Association for Professionals in Infection Control
      • Infectious Diseases Society of America Hand Hygiene Task Force
      Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
      • Pellowe C
      • Pratt R
      • Harper P
      • et al.
      Infection control: prevention of healthcare-associated infection in primary and community care.
      All hand hygiene products for use in clinical care must comply with current British Standards.
      • British Standards Institution
      Chemical disinfectants and antiseptics. Hygienic handrub. Test method and requirements (phase 2/step 2).
      Many studies have been conducted during the past 15 years to compare hand hygiene preparations, including ABHR and gels, antiseptic handwash and liquid soap.
      • World Health Organization
      RCTs and other quasi-experimental studies have generally demonstrated alcohol-based preparations to be more effective hand hygiene agents than non-medicated soap and antiseptic handwashing agents, although a small number of studies reported no statistically significant difference.
      • Lucet JC
      • Rigaud MP
      • Mentre F
      • et al.
      Hand contamination before and after different hand hygiene techniques: a randomized clinical trial.
      • Winnefeld M
      • Richard MA
      • Drancourt M
      • Grob JJ
      Skin tolerance and effectiveness of two hand decontamination procedures in everyday hospital use.
      • Larson EL
      • Aiello AE
      • Bastyr J
      • et al.
      Assessment of two hand hygiene regimens for intensive care unit personnel.
      • Girou E
      • Loyeau S
      • Legrand P
      • Oppein F
      • Brun-Buisson C
      Efficacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial.
      • Zaragoza M
      • Sallés M
      • Gomez J
      • Bayas JM
      • Trilla A
      Handwashing with soap or alcoholic solutions? A randomized clinical trial of its effectiveness.
      • Larson EL
      • Cimiotti J
      • Haas J
      • et al.
      Effect of antiseptic handwashing vs alcohol sanitizer on health care-associated infections in neonatal intensive care units.
      • Herruzo-Cabrera R
      • Garcia-Caballero J
      • Martin-Moreno JM
      • Graciani-Perez-Regadera MA
      • Perez-Rodriguez J
      Clinical assay of N-duopropenide alcohol solution on hand application in newborn and pediatric intensive care units: control of an outbreak of multiresistant Klebsiella pneumoniae in a newborn intensive care unit with this measure.
      • Herruzo-Cabrera R
      • Garcia-Caballero J
      • Fernandez-Acenero MJ
      A new alcohol solution (N-duopropenide) for hygienic (or routine) hand disinfection is more useful than classic handwashing: in vitro and in vivo studies in burn and other intensive care units.
      • Larson E
      • Silberger M
      • Jakob K
      • et al.
      Assessment of alternative hand hygiene regimens to improve skin health among neonatal intensive care unit nurses.
      • Kramer A
      • Rudolph P
      • Kampf G
      • Pittet D
      Limited efficacy of alcohol-based hand gels.
      • Moadab A
      • Rupley KF
      • Wadhams P
      Effectiveness of a nonrinse, alcohol-free antiseptic hand wash.
      • Guilhermetti M
      • Hernandes SED
      • Fukushigue Y
      • Garcia LB
      • Cardoso CL
      Effectiveness of hand-cleansing agents for removing methicillin-resistant Staphylococcus aureus from contaminated hands.
      • Paulson DS
      • Fendler EJ
      • Dolan MJ
      • Williams RA
      A close look at alcohol gel as an antimicrobial sanitizing agent.
      • Cardoso CL
      Effectiveness of hand-cleansing agents for removing Acinetobacter baumannii strain from contaminated hands.
      • Kampf G
      • Jarosch R
      • Rüden H
      Limited effectiveness of chlorhexidine based hand disinfectants against methicillin-resistant Staphylococcus aureus (MRSA).
      • Dyer DL
      • Gerenratch KB
      • Wadhams PS
      Testing a new alcohol-free hand sanitizer to combat infection.
      • Dharan S
      • Hugonnet S
      • Sax H
      • Pittet D
      Comparison of waterless hand antisepsis agents at short application times: raising the flag of concern.
      • Sickbert-Bennett EE
      • Weber DJ
      • Gergen-Teague MF
      • Sobsey MD
      • Samsa GP
      • Rutala WA
      Comparative efficacy of hand hygiene agents in the reduction of bacteria and viruses.
      Many of these studies involved the use of ABHR as part of a number of interventions, or multi-modal campaigns, to improve hand hygiene practice, and had methodological flaws that weaken the causal relationship between the introduction of ABHR and reductions in HCAI.
      • Gould DJ
      • Moralejo D
      • Drey N
      • Chudleigh JH
      Interventions to improve hand hygiene compliance in patient care.
      We identified one multi-variate, interrupted time series which suggested that the amount of ABHR used per patient-day was the only factor associated with a reduction in MRSA incidence density (p=0.011) in a neonatal ICU in Japan.
      • Sakamoto F
      • Yamada H
      • Suzuki C
      • Sugiura H
      • Tokuda Y
      Increased use of alcohol-based hand sanitizers and successful eradication of methicillin-resistant Staphylococcus aureus from a neonatal intensive care unit: a multivariate time series analysis.
      Incidence density fell over a 4-year period from an average of 15 per 1000 patient-days, with a peak of 20 per 1000 patient-days in August 2006, to 0 per 1000 patient-days in October 2008 and was sustained to July 2009 (average incidence density 7.5 per 1000 patient-days). The supporting evidence from laboratory studies of the efficacy of ABHR indicates that these products are highly effective at reducing hand carriage, whilst overcoming some of the recognised barriers to handwashing; most importantly, the ease of use at the point of patient care.
      These studies underpin a continuing trend to adopt ABHR for routine use in clinical practice. However, some studies highlight the need for continued evaluation of the use of ABHR within the clinical environment to ensure staff adherence to guidelines and effective hand decontamination technique.
      • Dharan S
      • Hugonnet S
      • Sax H
      • Pittet D
      Comparison of waterless hand antisepsis agents at short application times: raising the flag of concern.
      • Sickbert-Bennett EE
      • Weber DJ
      • Gergen-Teague MF
      • Sobsey MD
      • Samsa GP
      • Rutala WA
      Comparative efficacy of hand hygiene agents in the reduction of bacteria and viruses.

      Choice of decontamination: is it always necessary to wash hands to achieve decontamination?

      Choosing the method of hand decontamination will depend upon the assessment of what is appropriate for the episode of care, the availability of resources at or near the point of care, what is practically possible and, to some degree, personal preferences based on the acceptability of preparations or materials.
      In general, effective handwashing with liquid soap and water or the effective use of ABHR will remove transient microorganisms and render the hands socially clean. The effective use of ABHR will also substantially reduce resident microorganisms. This level of decontamination is sufficient for general social contact and most clinical care activities.
      • Pratt RJ
      • Pellowe CM
      • Wilson JA
      • et al.
      epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
      • World Health Organization
      • Boyce JM
      • Pittet D
      • Healthcare Infection Control Practices Advisory Committee
      • Society for Healthcare Epidemiology of America
      • Association for Professionals in Infection Control
      • Infectious Diseases Society of America Hand Hygiene Task Force
      Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
      Liquid soap preparations that contain an antiseptic affect both transient microorganisms and resident flora, and some exert a residual effect. The use of preparations containing an antiseptic is required in situations where prolonged reduction in microbial flora on the skin is necessary (e.g. surgery, some invasive procedures or in outbreak situations).
      • Pratt RJ
      • Pellowe CM
      • Wilson JA
      • et al.
      epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
      • World Health Organization
      • Boyce JM
      • Pittet D
      • Healthcare Infection Control Practices Advisory Committee
      • Society for Healthcare Epidemiology of America
      • Association for Professionals in Infection Control
      • Infectious Diseases Society of America Hand Hygiene Task Force
      Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
      ABHR is not effective against all microorganisms (e.g. some viruses such as Norovirus and spore-forming microorganisms such as C. difficile). It will not remove dirt and organic material, and may not be effective in some outbreak situations.
      • Gordin FM
      • Schultz ME
      • Huber RA
      • Gill JA
      Reduction in nosocomial transmission of drug-resistant bacteria after introduction of an alcohol-based handrub.
      • Faoagali JL
      • George N
      • Fong J
      • Davy J
      • Dowser M
      Comparison of the antibacterial efficacy of 4% chlorhexidine gluconate and 1% triclosan handwash products in an acute clinical ward.
      We identified two laboratory studies which demonstrated that ABHR was not effective in removing C. difficile spores from hands.
      • Oughton MT
      • Loo VG
      • Dendukuri N
      • Fenn S
      • Libman MD
      Hand hygiene with soap and water is superior to alcohol rub and antiseptic wipes for removal of Clostridium difficile.
      • Jabbar U
      • Leischner J
      • Kasper D
      • et al.
      Effectiveness of alcohol-based hand rubs for removal of Clostridium difficile spores from hands.
      In the first study, a comparison of liquid soap and water, chlorhexidine gluconate (CHG) soap and water, antiseptic hand wipes and ABHR resulted in all the soap and water protocols yielding greater mean colony-forming unit (cfu) reductions, followed by the antiseptic hand wipes, than ABHR. ABHR was equivalent to no intervention (0.06 log10 cfu/mL, 95% CI −0.34 to 0.45 log10 cfu/mL).
      • Oughton MT
      • Loo VG
      • Dendukuri N
      • Fenn S
      • Libman MD
      Hand hygiene with soap and water is superior to alcohol rub and antiseptic wipes for removal of Clostridium difficile.
      In the second study, three ABHR preparations with a minimum 60% alcohol concentration were compared with antiseptic (CHG) soap and water. Antiseptic soap and water reduced spore counts significantly compared with each of the ABHRs (CHG vs Isagel, p=0.005; CHG vs Endure, p=0.010; CHG vs Purell, p=0.005). In addition, 30% of the residual spores were readily transferred by handshake following the use of ABHR.
      • Jabbar U
      • Leischner J
      • Kasper D
      • et al.
      Effectiveness of alcohol-based hand rubs for removal of Clostridium difficile spores from hands.
      Recent evidence from a laboratory study that compared the efficacy of liquid soap and water and ABHR with and without CHG against H1N1 influenza virus demonstrated that all the hand hygiene protocols were effective in reducing virus copies.
      • Grayson ML
      • Melvani S
      • Druce J
      • et al.
      Efficacy of soap and water and alcohol-based hand-rub preparations against live H1N1 influenza virus on the hands of human volunteers.
      A further study that compared the use of liquid soap and water and 65% ethanol hand sanitisers for the removal of Rhinovirus indicated that the hand sanitisers were more effective than soap and water.
      • Turner RB
      • Fuls JL
      • Rodgers ND
      Effectiveness of hand sanitizers with and without organic acids for removal of rhinovirus from hands.
      Two economic evaluations from the USA, included in recent NICE primary care guidelines, suggest that non-compliance with hand hygiene guidelines results in increased infection-related costs.
      • National Clinical Guideline Centre
      Although compliance increases procurement costs of hand hygiene products, even a small increase in compliance is likely to result in reduced infection costs. We identified a further economic analysis of a hand hygiene programme based on the introduction of point-of-use ABHR and associated implementation materials. This demonstrated a reduction in episodes of HCAI and a saving of $23.7 for every $1 spent on the programme when future costs were considered. Sensitivity analyses showed that the programme remained cost saving in all alternative scenarios.
      • Chen Y
      • Sheng W
      • Wang J
      • et al.
      Effectiveness and limitations of hand hygiene promotion on decreasing healthcare-associated infections.
      ABHR is likely to be less costly and result in greater compliance.
      National and international guidelines suggest that the acceptability of agents and techniques is an essential criterion for the selection of preparations for hand hygiene.
      • Pratt RJ
      • Pellowe CM
      • Wilson JA
      • et al.
      epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
      • World Health Organization
      • Boyce JM
      • Pittet D
      • Healthcare Infection Control Practices Advisory Committee
      • Society for Healthcare Epidemiology of America
      • Association for Professionals in Infection Control
      • Infectious Diseases Society of America Hand Hygiene Task Force
      Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
      Acceptability of preparations is dependent upon the ease with which the preparation can be used in terms of time and access, together with their dermatological effects.
      • British Standards Institution
      Chemical disinfectants and antiseptics. Hygienic handrub. Test method and requirements (phase 2/step 2).
      ABHR is preferable for routine use due to its efficacy, availability at the point of care and acceptability to healthcare workers.
      • World Health Organization
      However, ABHR does not remove organic matter and is ineffective against some microorganisms; therefore, handwashing is required.
      • SP7
        Use an alcohol-based hand rub for decontamination of hands before and after direct patient contact and clinical care, except in the following situations when soap and water must be used:
        • when hands are visibly soiled or potentially contaminated with body fluids; and
        • when caring for patients with vomiting or diarrhoeal illness, regardless of whether or not gloves have been worn.
        Class A

      Is hand decontamination technique important?

      Investigations of technique for hand decontamination are limited and generally laboratory-based or small-scale observational designs. Hand hygiene technique involves both the preparation and the physical process of decontamination.
      • Pratt RJ
      • Pellowe CM
      • Wilson JA
      • et al.
      epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
      • World Health Organization
      • Boyce JM
      • Pittet D
      • Healthcare Infection Control Practices Advisory Committee
      • Society for Healthcare Epidemiology of America
      • Association for Professionals in Infection Control
      • Infectious Diseases Society of America Hand Hygiene Task Force
      Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
      Hands and wrists need to be fully exposed to the hand hygiene product and therefore should be free from jewellery and long-sleeved clothing. A number of small-scale observational studies have demonstrated that wearing rings and false nails is associated with increased carriage of microorganisms and, in some cases, linked to the carriage of outbreak strains. Department of Health guidance on uniforms and work wear and NICE guidelines indicate that healthcare workers should remove rings and wrist jewellery, and wear short-sleeved clothing whilst delivering patient care.
      • National Clinical Guideline Centre
      • Department of Health
      Evidence for the duration of hand decontamination has been considered in previous systematic reviews underpinning guidelines, and suggests that different durations of handwashing and hand rubbing do not significantly affect the reduction of bacteria.
      • Lucet JC
      • Rigaud MP
      • Mentre F
      • et al.
      Hand contamination before and after different hand hygiene techniques: a randomized clinical trial.
      • Sickbert-Bennett EE
      • Weber DJ
      • Gergen-Teague MF
      • Sobsey MD
      • Samsa GP
      • Rutala WA
      Comparative efficacy of hand hygiene agents in the reduction of bacteria and viruses.
      The WHO guidelines indicate that decontamination using ABHR should take 20–30 s for a seven-step process, and that handwashing should take 40–60 s for a nine-step process.
      • World Health Organization
      We identified one recent RCT in a single hospital which demonstrated that allowing staff to decontaminate their hands ‘in no particular order’ took less time and was as effective as using the WHO seven-step technique using ABHR or liquid antimicrobial soap and water (p=0.04 and p<0.001, respectively). All three of the protocols tested in this study were effective in reducing hand bacterial load (p<0.01).
      • Chow A
      • Arah OA
      • Chan S
      • et al.
      Alcohol handrubbing and chlorhexidine handwashing protocols for routine hospital practice: a randomized clinical trial of protocol efficacy and time effectiveness.
      A similar result was reported by authors of a laboratory study that tested the EN1500 six-step technique against a range of other protocols. They reported that allowing volunteers to use their own ‘responsible application’ or a new five-step technique resulted in better coverage of the hands during hand decontamination.
      • Kampf G
      • Reichel M
      • Feil Y
      • Eggerstedt S
      • Kaulfers P
      Influence of rub-in technique on required application time and hand coverage in hygienic hand disinfection.
      A number of laboratory-based studies that investigated methods of hand drying suggested that there is no significant difference in the efficacy of different methods of drying hands, but that good-quality paper towels dry hands efficiently and remove bacteria effectively.
      • Gustafson DR
      • Vetter EA
      • Larson DR
      • et al.
      Effects of 4 hand-drying methods for removing bacteria from washed hands: a randomized trial.
      • Yamamoto Y
      • Ugai K
      • Takahashi Y
      Efficiency of hand drying for removing bacteria from washed hands: comparison of paper towel drying with warm air drying.
      Current guidance on infection control in the built environment suggests that air and jet driers are not appropriate for use in clinical areas.
      • Department of Health
      We identified one systematic review of studies on hand drying that failed to meet the quality criteria for inclusion.
      • Huang C
      • Ma W
      • Stack S
      The hygienic efficacy of different hand-drying methods: a review of the evidence.
      Due to the methodological limitations of studies, evidence recommendations are based on national and international guidelines which state that the duration of hand decontamination, the exposure of all aspects of the hands and wrists to the preparation being used, the use of vigorous rubbing to create friction, thorough rinsing in the case of handwashing, and ensuring that hands are completely dry are key factors in effective hand hygiene and the maintenance of skin integrity.
      • Pratt RJ
      • Pellowe CM
      • Wilson JA
      • et al.
      epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
      • World Health Organization
      • Boyce JM
      • Pittet D
      • Healthcare Infection Control Practices Advisory Committee
      • Society for Healthcare Epidemiology of America
      • Association for Professionals in Infection Control
      • Infectious Diseases Society of America Hand Hygiene Task Force
      Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
      • SP8
        Healthcare workers should ensure that their hands can be decontaminated effectively by:
        • removing all wrist and hand jewellery;
        • wearing short-sleeved clothing when delivering patient care;
        • making sure that fingernails are short, clean, and free from false nails and nail polish; and
        • covering cuts and abrasions with waterproof dressings.
        Class D/GPP
      • SP9
        Effective handwashing technique involves three stages: preparation, washing and rinsing, and drying.
        • Preparation: wet hands under tepid running water before applying the recommended amount of liquid soap or an antimicrobial preparation.
        • Washing: the handwash solution must come into contact with all of the surfaces of the hand. The hands should be rubbed together vigorously for a minimum of 10–15 s, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers. Hands should be rinsed thoroughly.
        • Drying: use good-quality paper towels to dry the hands thoroughly.
        Class D/GPP
      • SP10
        When decontaminating hands using an alcohol-based hand rub, hands should be free of dirt and organic material and:
        • hand rub solution must come into contact with all surfaces of the hand; and
        • hands should be rubbed together vigorously, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers, until the solution has evaporated and the hands are dry.
        Class D/GPP

      Does hand decontamination damage skin?

      Expert opinion suggests that skin damage is generally associated with the detergent base of the preparation and/or poor handwashing technique.
      • Pratt RJ
      • Pellowe C
      • Loveday HP
      • Department of Health (England)
      • et al.
      The epic project: developing national evidence-based guidelines for preventing healthcare associated infections. Phase I: Guidelines for preventing hospital-acquired infections.
      • Pratt RJ
      • Pellowe CM
      • Wilson JA
      • et al.
      epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
      • World Health Organization
      • Boyce JM
      • Pittet D
      • Healthcare Infection Control Practices Advisory Committee
      • Society for Healthcare Epidemiology of America
      • Association for Professionals in Infection Control
      • Infectious Diseases Society of America Hand Hygiene Task Force
      Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
      In addition, the frequent use of some hand hygiene agents may cause damage to the skin and alter normal hand flora. Sore hands are associated with increased colonisation by potentially pathogenic microorganisms and increase the risk of transmission.
      • Pratt RJ
      • Pellowe C
      • Loveday HP
      • Department of Health (England)
      • et al.
      The epic project: developing national evidence-based guidelines for preventing healthcare associated infections. Phase I: Guidelines for preventing hospital-acquired infections.
      • Pratt RJ
      • Pellowe CM
      • Wilson JA
      • et al.
      epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
      • World Health Organization
      • Boyce JM
      • Pittet D
      • Healthcare Infection Control Practices Advisory Committee
      • Society for Healthcare Epidemiology of America
      • Association for Professionals in Infection Control
      • Infectious Diseases Society of America Hand Hygiene Task Force
      Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
      The irritant and drying effects of liquid soap and antiseptic soap preparations have been identified as one of the reasons why healthcare practitioners fail to adhere to hand hygiene guidelines.
      • Pratt RJ
      • Pellowe C
      • Loveday HP
      • Department of Health (England)
      • et al.
      The epic project: developing national evidence-based guidelines for preventing healthcare associated infections. Phase I: Guidelines for preventing hospital-acquired infections.
      • Pratt RJ
      • Pellowe CM
      • Wilson JA
      • et al.
      epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
      • World Health Organization
      • Boyce JM
      • Pittet D
      • Healthcare Infection Control Practices Advisory Committee
      • Society for Healthcare Epidemiology of America
      • Association for Professionals in Infection Control
      • Infectious Diseases Society of America Hand Hygiene Task Force
      Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
      • Pietsch H
      Hand antiseptics: rubs versus scrubs, alcoholic solutions versus alcoholic gels.
      In addition, washing hands regularly with liquid soap and water before or after the use of ABHR is associated with dermatitis and is not necessary.
      • World Health Organization
      Systematic reviews conducted to underpin national guidelines
      • Pratt RJ
      • Pellowe C
      • Loveday HP
      • Department of Health (England)
      • et al.
      The epic project: developing national evidence-based guidelines for preventing healthcare associated infections. Phase I: Guidelines for preventing hospital-acquired infections.
      • Pratt RJ
      • Pellowe CM
      • Wilson JA
      • et al.
      epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
      • World Health Organization
      • Boyce JM
      • Pittet D
      • Healthcare Infection Control Practices Advisory Committee
      • Society for Healthcare Epidemiology of America
      • Association for Professionals in Infection Control
      • Infectious Diseases Society of America Hand Hygiene Task Force
      Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
      • Pellowe C
      • Pratt R
      • Harper P
      • et al.
      Infection control: prevention of healthcare-associated infection in primary and community care.
      have identified a range of studies that compared the use of alcohol-based preparations with liquid soap and water using self-assessment of skin condition by nurses. These studies found that ABHR was associated with less skin irritation than liquid soap and water.
      • Winnefeld M
      • Richard MA
      • Drancourt M
      • Grob JJ
      Skin tolerance and effectiveness of two hand decontamination procedures in everyday hospital use.
      • Larson EL
      • Aiello AE
      • Bastyr J
      • et al.
      Assessment of two hand hygiene regimens for intensive care unit personnel.
      • Larson EL
      • Cimiotti J
      • Haas J
      • et al.
      Effect of antiseptic handwashing vs alcohol sanitizer on health care-associated infections in neonatal intensive care units.
      • Larson E
      • Silberger M
      • Jakob K
      • et al.
      Assessment of alternative hand hygiene regimens to improve skin health among neonatal intensive care unit nurses.
      • Boyce JM
      • Kelliher S
      • Vallande N
      Skin irritation and dryness associated with two hand-hygiene regimens: soap-and-water hand washing versus hand antisepsis with an alcoholic hand gel.
      • Forrester BG
      • Roth VS
      Hand dermatitis in intensive care units.
      • Kampf G
      • Muscatiello M
      Dermal tolerance of Sterillium, a propanol-based hand rub.
      In addition, a longitudinal study of the introduction and subsequent use of ABHR over a 7-year period observed no reports of irritant and contact dermatitis associated with the use of ABHR.
      • Pittet D
      • Hugonnet S
      • Harbarth S
      • et al.
      Effectiveness of a hospital-wide programme to improve compliance with hand hygiene.
      We identified a recent study which suggested that two ABHR preparations containing a glycerol emollient were more acceptable to staff (p<0.001).
      • Pittet D
      • Allegranzi B
      • Sax H
      • et al.
      Double-blind, randomized, crossover trial of 3 hand rub formulations: fast-track evaluation of tolerability and acceptability.
      Hand moisturisers/emollients that are for shared use are more likely to become contaminated, and have been associated with an outbreak of infection in a neonatal unit.
      • Becks VE
      • Lorenzoni NM
      Pseudomonas aeruginosa outbreak in a neonatal intensive care unit: a possible link to contaminated hand lotion.
      Current national and international guidance suggests that skin care, through the appropriate use of hand lotion or moisturisers added to hand hygiene preparations, is an important factor in maintaining skin integrity, encouraging adherence to hand decontamination practices and assuring the health and safety of healthcare practitioners.
      • Pratt RJ
      • Pellowe CM
      • Wilson JA
      • et al.
      epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
      • World Health Organization
      • Boyce JM
      • Pittet D
      • Healthcare Infection Control Practices Advisory Committee
      • Society for Healthcare Epidemiology of America
      • Association for Professionals in Infection Control
      • Infectious Diseases Society of America Hand Hygiene Task Force
      Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
      • SP11
        Clinical staff should be made aware of the potentially damaging effects of hand decontamination products, and encouraged to use an emollient hand cream regularly to maintain the integrity of the skin. Consult the occupational health team or a general practitioner if a particular liquid soap, antiseptic handwash or alcohol-based hand rub causes skin irritation.
        Class D/GPP

      How can adherence to hand hygiene guidance be promoted?

      National and international guidelines emphasise the importance of adherence to hand hygiene guidance, and provide an overview of the barriers and factors that influence hand hygiene compliance.
      • Pratt RJ
      • Pellowe C
      • Loveday HP
      • Department of Health (England)
      • et al.
      The epic project: developing national evidence-based guidelines for preventing healthcare associated infections. Phase I: Guidelines for preventing hospital-acquired infections.
      • Pratt RJ
      • Pellowe CM
      • Wilson JA
      • et al.
      epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
      • World Health Organization
      • Boyce JM
      • Pittet D
      • Healthcare Infection Control Practices Advisory Committee
      • Society for Healthcare Epidemiology of America
      • Association for Professionals in Infection Control
      • Infectious Diseases Society of America Hand Hygiene Task Force
      Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
      The use of multi-modal approaches to improving hand hygiene practice and behaviour has been advocated for over 10 years. Observational studies have consistently reported an association between multi-modal interventions involving the introduction of near-patient ABHR, audit and feedback, reminders and education, and greater compliance by healthcare staff.
      • Pittet D
      • Hugonnet S
      • Harbarth S
      • et al.
      Effectiveness of a hospital-wide programme to improve compliance with hand hygiene.
      • Hilburn J
      • Hammond BS
      • Fendler EJ
      • Groziak PA
      Use of alcohol hand sanitizer as an infection control strategy in an acute care facility.
      • Rosenthal VD
      • Guzman S
      • Safdar N
      Reduction in nosocomial infection with improved hand hygiene in intensive care units of a tertiary care hospital in Argentina.
      • Rosenthal VD
      • Guzman S
      • Safdar N
      Effect of education and performance feedback on rates of catheter-associated urinary tract infection in intensive care units in Argentina.
      • Won S
      • Chou H
      • Hsieh W
      • et al.
      Handwashing program for the prevention of nosocomial infections in a neonatal intensive care unit.
      • MacDonald A
      • Dinah F
      • MacKenzie D
      • Wilson A
      Performance feedback of hand hygiene, using alcohol gel as the skin decontaminant, reduces the number of inpatients newly affected by MRSA and antibiotic costs.
      • Wendt C
      • Knautz D
      • von Baum H
      Differences in hand hygiene behavior related to the contamination risk of healthcare activities in different groups of healthcare workers.
      • Cohen B
      • Saiman L
      • Cimiotti J
      • Larson E
      Factors associated with hand hygiene practices in two neonatal intensive care units.
      • Brown SM
      • Lubimova AV
      • Khrustalyeva NM
      • et al.
      Use of an alcohol-based hand rub and quality improvement interventions to improve hand hygiene in a Russian neonatal intensive care unit.
      • Kuzu N
      • Özer F
      • Aydemir S
      • Yalcin AN
      • Zencir M
      Compliance with hand hygiene and glove use in a university-affiliated hospital.
      • Kim PW
      • Roghmann M
      • Perencevich EN
      • Harris AD
      Rates of hand disinfection associated with glove use, patient isolation, and changes between exposure to various body sites.
      • McGuckin M
      • Taylor A
      • Martin V
      • Porten L
      • Salcido R
      Evaluation of a patient education model for increasing hand hygiene compliance in an inpatient rehabilitation unit.
      • McGuckin M
      • Waterman R
      • Storr IJ
      • et al.
      Evaluation of a patient-empowering hand hygiene programme in the UK.
      An early systematic review of 21 studies involving interventions to improve hand hygiene compliance concludes that:
      • single interventions have a short-term influence on hand hygiene;
      • reminders have a modest but sustained effect;
      • feedback increases rates of hand hygiene but must be regular;
      • near-patient alcohol-based preparations improve the frequency with which healthcare workers clean their hands; and
      • multi-faceted approaches have a more marked effect on hand hygiene and rates of HCAI.
        • Naikoba S
        • Hayward A
        The effectiveness of interventions aimed at increasing handwashing in healthcare workers - a systematic review.
      National hand hygiene campaigns have been modelled on the multi-modal approach and implemented across the world.
      • World Health Organization
      • Pittet D
      • Hugonnet S
      • Harbarth S
      • et al.
      Effectiveness of a hospital-wide programme to improve compliance with hand hygiene.
      • Magiorakos AP
      • Leens E
      • Michael S
      • et al.
      National hand hygiene campaigns in Europe, 2000–2009. Euro surveillance: bulletin Européen sur les maladies transmissibles.
      • Grayson ML
      • Russo PL
      • Cruickshank M
      • et al.
      Outcomes from the first 2 years of the Australian national hand hygiene initiative.
      In England and Wales, the National Patient Safety Agency's ‘Cleanyourhands Campaign’ was piloted and implemented between 2004 and 2008 with the aim of creating sustainable change in hand hygiene compliance. The campaign comprised the use of near-patient ABHR, national poster materials, audit and feedback, and materials for patient engagement.
      Recent Cochrane reviews of randomised and controlled clinical trials, interrupted time series and controlled before-after studies have suggested that the majority of studies conducted in this field have methodological biases that exclude them from this review.
      • Gould DJ
      • Moralejo D
      • Drey N
      • Chudleigh JH
      Interventions to improve hand hygiene compliance in patient care.
      • Gould DJ
      • Chudleigh JH
      • Moralejo D
      • Drey N
      Interventions to improve hand hygiene compliance in patient care.
      We identified four systematic reviews of interventions to improve hand hygiene compliance.
      • Gould DJ
      • Moralejo D
      • Drey N
      • Chudleigh JH
      Interventions to improve hand hygiene compliance in patient care.
      • Backman C
      • Zoutman DE
      • Marck PB
      An integrative review of the current evidence on the relationship between hand hygiene interventions and the incidence of health care-associated infections.
      • Aboelela SW
      • Stone PW
      • Larson EL
      Effectiveness of bundled behavioural interventions to control healthcare-associated infections: a systematic review of the literature.
      • Cherry MG
      • Brown JM
      • Bethell GS
      • Neal T
      • Shaw NJ
      Features of educational interventions that lead to compliance with hand hygiene in healthcare professionals within a hospital care setting. A BEME systematic review: BEME Guide No. 22.
      The most recent Cochrane review identified 84 studies published after 2006 for potential inclusion, but only four studies (one RCT, two interrupted time series and one controlled before-after study) were included following detailed quality assessment.
      • Gould DJ
      • Moralejo D
      • Drey N
      • Chudleigh JH
      Interventions to improve hand hygiene compliance in patient care.
      The heterogeneity of interventions and methods precluded the pooling and meta-analysis of results, and it was concluded that multi-faceted campaigns that include social marketing or staff engagement may be more effective than campaigns without these components, and that education or product substitution alone were less effective.
      An integrative systematic review of 35 studies that reported a wide range of interventions, including multi-modal interventions and hand hygiene product changes, only scored nine of the included studies as having limited or no fatal flaws.
      • Backman C
      • Zoutman DE
      • Marck PB
      An integrative review of the current evidence on the relationship between hand hygiene interventions and the incidence of health care-associated infections.
      The authors concluded that design limitations made it difficult to generalise the study results or isolate the specific effects of hand hygiene (or other interventions) on reductions in HCAI.
      An earlier systematic review of ‘bundled’ behavioural intervention studies that reported HCAI or rates of colonisation as the primary outcome identified 33 potential studies for inclusion; of these, only four had quality scores >80%. Again, due to the heterogeneity of study interventions and outcomes, the results were narratively synthesised.
      • Aboelela SW
      • Stone PW
      • Larson EL
      Effectiveness of bundled behavioural interventions to control healthcare-associated infections: a systematic review of the literature.
      The authors concluded that the formation of multi-disciplinary quality improvement teams and educational interventions might be effective strategies to improve hand hygiene and reduce rates of HCAI.
      The final systematic review focused specifically on educational interventions to improve hand hygiene compliance and competence in hospital settings, and included all study designs that reported at least one outcome measure of hand hygiene competence and had a follow-up of at least 6 months.
      • Cherry MG
      • Brown JM
      • Bethell GS
      • Neal T
      • Shaw NJ
      Features of educational interventions that lead to compliance with hand hygiene in healthcare professionals within a hospital care setting. A BEME systematic review: BEME Guide No. 22.
      Thirty studies met the inclusion criteria for the review, but it was not possible to separate competence from compliance. Educational interventions taught or re-taught the correct methods for hand hygiene and then assessed compliance. The authors concluded that educational interventions had a greater impact if compliance with hand hygiene was low. Multiple interventions were better than single interventions in sustaining behaviour change, as were continuous, rather than one-off, interventions. However, it was not possible to determine the duration or sustainability of behaviour change in these studies.
      We identified six new studies in our systematic review: one cluster RCT and process evaluation,
      • Huis A
      • Schoonhoven L
      • Grol R
      • Donders R
      • Hulscher M
      • van Achterberg T
      Impact of a team and leaders-directed strategy to improve nurses' adherence to hand hygiene guidelines: a cluster randomised trial.
      • Huis A
      • Holleman G
      • van Achterberg T
      • Grol R
      • Schoonhoven L
      • Hulscher M
      Explaining the effects of two different strategies for promoting hand hygiene in hospital nurses: a process evaluation alongside a cluster randomised controlled trial.
      one step-wedge cluster RCT,
      • Fuller C
      • Duckworth G
      • Jeanes A
      • et al.
      The Feedback Intervention Trial (FIT) – improving hand-hygiene compliance in UK healthcare workers: a stepped wedge cluster randomised controlled trial.
      two interrupted time series studies
      • Chen Y
      • Sheng W
      • Wang J
      • et al.
      Effectiveness and limitations of hand hygiene promotion on decreasing healthcare-associated infections.
      • Stone SP
      • Jeanes A
      • Roberts J
      • et al.
      Evaluation of the national Cleanyourhands campaign to reduce Staphylococcus aureus bacteraemia and Clostridium difficile infection in hospitals in England and Wales by improved hand hygiene: four year, prospective, ecological, interrupted time series study.
      and one controlled before-after study
      • Benning A
      • Carmalt M
      • Rudge G
      • et al.
      Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase.
      that evaluated multi-modal interventions with varying components. In a cluster RCT that also included a process evaluation, the authors tested a set of core elements in a ‘state-of-the-art strategy’ (SAS) against a team-leader-directed strategy (TDS) at baseline (T1), immediately following the intervention (T2) and 6 months later (T3) to ascertain the additional benefits of leadership and staff engagement components.
      • Huis A
      • Schoonhoven L
      • Grol R
      • Donders R
      • Hulscher M
      • van Achterberg T
      Impact of a team and leaders-directed strategy to improve nurses' adherence to hand hygiene guidelines: a cluster randomised trial.
      • Huis A
      • Holleman G
      • van Achterberg T
      • Grol R
      • Schoonhoven L
      • Hulscher M
      Explaining the effects of two different strategies for promoting hand hygiene in hospital nurses: a process evaluation alongside a cluster randomised controlled trial.
      In the intention-to-treat analysis (ITT), an OR of 1.64 (95% CI 1.33–2.02, p<0.001) in favour of the TDS between T2 and T3 suggested that engaging ward leadership and the involvement of teams in setting norms and targets resulted in greater compliance with hand hygiene. However, there was no significant difference between the groups' compliance at T3 in the ITT (p=0.187), with the SAS also having a sustained effect.
      • Huis A
      • Schoonhoven L
      • Grol R
      • Donders R
      • Hulscher M
      • van Achterberg T
      Impact of a team and leaders-directed strategy to improve nurses' adherence to hand hygiene guidelines: a cluster randomised trial.
      The process evaluation examined the extent to which the content, dosage and coverage of the intervention had been delivered.
      • Huis A
      • Holleman G
      • van Achterberg T
      • Grol R
      • Schoonhoven L
      • Hulscher M
      Explaining the effects of two different strategies for promoting hand hygiene in hospital nurses: a process evaluation alongside a cluster randomised controlled trial.
      An as-treated analysis demonstrated a greater effect size for the TDS at T3 with a significant difference in hand hygiene compliance (p<0.01). The process evaluation also suggested that feedback about individual hand hygiene performance at T2 and T3 (p<0.05 and p<0.01, respectively), challenging colleagues on undesirable hand hygiene practice (p<0.01), and support from colleagues in performing hand hygiene (p<0.01) were positively correlated with changes in nurses' hand hygiene compliance.
      • Huis A
      • Holleman G
      • van Achterberg T
      • Grol R
      • Schoonhoven L
      • Hulscher M
      Explaining the effects of two different strategies for promoting hand hygiene in hospital nurses: a process evaluation alongside a cluster randomised controlled trial.
      The second cluster RCT used a step-wedge design to assess a behavioural feedback intervention in intensive therapy units (ITUs) and acute care of the elderly (ACE) wards at sites participating in the ‘Cleanyourhands Campaign’.
      • Fuller C
      • Duckworth G
      • Jeanes A
      • et al.
      The Feedback Intervention Trial (FIT) – improving hand-hygiene compliance in UK healthcare workers: a stepped wedge cluster randomised controlled trial.
      The primary and secondary outcome measures were hand hygiene compliance measured by covert direct observation for 1 h every 6 weeks, and soap and ABHR procurement, respectively. Sixty wards were recruited, of which 33 implemented the intervention. The ITT analysis (60 wards) showed a significant effect of the intervention in the ITUs but not the ACE wards, equating to a 7–9% increase in compliance, with estimated OR of 1.44 (95% CI 1.018–1.76, p=<0.001) in ITUs and estimated OR of 1.06 (95% CI 0.87–1.25, p=0.5) in ACE wards. The per-protocol analysis (33 wards) showed a significant increase in compliance in both ACE wards and ITUs of 10–13% and 13–18%, respectively, with estimated OR of 1.67 (95% CI 1.26–2.22, p≤0.001) in ACE wards and estimated OR of 2.09 (95% CI 1.55–2.81, p≤0.001) in ITUs. The authors concluded that individual feedback and team action planning resulted in moderate but sustained improvements in hand hygiene adherence. The difficulties in implementing this intervention point to the problems that might be faced in a non-trial context.
      Two interrupted time series studies of the 4-year national ‘Cleanyourhands Campaign’ in England and a 4-year hospital-wide programme in Taiwan demonstrated increased hand hygiene compliance (measured by procurement of ABHR and liquid soap) and reductions in HCAI [MRSA and C. difficile, and MRSA and extensively-drug-resistant Acinetobacter (XDRAB)].
      • Chen Y
      • Sheng W
      • Wang J
      • et al.
      Effectiveness and limitations of hand hygiene promotion on decreasing healthcare-associated infections.
      • Stone SP
      • Jeanes A
      • Roberts J
      • et al.
      Evaluation of the national Cleanyourhands campaign to reduce Staphylococcus aureus bacteraemia and Clostridium difficile infection in hospitals in England and Wales by improved hand hygiene: four year, prospective, ecological, interrupted time series study.
      In the national study, increased procurement of soap was independently associated with reductions in C. difficile infection (adjusted incidence rate ratio for 1-mL increase per patient-bed-day 0.993, 95% CI 0.990–0.996, p<0.0001) and MRSA in the last four quarters of the study (adjusted incidence rate ratio for 1-mL increase per patient-bed-day 0.990, 95% CI 0.985–0.995, p<0.0001).
      • Stone SP
      • Jeanes A
      • Roberts J
      • et al.
      Evaluation of the national Cleanyourhands campaign to reduce Staphylococcus aureus bacteraemia and Clostridium difficile infection in hospitals in England and Wales by improved hand hygiene: four year, prospective, ecological, interrupted time series study.
      The ‘Cleanyourhands Campaign’ was not independent of other national programmes to reduce MRSA bloodstream infections and C. difficile infection. Analysis also identified that the publication of the Health Act and the Department of Health improvement team visits were associated with reductions in MRSA and C.difficile. In the hospital-wide study,
      • Chen Y
      • Sheng W
      • Wang J
      • et al.
      Effectiveness and limitations of hand hygiene promotion on decreasing healthcare-associated infections.