1,721,020 research outputs found
Re-visiting contact precautions – 25 years on
Full text linkIn a recent attempt to conduct a systematic review for evidence for the efficacy of contact precautions in preventing the transmission of respiratory viruses of concern, no evidence was found. Understandably, in the early days of the COVID-19 pandemic when there was little information about routes of transmission and high levels of concern, a full range of precautions were applied including contact precautions (CP). However, the legacy of this approach needs careful evaluation in the context of widespread unsafe use of personal protective equipment (PPE), and significant transmission of both SAR-CoV-2 and other pathogens during the pandemic. There is a danger that CP is perceived as the best ‘precautionary’ approach to minimising transmission of infection with scant regard for evidence for its efficacy or consideration of the rationale and risks associated with it
Contact precautions for clostridium difficile and methicillin-resistant staphylococcus aureus (MRSA)
No full textThis paper presents an overview of the key findings, key issues and implications emerging from a single case study designed to explore a group of nurses' and healthcare assistants' infection control practice, and to introduce interventions aimed at implementing best practice. The study was undertaken on one hospital ward and the sample comprised all permanently employed nurses and healthcare assistants (n=18). Guidelines on Contract Precautions were developed and informed by an expert panel of infection control nurses (n=100) from across the UK. The detailed investigation of individual participant's responses to the intervention during its implementation provided unique insights into the factors which influence nurses' and healthcare assistants' decision making in relation to infection control practice. Analyses of the data from all three phases of the study revealed that participants experienced great difficulty comprehending infection control recommendations and varied in the extent to which they adopted them. Their capacity to understand and implement these recommendations was hampered, not only by a lack of knowledge, but also by irrational beliefs, inaccurate perceptions of risk, both in relation to themselves and patients, and a lack of ability or willingness to exercise clinical judgement, particularly in relation to glove use. These findings highlight the need for further study in the drive to improve this crucial aspect of health care services
Interventions to minimise the initial use of indwelling urinary catheters in acute care: a systematic review
No full textBackground Indwelling urinary catheters (IUC) are the primary cause of urinary tract infection in acute care. Current research aimed at reducing the use of IUCs in acute care has focused on the prompt removal of catheters already placed. This paper evaluates attempts to minimise the initial placement of IUCs.ObjectivesTo evaluate systematically the evidence of the effectiveness of interventions to minimise the initial placement of IUCs in adults in acute care.Design Studies incorporating an intervention to reduce the initial placement of IUCs in an acute care environment in patients aged 18 and over that reported on the incidence of IUC placement were included in the review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist has been used as a tool to guide the structure of the review.Data SourcesMEDLINE, CINAHL, EMBASE, National Health Service Centre for Review and Dissemination and Cochrane Library.Review Methods A systematic review to identify and synthesise research reporting on the impact on interventions to minimise the use of IUCs in acute care published up to July 2011.Results 2689 studies were scanned for eligibility. Only eight studies were found that reported any change (increase or decrease) in the level of initial placement of IUCs as a result of an intervention in acute care. Of the eight, six had an uncontrolled before-after design. Seven demonstrated a reduction in the initial use of IUCs post-intervention. There was insufficient evidence to support or rule out the effectiveness of interventions due to the small number of studies, limitations in study design and variation in clinical environments. Notably, each study listed the indications considered to be acceptable uses of an IUC and there was substantial variation between the lists of indications.Conclusions More work is needed to establish when the initial placement of an IUC is appropriate in order to better understand when IUCs are overused and inform the development of methodologically robust research on the potential of interventions to minimise the initial placement of IUCs
“It's easier to stick a tube in”: a qualitative study to understand clinicians’ individual decisions to place urinary catheters in acute medical care
No full textBackground Indwelling urinary catheters (IUCs) placed in acute care are a leading cause of healthcare-associated urinary tract infection. Despite initiatives to minimise the placement of IUCs, levels of inappropriate use are still considered unacceptable. IUC practice is difficult to change, and factors influencing clinicians’ decisions need to be better understood. Objective To explore why clinicians decide to place IUCs in acute medical care. Methods We conducted a qualitative study in the emergency department and acute medical wards of a 1200+ bed hospital, undertaking 30 retrospective think aloud and 20 semistructured interviews with nurses and physicians who made the decision to place an IUC. A purposive sample and thematic analysis were used. Results Opinions on when an IUC was warranted varied considerably. Inconsistency in decision-making was caused by differing beliefs on when an IUC was appropriate for each clinical indication. Numerous patient and non-patient factors, including clinical setting, resources, patient age and gender and staff workload, also impacted on each decision. Assessing when the benefit of an IUC outweighed the risk could be problematic due to conflicting goals. Conclusions These findings help to explain why clinicians sometimes deviate from IUC best practice guidance and resist interventions to modify practice. In order to engage nurses and physicians in change, interventions to reduce IUC use should acknowledge and respond to the complexity and lack of clarity often faced by clinicians making the decision to place an IUC. However, it is equally important that inconsistencies in IUC-related beliefs are recognised, investigated and, where appropriate, challenged.</p
How do doctors, nurses and healthcare assistants in the Acute Medical Unit look after patients who have diarrhoea and vomiting? An ethnographic study
No full textSingle room isolation to prevent the transmission of infection: development of a patient journey tool to support safe practice
No full textA variety of infection prevention and control precautions are used to minimise the risk of infection spread from person to person, both patients and staff. Standard Precautions (SPs), including hand hygiene and use of personal protective equipment (PPE), are applied routinely to all patients, whereas transmission-based precautions (TBPs) are used when a patient is known or suspected to have an epidemiologically important infectious disease or condition, in order to further reduce the risk of spread of infection.The use of single room isolation is part of TBPs and is a cornerstone of hospital infection prevention and control practice. However, successfully implementing TBPs, including single room isolation, continues to be a challenge in the UK for a number of reasons.Effective approaches to increasing the quality and safety of patient care are increasingly based on utilising simple tools that increase the likelihood that care will be provided in a reliable way. The tool presented is intended to facilitate both learning and practice in relation to TBPs and to promote the delivery of safe patient care in relation to single room isolation. It is designed for use in those situations when a single room is available for patient isolation. It also highlights the other important TBPs to be taken to prevent the spread of infection, whether or not a single room is available. It can be adapted for use with any organism or disease for which TBPs are recommended. At a time when healthcare associated infections (HCAI) such as Clostridium difficile and meticillin resistant Staphylococcus aureus (MRSA) continue to have an impact on both acute and community care settings, and their reduction is embedded within national targets for NHS healthcare providers, tools that make it easy for healthcare workers to apply safe practices within their daily routines are essential.Initial testing suggests that this tool is acceptable to healthcare workers and further study will identify its potential contribution to healthcare workers' knowledge and practice in this area
Intermittent catheter techniques, strategies and designs for managing long‐term bladder conditions
No full textBackgroundIntermittent catheterisation (IC) is a commonly recommended procedure for people with incomplete bladder emptying. Frequent complications are urinary tract infection (UTI), urethral trauma and discomfort during catheter use. Despite the many designs of intermittent catheter, including different lengths, materials and coatings, it is unclear which catheter techniques, strategies or designs affect the incidence of UTI and other complications, measures of satisfaction/quality of life and cost‐effectiveness.This is an update of a Cochrane Review first published in 2007. ObjectivesTo assess the clinical and cost‐effectiveness of different catheterisation techniques, strategies and catheter designs, and their impact, on UTI and other complications, and measures of satisfaction/quality of life among adults and children whose long‐term bladder condition is managed by intermittent catheterisation.Search methodsWe searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 12 April 2021), the reference lists of relevant articles and conference proceedings, and we attempted to contact other investigators for unpublished data or for clarification.Selection criteriaRandomised controlled trials (RCTs) or randomised cross‐over trials comparing at least two different catheterisation techniques, strategies or catheter designs.Data collection and analysisAs per standard Cochrane methodological procedures, two review authors independently extracted data, assessed risk of bias and assessed the certainty of evidence using GRADE. Outcomes included the number of people with symptomatic urinary tract infections, complications such as urethral trauma/bleeding, comfort and ease of use of catheters, participant satisfaction and preference, quality of life measures and economic outcomes.Main resultsWe included 23 trials (1339 randomised participants), including twelve RCTs and eleven cross‐over trials. Most were small (fewer than 60 participants completed), although three trials had more than 100 participants. Length of follow‐up ranged from one month to 12 months and there was considerable variation in definitions of UTI. Most of the data from cross‐over trials were not presented in a useable form for this review.Risk of bias was unclear in many domains due to insufficient information in the trial reports and several trials were judged to have a high risk of performance bias due to lack of blinding and a high risk of attrition bias. The certainty of evidence was downgraded for risk of bias, and imprecision due to low numbers of participants. Aseptic versus clean techniqueWe are uncertain if there is any difference between aseptic and clean techniques in the risk of symptomatic UTI because the evidence is low‐certainty and the 95% confidence interval (CI) is consistent with possible benefit and possible harm (RR 1.20 95% CI 0.54 to 2.66; one study; 36 participants). We identified no data relating to the risk of adverse events comparing aseptic and clean techniques or participant satisfaction or preference. Single‐use (sterile) catheter versus multiple‐use (clean)We are uncertain if there is any difference between single‐use and multiple‐use catheters in terms of the risk of symptomatic UTI because the certainty of evidence is low and the 95% CI is consistent with possible benefit and possible harm (RR 0.98, 95% CI 0.55, 1.74; two studies; 97 participants). One study comparing single‐use catheters to multiple‐use catheters reported zero adverse events in either group; no other adverse event data were reported for this comparison. We identified no data for participant satisfaction or preference.Hydrophilic‐coated catheters versus uncoated cathetersWe are uncertain if there is any difference between hydrophilic and uncoated catheters in terms of the number of people with symptomatic UTI because the certainty of evidence is low and the 95% CI is consistent with possible benefit and possible harm (RR 0.89, 95% CI 0.69 to 1.14; two studies; 98 participants). Uncoated catheters probably slightly reduce the risk of urethral trauma and bleeding compared to hydrophilic‐coated catheters (RR 1.37, 95% CI 1.01 to 1.87; moderate‐certainty evidence). The evidence is uncertain if hydrophilic‐coated catheters compared with uncoated catheters has any effect on participant satisfaction measured on a 0‐10 scale (MD 0.7 higher, 95% CI 0.19 to 1.21; very low‐certainty evidence; one study; 114 participants). Due to the paucity of data, we could not assess the certainty of evidence relating to participant preference (one cross‐over trial of 29 participants reported greater preference for a hydrophilic‐coated catheter (19/29) compared to an uncoated catheter (10/29)). Authors' conclusionsDespite a total of 23 trials, the paucity of useable data and uncertainty of the evidence means that it remains unclear whether the incidence of UTI or other complications is affected by use of aseptic or clean technique, single (sterile) or multiple‐use (clean) catheters, coated or uncoated catheters or different catheter lengths. The current research evidence is uncertain and design and reporting issues are significant. More well‐designed trials are needed. Such trials should include analysis of cost‐effectiveness because there are likely to be substantial differences associated with the use of different catheterisation techniques and strategies, and catheter designs
Investigating the implementation of a complex intervention to reduce central line-associated bloodstream infections in the Neonatal Intensive Care Unit, using Normalisation Process Theory
No full textBackground: Care bundles may reduce neonatal CLABSIs by 60% though it is often unclear if it is the intervention, the implementation, or both, that results in CLABSI reductions. This study aimed to investigate the implementation of a CLABSI care bundle in a UK neonatal intensive care unit (NICU). Methods: A focused ethnographic design was used underpinned by Normalisation Process Theory. Data collection included Normalisation MeAsure Development (NoMAD) surveys, observations of practice with dyadic think aloud interviews, and semi-structured interviews. Outcome and processes measures were collected. Data analysis used descriptive statistics and thematic analysis. Results: There was only partial bundle implementation, with minimal changes in survey scores and influences across individual, team and organisational levels moderating bundle adoption. Organisational culture sometimes undermined implementation and there were challenges relating to reinforcement and endorsement. Conclusions: The introduction of a care bundle into a tertiary UK NICU did not result in sustained reductions in CLABSIs, which is one of few negative studies. Understanding the mechanisms by which an intervention works (or not) in specific contexts is important to optimise the delivery of evidence-based care.</p
Biofilm development on urinary catheters promotes the appearance of viable but non-culturable (VBNC) bacteria
No full textCatheter-associated urinary tract infections have serious consequences, both for patients and in impacting on healthcare resources. Much work has been carried out to develop an antimicrobial catheter. Although such developments have shown promise under laboratory conditions, none have demonstrated a clear advantage in clinical trials.Using a range of microbiological and advanced microscopy techniques, a detailed laboratory study comparing biofilm development on silicone, hydrogel latex and silver alloy coated hydrogel latex catheters was carried out. Biofilm development by Escherichia coli, Pseudomonas aeruginosa and Proteus mirabilis on three commercially available catheters was tracked over time. Samples were examined with episcopic differential interference contrast (EDIC) microscopy, culture analysis and staining techniques to quantify viable but non-culturable (VBNC) bacteria.Both qualitative and quantitative assessment found biofilms to develop rapidly on all three materials. EDIC microscopy revealed the rough surface topography of the materials. Differences between culture counts and quantification of total and dead cells demonstrated the presence of VBNC populations, where bacteria retain viability but are not metabolically active.The use of non-culture based techniques showed the development of widespread VBNC populations. These VBNC populations were more evident on silver alloy coated hydrogel latex catheters, indicating a bacteriostatic effect at best. The laboratory tests reported here, that detect VBNC bacteria, allow more rigorous assessment of antimicrobial catheters offering an explanation for why there is often minimal benefit to patients.IMPORTANCE Several antimicrobial urinary catheter materials have been developed but, although laboratory studies may show a benefit, none have significantly improved clinical outcomes. The use of poorly designed laboratory testing and lack of consideration to the impact of VBNC populations may be responsible. While the presence of VBNC populations is becoming more widely reported, there remains a lack of understanding of the clinical impact or influence of exposure to antimicrobial products. This is the first study to investigate the impact of antimicrobial surface materials and the appearance of VBNC populations. This demonstrates how improved testing is needed prior to clinical trials uptake
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