Levels of evidence (I-IV) and grading of recommendations (A-D) are defined at the end of the Major Recommendations field. In addition, some recommendations are based directly on UK health and safety legislation and are designated H&S.
Standard Principles
The recommendations on standard principles provide guidance on infection control precautions that should be applied by all healthcare personnel, and other carers, to the care of patients in community and primary care settings.
The recommendations are divided into three broad recommendation headings:
- Hand hygiene
- The use of personal protective equipment
- The safe use and disposal of sharps
- Education of patients their carers and healthcare personnel
Hand Hygiene
B - Hands must be decontaminated immediately before each and every episode of direct patient contact or care and after any activity or contact that could potentially result in hands becoming contaminated.
A - Hands that are visibly soiled, or potentially grossly contaminated with dirt or organic material, must be washed with liquid soap and water.
A - Hands must be decontaminated, preferably with an alcohol-based hand rub unless hands are visibly soiled, between caring for different patients and between different care activities for the same patient.
D - Before regular hand decontamination begins, all wrist and ideally hand jewellery should be removed. Cuts and abrasions must be covered with waterproof dressings. Fingernails should be kept short, clean, and free from nail polish.
D - An effective handwashing technique involves three stages: preparation, washing and rinsing, and drying. Preparation requires wetting hands under tepid running water before applying liquid soap or an antimicrobial preparation. The handwash solution must come into contact with all of the surfaces of the hand. The hands must be rubbed together vigorously for a minimum of 10-15 seconds, paying particular attention to the tips of the fingers, the thumbs, and the areas between the fingers. Hands should be rinsed thoroughly before drying with good quality paper towels.
D - When decontaminating hands using an alcohol handrub, hands should be free from dirt and organic material. The handrub solution must come into contact with all surfaces of the hand. The hands must 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.
D - An emollient hand cream should be applied regularly to protect skin from the drying effects of regular hand decontamination. If a particular soap, antimicrobial hand wash, or alcohol product causes skin irritation an occupational health team should be consulted.
Use of Personal Protective Equipment
D, H&S - Selection of protective equipment should be based on an assessment of the risk of transmission of microorganisms to the patient and the risk of contamination of the healthcare practitioner's clothing and skin by patients' blood, body fluids, secretions, or excretions.
D, H&S - Gloves must be worn for invasive procedures, contact with sterile sites and non-intact skin or mucous membranes, and all activities that have been assessed as carrying a risk of exposure to blood, body fluids, secretions, or excretions, or to sharp or contaminated instruments.
D, H&S - Gloves must be worn as single-use items. They must be put on immediately before an episode of patient contact or treatment and removed as soon as the activity is completed. Gloves must be changed between caring for different patients and between different care or treatment activities for the same patient.
D, H&S - Gloves must be disposed of as clinical waste and hands decontaminated after the gloves have been removed.
H&S - Gloves that are acceptable to healthcare personnel and that conform to European Community (CE) standards must be available.
H&S - Sensitivity to natural rubber latex in patients, carers, and healthcare personnel must be documented, and alternatives to natural rubber latex gloves must be available.
D, H&S - Neither powdered gloves nor polythene gloves should be used in healthcare activities.
D, H&S - Disposable plastic aprons should be worn when there is a risk that clothing may be exposed to blood, body fluids, secretions, or excretions, with the exception of sweat.
D, H&S - Full-body fluid-repellent gowns must be worn where there is a risk of extensive splashing of blood, body fluids, secretions, or excretions, with the exception of sweat, onto the skin or clothing of healthcare practitioners (for example when assisting with childbirth).
D, H&S - Plastic aprons should be worn as single-use items, for one procedure or episode of patient care, and then discarded and disposed of as clinical waste.
D, H&S - Face masks and eye protection must be worn where there is a risk of blood, body fluids, secretions, or excretions splashing into the face and eyes.
D, H&S - Respiratory protective equipment, for example a particulate filter mask, must be used when clinically indicated.
Safe Use and Disposal of Sharps
D, H&S - Sharps must not be passed directly from hand to hand, and handling should be kept to a minimum.
D, H&S - Needles must not be recapped, bent, broken, or disassembled before use or disposal.
D, H&S - Used sharps must be discarded into a sharps container (conforming to UN3291 and BS 7320 standards) at the point of use by the user. These must not be filled above the mark that indicates that they are full.
D, H&S - Containers in public areas must be located in a safe position and must not be placed on the floor. They must be disposed of by the licensed route in accordance with local policy.
D, H&S - Needle safety devices must be used where there are clear indications that they will provide safer systems of working for healthcare personnel.
D - Everyone involved in providing care in the community should be educated about standard principles and trained in hand decontamination, the use of protective clothing, and the safe disposal of sharps.
D - Adequate supplies of liquid soap, handrub, towels, and sharps containers should be made available wherever care is delivered.
Care of Patients with Long-Term Urinary Catheters
These guidelines apply to adults and children and should be used in conjunction with the guidance on standard principles (see above). These guidelines focus on preventing infection. However, because infection has a complex interrelationship with encrustation and blockage, these aspects of catheter management are also addressed.
The recommendations are divided into five distinct interventions:
- Education of patients, their carers, and healthcare personnel
- Assessing the need for catheterisation
- Selection of catheter drainage options
- Catheter insertion
- Catheter maintenance
Education of Patients, Their Carers, and Healthcare Personnel
D - Patients and carers should be educated about and trained in techniques of hand decontamination, insertion of intermittent catheters where applicable, and catheter management before discharge from hospital.
D - Community and primary healthcare personnel must be trained in catheter insertion, including suprapubic catheter replacement and catheter maintenance.
D - Follow-up training and ongoing support of patients and carers should be available for the duration of long-term catheterisation.
Assessing the Need for Catheterisation
D - Indwelling urinary catheters should be used only after alternative methods of management have been considered.
D - The patient's clinical need for catheterisation should be reviewed regularly and the urinary catheter removed as soon as possible.
D - Catheter insertion, changes, and care should be documented.
Catheter Drainage Options
C - Following assessment, the best approach to catheterisation that takes account of clinical need, anticipated duration of catheterisation, patient preference, and risk of infection should be selected.
A - Intermittent catheterisation should be used in preference to an indwelling catheter if it is clinically appropriate and a practical option for the patient.
D - For urethral and suprapubic catheters, the choice of catheter material and gauge will depend on an assessment of the patient's individual characteristics and predisposition to blockage.
D - In general, the catheter balloon should be inflated with 10 mL of sterile water in adults and 3-5 mL in children.
A - In patients for whom it is appropriate, a catheter valve may be used as an alternative to a drainage bag.
Catheter Insertion
D - All catheterisations carried out by healthcare personnel should be aseptic procedures. After training, healthcare personnel should be assessed for their competence to carry out these types of procedures.
A - Intermittent self-catheterisation is a clean procedure. A lubricant for single-patient use is required for nonlubricated catheters.
D - For urethral catheterisation, the meatus should be cleaned before insertion of the catheter, in accordance with local guidelines/policy.
D - An appropriate lubricant from a single-use container should be used during catheter insertion to minimise urethral trauma and infection.
Catheter Maintenance
D - Indwelling catheters should be connected to a sterile closed urinary drainage system or catheter valve.
D - Healthcare personnel should ensure that the connection between the catheter and the urinary drainage system is not broken except for good clinical reasons, (for example changing the bag in line with the manufacturer's recommendations).
D - Healthcare personnel must decontaminate their hands and wear a new pair of clean, non-sterile gloves before manipulating a patient's catheter, and must decontaminate their hands after removing gloves.
A - Carers and patients managing their own catheters must wash their hands before and after manipulation of the catheter, in accordance with the recommendations in the Standard Principles section.
D - Urine samples must be obtained from a sampling port using an aseptic technique.
D - Urinary drainage bags should be positioned below the level of the bladder and should not be in contact with the floor.
D - A link system should be used to facilitate overnight drainage, to keep the original system intact.
D - The urinary drainage bag should be emptied frequently enough to maintain urine flow and prevent reflux and should be changed when clinically indicated.
A - The meatus should be washed daily with soap and water.
D - Each patient should have an individual care regimen designed to minimise the problems of blockage and encrustation. The tendency for catheter blockage should be documented in each newly catheterised patient.
A - Bladder instillations or washouts must not be used to prevent catheter-associated infection.
D - Catheters should be changed only when clinically necessary or according to the manufacturer's current recommendations.
B - Antibiotic prophylaxis when changing catheters should only be used for patients with a history of catheter-associated urinary tract infection following catheter change or for patients who have a heart valve lesion, septal defect, patent ductus, or prosthetic valve.
D - Reusable intermittent catheters should be cleaned with water and stored dry in accordance with the manufacturer's instructions.
Care During Enteral Feeding
These guidelines apply to adults and children and should be used in conjunction with the guidance on Standard Principles.
The recommendations are divided into four distinct interventions:
- Education of patients, their carers, and healthcare personnel
- Preparation and storage of feeds
- Administration of feeds
- Care of insertion site and enteral feeding tube
Education of Patients, Their Carers, and Healthcare Personnel
D - Patients and carers should be educated about and trained in the techniques of hand decontamination, enteral feeding, and the management of the administration system before being discharged from hospital.
D - Community staff should be trained in enteral feeding and management of the administration system.
D - Follow-up training and ongoing support of patients and carers should be available for the duration of home enteral tube feeding.
Preparation and Storage of Feeds
A - Wherever possible pre-packaged, ready-to-use feeds should be used in preference to feeds requiring decanting, reconstitution, or dilution.
B - The system selected should require minimal handling to assemble and be compatible with the patient's enteral feeding tube.
A - Effective hand decontamination must be carried out before starting feed preparation.
D - When decanting, reconstituting, or diluting feeds, a clean working area should be prepared and equipment dedicated for enteral feed use only should be used.
D - Feeds should be mixed using cooled boiled water or freshly opened sterile water and a no-touch technique.
D - Feeds should be stored according to the manufacturer's instructions and, where applicable, food hygiene legislation.
D - Where ready-to-use feeds are not available, feeds may be prepared in advance, stored in a refrigerator, and used within 24 hours.
Administration of Feeds
C - Minimal handling and an aseptic no-touch technique should be used to connect the administration system to the enteral feeding tube.
C - Ready-to-use feeds may be given for a whole administration session, up to a maximum of 24 hours. Reconstituted feeds should be administered over a maximum 4-hour period.
B - Administration sets and feed containers are for single use and must be discarded after each feeding session.
Care of Insertion Site and Enteral Feeding Tube
D - The stoma should be washed daily with water and dried thoroughly.
D - To prevent blockage, the enteral feeding tube should be flushed with fresh tap water before and after feeding or administering medications. Enteral feeding tubes for patients who are immunosuppressed should be flushed with either cooled freshly boiled water or sterile water from a freshly opened container.
Care of Patients with Central Venous Catheters
These recommendations apply to the care in the community of all adults and children with central venous catheters (CVCs) that are being used for the administration of fluids, medications, blood components and/or total parenteral nutrition. They should be used in conjunction with the recommendations on Standard Principles.
These recommendations do not specifically address the more technical aspects of the care of patients receiving haemodialysis, who will generally have their CVCs managed in dialysis centres.
The recommendations are divided into four intervention categories:
- Education of patients, their carers, and healthcare personnel
- General asepsis
- Catheter site care
- Standard principles for catheter management
Education of Patients, Their Carers, and Healthcare Personnel
D - Before discharge from hospital, patients and their carers should be taught any techniques they may need to use to prevent infection and safely manage a central venous catheter.
D - Community healthcare personnel caring for a patient with a central venous catheter should be trained, and assessed as competent, in using and consistently adhering to the infection prevention practices described in this guideline.
D - Follow-up training and support should be available to patients with central venous catheters and their carers.
General Asepsis
B - An aseptic technique must be used for catheter site care and for accessing the system.
A - Before accessing or dressing central venous catheters, hands must be decontaminated either by washing with an antimicrobial liquid soap and water or by using an alcohol handrub.
A - Hands that are visibly soiled or contaminated with dirt or organic material must be washed with soap and water before using an alcohol handrub.
D - Following hand antisepsis, clean gloves and a no-touch technique or sterile gloves should be used when changing the insertion site dressing.
Catheter Site Care
A - Preferably, a sterile, transparent, semipermeable polyurethane dressing should be used to cover the catheter site.
D - If a patient has profuse perspiration or if the insertion site is bleeding or oozing, a sterile gauze dressing is preferable to a transparent, semi-permeable dressing.
D - Gauze dressings should be changed when they become damp, loosened, or soiled, and the need for a gauze dressing should be assessed daily. A gauze dressing should be replaced by a transparent dressing as soon as possible.
A - Transparent dressings should be changed every 7 days or sooner if they are no longer intact or moisture collects under the dressing.
A - Dressings used on tunnelled or implanted central venous catheter sites should be replaced every 7 days until the insertion site has healed, unless there is an indication to change them sooner.
A - An alcoholic chlorhexidine gluconate solution should be used to clean the catheter site during dressing changes, and allowed to air dry. An aqueous solution of chlorhexidine gluconate should be used if the manufacturer's recommendations prohibit the use of alcohol with the product.
D - Individual sachets of antiseptic solution or individual packages of antiseptic-impregnated swabs or wipes should be used to disinfect the dressing site.
D - Healthcare personnel should ensure that catheter-site care is compatible with catheter materials (tubing, hubs, injection ports, luer connectors and extensions) and carefully check compatibility with the manufacturer's recommendations.
General Principles for Catheter Management
C - The injection port or catheter hub should be decontaminated using either alcohol or an alcoholic solution of chlorhexidine gluconate before and after it has been used to access the system.
D - In-line filters should not be used routinely for infection prevention.
A - Antibiotic lock solutions should not be used routinely to prevent catheter-related bloodstream infections (CRBSI).
A - Systemic antimicrobial prophylaxis should not be used routinely to prevent catheter colonisation or CRBSI, either before insertion or during the use of a central venous catheter.
D - Preferably, a single lumen catheter should be used to administer parenteral nutrition. If a multilumen catheter is used, one port must be exclusively dedicated for total parenteral nutrition (TPN), and all lumens must be handled with the same meticulous attention to aseptic technique.
D - Preferably, a sterile 0.9 percent sodium chloride injection should be used to flush and lock catheter lumens.
D - When recommended by the manufacturer, implanted ports or opened-ended catheter lumens should be flushed and locked with heparin sodium flush solutions.
D - Systemic anticoagulants should not be used routinely to prevent CRBSI.
D - If needleless devices are used, the manufacturer's recommendations for changing the needleless components should be followed.
D - When needleless devices are used, healthcare personnel should ensure that all components of the system are compatible and secured, to minimise leaks and breaks in the system.
D - When needleless devices are used, the risk of contamination should be minimised by decontaminating the access port with either alcohol or an alcoholic solution of chlorhexidine gluconate before and after using it to access the system.
A - In general, administration sets in continuous use need not be replaced more frequently than at 72-hour intervals unless they become disconnected or a catheter-related infection is suspected or documented.
D - Administration sets for blood and blood components should be changed every 12 hours, or according to the manufacturer's recommendations.
D - Administration sets used for TPN infusions should generally be changed every 24 hours. If the solution contains only glucose and amino acids, administration sets in continuous use do not need to be replaced more frequently than every 72 hours.
Definitions
Evidence Categories
Ia: Evidence from meta-analysis of randomised controlled trials
Ib: Evidence from at least one randomised controlled trial
IIa: Evidence from at least one controlled study without randomisation
IIb: Evidence from at least one other type of quasi-experimental study
III: Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies and case-control studies
IV: Evidence from expert committee reports or opinions and/or clinical experience of respected authorities.
Recommendation Grades
Grade A - Directly based on category I evidence
Grade B - Directly based on category II evidence, or extrapolated recommendation from category I evidence
Grade C - Directly based on category III evidence, or extrapolated recommendation from category I or II evidence
Grade D - Directly based on category IV evidence, or extrapolated recommendation from category I, II or III evidence
