INFECTION CONTROL: SERIES SPONSORFD BY RPIGENT MEDICAI
Implementing evidence-based
practice in infection control
Deborah Ward
E
vidence based practice (LBl') has been
defined as an approach to problem solv-
ing in clinical practice which involves
asking questions and searchmg literature in
order to ailopt an evidence based iiuervenCKni
for a pruhlem (Rosenberg and Donald, 1995).
The current chmate in health care requires
nurses to be able to appls the best evidence,
usually through using research {Table i I, m
order to provide the most effective health care.
Nurses .ire also expected to contrihute to the
development ot HBP. However, there is room
to question the evidence hase for a number of
nursing interventions. Jenneretal (1999) argue
that rituals nia\ be followed \Mthi)ut any evi-
dence as to their \alue, despite i.IM' being cen-
tral til the concept of delivering health care
within a quality' assurance programme.
Basing health care on sound evidence is seen
as one of the ways in which clinical governance
can be successful (NHS Executive, 1999). The
NHS clinical governance document looks at
quality witliin the NHS and states that compre-
hensive and sound research is the first building
block in evidence-based decision-making and
that the use of research should be encouraged in
order to improve qualit> within the ser\ice
(MHS Executive, 1999). Tlie aims of this docu-
ment will be assisted by the National Institute
for Clinical Hxcellence (NICK) which has been
established to produce and disseminate evi-
dence-based guidance which can be used by
staff who care for patients within the NHS.
EVIDENCE-BASED PRACTICE
IN INFECTION CONTROL
One of the responsibilities of the infection con-
trol nurse is to try to ensure that clinical prac-
tice and infection control policies are based on
evidence rather than ritual. I Inwever, there are
some infection control practices, e.g. manage-
ment of body fluids, which are based on ritual
or habit and are not consistent with current
research evidence. There are also practices gov-
erned by legislation which seem to have little
liMiHNAl t NURSING. 2000, Voi 9, No 5
Abstract
Evidence-based practice is seen as a way of providing more effective
health care and is considered to be vital in the current healthcare climate.
However, in many areas of practice, and specifically in infection control,
there Is often little or no evidence to back or refute certain practices. This
article looks at ritualistic practices, interventions with indirect evidence
to support them and practices with overwhelming evidence in their favour
which are not always followed, tt Is concluded that nurses need to
integrate the best available evidence with clinical judgment and ensure
that available evidence is disseminated appropriately.
convincing evidence to supp<)rt them, e.g. dis-
posal of chiiical waste. KBP is difficult to
implement in mtection control as man\ prac-
tices are based on experience bicause rhere is
lirrle research evidence available. However,
even where evidence is available, EBP is not
always carried out.
Although there are man\ areas of practice
which are based on ritual rather than evi-
dence, some practices in intection control are
commonU' highlighted as being nicjre ritualis-
tic than others. These include waste disposal,
the use of theatre masks and procedures for
dealing with blimd spillages.
Waste disposal
There is much legislation which governs
waste disposal [Tahle 2). The regulations
Table 1 . Benefits of research
Enhancement of knowledge
Provides a basis for practice
Improvements in care
Gives credibility to the profession
Deborah Ward is
Validation and standardization Community Infection
of practice Control Nurse,
HuJdorsHL-M NHS Trust,
Development of practice i'nnccss KoKil (
He.ilth Ccmrc, Mu
Increased cost-effectiveness
Accepted for put -,'
Increased clinical effectiveness November 1 y VM
INFICTION CONTUOl
place .1 iliii\ tit care on trusts in relaiion to
chiiical w.isie disposal. Infection control
policies state what shoukl be dttne with clin-
Kal wasie according lo iliis legislation. Ihe
segregation, labelling, transport ami iiicmer-
aiioii ot clinical waste is said to be rei|uired
in <irder to pmieti staff, p-itients ;intl ihe gen-
eral piibhi iriitllipps. I '^'''^l, 1 lowevir. it
nuist be askiil what arc ihese people hemg
prolecteil I nun:'
Kiitala .mi\ M.ivhall (I'-'42) state thai the
potential lor intection as a result ot contact
with non-sharp medical waste is virtually non-
eMstent. There is actLi.illy no evidence rli.ic
iiiidical waste contains m<re of a h.i/.inl than
household \\.iste. In fact, reports have shown
th.it household wjste contains the same or a
bigger biohurtlen than hospit.il waste Ironi var-
uuis ward are.is (Kaln4>wski ei al. I^S.?; Mose
and Reinthakr. WS5; lager et al. rS9). The
i>iil\ n pe (t clinical waste that has been shown
lo transmit infection or infectious diseases are
sharps. It h.is, however, been suggested that it
IS the )tteiisi\e nature ot some t\pes ot clinical
\s.is[e which warrants ilie special pro\ision
railiiT iliaii ihe infection risk .issociateil with
ilu ni I tVp.irlinent of the I tnironnieiil,
The use of masks in theatre
Kace masks as an item ot protective clothing
are most otteii worn by operating tlieaire staff
.IS a method ot reducing the risk ot iransniis-
sion of microorganisms trom the respiratory
tracts nt lie.ildicare sratt to rhe surgical wound.
I liiwever., tliere is little e\ideiice to suggest rhat
the wearing ot masks hy theatre stall reduces
the incidence of surgical wound infection.
Table 2. Legislation which governs waste disposal
The Health and Safety at Work. etc. Act 1974
Control of Pollution (Special Waste) Regulations 1980
The Envirotimental Protection Act 1990
Controlled Waste Regulations 1991
Envif Protection (Duty of Care) Regulations 1991
Hazardous lo Health Regulations 1994
,i Licensing Regulations 1994 (Amended in 1995)
jetton Act 1990 (Special Waste Regulations)
s tiy Road Regulations 1996
llealthcare staff als() state that they hiivc
.idopteil the use of m^isks in operating the-
atres as a method of protecting themselves
troni infection (McCluskey, 1996). However,
ag.un. there is no evidence that masks protect
stall from airborne bacteria (Ransjo, 1986) in
the operating theatre.
jenneret al (1999) state that the practice of
mask wearing continues despite a lack of evi-
ileiice to support its v.ilue., because it is con-
sidered unethical To vary treatment in a way
which tnay result in a worse outcome than
current treatment. For example, staff who
stop wearing a mask in theatre may attribute
the first surgical wound infection to this
change in practice, even though it may not be
related. This makes it very difficult to change
an infection control intervention that is well
established. Theatre staff may be unwilling to
change, despite research evidence., if they feel
that the wearing of masks is of value in the
prevention *jf infection.
Body fluid spillages
Infection control pi)licies usually state that
hlood and body fluid spillages should be
soaked up and the area disinfected with an
appropriate concentration of sodium
h\ pocblorite solution. This is one of the
components o[ universal precautions where
all body fluids are treated as a potential
MUirce ot intection. It is known that such a
solution will kill blood-borne viruses but
there is no evidence to support their use in
body tiuid spillages.
The concept is that such spillages pose a
hazard to staff which is reduced by the use of
chlorine; thus, the only reason for carr>'mg out
the procedure is to protect staff. However,
how much ot a hazard a bod> tluid spillage is
has to be questioned. Cooper (1999) states
that the use of chlorine should not be neces-
sary if protective clothing is wotn when deal-
ing with a spillage. She also points out that
similar contact is made with blood and body
tluids in ilirect patient care but healthcare staff
would hardly pour chlorine onto a patient to
render him/her less of a hazard.
Ihe procedure for cleaning body tluid
spillages does not seem to be based on clear
evidence and yet it is still advocated despite
the considerable risks attached to the use of
chlorine solution, e.g. irritation tu the nose,
eyes and skin and the inhalation cif toxic
tunies if not used correctlv.
louRNAL Ul Nim.MN(;. 2000. VtiL V. N o
 IMPLEMErmNG EVIDENCE-BASED PRACHCE IN INFECTION COKTROL
OTHER PRACTICES
Infection control practices are often based on
logical assumptions alwut the evidence ot
another intervention and not on evidence for
that particular practice, e.g. the use of
ritampicin as prophylaxis tor ci)ntacts ot
patients with meningoctKcal disease. Although
there is conclusive evidence that ritampicin sig-
nificantly reduces carriage ot the bacteria
which causes a particular disease (Regg, 1995),
there are no trials which show that the use ot
ritampicin reduces rhe number ot secondary
cases (Pearson et al, 1995). However, the ethi-
cal implications of such a trial are consider-
able and the hypothesis is that if there is a
reduction in carnage, there will be a reduc
tion in transmission to others and therefore a
reduction in secondary cases.
There is also a lack of research evidence to
support the theor)' that a lack of cleaning in
hospitals increases infection rates. Studies have,
howevec, demonstrated environmental contam-
ination with microorganisms such as
CUtstridiuni difficile (kaatz. I'^SS) and van-
comycin-resistant enterococci (Noble et al,
1998). This has led to various rep<rts and agen-
cies advocating a clean environment as a
method ot preventing outbreaks AWS reducing
the spread of antimicrobial-resistant organisms
(Ayliffe et al, 1998; House of Lords Select
Committee on Science and lechiiology. 1998;
Standing Medical Advisory Committee Sub-
committee on Antmiicrobial Resistance, 1998).
These interventions lack concrete evidence
for their implementation. Conversely, there
are some interventions which have overwhelm-
ing evidence to back their value and yet staff do
not carr>' them out.
Hattdwasbing
Handwashing is, without doubt, the most valu-
able action in the prevention of cross-infection
(Infection Control Nurses Association (lCNA),
1998). Hands are a well documented vehicle
for the transmission of infection from one per-
son t(t another and are, in fact, considered to be
the main route of the spread of cross-infeaion
(Larson, 1981; F.lliort, 1992).
However, several studies have shown that
siaff are non-compliant with handwashing
(Emmerson ct al, 1996). Several reasons have
been given for rhis, including staff shortages, a
perceived lack of time, a lack of adequate and
convt-nienrly located facilities, excessive work
lOURNAL lit NURJINO. 2000. V( **. N o S
Table 3. Reasons why gloves are not worn appropriately
High workload
Lack of availability of gloves
Lack of knowledge/education
Cost constraints
Lack of clarity in infection control policies
A perceived lack of risk
Misinterpretation of universal precautions
Ritual instead of risk assessment
Latex sensitivity
Lack of motivation
Discomfort
Reduced dexterity
Fear of offending patients
Sources: Unden (1991); Gould (1994); Waters (1997); Mahony (1998)
load and a lack of education (Larson and
Killien, 1982; Gould and Ream, 1993). Despite
these findings, it has also been shown that even
when staff are educated the practice is soon
reduced to previous levels. Williams and
Buckles (1988) found this to be due to a lack of
motivation and a poor attitude towards hand-
washing. Despite overwhelming evidence in
favour of this inten-ention, if staff are not moti-
vated they will not comply with the practice.
Tbc use of cloth towels in clinical areas
Several studies h,ive shown cloth towels to be a
reservoir for baaeria; they quickly become
heavily contaminated and may be a significant
source of intection (Biackmore, 198"/; Ansari et
al, 1991). However, they are still used in the
treatment rooms of health centres, clinics and
GP surgeries. Tins is quite itften due to the cost
implications of other methods such as dispos-
able paper towels. It may also Iv due to lack of
knowledge among clinical stall regarding the
research evidence. Hand dr>'mg is not consid-
ered to be as important as handwashing, despite
the fact that bacteria have been shown to be
transferred more readily Ivtween wet hands
than dry ones (Hofhnan and Wilson, 1994).
Glove use
Although research has shown rhat latex
gloves are one ot the most effective barriers
 CONTROL
Table 4. Current barriers to the use of research
and evidence-based practice
Poor access to evidence
Raws in available evidence
Inability to interpret evidence
Conflicting evidence
Poor support at a higher level
Lack of understanding of research
No convincing evidence available
Poor dissemination of research findings
Fear of erosion of practitioner autonomy
Sources: Brown (1995); Cavanagh and Tross (1996); Walsh (1997);
Jenneret al (1999)
.ij;.iinst micrii(>ri:anisnis (Knrnitwic/ ct al,
l y v i ; tllscn er j l , 1993) .ind thai they should
be worn \vlicne\er there is rhc potential tor
conrnct with blood or other body fluids, niirs-
ini; s[,ilt Jo not al\\a\s wc.ir gloves in situa-
tmns where rhcy should (Strm^iLr et .ll, 1991;
/ u i i a k u l t Lt .ll, 1993).
Alihoiinh the use of j;|ovcs h.is mcrciscd
rapiJIv over the p.ist 10-15 vears, they arc
not aluaxs worn apprupri.iteK. This non-
tonipli.ince has lieen linked to several tac-
lor;. {Tal>lc J). including an uicrcasinj; work-
Uiad. a lack nt availability of gloves and a
pimr relationship between knowledge and
pr.Kiice with staff iK'i rel.uuiL; uh.it they
know ah(Kit universal prec.uitioiis when
dealing with body fluids to actual situations
in patient care.
CONCLUSION
While EBP appears to he a useful concept it
still has a long way t<> go betore it is fully
utih/ed in infection control, although work
IS currenti) being carrieti out on behalf of
the D o H ro look at the development of
national guidelines for infection control
using systematic reviews. While there seems
to be a great Jcal ot research upon which to
base practice in some interventions, there is
little or none in others.
There are several reasons for this. Although
the moMvation to look at research and
explore new methods lo improve care is
increasing m the nursing profession, there are
sever.I' harriers to using I I^P fTai'lr **
("iiinprehensive strategics such as systematic
reviews currently aim to identify as many
studies as possible that provide evidence of
the effectiveness of a particular healthcare
III u r vent ion (French, I94S|. I lowever, in
soiiu- .ircas ot practice, inlectioii control in
p,u iKul.ir, [here may be a lack of evidence
cither tor or against a particular intervention,
or ihe evidence may hf limited. Miilrow
(1494) warns against basing practice on the
evidence of one study alone but it may be dif-
ficult to obtain any more than one appropri-
ate and relevant study relating to sume
healthcare practices.
riure have also been difficulties in foster-
ing .1 culture in nursing which encourages the
evaluation and dissemination ot research,
rhe NHS research and development strategy
IS .limed ,11 ensuring that high quality research
IS used as .1 basis for the delivery of care
(DoH, 19*^1). A task force report has also
stated that the research and development
strategy should improve the research skills of
nurses .ind improve the research base of nurs-
ing (Ool I, |993). A combinatKHi of the clini-
cal ginernaiiCL' initiative, NICIH and the
research and development strategy should
assist in promoting and de\eloping evidence-
based practice m nursing.
I l<i\\e\er, although practice based on
appropriate, sound research is a good thing, it
must not be forgotten that clinical e.vperience
and ludgment may also play a part, parricu-
larly tii areas where little research has been
carried tmt. Tbis is highhghtetl in the NHS
Executive's (1999) clinical governance docu-
ment which states that the ability to learn
from relevant experiences is a crucial element
in a quality framework.
Castkdine (|99?) has also highlighted that
KBP could lead to an obsession with acade-
mia and advises nurses to integrate the best
knowledge available with clinical judgment in
wisw of the fact that, in many circumstances,
external evidence cannot replace the clinical
expertise of individual nurses.
However, where there is evidence, there
needs to be some mechanism of disseminat-
ing the Information in order tbat all nurses
\::in base their interventions on it. Nurses
need to be given additional knowledge in
order to relate research findings to practice
as, despite there being many practices in
nursing which are based on ritual rather
than reason, staff are c<)ntinuing to carry
BRITUII IOURNAL ot NuRMNi,. 2000. VoL 9. No 5
 IMPLEMENTING EVIDENCE-BASED PRACTICE iU INFLCMON CONTROL
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27
KEY POINTS
Evidence*based practice (EBP) is currently seen as being central
to the delivery of quality healthcare.
EBP can be problematic in areas wtiere there is little research
available.
In infection control, rituals still persist despite evidence against
Practices which have a firm evidence base are not always ca-.t.
Nurses need to be encouraged to integrate the best available
evidence with clinical judgment.