Informing national policy and practice in infection prevention and control to save lives
Submitting InstitutionUniversity of West London
Unit of AssessmentAllied Health Professions, Dentistry, Nursing and Pharmacy
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Summary of the impact
Healthcare-associated infections (HCAI) and antimicrobial resistance pose
a constant threat to patients accessing healthcare in a range of settings.
HCAI prolong recovery; delay discharge from hospital and, in extreme
circumstances, cause serious disability or death. This case study
describes the impact of the Epic (evidence-based practice
in infection control) research programme that focuses on
the translation of evidence into national infection prevention and control
guidelines for the NHS. Through evaluation of initiatives to reduce the
threat of HCAI and associated disability to patients, and by generating
evidence to support the development of government policy, Epic has led to
safer care for people during periods of health-related vulnerability, and
The underpinning research was developed iteratively from an initial
research contract from the Department of Health (DH) in 1998, resulting in
Epic — a long-term multi-professional nurse-led research programme. Epic
has generated a portfolio of research, implementation, education and
evaluation activity that has had a sustained impact upon the practice of
healthcare professionals and the quality of care provided for patients
throughout the NHS.
Key aspects of the research and its impact are:
National evidence-based guidelines: a programme of systematic
review and evaluation of evidence across five key areas of clinical
practice underpinned the development of the first national
evidence-based guidelines for preventing HCAI in NHS care facilities in
England (Epic1), and subsequent updating to incorporate new evidence
(Epic2). These guidelines have been widely cited by other national and
international infection prevention guidelines;
Dissemination of evidenced-based practice: driving effective
infection prevention and control practice by using Epic as a framework
for education, training and local implementation in the NHS in England.
The dissemination programme was undertaken in collaboration with key
stakeholders including: the Modernisation Agency, the Department of
Health, the Infection Prevention Society, the NHS University (now the
NHS Core Learning Unit), the Health Protection Agency, and industry
Evidence evaluation to underpin national strategy and policy:
the systematic review and evaluation of evidence was instrumental in
defining national policy in vital aspects of HCAI prevention including:
the roles and responsibilities of community infection control nurses,
screening for methicillin resistant Staphylococcus aureus
(MRSA), high impact interventions for the prevention of urinary catheter
associated infection, central vascular catheter related infections,
healthcare worker uniform policy, and pseudomonas infection from water
Evaluation of a national programme to reduce MRSA bloodstream
infections: to identify and confirm key factors for successful
implementation of a programme to reduce risks to patients from HCAI, and
to inform translation to clinical practice and the prevention of other
HCAI research network and service user research forum (SURF):
established to engage researchers and the public in identifying research
priorities, and to support the work of the independent advisory
committee on antimicrobial resistance and healthcare associated
Key researchers in this programme of research at the Unviersity:
- Heather Loveday, Professor of Evidence-based Healthcare
- Robert Pratt, Professor of Nursing (1994-2011) retired;
- Dr Peter Harper, Senior Lecturer (1994-2010) retired;
- Dr Carol Pellowe Principal Lecturer (1994-2011);
- Jennie Wilson, Research Fellow (2005-2012) and Reader 2012-present.
Supporting Grants (Funder)
2012-2013: Epic National Guidelines for the Prevention of HCAI
in NHS Hospitals in England. Evidence updating and revision; £115,000
DH Policy Research Programme (PRP).
- 2012: Rapid Systematic Review of Pseudomonas and healthcare water
systems; £35,000 DH PRP.
2012-2013: Patient Experience of MRSA Screening — A qualitative
study; £65,000 DH PRP
2009-2013: National HCAI Research Network and SURF; £700,000
2010-2010: Exploratory case study of health care economy HCAI
improvement examples; £55,000 DH PRP.
2009-2010: Look Back: A Multiple Methods Evaluation of the DH
(England) Cleaner Hospitals Programme to Reduce MRSA Bloodstream
Infections; £90,000 DH PRP.
2005-2006: An evidence review of the microbiological and social
significance of uniforms and uniform policy in the prevention and
control of healthcare-associated infections; £31,500 DH
Patient Environment Division.
2004-2005: Systematic review of the evidence for interventions
for the prevention and control of methicillin resistant Staphylococcus
aureus (1996-2004); £30,000 DH Communicable Disease
Policy Unit (CDPU).
2003-2003: A Comparison of International Practices in the
Management and Control of Healthcare-association Infections; £18,500
National Audit Office (NAO).
2000-2002: A multiple methods review of the roles and
responsibilities of community infection control and communicable disease
control nurses in England; £180,000 DH CDPU.
2004-2006: The CHART Study; £325,000 DH PRP.
2005-2005: Systematic review and guideline development of
interventions to prevent HCAI in Hospital settings: update; £101,850
2000-2003: Systematic review of interventions to prevent HCAI
in Community and Primary Care settings; £450,000 DH CDPU.
1998-2000: Systematic review and guideline development of
interventions to prevent HCAI in Hospital settings; £150,000 DH
References to the research
1. Pratt RJ, Pellowe C, Loveday HP, Robinson N, Smith GW, and the Epic
guideline development team; Barrett S, Davey P, Harper P, Loveday C,
McDougall C, Mulhall A, Privett S, Smales C, Taylor L, Weller B, and
Wilcox M. (2001). The Epic Project: Developing National Evidence-based
Guidelines for Preventing Healthcare Associated Infections. Phase 1:
Guidelines for Preventing Hospital-acquired Infections. Journal of
Hospital Infection 47(Supplement): S1-S82.
2. Loveday HP, Pellowe CM, Jones SRLJ, Pratt RJ. A systematic review of
the evidence for interventions for the prevention and control of
meticillin-resistant Staphylococcus aureus (1996-2004): report to the
Joint MRS Working Party (Subgroup A). Journal of Hospital Infection
May 2006;63 (Supplement 1): S45-S70
3. Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, Harper PJ, Jones SRLJ,
McDougall C, Wilcox MH. epic2 — National Evidence-Based Guidelines for
Preventing Healthcare-Associated Infections in NHS Hospitals. Journal
of Hospital Infection 2007 January; 65(1): supplement 1.
4. Wilson JA, Loveday HP, Hoffman PN, Pratt RJ. Uniform: an evidence
review of the microbiological significance of uniforms and uniform policy
in the prevention and control of healthcare-associated infections. Report
to the Department of Health (England). Journal of Hospital Infection
August 2007; 66(4):301-307.
5. Curran E, Harper P, Loveday H, Gilmour H, Jones S, Benneyan J, Hood J,
Pratt R. Results of a multicentre randomised controlled trial of
statistical process control charts and structured diagnostic tools to
reduce ward-acquired meticillin-resistant Staphylococcus aureus:
the CHART Project. Journal of Hospital Infection 2008;
6. Loveday HP, Pellowe C, Steiner J Primary Care Organisations:
identifying best practice for preventing healthcare associated infections
through commissioning. A Confidential Report to the Department of Health
HCAI Cleanliness Division, November 2010.
7. Loveday HP, Harper P, Dunnett A, Lido C, Pellowe C, Steiner J and
Robert J.Pratt. Look Back: A Retrospective Evaluation of the Department of
Health (England) Cleaner Hospitals Programme to Reduce MRSA Bloodstream
Infections. A Confidential Report to the Department of Health HCAI
Cleanliness Division, January 2010.
Details of the impact
The Epic Guidelines for hospitals, and community and primary care have
been published in the peer reviewed Journal of Hospital Infection (JHI) on
three occasions and made free-to-view by the publishers Elsevier. The
Epic2 Guidelines published in 2007 were among the top ten cited papers in
Journal of Hospital Infection in 2008. Several summary articles were
disseminated via journals with a wider readership. In 2011 BioMedLib
included four of our publications in the top ten articles published in the
evidence-based infection prevention and control guideline domain.
Epic2 is cited in the USA (Hospital Infection Control Practice Advisory
Committee/Centers for Disease Control) Urinary Catheter Guidelines (2009)
and the Australian National Guidelines (2010) as one of the systematically
developed national guidelines used to generate the questions for the
systematic review (CDC) and recommendations within the guideline (ACSQH).
The WHO Hand Hygiene Guideline (2009) included Epic2 as one of the
guidelines reviewed for rigour of development and consistency with the
final WHO version (see citations below). Our systematic reviews
underpinned national policy advice and guidance related to MRSA screening,
one of the main pillars of preventing the transmission of MRSA, and which
has had a major impact in driving reductions of 50% in MRSA bloodstream
infections across the NHS between 2005 and 2009 as evidenced in the
Department of Health archive. Our systematic review of the significance of
uniforms as a vector of HCAI, was incorporated into national policy
related to healthcare worker uniforms in 2011.
In 2003 the Chief Medical Officer of England published `Winning Ways',
which used the evidence from Epic (2001 & 2003) to develop one of the
seven areas for action to reduce HCAI, and in 2007 the guidelines were
used to underpin the high impact interventions for the reduction in MRSA
bloodstream infections. These high impact interventions formed the
backbone of practice improvement strategies developed by the DH in England
that resulted in an initial 50% reduction in meticillin resistant Staphylococcus
aureus (MRSA) bloodstream infections between 2005 and 2009 with
sustained reduction of infections by 80% to date. National Quality
Improvement Audit Tools developed by the Infection Prevention Society and
available electronically free to NHS trusts across the UK, are largely
based on the evidence from Epic2.
The Epic guidelines were widely disseminated via a range of initiatives
including a national programme of educational events in collaboration with
the Infection Prevention Society, CR BARD (BARD Medical) and Ethicon
(Johnston & Johnston Ltd), and national and international conference
presentations. The guidelines now provide an evidence-base for clinical
policies on the prevention and control of HCAI across NHS Trusts in the
UK. In addition, a programme delivered by the researchers in collaboration
with the Modernisation Agency from 2002-2003 applied improvement
methodology with multidisciplinary teams from the NHS to develop projects
to reduce HCAI.
This methodology was later applied between 2006-2009 as part of the DH
programme to achieve a 50% reduction in MRSA bloodstream infections and a
30% reduction in Clostridium difficile infection. Epic guidelines
also formed the basis for NHS e-learning programmes developed in 2007 by
the researchers in collaboration with Intuition® and the Core Learning
Unit (CLU) on infection control practice for clinical and non-clinical
staff, and the prevention of device related infections. This won the
Institute of IT training e-learning project of the year silver award 2007.
The programme for non-clinical staff was subsequently updated in 2012 as
part of the national Skills for Health programme.
In December 2009 the Chief Nursing Officer launched eight high impact
actions, one of which was to reduce infections related to the use of
indwelling urethral catheters. This action, together with the subsequent
Harm Free Care — Safety Thermometer that has been adopted by most NHS
Trusts in England, is based on evidence evaluated and synthesised in
Hosted by the University of West London (then TVU), the establishment in
2006 of the Healthcare Associated Infection Research Network (HCAI RN),
has delivered forward momentum in ensuring that patients and the public
are involved in the prioritisation, development and conduct of research in
the field of infection prevention and control. Since its inception in 2007
the Service User Research Forum (SURF) has ensured that researchers have
access to members of the public interested in HCAI research with core
training related to meaningful engagement with research groups, to meet
the National Institute Health Research requirement that patient and public
Involvement is a reality in publicly funded research. This is demonstrated
by the inclusion of service users researchers as members of funded
research teams and steering groups.
Sources to corroborate the impact
- Gould, C.V., Umscheid, C.A., Agarwal, R.K., Kuntz, G., Pegues, D.A.
& Healthcare Infection Control Practices Advisory Committee (2010)
Guideline for Prevention of Catheter-Associated Urinary Tract Infections
2009. Infect Control Hosp Epidemiol; 31(4): 319-326.
- NHMRC (2010) Australian Guidelines for the Prevention and Control of
Infection in Healthcare. Commonwealth of Australia.
- World Health Organization: WHO Patient Safety. WHO guidelines on
hand hygiene in health care. World Health Organization. Geneva:
- Department of Health Uniforms and workwear: Guidance on uniform and
workwear policies for NHS employers. London. Department of Health. 2010.
- NHS Core Learning Unit Infection Prevention and Control Programmes for
Clinical and non Clinical Staff http://www.corelearningunit.nhs.uk/
- Quality Improvement Tools
- Department of Health. (2008). Clean, Safe Care — reducing
infections and saving lives. London: Department of Health.
Department of Health.