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Antimicrobial stewardship

About

What is covered

This NICE Pathway covers systems and processes for effective antimicrobial medicine use, and interventions to change people's behaviour to help reduce antimicrobial resistance and stop the spread of resistant microbes.

Who is it for?

  • Organisations commissioning (for example, clinical commissioning groups or local authorities), providing or supporting the provision of care (for example, national or professional bodies, directors of public health, health and wellbeing boards, healthcare trusts and locum agencies).
  • Organisations and individuals with responsibility for providing information and advice to the public, including local authority public health teams.
  • Health and social care practitioners.
  • Childcare and education providers.
  • Adults, young people and children (including neonates) using antimicrobials or those caring for these groups. This includes people and organisations involved with the prescribing and management of antimicrobials in health and social care settings, including prescribers, primary care and community pharmacy teams.
  • The general public.
The guidance may also be relevant to individual people and organisations delivering non-NHS healthcare services, and to other devolved administrations.
It is anticipated that health and social care providers and commissioners of services will need to work together to ensure that patients benefit from the good practice recommendations in this guidance.

Updates

Updates to this NICE Pathway

15 September 2021 Infection prevention and control (NICE quality standard 61) added.
18 February 2020 SepsiTest assay for rapidly identifying bloodstream bacteria and fungi (NICE diagnostics guidance 20) added to clinical assessment.
24 January 2017 Antimicrobial stewardship: changing risk-related behaviours in the general population (NICE guideline NG63) added.
21 April 2016 Antimicrobial stewardship (NICE quality standard 121) added.
6 October 2015 Procalcitonin testing for diagnosing and monitoring sepsis (NICE diagnostics guidance 18) added to clinical assessment.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on effective antimicrobial medicine use and preventing the spread of resistant microbes in an interactive flowchart

What is covered

This NICE Pathway covers systems and processes for effective antimicrobial medicine use, and interventions to change people's behaviour to help reduce antimicrobial resistance and stop the spread of resistant microbes.

Who is it for?

  • Organisations commissioning (for example, clinical commissioning groups or local authorities), providing or supporting the provision of care (for example, national or professional bodies, directors of public health, health and wellbeing boards, healthcare trusts and locum agencies).
  • Organisations and individuals with responsibility for providing information and advice to the public, including local authority public health teams.
  • Health and social care practitioners.
  • Childcare and education providers.
  • Adults, young people and children (including neonates) using antimicrobials or those caring for these groups. This includes people and organisations involved with the prescribing and management of antimicrobials in health and social care settings, including prescribers, primary care and community pharmacy teams.
  • The general public.
The guidance may also be relevant to individual people and organisations delivering non-NHS healthcare services, and to other devolved administrations.
It is anticipated that health and social care providers and commissioners of services will need to work together to ensure that patients benefit from the good practice recommendations in this guidance.

Updates

Updates to this NICE Pathway

15 September 2021 Infection prevention and control (NICE quality standard 61) added.
18 February 2020 SepsiTest assay for rapidly identifying bloodstream bacteria and fungi (NICE diagnostics guidance 20) added to clinical assessment.
24 January 2017 Antimicrobial stewardship: changing risk-related behaviours in the general population (NICE guideline NG63) added.
21 April 2016 Antimicrobial stewardship (NICE quality standard 121) added.
6 October 2015 Procalcitonin testing for diagnosing and monitoring sepsis (NICE diagnostics guidance 18) added to clinical assessment.

Sources

NICE guidance and other sources used to create this interactive flowchart.
SepsiTest assay for rapidly identifying bloodstream bacteria and fungi (2016, updated 2020) NICE diagnostics guidance 20
Antimicrobial stewardship (2016) NICE quality standard 121
Infection prevention and control (2014) NICE quality standard 61
Fungitell for antifungal treatment stratification (2017) NICE medtech innovation briefing 118

Quality standards

Antimicrobial stewardship

These quality statements are taken from the antimicrobial stewardship quality standard. The quality standard defines clinical best practice for antimicrobial stewardship and should be read in full.

Infection prevention and control

These quality statements are taken from the infection prevention and control quality standard. The quality standard defines clinical best practice for infection prevention and control and should be read in full.

Quality statements

Advice on self-limiting conditions

This quality statement is taken from the antimicrobial stewardship quality standard. The quality standard defines clinical best practice in antimicrobial stewardship and should be read in full.

Quality statement

People with a self-limiting condition, as assessed by a primary care prescriber, receive advice about self-management and adverse consequences of overusing antimicrobials.

Rationale

People with common colds, sore throat, flu, otitis media and other self-limiting conditions may not know that they are likely to get better without treatment and they may expect to be prescribed an antimicrobial. Primary care prescribers should manage people’s expectations by describing the adverse consequences of using antimicrobials when they are not needed, both for the person and the population as a whole. They should also give advice on what the person can do to help their condition improve (self-management).

Quality measures

Structure
a) Evidence of local arrangements to ensure that people with a self-limiting condition, as assessed by a primary care prescriber, receive advice about self-management and adverse consequences of overusing antimicrobials.
Data source: Local data collection.
b) Evidence of local arrangements to promote self-management of self-limiting conditions and raise awareness of risks associated with overusing antimicrobials.
Data source: Local data collection.
Process
a) Proportion of presentations in primary care assessed as a self-limiting condition with a record stating that advice about self-management was given.
Numerator – the number in the denominator with a record stating that advice about self-management was given.
Denominator – the number of presentations in primary care assessed as a self-limiting condition.
Data source: Local data collection and the Royal College of General Practitioners TARGET antibiotics toolkit.
b) Proportion of presentations in primary care assessed as a self-limiting condition with a record stating that advice about the adverse consequences of overusing antimicrobials was given.
Numerator – the number in the denominator with a record stating that advice about the adverse consequences of overusing antimicrobials was given.
Denominator – the number of presentations in primary care assessed as a self-limiting condition.
Data source: Local data collection.
Outcome
Antimicrobial prescribing rates in primary care.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (such as GP practices, health centres, pharmacies, community services) ensure that systems are in place for people with a self-limiting condition to receive advice about self-management and the adverse consequences of overusing antimicrobials.
Prescribers in primary care (such as GPs, nurses and pharmacists) ensure that they provide people with a self-limiting condition with advice on self-management and the adverse consequences of overusing antimicrobials.
Commissioners (clinical commissioning groups, NHS England) ensure that they commission services that provide people with a self-limiting condition with advice on self-management and the adverse consequences of overusing antimicrobials.
People with a condition that is likely to get better on its own (such as cold, flu, earache or tonsillitis) who go to a GP, practice nurse or pharmacist are given advice on what they can do to help their condition improve and why it’s important only to use antimicrobials when they are really needed.

Source guidance

Definitions of terms used in this quality statement

Self-limiting condition
A condition that resolves on its own and has no long-term harmful effect on a person's health (assuming that they are not immunosuppressed). Examples include colds, flu, oral thrush and winter vomiting bugs. [NICE’s guideline on antimicrobial stewardship: changing risk-related behaviours in the general population, terms used in this guideline]
Advice for people with self-limiting conditions
Prescribers should discuss with the person and/or their family members or carers (as appropriate):
  • the likely nature of the condition
  • why prescribing an antimicrobial may not be the best option
  • alternative options to prescribing an antimicrobial
  • their views on antimicrobials, taking into account their priorities or concerns about their current illness and whether they want or expect an antimicrobial
  • the benefits and harms of immediate antimicrobial prescribing
  • how long they should expect the symptoms of their self-limiting condition to last
  • what they should do if their condition gets worse (safety netting advice) or if they have problems as a result of treatment
  • what they can do to minimise spreading the infection to others (such as good hand hygiene).

Equality and diversity considerations

Healthcare professionals may need to consider how to advise people who have difficulties understanding the information given to them because of difficulty in understanding English or cognitive impairment.

Back-up (delayed) prescribing

This quality statement is taken from the antimicrobial stewardship quality standard. The quality standard defines clinical best practice in antimicrobial stewardship and should be read in full.

Quality statement

Prescribers in primary care can use back-up (delayed) antimicrobial prescribing when there is clinical uncertainty about whether a condition is self-limiting or is likely to deteriorate.

Rationale

When there is clinical uncertainty about whether a condition is self-limiting or is likely to deteriorate, back-up prescribing (also known as delayed prescribing) offers healthcare professionals an alternative to immediate antimicrobial prescribing. It encourages self-management as a first step, but allows a person to access antimicrobials without another appointment if their condition gets worse.

Quality measures

Structure
Evidence of local arrangements to ensure that prescribers in primary care can use back-up (delayed) antimicrobial prescribing if there is uncertainty about whether a condition is self-limiting or is likely to deteriorate.
Data source: Local data collection.
Process
a) Proportion of prescriptions for antimicrobials issued as a back-up (delayed) prescription.
Numerator – the number in the denominator issued as a back-up (delayed) prescription.
Denominator – the number of prescriptions for antimicrobials issued.
Data source: Local data collection.
b) Proportion of people issued a back-up (delayed) prescription for antimicrobials who are advised when to use the prescription.
Numerator – the number in the denominator who are told when to use the prescription.
Denominator – the number of people issued a back-up (delayed) prescription for antimicrobials.
Outcome
a) Back-up (delayed) prescriptions for antimicrobials that are dispensed.
Data source: Local data collection.
b) Antimicrobial prescribing rates in primary care.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (such as GP practices, health centres, pharmacies) ensure that systems are in place to allow back-up (delayed) antimicrobial prescribing if there is uncertainty about whether a condition is self-limiting or is likely to deteriorate.
Prescribers in primary care (such as GPs, nurses, pharmacists) can use back-up (delayed) antimicrobial prescribing if there is uncertainty about whether a condition is self-limiting or is likely to deteriorate.
Commissioners (clinical commissioning groups, NHS England) allow and monitor the use of back-up (delayed) antimicrobial prescribing when there is uncertainty about whether a condition is self-limiting or is likely to deteriorate.
People with conditions that may need antimicrobial treatment, but may get better without treatment, are told that they can have a prescription for an antimicrobial but they should only use it if their condition gets worse. This is known as a back-up or delayed prescription. They are given clear advice about when they should use the prescription.

Source guidance

Definitions of terms used in this quality statement

Back-up (delayed) prescribing
A back-up (delayed) prescription is a prescription (which can be post dated) given to a patient or carer, with the assumption that it will not be dispensed immediately, but in a few days if symptoms worsen.
When using back up (delayed) antibiotic prescribing, patients should be offered:
  • reassurance that antibiotics are not needed immediately because they are likely to make little difference to symptoms and may have side effects (for example, diarrhoea, vomiting and rash)
  • advice about how to recognise whether they need to use the antimicrobials, and if so:
    • how to get them
    • when to start taking or using them
    • how to take or use them.
  • advice about re-consulting if symptoms get significantly worse despite using the back up (delayed) prescription.
A back-up (delayed) prescription with instructions about use can either be given to the patient or left at an agreed location (for example, the local pharmacy) to be collected at a later date. [NICE’s guideline on antimicrobial stewardship: changing risk-related behaviours in the general population, recommendation 1.5.4, and NICE’s guideline on antimicrobial stewardship: systems and processes for effective antimicrobial medicine use, recommendation 1.1.34 and expert opinion]

Equality and diversity considerations

Prescribers may need to consider how to advise people who have difficulties in understanding the information given to them because of difficulty in understanding English or cognitive impairment.

Recording information

This quality statement is taken from the antimicrobial stewardship quality standard. The quality standard defines clinical best practice in antimicrobial stewardship and should be read in full.

Quality statement

People prescribed an antimicrobial have the clinical indication, dose and duration of treatment documented in their clinical record.

Rationale

Recording in patients’ records the clinical indication (that is, the results of clinical assessment, symptoms and diagnosis) for an antimicrobial, and the prescribed dose and duration of treatment, allows better management during follow-up of care and transfer of care to another setting. It also supports monitoring of prescribing practice and identification of appropriate and inappropriate prescribing in all settings.

Quality measures

Structure
Evidence of local arrangements and processes to ensure that all prescribers document the clinical indication, dose and duration of treatment in patients’ records when prescribing an antimicrobial.
Data source: Local data collection.
Process
Proportion of prescriptions for antimicrobials with the clinical indication, dose and duration of treatment documented.
Numerator – the number in the denominator with the clinical indication, dose and duration of treatment documented.
Denominator – the number of prescriptions for antimicrobials.
Outcome
Antimicrobial prescribing rates.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (such as hospitals, walk-in centres, GP practices, health centres, dental care providers, pharmacies, community services) monitor standards of record-keeping to check that clinical indication, dose and duration of treatment are documented when antimicrobials are prescribed.
Prescribers document in patients’ clinical records the clinical indication, dose and duration of treatment when they prescribe antimicrobials.
Commissioners (clinical commissioning groups, NHS England) ensure that services monitor standards of record-keeping to check that clinical indication, dose and duration of treatment are documented when antimicrobials are prescribed.
People who are prescribed an antimicrobial have the reason recorded in their medical record, as well as how long they should take the antimicrobial and the dose.

Source guidance

Microbiological samples

This quality statement is taken from the antimicrobial stewardship quality standard. The quality standard defines clinical best practice in antimicrobial stewardship and should be read in full.

Quality statement

People in hospital who are prescribed an antimicrobial have a microbiological sample taken and their treatment reviewed when the results are available.

Rationale

Analysing microbiological samples allows more targeted and effective prescribing of narrow spectrum antimicrobials or stopping antimicrobials if they are not necessary or effective. In hospital, microbiological samples should be taken before antimicrobials are prescribed. In some situations, it may be necessary to start antimicrobial treatment immediately (for example, in people with severe sepsis or life-threatening infections) but the treatment should be reviewed when the microbiological results are available.

Quality measures

Structure
Evidence of local arrangements and processes to ensure that people in hospital who are prescribed an antimicrobial have a microbiological sample taken and their treatment reviewed when the results are available.
Process
a) Proportion of prescriptions for antimicrobials issued to people admitted to hospital with a record of a microbiological sample being taken.
Numerator – the number in the denominator with a record of a microbiological sample being taken.
Denominator – the number of prescriptions for antimicrobials issued to people admitted to hospital.
Data source: Local data collection.
b) Proportion of prescriptions for antimicrobials issued to people admitted to hospital and reviewed when microbiological results become available.
Numerator – the number in the denominator reviewed when the microbiological results become available.
Denominator – the number of prescriptions for antimicrobials issued to people admitted to hospital with a record of a microbiological sample being taken.
Data source: Local data collection.
Outcome
a) Altered or withdrawn prescriptions for antimicrobials following microbiological results showing lack of effectiveness of initial antimicrobial treatment.
Data source: Local data collection.
b) Antimicrobial prescribing rates in hospitals.
Data source: Local data collection.
c) Length of hospital stay.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (hospitals) ensure that systems are in place for people in hospital to have a microbiological sample taken before they are prescribed an antimicrobial, and have the treatment reviewed when the microbiological results are available.
Prescribers in hospitals ensure that microbiological samples are taken before they prescribe antimicrobials and that they review the treatment when the microbiological results are available.
Commissioners (clinical commissioning groups, NHS England) ensure that they commission services that take microbiological samples from people in hospital before they are prescribed antimicrobials, and that review the treatment when the microbiological results are available.
People who are in hospital have a sample taken before they are prescribed an antimicrobial to find out what is causing the infection. They may be given an antimicrobial immediately, but once the test results come back the prescription is checked to make sure that the antimicrobial is the right one and will work against the infection.

Source guidance

Data collection and feedback

This quality statement is taken from the antimicrobial stewardship quality standard. The quality standard defines clinical best practice in antimicrobial stewardship and should be read in full.

Quality statement

Individuals and teams responsible for antimicrobial stewardship monitor data and provide feedback on prescribing practice at prescriber, team, organisation and commissioner level.

Rationale

Monitoring and reviewing prescribing data enables individuals and teams responsible for antimicrobial stewardship to check adherence to local formularies, provide feedback, recognise good practice and to challenge inappropriate prescribing. It also allows peer review, and identifying training needs and areas for quality improvement.

Quality measures

Structure
a) Evidence of local arrangements to deliver an antimicrobial stewardship programme.
Data source: Local data collection.
b) Evidence of local arrangements and processes to ensure that individuals and teams responsible for antimicrobial stewardship monitor data and provide feedback on prescribing practice at prescriber, team, organisation and commissioner level.
Data source: Local data collection.
Process
a) Proportion of prescribers who receive feedback on their antimicrobial prescribing practice.
Numerator – the number in the denominator who receive feedback on their antimicrobial prescribing practice.
Denominator – the number of prescribers.
Data source: Local data collection.
b) Proportion of teams within an organisation that receive feedback on their antimicrobial prescribing practice.
Numerator – the number in the denominator that receive feedback on their antimicrobial prescribing practice.
Denominator – the number of teams prescribing antimicrobials within an organisation.
Data source: Local data collection.
c) Proportion of organisations within a specified commissioning area that receive feedback on their antimicrobial prescribing practice.
Numerator – the number in the denominator that receive feedback on their antimicrobial prescribing practice.
Denominator – the number of organisations prescribing antimicrobials within a specified commissioning area.
Outcome
Antimicrobial prescribing rates.

What the quality statement means for different audiences

Service providers (such as hospitals, GP practices, walk-in centres, dental practices, pharmacies, community health services) ensure that systems are in place for individuals and teams responsible for antimicrobial stewardship within the service to monitor data and provide feedback on prescribing at prescriber, team, organisation and commissioner level. The frequency and specific content of the feedback should be agreed locally between commissioners and service providers.
Prescribers receive feedback on their individual antimicrobial prescribing practice and the antimicrobial prescribing practice of their team, organisation and commissioning group from individuals and teams responsible for antimicrobial stewardship within the organisation.
Commissioners (clinical commissioning groups, NHS England) ensure that they commission services that have individuals and teams responsible for antimicrobial stewardship who monitor data and provide feedback on antimicrobial prescribing practice at prescriber, team, organisation and commissioner level. The frequency and specific content of the feedback should be agreed locally between commissioners and service providers.
People receive care from healthcare professionals whose prescribing of antimicrobials is monitored to make sure that it is safe and appropriate.

Source guidance

Definitions of terms used in this quality statement

Antimicrobial stewardship
The term ‘antimicrobial stewardship’ is defined as an organisational or healthcare-system-wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness. [NICE’s guideline on antimicrobial stewardship: systems and processes for effective antimicrobial medicine use]

Electronic prescribing systems: developmental

This quality statement is taken from the antimicrobial stewardship quality standard. The quality standard defines clinical best practice in antimicrobial stewardship and should be read in full.
Developmental quality statements set out an emergent area of cutting-edge service delivery or technology currently found in a minority of providers and indicating outstanding performance. They will need specific, significant changes to be put in place, such as redesign of services or new equipment.

Quality statement

Prescribers in secondary and dental care use electronic prescribing systems that link indication with the antimicrobial prescription.

Rationale

Although most GP practices already use electronic prescribing systems, many secondary care services (inpatient and outpatient) and dental care settings don’t have access to this technology. Linking the indication with the antimicrobial prescription using electronic prescribing supports antimicrobial stewardship by highlighting inappropriate prescribing, and monitoring individual prescribing practice.

Quality measures

Structure
Evidence of local arrangements to ensure that prescribers of antimicrobials in secondary care and dental care settings have access to electronic prescribing systems that link indication with the antimicrobial prescription.
Data source: Local data collection.
Process
a) Proportion of secondary care services using electronic prescribing systems that link the indication with the antimicrobial prescription.
Numerator – the number in the denominator using electronic prescribing systems that link the indication with the antimicrobial prescription.
Denominator – the number of secondary care services.
Data source: Local data collection.
b) Proportion of dental practices using electronic prescribing systems that link the indication with the antimicrobial prescription.
Numerator – the number in the denominator using electronic prescribing systems that link the indication with the antimicrobial prescription.
Denominator – the number of dental practices.
Data source: Local data collection.
Outcome
Antimicrobial prescribing rates.

What the quality statement means for different audiences

Service providers (such as hospitals and dental practices) ensure that prescribers of antimicrobials have access to electronic prescribing systems that link indication with the antimicrobial prescription.
Prescribers use electronic prescribing systems that link indication with the antimicrobial prescription.
Commissioners (clinical commissioning groups, NHS England) ensure that they commission services with electronic prescribing systems that link indication with the antimicrobial prescription.
People receive care from healthcare services that have electronic systems for prescribing. These systems support prescribing of antimicrobials according to diagnosis as well as local and national guidance on antimicrobial use.

Source guidance

Antimicrobial stewardship

This quality statement is taken from the infection prevention and control quality standard. The quality standard defines clinical best practice for infection prevention and control and should be read in full.

Quality statement

People are prescribed antibiotics in accordance with local antibiotic formularies as part of antimicrobial stewardship.

Rationale

Antibiotic resistance poses a significant threat to public health, particularly because antibiotics underpin routine medical practice in both primary and secondary care. To help prevent the development of current and future bacterial resistance, it is important to prescribe antibiotics according to the principles of antimicrobial stewardship, such as prescribing antibiotics only when they are needed (and not for self-limiting mild infections such as colds and most coughs, sinusitis, earache and sore throats) and reviewing the continued need for them. These principles should be set out within local antibiotic guidelines and pathways and be consistent with the local antibiotic formulary. Local antibiotic formularies should indicate a range of antibiotics for managing common infections, and permit use of other antibiotics only on the advice of the microbiologist or physician responsible for the control of infectious diseases.

Quality measures

Structure
a) Evidence of local antibiotic formularies governing the use of antibiotics to ensure that people are prescribed antibiotics appropriately.
Data source: Local data collection.
b) Evidence that local antibiotic formularies are reviewed regularly.
Data source: Local data collection.
c) Evidence of local audits of the appropriateness of antibiotic prescribing.
Data source: Local data collection.
Outcome
Antibiotic prescribing rates (primary and secondary care).
Data source for primary care: National prescribing comparator data available from the NHS Digital Information Services Portal, specifically the number of prescription items for antibacterial drugs per Specific Therapeutic Group Age-sex weightings Related Prescribing Unit (STAR-PU), and the number of prescription items for cephalosporins and quinolones as a percentage of the total number of prescription items for selected antibacterial drugs (British National Formulary [BNF]).
Data source for secondary care: Local data collection.

What the quality statement means for different audiences

Service providers ensure that they have antimicrobial stewardship initiatives in place, including local antibiotic formularies for antibiotic prescribing.
Healthcare professionals ensure that when they prescribe antibiotics they do so in accordance with local antibiotic formularies as part of antimicrobial stewardship.
Commissioners ensure that they commission services that have antimicrobial stewardship initiatives and in which people are prescribed antibiotics in accordance with local antibiotic formularies.
People are offered antibiotics according to local guidance about which ones are most suitable. This includes not being offered antibiotics if they don’t need them (for example, if they have a cold, a sore throat, most coughs or earache). This is to try to reduce the problem of antibiotic resistance, which is when an infection no longer responds to treatment with one or more types of antibiotic and so is more likely to spread and can become serious.

Source guidance

Definitions of terms used in this quality statement

Local antibiotic formulary
A local antibiotic formulary is a local policy document produced by a multi professional team, usually in a hospital trust or commissioning group, combining best evidence and clinical judgement. [NICE’s full guideline on surgical site infections, glossary]
A local antibiotic formulary is defined as 'the output of processes to support the managed introduction, utilisation or withdrawal of healthcare treatments within a health economy, service or organisation. [NICE’s guideline on developing and updating local formularies]
Local policies often limit the antibiotics that may be used to achieve reasonable economy consistent with adequate cover, and to reduce the development of resistant organisms. A policy may indicate a range of antibiotics for general use, and permit other antibiotics only on the advice of the medical microbiologist or physician responsible for the control of infectious diseases. [BNF Antibacterials, principles of therapy]
Antimicrobial stewardship
Antimicrobial stewardship is an organisational or healthcare-system-wide approach to promoting and monitoring judicious use of antimicrobial drugs to preserve their future effectiveness. [Adapted from the Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI)’s antimicrobial prescribing and stewardship competencies]
The approach to prescribing in line with the principles of antimicrobial stewardship recommended for secondary care is as follows:
  • Do not start antibiotics without clinical evidence of bacterial infection.
  • If there is evidence or suspicion of bacterial infection, use local guidelines to start prompt, effective antibiotic treatment.
  • Document the following on the medicines chart and in the person’s medical notes: clinical indication, duration or review date, route and dose.
  • Obtain cultures – knowing the susceptibility of an infecting organism can lead to narrowing of broad-spectrum therapy, changing therapy to effectively treat resistant pathogens, and stopping antibiotics when cultures suggest an infection is unlikely.
  • Prescribe single-dose antibiotics for surgical prophylaxis if antibiotics have been shown to be effective.
  • Review the clinical diagnosis and the continuing need for antibiotics by 48 hours from the first antibiotic dose and make a clear plan of action – the ‘Antimicrobial Prescribing Decision’. The 5 Antimicrobial Prescribing Decision options are: Stop, Switch Intravenous to Oral, Change, Continue, and Outpatient Parenteral Antibiotic Therapy (OPAT).
  • Clearly document the review and subsequent decision in the person’s medical notes.
The approach to prescribing in line with the principles of antimicrobial stewardship recommended for primary care is as follows:
  • Prescribe an antibiotic only if there is likely to be a clear clinical benefit.
  • Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections.
  • Limit prescribing over the phone to exceptional cases.
  • Use simple generic antibiotics if possible. Avoid broad-spectrum antibiotics (for example, co-amoxiclav, quinolones and cephalosporins) if narrow-spectrum antibiotics remain effective, because the former increase the risk of Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA) and antibiotic resistant urinary tract infections.
  • Avoid widespread use of topical antibiotics (especially those that are also available as systemic preparations, such as fusidic acid).

Organisational responsibility

This quality statement is taken from the infection prevention and control quality standard. The quality standard defines clinical best practice for infection prevention and control and should be read in full.

Quality statement

Organisations that provide healthcare have a strategy for continuous improvement in infection prevention and control, including accountable leadership, multi-agency working and the use of surveillance systems.

Rationale

It is essential that organisations and agencies work together to coordinate strategies for infection prevention and control across a local area. It is equally important to share information across organisations in order to meet responsibilities for establishing the current position on infection control, monitoring the impact of quality improvement initiatives and ongoing surveillance. Leadership underpins all infection prevention and control, and is vital to ensure that this remains a priority for the organisation as a whole and each person working within it.

Quality measures

Structure
a) Evidence that the organisation includes infection prevention and control within its overall strategy.
Data source: Local data collection.
b) Evidence that the organisation’s board is up to date with, and has a working knowledge and understanding of, infection prevention and control.
Data source: Local data collection.
c) Evidence that a lead for infection prevention and control has been assigned and is taking an active role.
Data source: Local data collection.
d) Evidence of support for, and participation in, joint working initiatives beyond mandatory or contractual requirements, to reduce healthcare-associated infections locally.
Data source: Local data collection.
e) Evidence of an adequately resourced surveillance system with specific, locally defined objectives and priorities for preventing and managing healthcare-associated infections.
Data source: Local data collection.
Outcome
Incidence of healthcare-associated infection.
Data source: 2014/15 NHS Outcomes Framework indicator 5.2 and 2014/15 CCG Outcomes Indicator Set indicators 5.3 and 5.4 measure incidence of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. Data are derived from Public Health England’s mandatory reporting of healthcare-associated infections (also reported by the NHS Digital National Indicator Library).

What the quality statement means for different audiences

Service providers ensure that a strategy is in place for continuous improvement in infection prevention and control that includes accountable leadership, multi-agency working and surveillance systems.
Healthcare professionals ensure that they implement strategies for continuous improvement in infection prevention and control through accountable leadership, multi-agency working and adhering to the requirements of surveillance systems.
Commissioners ensure that they commission services from organisations that have strategies for continuous improvement in infection prevention and control that include accountable leadership, multi-agency working and surveillance systems.
People receive healthcare from organisations that aim to continually improve their approach to preventing infection (for example, by sharing information with other organisations and monitoring rates of infection).

Source guidance

Definitions of terms used in this quality statement

Board
A board is defined as a group of members with overall responsibility and accountability for the governance, safety and quality of an organisation [Expert opinion]

Hand decontamination

This quality statement is taken from the infection prevention and control quality standard. The quality standard defines clinical best practice for infection prevention and control and should be read in full.

Quality statement

People receive healthcare from healthcare workers who decontaminate their hands immediately before and after every episode of direct contact or care.

Rationale

Effective hand decontamination, even after wearing gloves, results in significant reductions in the carriage of potential pathogens on the hands and decreases the incidence of preventable healthcare-associated infections, leading in turn to a reduction in morbidity and mortality. Hand decontamination is considered to have a high impact on outcomes that are important to patients. Although hand hygiene has improved over recent years, remaining misconceptions about this standard principle of infection control are reported and good practice is still not universal.

Quality measures

Structure
a) Evidence of local arrangements to ensure the availability of facilities for hand decontamination.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that all healthcare workers receive training in hand decontamination.
Data source: Local data collection.
c) Evidence of local arrangements to ensure that regular local hand hygiene observation audits are undertaken.
Data source: Local data collection.
Outcome
Incidence of healthcare-associated infection.
Data source: 2014/15 NHS Outcomes Framework indicator 5.2

What the quality statement means for different audiences

Service providers ensure that healthcare workers are trained in effective hand decontamination techniques, and that handrub and handwashing facilities are available so that healthcare workers can decontaminate their hands immediately before and after every episode of direct contact or care.
Healthcare workers ensure that they are trained in effective hand decontamination techniques, and that they decontaminate their hands immediately before and after every episode of direct contact or care, even when gloves have been worn.
Commissioners ensure that they commission services in which healthcare workers are trained in effective hand decontamination techniques and decontaminate their hands immediately before and after every episode of direct contact or care, and that hand hygiene observation audits are carried out regularly.
People receiving healthcare are looked after by healthcare workers who always clean their hands thoroughly (using handrub or soap and water), both immediately before and immediately after coming into contact with the person or carrying out care.

Source guidance

Definitions of terms used in this quality statement

Hand decontamination
Hand decontamination is the use of handrub or handwashing to reduce the number of bacteria on the hands. The term is often interchangeable with ‘hand hygiene’.
An alcohol-based handrub should be used for hand decontamination before and after direct contact or care, except in the following situations when soap and water must be used:
  • when hands are visibly soiled or potentially contaminated with body fluids or
  • when caring for patients with vomiting or diarrhoeal illness, regardless of whether or not gloves have been worn.
Direct contact or care
Direct contact or care refers to 'hands on' or face-to-face contact with patients. This encompasses any physical aspect of the healthcare of a patient, including treatments, self-care and administration of medication. [NICE’s guideline on healthcare-associated infections]

Urinary catheters

This quality statement is taken from the infection prevention and control quality standard. The quality standard defines clinical best practice for infection prevention and control and should be read in full.

Quality statement

People who need a urinary catheter have their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed.

Rationale

Catheter-associated urinary tract infections comprise a large proportion of healthcare-associated infections, and can occur whether a person has either a short-term or a long-term catheter. There is a strong association between duration of urinary catheterisation and risk of infection, and catheters are sometimes inserted inappropriately or there is a delay in removing them. This risk is greatly reduced by complying with all parts of the process for safe catheter insertion, maintenance and removal as soon as it is no longer needed. This is important in terms of both infection prevention and patient comfort and experience.

Quality measures

Structure
Evidence of a written protocol to ensure that people who need a urinary catheter have their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed.
Data source: Local data collection.
Process
a) Proportion of people with a short-term urinary catheter who had their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed.
Numerator – the number of people in the denominator for whom all of the specified procedures were completed for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed.
Denominator – the number of people who have had a short-term urinary catheter.
Data source: Local data collection.
b) Proportion of people with a long-term urinary catheter who had their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed.
Numerator – the number of people in the denominator for whom all of the specified procedures were completed for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed were completed.
Denominator – the number of people who have had a long-term urinary catheter.
Data source: Local data collection.
Outcome
a) Incidence of healthcare-associated infection.
Data source: 2014/15 NHS Outcomes Framework indicator 5.2 and 2014/15 CCG Outcomes Indicator Set indicators 5.3 and 5.4 measure incidence of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. Data are derived from Public Health England’s mandatory reporting of healthcare-associated infections (also reported by the NHS Digital’s National Indicator Library).
b) Incidence of catheter-associated urinary tract infection.
Data source: Local data collection. NHS safety thermometer.

What the quality statement means for different audiences

Service providers ensure that systems and facilities are in place to enable staff to complete specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed, in order to minimise the risk of infection.
Healthcare workers ensure that they complete specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed, in order to minimise the risk of infection.
Commissioners ensure that they commission services in which specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed are completed, in order to minimise the risk of infection.
People who need a urinary catheter have their risk of infection minimised by healthcare workers carrying out procedures to make sure that the catheter is inserted, looked after and removed correctly and safely. These procedures include things like cleaning hands, using a lubricant when inserting the catheter, emptying the drainage bag when necessary, and removing the catheter as soon as it is no longer needed. A urinary catheter is a thin flexible tube used to drain urine from the bladder.

Source guidance

Definitions of terms used in this quality statement

Urinary catheter
A urinary catheter is a catheter that is inserted in the urethra and remains in place until it is no longer needed. Both short-term (used for 28 days or less) and long-term (used for more than 28 days) urinary catheters are used. [Adapted from NICE’s full guideline on healthcare-associated infections and epic3: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England]
Specified procedures necessary for the safe insertion, maintenance and appropriate removal of urinary catheters
Assessing the need for catheterisation
  • Catheterisation should be used only after considering alternative methods of management. The person’s clinical need for catheterisation should be reviewed regularly and the urinary catheter removed as soon as possible. The need for catheterisation, as well as details about insertion, changes and care should be documented.
Hand hygiene
  • Healthcare workers must decontaminate their hands and wear a new pair of clean, non-sterile gloves before manipulating a person’s catheter, and must decontaminate their hands after removing gloves.
Catheter insertion
  • The meatus should be cleaned before the catheter is inserted, in accordance with local guidelines or policy (for example, with sterile normal saline).
  • An appropriate lubricant from a single-use container should be used during catheter insertion to minimise urethral trauma and infection.
Catheter maintenance
  • Indwelling catheters should be connected to a sterile closed urinary drainage system or catheter valve. Healthcare workers 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).
  • Urinary drainage bags should be positioned below the level of the bladder, and should not be in contact with the floor. The urinary drainage bag should be emptied frequently enough to maintain urine flow and prevent reflux, and should be changed when clinically indicated. A separate and clean container should be used for each person. Contact between the urinary drainage tap and container should be avoided.
  • Urine samples must be obtained from a sampling port using an aseptic technique.
  • The meatus should be washed daily with soap and water as part of routine daily personal hygiene.

Vascular access devices

This quality statement is taken from the infection prevention and control quality standard. The quality standard defines clinical best practice for infection prevention and control and should be read in full.

Quality statement

People who need a vascular access device have their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the device and its removal as soon as it is no longer needed.

Rationale

Vascular access devices are one of the main causes of healthcare-associated infections, and bloodstream infections associated with central venous device insertion are a major cause of morbidity. The risk of infection is greatly reduced by complying with all parts of the process for safe insertion and maintenance of the device and its removal as soon as it is no longer needed.

Quality measures

Structure
Evidence of a written protocol to ensure that people who need a vascular access device have their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the device and its removal as soon as it is no longer needed.
Data source: Local data collection.
Process
Proportion of people with a vascular access device who had their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the device and its removal as soon as it is no longer needed.
Numerator – the number of people in the denominator for whom all of the specified procedures were completed for the safe insertion and maintenance of the device and its removal as soon as it is no longer needed.
Denominator – the number of people who have had a vascular access device.
Data source: Local data collection. Contained in the UK Renal Registry Annual Report.
Outcome
Incidence of vascular access device-related bloodstream infection.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems and facilities are in place to enable staff to complete specified procedures necessary for the safe insertion and maintenance of the vascular access device and its removal as soon as it is no longer needed, in order to minimise risk of infection.
Healthcare workers ensure that they complete specified procedures necessary for the safe insertion and maintenance of the vascular access device and its removal as soon as it is no longer needed, in order to minimise the risk of infection.
Commissioners ensure that they commission services in which specified procedures necessary for the safe insertion and maintenance of the vascular access device and its removal as soon as it is no longer needed are completed, in order to minimise the risk of infection.
People who need a vascular access device have their risk of infection minimised by healthcare workers carrying out procedures to make sure that the device is inserted, looked after and removed correctly and safely. These procedures include things like using sterile procedures when inserting the device, using the correct antiseptics and dressings, and removing the device as soon as it is no longer needed. A vascular access device is a tube that is inserted into a main vein or artery and used to administer fluids and medication, monitor blood pressure and collect blood samples.

Source guidance

Definitions of terms used in this quality statement

Vascular access device
A vascular access device is an indwelling catheter, cannula or other instrument used to obtain venous or arterial access. Both central and peripheral vascular access devices are available.
Specified procedures necessary for the safe insertion, maintenance and appropriate removal of vascular access devices
General asepsis
  • Healthcare workers must decontaminate their hands before accessing or dressing a vascular access device, using an alcohol handrub or by washing with liquid soap and water if hands are contaminated. An aseptic technique must be used for vascular access device catheter site care, when accessing the system and when administrating intravenous medication.
Skin decontamination
  • The skin should be decontaminated at the insertion site with 2% chlorhexidine gluconate in 70% alcohol and allowed to dry before inserting a vascular access device.
Vascular access device site care
  • A sterile transparent semipermeable membrane dressing should be used to cover the vascular access device insertion site. This should be changed every 7 days, or sooner if it is no longer intact or if moisture collects under the dressing.
  • A single-use application of 2% chlorhexidine gluconate in 70% alcohol (or aqueous povidone iodine) should be used and allowed to dry when cleaning the insertion site during dressing changes.
Vascular access device management
  • A single-use application of 2% chlorhexidine gluconate in 70% alcohol (or aqueous povidone iodine) should be used to decontaminate the access port or catheter hub. The hub should be cleaned for 15 seconds and allowed to dry before accessing the system.
  • Preferably, a sterile 0.9% sodium chloride injection should be used to flush and lock catheter lumens.
  • Administration sets for blood and blood components should be changed when the transfusion episode is complete or every 12 hours (whichever is sooner), or according to the manufacturer's recommendations. Administration sets used for total parenteral nutrition 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.
Review of vascular access devices
  • Peripheral vascular catheter insertion sites should be inspected during every shift at a minimum, and a visual phlebitis score should be recorded.
  • Central venous catheter insertion sites should be inspected daily.

Educating people about infection prevention and control

This quality statement is taken from the infection prevention and control quality standard. The quality standard defines clinical best practice for infection prevention and control and should be read in full.

Quality statement

People with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate), are educated about the safe management of the device or equipment, including techniques to prevent infection.

Rationale

Because many people with a urinary catheter, vascular access device or enteral feeding tube manage their own device or equipment, it is important that they and their family members or carers are confident about, and proficient in, infection prevention and control practices and the safe management of the device or equipment.

Quality measures

Structure
Evidence of local arrangements for people with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate), to be educated about the safe management of their device or equipment, including techniques to prevent infection.
Data source: Local data collection.
Process
Proportion of people with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate), who are educated about the safe management of their device or equipment, including techniques to prevent infection.
Numerator – the number of people in the denominator who are educated about the safe management of their device or equipment, including techniques to prevent infection.
Denominator – the number of people with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate).
Data source: Local data collection.
Outcome
a) Incidence of healthcare-associated infection.
Data source: 2014/15 NHS Outcomes Framework indicator 5.2 and 2014/15 CCG Outcomes Indicator Set indicators 5.3 and 5.4 measure incidence of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. Data are derived from Public Health England’s mandatory reporting of healthcare-associated infections (also reported by the NHS Digital’s National Indicator Library).
b) People with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate), feel able to manage their device or equipment.
Data source: Local data collection using a patient survey to demonstrate that patients and carers have understood their education.

What the quality statement means for different audiences

Service providers ensure that there are systems in place for people with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate), to be educated about the safe management of the device or equipment, including techniques to prevent infection.
Healthcare workers ensure that they educate people with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate), about the safe management of the device or equipment, including techniques to prevent infection.
Commissioners ensure that they commission services in which people with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate), are educated about the safe management of the device or equipment, including techniques to prevent infection.
People who have a urinary catheter, a vascular access device or an enteral feeding tube, and any family members or carers who help them with this equipment, are given information and advice about how to look after the equipment safely and effectively. This includes advice about how to prevent infection. Enteral feeding is a type of feeding used for people who cannot eat normally in which liquid food is given through a tube directly into the gut.

Source guidance

Definitions of terms used in this quality statement

Urinary catheter
A urinary catheter is a catheter that is inserted in the urethra and remains in place until it is no longer needed. Both short-term (used for 28 days or less) and long-term (used for more than 28 days) urinary catheters are used. [Adapted from NICE’s full guideline on healthcare-associated infections and epic3: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England]
Vascular access device
A vascular access device is an indwelling catheter, cannula or other instrument used to obtain venous or arterial access. Both central and peripheral vascular access devices are available.
Enteral feeding
Enteral feeding is feeding via a tube that can include any method of providing nutrition via the gastrointestinal tract. [NICE’s full guideline on healthcare-associated infections]
Education about infection prevention and control
Education for people and their carers about infection prevention and control should always cover the techniques of hand decontamination. In addition education should be provided as follows:
  • For people with a urinary catheter, education should cover insertion of intermittent catheters where applicable, how to manage the catheter and drainage system, how to minimise the risk of urinary tract infections and how to obtain additional supplies suitable for individual needs.
  • For people with a vascular access device, education should cover any technique needed to prevent infection and safely manage the device.
  • For people needing enteral feeding, education should cover techniques of feeding and management of the administration system.

Equality and diversity considerations

People with a cognitive impairment or a lack of mobility may need additional support to undertake hand decontamination and other techniques to prevent infection. Language barriers should not be a reason for not providing advice.
If religious beliefs are a source of concern in relation to the use of alcohol handrubs for hand decontamination, people could be made aware of the official views of religious bodies about the products. If information is available, people should be directed to these sources.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Glossary

(loss of effectiveness of any anti-infective medicine, including antiviral, antifungal, antibacterial and antiparasitic medicines)
(an organisational or healthcare-system-wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness)
(any anti-infective therapy (antiviral, antifungal, antibacterial and antiparasitic medicines) and any formulation (oral, parenteral and topical agents))
(all anti-infective therapies (antiviral, antifungal, antibacterial and antiparasitic medicines) and all formulations (oral, parenteral and topical agents))
(a preparation applied to the hands to reduce the number of viable microorganisms. This guidance refers to handrubs compliant with British standards (BS EN1500; standard for efficacy of hygienic handrubs using a reference of 60% isopropyl alcohol))
(preparations applied to the hands to reduce the number of viable microorganisms. This guidance refers to handrubs compliant with British standards (BS EN1500; standard for efficacy of hygienic handrubs using a reference of 60% isopropyl alcohol))
(the wider care team, including but not limited to, case managers, care coordinators, GPs, hospital doctors, microbiologists, pharmacists, nurses and social workers)
'inappropriate antimicrobial demand' refers to people asking for antimicrobials for conditions against which they are ineffective (for example antibiotics to treat a viral infection such as a cold) or for self-limiting infections that will resolve on their own, with no long-term harm to the person's health. 'Inappropriate antimicrobial use' refers to the way in which people may misuse antimicrobials that they have been prescribed or supplied with, and which may result in the antimicrobials becoming ineffective in treating infections. This is because the bacteria, virus, fungus or parasite they are designed to treat may become resistant to the antimicrobial. Examples of inappropriate use include not taking or using the antimicrobials as prescribed and sharing them with others
(for example, a drug and therapeutics committee, area prescribing committee or local formulary decision-making group)
(services that can advise people whether they have a self-limiting infection that they can safely manage themselves or whether their infection needs medical attention; examples include community pharmacies, practice nurses, 111, other locally developed advice and helplines, and emergency and out-of-hours primary care services)
(includes all commissioners (clinical commissioning groups and local authorities) and providers (hospitals, GPs, out-of-hours services, dentists and social enterprises) of health or social care services, unless specified otherwise; occasionally, in order to make a recommendation more specific to the intended care setting, the setting is specified, for example the recommendation will state 'hospital')
(evidence-based materials that have been developed through a research-based approach with the target audience, wherever possible; they may be in a variety of formats, including posters, leaflets, digital and online resources)
(advising people what to do if their condition deteriorates or does not improve within a certain time, or if they develop adverse effects as a result of the treatment)
(approaches a person can use to look after themselves in a healthy way; for example, drinking plenty of fluids and getting sufficient rest when you have a cold)
(an infection that resolves on its own and has no long-term harmful effect on a person's health (assuming that they are not immunosuppressed); examples include colds, flu, oral thrush, winter vomiting bug)
(infections that resolve on their own and have no long-term harmful effect on a person's health (assuming that they are not immunosuppressed); examples include colds, flu, oral thrush, winter vomiting bug)

Paths in this pathway

Pathway created: August 2015 Last updated: September 2021

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