Talk on how to write guidelines during ICAN 2014 in Harare, Zimbabwe

1. Guidelines 04-11-14
As
a
great
philosopher
(Marx*)
once
said:
“Outside
of
a
dog,
a
book
(guideline)
is
Man’s
best
friend.
Inside
of
a
dog,
it’s
too
dark
to
read”
*
Groucho
Marx
¤ Target
audience
100%
¤ Heard
about
it
80%
¤ Seen
it
50%
¤ Got
it/bought
it
30%
¤ Used
it
20%
¤ Used
it
as
intended
5%
Henk-Jan Smid, ZonMw
Why don’t they listen to Infection Control?
Multi-Resistant
Medical Specialist
¤ Resistant
to
good
advice
¤ Allergic
to
professional
guidelines
¤ Non-­‐compliant
with
infecUon
control
¤ Blind
to
nosocomial
infecUons
¤ Other
prioriUes
ICAN 2014 1

2. Guidelines 04-11-14
Guidelines
Guidelines
More
guidelines
Policing
One-­‐track
mind
Guidelines
Guidelines
Too many
Too long
Too many details
Too many rules
Too theoretical
Moor needed
Too short
Not enough details
Not enough rules
Not enough theory
50%
50%
50%
50%
50%
… luckily both groups agree on one thing …
Guidelines are completely useless
… but do not expect wonders
¤ InternaUonal
guidelines
² by
socieUes/inst
e.g.
HICPAC,
CDC,
ECDC
¤ NaUonal
guidelines
² government
driven
² by
naUonal
professional
socieUes
e.g.
SHEA,
APIC,
IDSA,
…
¤ Local
guidelines
² hospital-­‐wide
(local
IC-­‐driven)
² department-­‐specific
(user-­‐driven)
ICAN 2014 2

3. Guidelines 04-11-14
¤ Should
be
looked
at
when
naUonal
guidelines
are
missing
or
¤ When
naUonal
policies
get
up-­‐dated
Can be very helpful, but …
translation alone is not enough
need to be adapted to your national
and local situation
¤ Each
country
should
have
an
independent
naUonal
infecUon
control
insUtute,
supported
by
the
government:
¤ CDC
(Centers
for
Diseases
Control
and
infecUon
prevenUon)
¤ WIP
(Werkgr.
InfecUePrevenUe),
Netherlands
² www.wip.nl
¤ RKI
(Robert
Koch
InsUtut),
Germany
¤ ….
¤ Task
of
the
naUonal
infecUon
control
insUtute:
² Produces
guidelines
² Serves
as
a
documentaUon
center
² Answers
(acute)
quesUons
¤ Members
=
specialists
in
the
field
of
Clinical
Microbiology,
InfecUous
Diseases
&
Inf.
Control
¤ Access
for
HCWs:
easy
&
cheap
¤ “Broadly
based”
=
concepts
widely
commented
by
“users”,
PH,
and
government
¤ IdenUfy
topic
and
priority
¤ ConsUtute
core
group
to
write
first
concept
² ICP,
Clinical
microbiologist,
infecUous
diseases
² “User”
=
surgeon,
ICU
MD’s,
nurses,
…
¤ Discuss
first
concept
among
members
NIC
¤ Send
2nd
concept
to
users
and
specialists
¤ Send
3rd
concept
to
“ministry”
and
Health
Council
¤ Implement
definiUve
version
¤ Re-­‐evaluate/revise
ader
3-­‐4
years
or
with
any
external
need
Keep it short
Keep it simple
Keep the clinical
practice in mind
Not too many
details
As clear as possible
Consistent with
earlier guidelines
Cite the literature
and the sources
Include tables
& flow-charts
ICAN 2014 3

4. Guidelines 04-11-14
Is this
evidence
based?? Don’t you mean
eminence based?
Inf. Control
Guideline
… but do not exclusively use RCTs as evidence
for every single IC intervention
¤ CATEGORY
1A
=
strongly
recommended
for
all
hospitals
and
strongly
supported
by
well-­‐designed
experimental
and
epidemiological
studies
¤ CATEGORY
1B
=
strongly
recommended
for
all
hospitals
and
viewed
as
effecUve
by
experts
in
the
field
and
a
consensus
of
HICPAC,
based
on
strong
raUonale
and
suggesUve
evidence,
even
though
definiUve
scienUfic
studies
may
not
have
been
done
¤ …
they
can
lead
to
lack
of
compliance
among
HCWs
who
may
furthermore
ignore
those
parts
of
the
guidelines
that
were
really
important
Guidelines for Glycopeptide-resistant S. aureus
¤ Private
nurse
(one-­‐on-­‐one)
¤ Private
doctor
(one-­‐on-­‐one)
¤ Guard
in
front
of
the
door
¤ No
vistors
¤ PaUent
not
allowed
to
leave
room
¤ Do
not
keep
(destroy)
resistant
strain
ICAN 2014 4

5. Guidelines 04-11-14
That is an
easy one …
From left to right!
ICAN 2014 5

6. Guidelines 04-11-14
Adapt
the
guidelines
to
fit:
¤ Local
hospital
structure
² e.g.
presence
of
isolaUon
room
for
Tb
¤ Local
epidemiology
²
e.g.
mulU-­‐resistant
Gram-­‐negaUve
rods
may
in
some
hospitals
only
be
characterized
as
aminoglycoside-­‐resistant
today
only
ESBL/CPE
¤ Adapt
the
guidelines
to
fit:
² Not
always!
Some.mes
guidelines
could
be
used
to
change
your
hospital
structure
Make SOPs of how to implement guidelines
Logistics within the hospital
Responsibilities
PR (actions, posters, intranet, … )
Teaching, in-services, …
Audit implementation
¤ NaUonal
guidelines
are
not
LAW,
thus
different
prevenUve
measurements
may
be
taken
with
good
reasoning
¤ Hospital
guidelines
may
over
rule
state-­‐of-­‐
the-­‐art
literature
or
naUonal
guidelines
* including auto-sterile chiefs of staff
ICAN 2014 6

7. Guidelines 04-11-14
¤
Did
you
involve
your
clinical
colleagues
when
first
wriUng
your
guidelines
and
when
implemenUng
them?
¤
Assuming
that
most
of
you
silently
answerd
the
quesUon
with
“yes”…
…
& more
ESBL
CRE
MRSA
MDR-AB
XDR-TB
PRP
MERS-Cov
C.dif
Noro
Flu
LA-MRSA
CNR-GNR
SARS
Fungi
CR-ESCO
CA-MRSA
TBC
…
Please,
no
more!
IC needs to be to-the-point
The Ten Commandments
of Infection Control
The ten commandments of Infection Control
Thou shalt trust in God,
from all others thou shalt
require hard data.
Thou shalt not trust
statistics, unless thou
made them up thyself
ICAN 2014 7

8. Guidelines 04-11-14
The ten commandments of Infection Control
Thou shalt not follow CDC
or other guidelines to the
point of ignoring thy
common sense
Thou shalt not touch thy
patient with unwashed *
hands
*undisinfected !
The ten commandments of Infection Control
Thou shalt love clinicians
to death - even if they
never listen.
Thou shalt not bow to an
administrator or worship
hospital finances when
dealing with an outbreak
The ten commandments of Infection Control
Thou shalt not envy thy
neighbor’s facility, or want
to pinch his ICPs.
Thou shalt not believe
those who claim to be free
of nosocomial infections
The ten commandments of Infection Control
Thou shalt shut thy gob when
politely asked, and not drone
on endlessly.
Thou shalt notice when thy
audience is bored rigid.
ICAN 2014 8