Hand Hygiene
"last update: 28 Oct 2024"
- Methodology
A comprehensive search for guidelines was undertaken to identify the most relevant guidelines to consider for adaptation.
Inclusion/ exclusion criteria followed in the search and retrieval of guidelines to be adapted:
▪️ Selecting only evidence-based guidelines (guideline must include a report on systematic literature searches and explicit links between individual recommendations and their supporting evidence)
▪️ Selecting only national and/or international guidelines
▪️ Specific range of dates for publication (using Guidelines published or updated in 2013 and later)
▪️ Selecting peer reviewed publications only
▪️ Selecting guidelines written in English language
▪️ Excluding guidelines written by a single author, not on behalf of an organization to be valid and comprehensive, a guideline ideally requires multidisciplinary input.
▪️ Excluding guidelines published without references as the panel needs to know whether a thorough literature review was conducted and whether current evidence was used in the preparation of the recommendations.
The following characteristics of the retrieved guidelines were summarized in:
- Developing organisation/authors
- Date of publication, posting, and release
- Country/language of publication
- Date of posting and/or release
- Dates of the search used by the source guideline developers.
All retrieved Guidelines were screened and appraised using AGREE II instrument (www.agreetrust.org) by at least three members. The panel decided on a cut-off point or ranked the guidelines (any guideline scoring above 50% on the rigor dimension was retained). The committee decided to adapt from
1. WHO Guidelines on Hand Hygiene in Health Care 2009
2. Infection Prevention and Control (IPC) National Irish Clinical Guideline No. 30 May 2023 Vol 1
3. Guideline for Hand Hygiene in Health-Care Settings Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force 2002, updated March 2024
➡️Evidence assessment
According to WHO Handbook for Guidelines, we used the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach to assess the quality of a body of evidence, develop and report recommendations. GRADE methods are used by WHO because these represent internationally agreed standards for making transparent recommendations. Detailed GRADE information is available on the following sites:
▪️ GRADE working group: http://www.gradeworkingroup.org
▪️ GRADE online training modules: http://cebgrade.mcmaster.ca/
▪️ GRADE profile software: http://ims.cochrane.org/revman/gradepro
Table (1) Quality and Significance of the four levels of evidence in GRADE
|
Quality |
Definition |
Implications |
|
High |
The guideline development group is very confident that the true effect lies close to that of the estimate of the effect |
Further research is very unlikely to change confidence in the estimate effect |
|
Moderate |
The guideline development group is moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibly that it is substantially different |
Further research is likely to have an important impact on confidence in the estimate of the effect and may change the estimate |
|
Low |
Confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the true effect |
Further research is very likely to have an important on confidence in the estimate of effect and is unlikely to change the estimate |
|
Very low |
The group has very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of the effect |
Any estimate of the effect is very uncertain |
Table (2) Factors that determine How
to upgrade or downgrade the quality of evidence.
|
Downgrade in presence of |
Upgrade in presence of |
|
Study limitations. 1- Serious limitations 2- Very serious limitations |
Dose- response gradient. +1 Evidence of a dose-response gradient |
|
Consistency 1- Important inconsistency |
Direction of plausible bias + All plausible confounders would have reduced the effect |
|
Directness 1- Some uncertainty 2- Major uncertainty |
Magnitude of the effect +1 Strong, no plausible Confounder, consistent and direct evidence |
|
Precision 1- Imprecise data |
+2 very strong, no major threats to validity and direct evidence |
|
Reporting bias 1- High probability of reporting bias |
|
➡️The strength of the recommendations
The strength of a recommendation communicates the importance of adherence to the recommendation.
▪️ Strong recommendations
With strong recommendations, the guideline communicates the message that the desirable effects of adherence to the recommendation outweigh the undesirable effects. This means that in most situations the recommendation can be adopted as policy.
▪️ Conditional recommendations
These are made when there is greater uncertainty about the four factors above or if local adaptation has to account for a greater variety in values and preferences, or when resource use makes the intervention suitable for some, but not for other locations. This means that there is a need for substantial debate and involvement of stakeholders before this recommendation can be adopted as policy.
When not to make recommendations?
When there is lack of evidence on the effectiveness of an intervention, it may be appropriate not to make a recommendation.
