Logistics 4 Information and communication-oriented

“All written procedures should be stated simply, unambiguously, and understandably, and should indicate methods to be used and criteria to be satisfied”

The guideline documentation anticipates the usability of the document: it includes aspects facilitating the ease of identifying information, enhance the comprehensibility of the guidelines or non-textual elements that tell the user what should be done. The guideline document acknowledges the importance of information and communication in an era of increased international trade of health services, e.g., by means of defining tasks and responsibilities, and explicitly mentioning who has to inform who in case of patient transport.

Infection Society, and the Infection Control Nurses Association in Great Britain (GB). British and American guidelines were selected due to the English language in which they were written and the international reputation of the institutions that provided the guidelines. The British and American guidelines are, to our knowledge, the most cited MRSA guidelines worldwide. We used national guidelines that were recognized as standards of care in the concerned country. The guidelines were identified by searching Google or the website of the responsible authorities. Keywords used were: “guidelines” or “protocol”, and “MRSA”. We included the most recent guidelines that were available at the time of research (October, 2005). Thirteen national guideline documents originating from four countries and seven different national authorities were included for analysis: GB (n=2), Germany (n=4), the Netherlands (NL) (n=3), and the USA (n=4) (Centers for Disease Control and Prevention, Atlanta, 2007 (a), 2007 (b), 2007 (c); Coia et al., 2006; Duckworth & Heathcock, 1995; Dutch Working party on Infection Prevention, 2005 (a), 2005 (b); Muto et al., 2003; National Coordinator Infectious Disease Control, 2005; Robert Koch Institute 2004; The Committee for Hospital Hygiene and Infection Prevention at the Robert Koch Institute, 1999, 2005; The Institute of Public Health, 2003, 2005).

2.2.2. Framework development and analysis

Two of the authors (FV, JvG) generated an initial list of items based on validated frameworks for guidelines used in industry and health care (see left column of Table 2.1.) (Fervers et al; 2006 McRobb, 1990; Nabitz et al., 2000; The AGREE Collaboration, 2003). They examined the 13 national MRSA guidelines and explored which guideline aspects could be related to each of the domains representing a global health perspective (see right column of Table 2.1.). During an iterative process of analyzing and discussing, the ultimate framework for global-health adjusted guidelines emerged, which is presented in Table 2.2.

In order to test the content validity of the framework, the two authors independently classified the items according to the definitions of the four domains (see right column of Table 2.1.) and Cohen’s Kappa index was calculated (Cohen, 1960). The results revealed that the items in the framework presented a Kappa of 0.77, implying a substantial inter-rater reliability (Landis & Koch, 1977). The coding scheme was used to check each of the 13 guidelines for the absence or presence of each item. This was also done independently by the two authors. The results were compared, and the lack of consensus regarding coding differences was solved by discussion.

2.3. Results

The analysis of national MRSA guidelines showed differences between the proportions of guidelines in which the items accompanying the four domains were present. Results are shown in Table 2.2.

2.3.1. Regulation function

According to Table 2.2., the British guidelines incorporated substantially more evidence-based items, implying that they used of levels of evidence and included lists of references. Half of the American and German guidelines included all evidence- related items. The Netherlands showed the least evidence-based elements: none of the three Dutch guidelines contained grades of evidence indicating the strength of scientific data.

Table 2.2. shows that German and British guidelines referred substantially more frequently to regulation and legislation compared to Dutch and American guidelines. An example of such a reference is: “All nursing and residential homes should have a designated member of staff to deal with infection control matters and to ensure that the proprietor’s responsibilities to provide adequate arrangements for prevention of infections in the home, under the Nursing Homes and Mental Nursing Homes Regulations 1984, are fulfilled.” (Duckworth & Heathcock, 1995).

2.3.2. Communication function

Based on the results, both the British and Dutch guidelines can be labeled as “risk- focused”. They both included definitions of risk categories, clinical information such as MRSA rates of the concerning country, and they both emphasized the risk of non-adherence to the guidelines by mentioning negative consequences. The German guidelines also included these risk categories, but they were not as obviously present as in the Dutch and British guideline documents. To illustrate these risk dimensions, a fragment from the British guideline for healthcare institutions is given: “Patients at high risk of carriage of MRSA include those who are: known to have been infected or colonized with MRSA in the past (Category 1b); frequent re-admissions to any healthcare facility (Category 1b); direct interhospital transfers (Category 1b); recent inpatients at hospitals abroad or hospitals in GB which are known or likely to have a high prevalence of MRSA (Category 1b); and residents of residential care facilities where there is a known or likely high prevalence of MRSA carriage (Category 1b).” (Coia et al., 2006). The USA were the only country producing guidelines in which patients and HCWs were not explicitly divided into risk categories.

American guidelines seemed to pay the least attention to information- and

communication items, compared to guidelines from other countries. German, British, and Dutch guidelines included schemes and specific recommendations for the information process, in contrast to the American guidelines, which did not. However, the American and Dutch guidelines did refer to the importance of information and communication technology (ICT). For instance: “A hospital computer system can be used to store information regarding long-term isolation indicators for patients known to be colonized with antibiotic-resistant pathogens such as MRSA or VRE. With optimal programming, this can come up automatically whenever the patient enters the healthcare system, whether in the hospital, emergency department, outpatient clinic, or a diagnostic or procedure area, providing an alert to HCWs who may be interacting with the patient for the first time and are unaware of the requirement for isolation.”

Table 2.2. Overview of criteria for the communication of infection control guidelines from a global health perspective, and the

degree to which countries’ national guidelines meet these criteria

Percentage of clinical practice guide- lines in which item is present

Items GB1 N=2* DE2 N=4* NL3 N=3* USA4 N=4* Domain 1: Evidence-based Regulation function

1. Levels of evidence (categories of importance) 50 50 0 50

2. Information about cost-effectiveness 50 50 33 50

3. Guidelines are supported by scientific evidence (with reference to source mentioned in text) 100 50 0 25

4. List of references 100 50 100 75