Download Standard Infection Control Precautions

Infection Prevention and Control Assurance - Standard Operating
Procedure 1 (IPC SOP 1)
Standard Infection Control Precautions
Why we have a procedure?
Adherence to this procedure will ensure that Black Country Partnership Foundation
Trust staff are protected as far as is reasonably practicable when providing care to
patients with a known or suspected infection or when there is anticipated contact with
patient’s blood or other bodily fluids. It will also ensure compliance with the Health
and Social Care Act 2008: Code of Practice for the NHS for the Prevention and
Control of Healthcare Associated Infections (revised January 2015).
This document has been developed to provide a framework to provide staff with clear
guidelines on basic infection prevention and control precautions.
What overarching policy the procedure links to?

This procedure is supported by the Infection Prevention and Control Assurance
Policy
Which services of the trust does this apply to? Where is it in operation?
Group
Mental Health Services
Learning Disabilities Services
Children and Young People Services
Inpatients



Community



Locations
all
all
all
Who does the procedure apply to?
All staff involved in the care of patients should adhere to these standard procedures
when dealing with a known or suspected outbreak of infection/ communicable
disease or anticipate contact with blood or other bodily fluids e.g.

Matrons, Service Managers, Ward Managers and all clinicians involved in the
delivery of care

Facilities staff
All staff have a responsibility for ensuring that the principles outlined within this
document are universally applied.
Standard Infection Control Precautions
Page 1 of 16
Version 1.0 December 2015
When should the procedure be applied?



Standard Infection Control Precautions (SICPs), are intended for use by all
staff, in all care settings at all times for all individuals whether infection is known
to be present or not, to ensure the safety of those being cared for and staff and
visitors in the care environment
The application of SICPs during care delivery is determined by the assessment
of risk and includes the task/level of interaction and/or the anticipated level of
exposure to blood or other body fluids
There are ten elements which make up standard infection control precautions
(SICPs) and are described below
Definitions
Standard Infection
Control Precautions
(SICPs)
SICPs are the basic infection prevention and control
measures necessary to reduce the risk of
transmission of micro-organisms from recognised
and unrecognised sources of infection. These
sources of (potential) infection include blood and
other body fluids secretions or excretions (excluding
sweat), non-intact skin or mucous membranes and
any equipment or items in the care environment that
are likely to become contaminated
Aerosol Generating
Procedure
Procedure performed on patients that are more
likely to generate higher concentrations of
respiratory aerosols than coughing, sneezing,
talking, or breathing, presenting healthcare
personnel with an increased risk of exposure to
infectious agents present in the aerosol e.g.
suctioning
How to carry out this procedure
Additional Information/ Associated Documents

Infection Prevention and Control Assurance Policy

Waste Management Policy and SOPs

Hand Hygiene Policy

Medical Devices Policy and SOPs

Infection Prevention and Control Assurance - Standard Operating Procedure 8
(IPC SOP 8) - Sharps and Blood/Body Fluid Contamination Injury – Immediate
Actions
Patient Placement
The potential for transmission of infection or infectious agents should be assessed at
the patient’s entry to the care area and should be continuously reviewed throughout
the stay, this should influence placement decisions in accordance with clinical need.
Standard Infection Control Precautions
Page 2 of 16
Version 1.0 December 2015
Staff should:

As part of the initial patient assessment complete the Infection Risk Assessment
and document findings on the risk assessment tool. Patients with a score above
6 the staff must contact the infection prevention and control team for advice on
placement and management

Avoid unnecessary movement of patients between care areas

Patients who may present an infection risk e.g. diarrhoea, vomiting, and
unexplained rash, flu-like symptoms etc. must be assessed and placed in a
suitable environment to minimise cross-transmission e.g. isolated in a single
room with a clinical wash-hand basin or cohort area
Example of the Infection Risk Assessment tool (located in the patient assessment
booklet):
Hand Hygiene
Hand hygiene is considered to be the single most important practice in reducing the
transmission of infectious agents, including Healthcare Associated Infections (HCAI),
when providing care.
Before performing hand hygiene:

Expose forearms

Remove all hand/wrist jewellery (a single, plain metal finger ring is permitted but
should be removed (or moved up/down) during hand hygiene)

Ensure finger nails are clean, short and that artificial nails or nail products are
not worn; and

Cover all cuts or abrasions with a waterproof dressing
Hand hygiene should be performed:

Before touching a patient
Standard Infection Control Precautions
Page 3 of 16
Version 1.0 December 2015




Before clean/aseptic procedures
After body fluid exposure risk
After touching a patient; and
After touching a patient’s immediate surroundings
N.B. please refer to the Hand Hygiene policy
Respiratory Hygiene
Respiratory hygiene and cough etiquette is designed to contain respiratory secretions
to prevent transmission of respiratory infections such as colds and influenza:
Staff should encourage patients to:

Cover the nose and mouth with a disposable tissue when sneezing, coughing,
or wiping and blowing the nose

Dispose of all used tissues promptly into a waste bin after use

Wash hands with non-antimicrobial liquid soap and warm water after coughing,
sneezing, using tissues, or after contact with respiratory secretions or objects
contaminated by these secretions

Keep contaminated hands away from the mucous membranes of the eyes and
nose; and

Cough/ sneeze into the inner elbow if tissues are not immediately available to
hand also known as “sneeze into your sleeve”
Staff should promote respiratory hygiene and cough etiquette to all individuals and
help those (e.g. elderly, children) who need assistance with containment of
respiratory secretions e.g. those who are immobile will need a supply of tissues and
receptacle (e.g. disposal bag) readily at hand for the prompt disposal of used tissues
and offered/assisted with hand hygiene/ decontamination.
Personal Protective Equipment (PPE)
The type of PPE used must provide adequate protection to staff against the risks
associated with the procedure or task being undertaken. PPE should be removed as
soon as is practicable, once the procedure is completed; and always changed
between patients or different tasks on the same patient.
All PPE should be:

Located close to the point of use, the use of wall mounted PPE dispensers are
recommended (if safe within the patient environment)

Stored to prevent contamination or deterioration in quality (check
manufacturer’s instructions) in a clean/ dry area until required for use

Expiry dates must be adhered to

Reusable items, e.g. non-disposable goggles/face shields/visors must have a
decontamination schedule with responsibility assigned and must always
decontaminated immediately after each use
Standard Infection Control Precautions
Page 4 of 16
Version 1.0 December 2015
General Guidance
GLOVES






APRONS
Worn when exposure to blood
and/or other body fluids is

anticipated/likely.
Changed immediately after
each patient and/or following
completion of a clinical
procedure or task.
Changed if a perforation or
puncture is suspected

Be appropriate for use, fit for
purpose and well-fitting to
avoid excessive sweating and
interference with dexterity
Gloves must be worn when
using cleaning products
Single use and disposable,
latex and powder free e.g.
nitrile gloves
GOGGLES/VISORS


Worn if blood and/or body
fluid contamination to the
eyes/face is anticipated/likely
(always during Aerosol
Generating Procedures
(AGPs).
Regular corrective
/prescription spectacles are
not adequate eye protection
GOWNS (long sleeved)
Worn to protect uniform or
clothes when contamination
is anticipated/likely e.g. when
in direct care contact with a
patient or contaminated
items, waste, laundry or
cleaning etc.
Aprons must be changed
between patients and/or
following completion of a
procedure or task

SURGICAL FACE MASKS
(fluid repellent)

Worn when there is a risk of
extensive splashing of blood
and/or other body fluids e.g.
in the event of a large body
fluid spillage, treating patients
with scabies; and changed
between patients and
immediately after completion
of a procedure
FFP3 RESPIRATOR MASKS
worn if splashing or spraying
of blood, body fluids,
secretions or excretions onto
the respiratory mucosa is
anticipated/likely
 well-fitting and fit for purpose
(fully covering the mouth and
nose)
 manufacturers’ instructions
must be adhered to ensure
the most appropriate
fit/protection;
 removed or changed:
- at the end of a procedure/task
- if the integrity of the mask is
breached, e.g. from moisture
build up after extended use or
from gross contamination with
blood or body fluids; and in
accordance with
manufacturers’ instructions



Are only to be worn following
advice from Infection
Prevention and Control Team
FFP3 face masks must only
be used for specific
situations.
Wearers need to be fit tested
to ensure the face masks fit
the face and offer maximum
protection.
NB fit testing can only be
undertaken by specially
trained personnel (contact
infection Prevention and
Control for details)
NB: All PPE used for patient care delivery must be disposed of correctly as clinical waste
Standard Infection Control Precautions
Page 5 of 16
Version 1.0 December 2015
Footwear must be:

Non-slip, clean and well maintained, and

Support and cover the entire foot to avoid contamination with blood or other
body fluids or potential injury from sharps
The Correct Sequence for Donning (Applying) PPE
Standard Infection Control Precautions
Page 6 of 16
Version 1.0 December 2015
The Correct Sequence for Removing PPE
Standard Infection Control Precautions
Page 7 of 16
Version 1.0 December 2015
Management of Care Equipment
Care equipment can become contaminated with blood, other body fluids, secretions
and excretions and transfer infectious agents during the delivery of care.
Care equipment is classified as either:
Single Use
Single Patient Use
Used once then
discarded. The
packaging carries this
symbol:
For use only on the
same patient this applies
to oral syringes.
Oral syringes must be
labelled with patient
initials and date
decontaminated and
discarded in adherence
with the manufacturers’
instructions
Reusable
(non-invasive
equipment)
Often referred to as
communal equipment reused on more than one
patient. MUST be
decontaminated between
each use e.g. commode.
The Manufacturers’ guidance must be adhered to for use and decontamination of all
care equipment and the guidance must be retained in the clinical area for reference.
(Additional information is also available in the Management of Medical Devices
Policy).
Decontamination of reusable non-invasive care equipment must be
undertaken:

Between each use

After blood or body fluid or other visible contamination

At regular predefined intervals as part of an equipment cleaning protocol

Before disinfection; and

Before inspection, servicing or repair
Cleaning schedules must be held within the clinical area documenting all re-useable
equipment in the area and must include responsibility for; frequency of; and method
(including appropriate cleaning solutions/disinfectants) of equipment
decontamination. The use of signature sheets and application of green ‘I am clean
tape’ is required.
It is the responsibility of the person in charge to ensure that the care area is safe for
practice and this includes environmental cleanliness/maintenance. The person in
charge has the authority to act if this is deficient, by reporting any issues to the
Estates and Facilities help desk immediately. If issues are not rectified within a
reasonable time timeframe then the issue will need to be escalated into management
chain and a DATIX incident report completed.
The care environment must be:

Free from clutter to facilitate effective cleaning, well maintained and in a good
state of repair; and be

Clean and routinely cleaned in accordance with the NHS National Cleaning
Standards for England

Domestic cleaning schedules must be displayed in all clinical areas
Standard Infection Control Precautions
Page 8 of 16
Version 1.0 December 2015
For routine cleaning by facilities staff a fresh solution of surfactant cleaner in warm
water is recommended for routine cleaning (diluted as per manufactures
instructions). This should be changed when dirty, at 15 minutes intervals or when
changing tasks.
For routine cleaning by nursing/clinical staff detergent or disinfection wipes can be
used, following the manufacturers’ instructions.
Disinfection of the environment is not required routinely; however a solution of
1,000ppm available chlorine should be used routinely on sanitary fittings. Staff
groups should be aware of their environmental cleaning schedules and clear on their
specific individual responsibilities. Cleaning protocols should include responsibility for
cleaning; frequency of cleaning; and method of environment decontamination.
Items must be cleaned in line with the manufacturers’ instructions to ensure items are
not damaged by cleaning products.
Cleaning and Maintenance of the Environment
It is the responsibility of the person in charge to ensure that the care area is safe for
practice and this includes environmental cleanliness/maintenance. The person in
charge has the authority to act if this is deficient, by reporting any issues to the
Estates and Facilities help desk immediately. If issues are not rectified within a
reasonable time timeframe then the issue will need to be escalated into management
chain and a DATIX incident report completed.
The care environment must be:

Free from clutter to facilitate effective cleaning, well maintained and in a good
state of repair; and be

Clean and routinely cleaned in accordance with the NHS National Cleaning
Standards for England

Domestic cleaning schedules must be displayed in all clinical areas
For routine cleaning by facilities staff a fresh solution of surfactant cleaner in warm
water is recommended for routine cleaning (diluted as per manufactures
instructions). This should be changed when dirty, at 15 minutes intervals or when
changing tasks.
For routine cleaning by nursing/clinical staff detergent or disinfection wipes can be
used, following the manufacturers’ instructions.
Disinfection of the environment is not required routinely; however a solution of
1,000ppm available chlorine should be used routinely on sanitary fittings. Staff
groups should be aware of their environmental cleaning schedules and clear on their
specific individual responsibilities. Cleaning protocols should include responsibility for
cleaning; frequency of cleaning; and method of environment decontamination.
Items must be cleaned in line with the manufacturers’ instructions to ensure items are
not damaged by cleaning products.
Standard Infection Control Precautions
Page 9 of 16
Version 1.0 December 2015
Safe Management of Linen
The laundry service for the trust is provided by an external company who provide
towels, sheets, blankets, pillow cases and laundry bags, these items are washed at a
central laundry facility.
General Principles – All Types of Linen

All used linen must be placed in an appropriate colour coded bag as detailed in
this procedure

Used linen must always be bagged at the bedside never carried through the
ward to the sluice/dirty utility room or laundry.

Skip/laundry bags must never be more than 2/3 full

Used linen handling must conform to the specifications of CfPP 01-04 as
outlined in this procedure

Staff must ensure they wear personal protective equipment when dealing with
used linen

Staff must always wash their hands after dealing with used linen and/ or after
removing personal protective equipment

Staff must ensure that items such as needles, syringes, instruments and other
foreign objects are not placed in laundry bags

No purchase of washing machines will take place without formal agreement by
the Infection Prevention and Control Team and Facilities Management Team

Only linen items that withstand the intensive laundry process may be purchased

All dirty linen must be sent to the external contractor for laundering as per the
contract

All Trust owned items of linen, including curtains, must be clearly labelled

Breaches to this procedure must be recorded and communicated via the
Incident Reporting process (DATIX)
Standard Infection Control Precautions
Page 10 of 16
Version 1.0 December 2015
Categories of Used/ Soiled Linen:
Category of Linen
Colour of Bag
Comments


Clean Linen


All used linen other than that listed
below falls within this category must be
placed within a white plastic laundry
bag.
 Other than Curtains RTS (return to
sender, Trust own items) and
Rejected items. Bags containing
used laundry must be stored in a
secure area, away from public
access whilst awaiting collection
 NB: Manual soaking/ washing of
soiled items must never be carried
out
 A sluice cycle or cold pre-wash must
be used for all soiled items
Soiled or
Fouled Linen
Infectious or
Heavily Soiled
Linen




Standard Infection Control Precautions
Any linen that has not been used
since it was last laundered
Clean linen must be in a good state
of repair, as tearing or roughness
can damage the patient’s skin
The condition of linen in use should
be monitored by the laundry
contractor and by all staff
NB: If linen is taken into an isolation
room and not used, the linen must
be treated as infected and
laundered prior to further use as it
may be potentially contaminated by
the environment
This is any used linen which is soiled
with blood or any other body fluid; and
all linen used by a patient even with a
known infection
All soiled / infected linen must be
placed in a soluble alginate (RED)
bag, inside the correct laundry bag
The soluble bag must be placed
directly into the washing machine to
minimise contact and prevent
transmission of infection to laundry
staff or contamination of the
environment
The outer plastic bag should be
disposed of as clinical waste
Page 11 of 16
Version 1.0 December 2015
Clean linen must be stored in a clean, appropriately maintained designated area,
preferably an enclosed cupboard. If clean linen is not stored in a cupboard then the
trolley used for storage must be designated for this purpose and completely covered
with an impervious covering that is able to withstand cleaning and/or disinfection.
Clean linen should be kept in the outer packaging until required – (packaging should
not be removed for storage unless it is visibly soiled).
For all used linen (often referred to as soiled linen):

Ensure a laundry receptacle is available as close as possible to the point of use
for immediate linen deposit. A disposable white plastic linen bag is used for this
purpose
Do not:

Rinse, shake or sort linen on removal from beds

Place used linen on the floor or any other surfaces e.g. a chair/table top

Re-handle used linen once bagged, or overfill laundry receptacles
For all foul/infectious linen i.e. linen that has been used by a patient who is known or
suspected to be infectious and/or linen that is contaminated with blood or other body
fluids e.g. faeces:

Place directly into a pink water-soluble/ alginate bag and secure; then place into
a red (or white) coloured linen bag and secure before placing in a laundry
receptacle, or

If the item(s) is grossly soiled and unlikely to be fit for reuse following laundering
then dispose of as healthcare waste (note for patient’s own clothing, permission
will need to be sought). The Facilities Helpdesk should be informed if hospital
linen is discarded

Store all used/infectious linen in a designated, safe, lockable area whilst
awaiting collection. Uplift schedules from used/infectious linen areas must be
acceptable to the care area and there should be no build-up of linen
receptacles/bags
Categories of Soiled Linens
Normal soiled used linen - this accounts for the majority of all used linen and can be
dealt with by:

Being bagged into the approved white plastic/blue linen laundry bags

Where it is to be washed within the unit, it should be placed into a dedicated
container whilst waiting processing (e.g. a laundry basket)
Heavily Soiled / Infected / Infested Linen - this is linen has been soiled by faeces,
blood or other bodily fluid and should include linen from all cases of diarrhoea of
unknown origin. It also includes linen from any patient identified with infection/
infestation.
All soiled /infected linen must be placed in a red soluble alginate bag, inside a plastic
(or linen) laundry bag. The red/pink soluble laundry bag can be placed directly into
the washing machine to minimise contact and prevent transmission of infection to
laundry staff or contamination of the environment.
There are two varieties of soluble bag available:

One which is for use in commercial laundries where water temperatures are
very high – fully dissolvable
Standard Infection Control Precautions
Page 12 of 16
Version 1.0 December 2015


One for use in domestic style washing machines – dissolving seam
Ordering codes are available on the infection prevention and control website
Storage and Collection of Used Laundry - Full used laundry bags should be stored
awaiting collection in a locked area and should be removed from the ward at least
daily.
Laundering processes

Flat Linen (e.g. bed linen, towels, hospital pyjamas etc.) - Laundering of hospital
flat linen should be carried out by a laundry contractor. The Infection Prevention
and Control Team must be consulted on the negotiation of any contract/
specification for laundry services. Laundries chosen must comply with the
requirements of DoH Choice Framework for Local Policy and Procedures 01-04
– Decontamination of linen for health and social care: Guidance for linen
processors implementing BS EN 14065. Compliance should be assured through
a site visit

Patients Personal Linen - All personal items of clothing which cannot be taken
home by visitors/relatives, should be laundered on site

Soiled/ infected /infested personal items should be bagged as above before
being transported to the laundry room. Each person’s items should be bagged
and washed separately on the appropriate cycle

Manual soaking or sluicing of items in bowls or sinks must NEVER be allowed.
This practice causes build-up of organisms in warm stagnant water and then
rubbing or ringing causes splatter to the surrounding areas, spreading
organisms around. If necessary use the pre wash cycle on the washing
machine

Always follow the machines user instructions

Heat resistant items should be washed in the hottest cycle available for the item

A cycle which reaches 71◦C for not less than 3mins or 65◦C for 10 mins.

Heat labile (sensitive) items should be washed in the hottest cycle possible for
the fabric

Laundry washed by patients as part of therapy - It is essential that when
patients are being encouraged to wash their own clothing as part of therapy that
the principles of infection prevention and control are also taught. This is part of
health education but also ensures that daily contact with, and facilities used by
other patients don’t expose them to infection risk.
Patients should be encouraged to; avoid soaking items before washing, avoid
contamination of appliances by soiled items, and to wash their hands following
handling their soiled laundry.


Laundry taken home by Relatives/ Carers - If soiled items are taken home by
relatives for laundering, no pre-washing or soaking of the item must take place
in the clinical area. Wherever possible, used linen should be wrapped in a
plastic bag (not yellow/orange clinical waste bags). If alginate bags are used,
they must be the type with the dissolvable seam as fully soluble bags may
cause blockage in domestic machines.
Staff Uniforms - Uniforms of clinical staff should be changed daily. If uniforms or
personal clothing of staff becomes soiled with blood or bodily fluids they should
be changed immediately, ideally staff should be wearing disposable aprons for
tasks where exposure to bodily fluids is anticipated. If a uniform is contaminated
in this manner then the potential to wash it on-site should be sought, if this is
Standard Infection Control Precautions
Page 13 of 16
Version 1.0 December 2015
not possible it should be placed into an alginate bag (with a seam) and taken
home to wash on the hottest setting for the fabric. It is current Trust policy for
staff to launder uniforms at home and it is recommended that this is done
separately to other household laundry at the hottest temperature for the fabric.
(The RCN says nurses who wash uniform at home are eligible to claim tax
relief. See Uniform Policy)
Management of Blood and Body Fluid Spillages
Spillages of blood and other body fluids are considered hazardous and must be dealt
with immediately by staff trained to undertake this safely. Responsibilities for the
cleaning of blood and body fluid spillages should be clear within each area/care
setting following the procedure below:
Standard Infection Control Precautions
Page 14 of 16
Version 1.0 December 2015
Safe Disposal of Waste
“Health Technical Memorandum 07-01: Safe management of healthcare waste”
contains the regulatory waste management guidance for the NHS in England
including waste classification, segregation, storage, packaging, transport, treatment
and disposal.
Full information on segregation and disposal of waste can be found in the Waste
Management Policy
Where do I go for further advice or information?



Infection Prevention and Control Team
Your Service Manager, Matron, General Manager, Head of Nursing, Group
Director
Your Group Governance Staff
Training
Staff may receive training in relation to this procedure, where it is identified in their
appraisal as part of the specific development needs for their role and responsibilities.
Please refer to the Trust’s Mandatory and Risk Management Training Needs
Analysis for further details on training requirements, target audiences and update
frequencies.
Monitoring / Review of this Procedure
In the event of planned change in the process(es) described within this document or
an incident involving the described process(es) within the review cycle, this SOP will
be reviewed and revised as necessary to maintain its accuracy and effectiveness.
Equality Impact Assessment
Please refer to overarching policy
Data Protection Act and Freedom of Information Act
Please refer to overarching policy
Standard Infection Control Precautions
Page 15 of 16
Version 1.0 December 2015
Standard Operating Procedure Details
Unique Identifier for this SOP is
BCPFT-COI-POL-05-01
State if SOP is New or Revised
New
Policy Category
Control of Infection
Executive Director
whose portfolio this SOP comes under
Policy Lead/Author
Job titles only
Committee/Group Responsible for
Approval of this SOP
Executive Director of Nursing, AHPs and
Governance
Infection Prevention and Control Team
Infection Prevention and Control Committee
Month/year consultation process
completed
November 2015
Month/year SOP was approved
December 2015
Next review due
December 2018
Disclosure Status
‘B’ can be disclosed to patients and the public
Review and Amendment History
Version
Date
Description of Change
1.0
Dec
2015
New Procedure established to supplement Infection Control
Assurance Policy
Standard Infection Control Precautions
Page 16 of 16
Version 1.0 December 2015