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Infection Control Policy Manual for Primary Medical and
Dental Care
Introduction & Framework
Infection Surveillance
Hand Hygiene
Uniforms
Standard Precautions
Management of Sharps
Spillages
Personal Protective Equipment
Clinical Waste
MRSA Screening & Management
C difficile Testing & Management
Legionella Control & Management
Specimens for Clinical Laboratories
Environmental Cleaning & Disinfection
Aseptic Non Touch Technique and Wound Management
Handling & Storage of Vaccines
Dental Decontamination
Staff Health & Immunisation
Invasive Devices
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Introduction & Framework
This Infection Prevention and Control Policy Manual has been developed by the
Infection Prevention and Control team at NHS Somerset as a template document for
clinical and non-clinical staff working within Primary Medical and Dental Practices in
Somerset. A consultation on the contents included staff from Primary Care, Estates,
Public Health, Occupational Health, Microbiology and the local Health Protection Unit
to ensure the information is accurate and reflects current best practice guidance.
This policy manual can be used as a basis upon which practices can build robust
and coherent Infection Prevention and Control systems and its use as a reference
point will support a consistent approach across healthcare settings within the county.
There are hyperlinks provided throughout the manual to direct users towards
relevant national guidance, monitoring and audit tools as well as staff resources and
patient information.
It is intended that this policy manual will be updated as new guidance is published,
and will be reviewed every 3 years to ensure that all advice contained within remains
current and relevant.
The document can be accessed by staff via the NHS Somerset intranet and
internet sites and via the Dental extranet.
It is the aim of an effective Infection Control programme to maintain a consistent
approach to the prevention and control of healthcare associated infections. The
responsibility of the practice is to ensure that an infection control programme is
detailed and carried out by competent, responsible staff, with each staff member
understanding their individual responsibilities. The practice will have in place clear
systems for managing the risk and monitoring for healthcare associated infection
including:
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An identified individual to be the lead for infection prevention and control who
is accountable to the registered provider
Mechanisms by which sufficient resources are made available to prevent and
control infections (such as provision of personal protective equipment,
training, reporting mechanisms, access to expert advice)
Provision of suitable information and training for staff, contractors and other
persons who may directly or indirectly contribute to care delivery on effective
control measures
A programme of audit to ensure key policies and practices are implemented
appropriately
A policy on information sharing when referring, admitting or transferring
service users between different providers of care
A nominated decontamination lead (dentistry only)
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Designated Infection Control Lead
The Infection Control Lead is responsible for the organisation of infection control
management and structure within the practice. This includes:
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the implementation and audit of infection control policies and have the
authority to challenge inappropriate practice
assessing the impact of changes in policy and practice, making
recommendations for change where indicated
know how to contact and liaise with the appropriate Infection Control Team,
Professional Dental Advisor, Consultant for Communicable Disease Control
(Proper Officer) or Health Protection Unit for expert advice and guidance
where required (over a 24 hour period).
production of an annual statement with regard to compliance, areas of good
practice and governance arrangements, which is available on request.
Guidance on content can be found at
www.dh.gov.uk/en/Publichealth/Healthprotection/Healthcareacquiredinfection/
Healthcareacquiredgeneralinformation/DH_4002303
Risk Assessment
The practice will undertake a suitable and sufficient assessment of risks to persons
receiving care. This assessment should include the identified steps taken to reduce
or control these risks. A record should be kept of both the assessment and the
measures to mitigate the risks and their implementation.
The practice will have in place appropriate methods to monitor risks and whether
further measures are required to reduce, prevent or control infection.
Assurance
The practice will demonstrate evidence that appropriate advice has been sought and
action taken to deal with occurrence of infection. This evidence includes the
production of an audit programme and resulting reports on implementation of
policies, as well as production of an annual statement.
Annual Programme
The infection prevention and control programme will:
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Set objectives to ensure the safety of users and staff
Identify priorities for action
Provide evidence of policy implementation
Report progress against the annual statement
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Infection Control Advice
Practice staff can seek advice from any of the following:
NHS Somerset Infection Prevention and Control Team – 01935 384184
Dorset and Somerset Health Protection Unit – 08442 253557
On call Microbiologist or CCDC – 01823 333444 (Via Switchboard)
NHS Somerset Dental Professional Advisor – 07778 879690 or e-mail
[email protected]
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Infection Surveillance
Healthcare Associated Infection Surveillance
Key Points
 Know the Methods of Surveillance
 Know the Alert Organisms
 Know the Alert Conditions
The main objectives of surveillance of healthcare-associated infections are:
 Early detection of outbreaks (where applicable)
 Timely investigation and institution of control measures
 Assessment of infection rates with time (e.g. minor ops)
Surveillance is part of routine infection control activity. It helps to identify risks of
infection and reinforces the need for good practices. Preventing cross transmission
and outbreaks depends on prompt recognition of one or more infections with alert
organisms and instituting special control measures to reduce the risk of spread.
Collection of accurate data allows comparison with other settings and measurement
of response to changes in practice (audit).
Laboratory-based Surveillance (Alert Organisms)
Laboratory-based surveillance is used in conjunction with Alert Condition
surveillance. The system is managed by the Somerset Microbiology department,
Dorset and Somerset Health Protection Unit and Infection Control Teams. Details of
surveillance activities are reported back to the NHS Somerset Infection Control
Assurance Committee by hospital IP&C teams, Health Protection staff and Infection
Control Doctors.
Positive microbiology reports are screened and may result in a case review, a search
for other carriers or infected patients and interventions by a nurse from the Infection
Prevention and Control Team. Approximately 70% of infections and alert organisms
are detected in this way. A patient may be placed in source isolation in hospital if
considered to be a risk of infection to others, or advice will be given to the
management of those within a primary or community care setting by the HPU or
NHS Somerset Infection Control Team.
Examples of Alert Organisms
BACTERIA
Meticillin-resistant Staphylococcus
aureus (MRSA)
VIRUSES
Rotavirus
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Streptococcus pyogenes (Streptococcus
Group A)
Streptococcus agalactiae (Streptococcus
Group B)
Penicillin-resistant Streptococcus
pneumoniae
Haemophilus influenzae
Legionella spp.
Glycopeptide-resistant enterococci
Neisseria spp.
Clostridium spp.
Salmonella or Shigella spp
Escherichia coli O157
Multi-resistant Gram negative bacilli
Panton Valentine Leukocidin producing
Staphylococcus aureus (PVL)
Any unusual bacteria
Respiratory syncytial virus
Varicella zoster
Influenza virus
Rubella
Parvovirus
Measles
Small round structured virus (Norovirus)
Surveillance (Alert Conditions)
Alert conditions are medical syndromes such as chicken pox or diarrhoea which
immediately suggest a risk of infection. It is the responsibility of staff to notify the
infection control team if they suspect an infection which may be a significant risk to
others. Appropriate specimens must be taken and sent promptly, properly labelled,
to the laboratory (For example, the first diarrhoeal stool from a patient must be sent
for exclusion of salmonellosis and Clostridium difficile infection).
Examples of Alert Conditions
Post surgical sepsis
Diarrhoea and/or vomiting
Diarrhoea with blood (dysentery or colitis)
Tuberculosis (chronic productive cough)
Whooping cough
Poliomyelitis
Diphtheria
Scabies
Meningitis
Viral hepatitis
Ophthalmia neonatorum
Pyrexia of unknown origin
Typhoid and paratyphoid fevers
Viral haemorrhagic fever
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Hand Hygiene
Hand hygiene refers to the process for the physical removal of dirt, blood, body fluids
and transient microorganisms from the hands (hand washing) and /or destruction of
microorganisms (hand antisepsis). It is an important measure for preventing the
spread of infection and is the cornerstone of good infection control as direct contact
is one of the main modes of transmission. Even during simple contact, such as
shaking hands or touching a patients face, bacteria and viruses are picked up on the
hands. Correctly performed, hand hygiene will remove transient microorganisms
from the surface of the skin. For routine healthcare interventions it is not necessary
to try and remove the resident bacterial flora, which have a symbiotic protective role.
However, for invasive surgical procedures e.g. vasectomy, more extensive
disinfection of the hands is required to reduce the numbers of resident bacteria
(surgical scrub).
When to Clean Your Hands
The National Patient Safety Agency and World Health Organisations
philosophy of the 5 moments for hand hygiene should be adopted within all
healthcare settings.
Summary of the 5 Moment to Clean Your Hands
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Before patient contact
After patient contact
After contact with blood or body fluids
Before an aseptic task
When leaving the patient environment
Hands should be washed with soap and water on removal of gloves. This will
ensure hands are clean following possible contamination during removal, and also
reduce the risk of healthcare workers developing a latex sensitivity due to the build
up of latex proteins on the skin.
Hand hygiene techniques
Please click the link to access hand hygiene and alcohol rub techniques posters,
which can be printed, laminated and displayed within the healthcare setting.
Hand Hygiene Techniques Poster
5 Moments of Hand Hygiene Poster
Hand Hygiene practice can be audited to inform and improve staff compliance.
5 moments for hand hygiene audit tool
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Use of Alcohol hand rubs
In preparation for healthcare interventions, hand hygiene should be carried out using
a skin disinfectant preferably an alcohol based hand rub. Alcohol (gel /solution) hand
rubs reduce the bacterial and viral load rapidly and are an effective alternative to
handwashing for clean hands. Alcohol based hand rubs have the advantages of
requiring no paper towels for drying, can be performed at the point of patient care,
and are less irritant to hands than soaps. Many products also incorporate a
moisturiser. It is important to allow the alcohol gel to dry naturally to ensure that it
has the full effect.
Alcohol will not remove dirt or kill bacterial spores such as those of C. difficile
so hands that are visibly soiled, potentially grossly contaminated with dirt or organic
material will need to be washed with liquid soap first. A non-medicated liquid soap
removes dirt and transient microorganisms rendering hands socially clean. Alcohol
hand gel can be used thereafter as long as hands remain visibly clean. Hand rubs
are also available in an individual dispenser that can be carried in the pocket or a
belt and are ideal where there is limited access to a sink such as on a domiciliary
visit, although hand rubs are not as effective on viruses such as Norovirus, they may
still be used where there is no access to soap and water.
As may occur with any skin preparation, a small proportion of people can develop
hypersensitivity to alcohol based hand rubs. Affected staff should change to an
alternative product and seek medical advice from Occupational Health or their GP.
Alcohol is flammable and care should be taken to avoid contact with direct heat or
sunlight, especially when it is stored in bulk. As is the case with all disinfectants a
Care of Substances Hazardous to Health (COSHH) assessment must be
undertaken. Keep it out of reach of children who might be tempted to drink it.
Hand hygiene standards
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Cuts and abrasion must be covered with a waterproof dressing
Fingernails should be kept short, clean and free from nail polish, artificial
nails and nail art
Remove wrist watches, jewellery and roll up/remove long sleeved
clothing. Rings (except plain wedding rings) should not be worn during a
clinical session
Before donning gloves, vigorously wash and/or rub all aspects of hands
and wrists using a skin disinfectant or alcohol hand rub (on clean hands)
Ensure hands are washed with soap and water on removal of gloves
Ensure that hands are dried thoroughly to reduce the risk of dry cracked
skin
Moisturise regularly to maintain the skin integrity and moisture levels
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Surgical hand washing (hand antisepsis) is used to destroy transient and
resident microorganisms
Hand antisepsis is indicated prior to some minor surgical procedures, periodontal
and implant surgery and aims to remove transient microorganisms and reduce
resident microorganisms. It requires a more time intensive technique using aqueous
antiseptic or alcohol solution. Hands are washed with antiseptic handwash solution
(Chlorhexidine (Hibiscrub), Povidine-iodine (Betadine) or Triclosan (Aquasept or
equivalent) for 2 minutes. Alternatively use an alcohol hand rub. Two x 5ml
applications of alcohol rub solution can be applied to visibly clean hands that have
been washed with soap and water. Rub hands and wrists using the method
described above until completely dry.
Dedicated Handwashing sink and consumables
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Easily accessible dedicated handwashing sink
Handwashing sinks need to comply with Health Building Note (HBN) 95
and Health Technical Memorandum (HTM) 64
No plugs or overflows
The water jet must not flow directly into the plughole. This reduces the
generation of contaminated aerosols
Sink, taps and tile surrounds should be visibly clean and free of clutter
Be supplied with hot and cold water (preferably with mixer taps to
avoid scalding )
Taps should preferably be automatic/sensor, elbow, wrist or foot
operated to reduce the risk of hand contamination
Liquid soap (dispensed in disposable cartridges rather than refillable
cartridges). Avoid refillable cartridges, which become contaminated with
microorganisms during the 'topping up' process
Soap bars are not suitable for use in the clinical setting as they easily
become colonised with Gram-negative bacteria and Pseudomonas spp.
and can therefore act as a source of cross-infection
Wall mounted disposable paper towels. Reusable towels or air hand
dryers are not suitable for clinical settings as they become readily
contaminated with microorganisms
Nailbrushes are not indicated for hand hygiene in healthcare settings.
If there is a need to clean nails, then a sterile brush should be used on
each occasion, and discarded after use
Please follow the link to the national guidance HTM 64 and HTM 61
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Uniforms
As professionals working in a clinical environment, it is the responsibility of each staff
member to ensure that his/her uniform is worn according to local policy and has a
neat and tidy professional appearance at all times. Those in uniform should wear a
clean one every day.
For clinical staff working out of uniform the following should be considered:
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Keep sleeves rolled above the wrist
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Wear a name badge
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Do not wear a wrist watch or jewellery
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Keep hair neat and tidy; long hair must be tied back
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Keep fingernails short and no false nails or varnish are permitted
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Protective clothing must be worn in accordance with protective clothing
guidelines
Healthcare workers in all settings carry out patient care that involves close or direct
contact with patients and inevitably, contamination of clothing will occur. This may be
visible contamination with body fluids or invisible contamination with microorganisms.
When providing care to a patient it is important, even when wearing a uniform, that
healthcare workers wear the relevant protective clothing if there is a risk of splashing
and contamination.
Preventing tunics and uniforms becoming a source of infection
Tunics and uniforms become contaminated with microorganisms during clinical
treatment. To date no reported dental studies have demonstrated transmission of
infection by this route but in hospital wards multi-drug resistant bacteria have been
transmitted via contaminated uniforms. Gentlemen's ties have been implicated in
transmission of MRSA and ties should not be worn when treating patients or should
be concealed under the tunic /uniform.
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Therefore, it is recommended that tunics /uniforms are washed and
changed daily
That all staff should be bare below the elbow when carrying out clinical
procedures
Click the following link for further information Department of Health Uniform
Guidance 2010
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Standard Precautions
Introduction
All blood and body fluids are potentially infectious and it is not always known whether
a patient has a disease that can be transmitted via blood (WHO, 2003). Body fluids
which contain large numbers of micro-organisms are a major source of pathogens.
Therefore, Standard Precautions, as well as protecting Healthcare Workers from
infection and blood borne viruses, could prevent transmission of many other
pathogens and make a contribution to the reduction of healthcare associated
infections.
Because any patient may carry organisms that could potentially cause infection,
hands must always be decontaminated appropriately and Personal Protective
Equipment should be used. If Standard Precautions are followed effectively patients
and carers will be protected from infection transmission.
United Kingdom Department of Health 1998 Guidelines on Standard
Precautions:
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Cover any cuts and grazes with an impermeable dressing
Wash hands or use an alcohol handrub before and after contact with
each patient and before putting on and removing gloves
Assess risk of accidental contamination with blood and body fluids
Wear appropriate protective clothing where contact with blood can be
anticipated
Change gloves and protective equipment between patients
Avoid sharps injuries by safe use and disposal
Clear up spillages properly (See Spillage Guidelines)
Follow safe procedures for the disposal of contaminated waste
(See Waste Disposal)
The precautions are based on the assumption that all blood and other body fluids,
such as saliva that might contain blood, should be treated as potentially infectious.
Patients with blood borne infections are often asymptomatic or unaware they are
infected.
Standard Precautions apply to contact with:
 Blood
 All body fluids, secretions and excretions (except sweat) regardless of
whether they contain blood
 Non intact skin
 Mucous membranes
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Measures that reduce the exposure of patients, the healthcare team, laboratory staff,
maintenance engineers, waste contractors and the general public to infection
include:
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Safe handling of sharps and needles
Immunisation (against hepatitis B)
Hand hygiene
Use of personal protective equipment (disposable gloves, protective
eyewear, masks, visors, gowns)
Use of rubber dam to minimise blood and saliva splatter (dentistry only)
Rigorous cleaning and sterilisation of instruments and equipment for
reuse and before repair
Zoning of work areas and use of surface disinfection
Decontamination of dental impressions
Prompt cleaning of blood and body fluid spillage with 10,000 ppm
chlorine releasing agent
Safe disposal of clinical and hazardous waste according to national
guidelines
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Management of Sharps
Key points:
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Safe disposal of needles (and scalpels) is the responsibility of the
healthcare worker that has used the items
Never re-sheath or recap needles
When do sharps injuries occur
Sharps and needle stick injuries are relatively uncommon and often only result in
minor injury to the skin, but they are significant due to the risk of transmission of
blood borne viruses infections e.g. hepatitis B, hepatitis C or HIV. Transmission can
occur either from the infected patient to the clinician or from the infected clinician to
the patient.
We know that many staff are reluctant to report sharps injuries so figures may be an
under-estimate of the true number of incidents, the majority of needle stick injuries
are sustained during re-sheathing, dismantling or disposal of the needle. Such
needle stick injuries are considered "avoidable" with good practice and the use of
preventive measures such as safety syringes with retractable sheaves, needle
guards and disposal of items as a single unit will reduce risk. Other high risk
procedures include clearing instruments away between patients and manual
instrument cleaning.
Exposure prone procedures (EPPs)
Assessment of the risk of a sharps injury depends on whether there is a possibility of
unrecognised bleed back into the recipient. Such an occurrence is referred to as an
exposure prone procedure (EPP). The term is applied to those clinical procedures
where the hands or finger tips that may come into contact with sharps (needle tips,
sharp instruments, or sharp tissues such as teeth or bone speckles) are not
completely visible at all times.
EPPs are classified into 3 broad categories based on the degree of visibility of the
hands and the risk of significant sharps injury occurring during the procedure.
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Category 1: Lowest risk of bleed back as the worker's hands are usually
visible, for example giving a local anaesthetic
Category 2: Intermediate risk of bleed back, hands are partially visible but if
bleed back occurs it would be recognised and acted on quickly
Category 3: Greatest risk of significant injury and unrecognised bleed back
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Sharp safe working:
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Avoid passing of sharp instruments from hand to hand during treatment
The same sharp instrument should not be touched by more than one
person at the same time. Place the sharp in a neutral zone in the tray or
bracket table. Alert the other person that you are putting a sharp
instrument into the neutral zone
Do not recap or re-sheath needles
Disposal of used needles (and scalpels) is the responsibility of the
healthcare worker who has used the item
Dispose of sharps (needles and instruments) immediately after end of
use
Use an instrument (mirror/cheek retractor) rather than fingers to retract
tongue and cheeks when using sharp implements. This has the added
advantage of enhancing visibility (dentistry only)
Do not bend needles
Don't leave burs in the handpiece at the end of treatment as they can
catch on skin and clothing. Remove them immediately after finishing
use, then the handpiece can be dismantled from the connector and
cleaned without risk of injury
To protect hands when cleaning instruments wear heavy-duty gloves
and goggles or visors to protect the eyes from splashes
For Further information see Clinical Guidelines 2. Infection control. Prevention of
healthcare -associated infections in primary and community care (CG139). National
Institute for Health and Clinical Excellence (NICE) 2012.
From 2013 there will be new guidance released by the Health and Safety Executive,
following the release of the EU Directive to prevent injuries and infections to
healthcare workers from a sharp object such as a needle stick. For further
information please click the following link. HSE
Disposal:
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Syringe and needle should be disposed of as one unit directly into a
sharps container
Ensure that the sharps bin is correctly assembled and that the lid is
securely fastened before commencing use
Containers should be conveniently placed close to the point of use. Wall
and trolley brackets can be used to ensure that bins are conveniently
located, especially in areas where space is limited
Sharps containers should not be placed on the floor, on an unstable
surface or above shoulder height. They should be inaccessible to
children and unauthorised persons
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Keep the aperture closed when the sharps container is not in use
(temporary closure mechanism)
Containers should be sealed and disposed of when three-quarters full
(do not attempt to press down on container to make more room!)
Never try to retrieve any items from a sharps container
Containers must not be placed into orange bags prior to disposal.
If a sharps container is damaged, place into larger container, lock and
label prior to disposal
The container should be labelled with practice name, address and date
as well as the name of the person who assembled and closed the
sharps bin before disposal
Ensure that sealed bins awaiting collection are housed in a locked area,
which is inaccessible to unauthorised persons
Managing sharps injuries
Immediate action following needle stick /sharps injuries or significant
contamination of eyes or mucous membranes
Sharps injuries are defined as any percutaneous injury or skin puncture involving
sharp instruments (dental bur, syringe needles or suture needles). Advice is
available from the SERCO Needlestick and Contamination Advice Line on
0844 826 0308 or out of hours contact your local Accident and Emergency
Department.
Immediate first aid reporting procedures and further management
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Encourage puncture site to bleed ( do not suck )
Wash site liberally with soap and running water for several minutes. Do
not scrub as this may inoculate virus into the tissues. Cover with
waterproof plaster
If exposed to splash contamination, wash eyes thoroughly with running
water or eye wash solution. Remove contact lens prior to washing eyes
Exposed oral mucous membranes - rinse vigorously with water and spit
out.
Report incident immediately, recheck medical history of patient and
assess for risk behaviours. Promptly contact Health and Wellbeing
Service /Accident and Emergency Department for urgent advice on
requirement for post exposure prophylaxis, information and counselling
Complete an Accident report form
Click the link for the Health Protection Agency Inoculation Injuries Flow Chart
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Assessment of significance of injury - Factors that increase risk of
transmission of blood borne viruses
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Type of exposure? E.g. percutaneous (punctured the skin), exposure of
broken skin or exposure of mucous membrane including the eye
(splash)?
Depth of the injury?
Device contaminated with blood?
Had the needle been in the patient's blood vessel?
Terminal HIV related illness in the source patient?
Source patient has high viral load for any of the blood borne viruses?
The answers you give will aid the risk assessment of the injury and inform the
decision on whether to administer HIV prophylaxis or if a booster immunisation of
hepatitis B or immunoglobulin is required. In order to be able to answer these
questions you may need to recheck the patient's medical history or ask additional
specific questions (see below).
Assessment of patient's risk factors
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Has the patient ever had HCV, HBV or HIV infection?
Ever had unprotected sexual intercourse between men?
Had unprotected heterosexual sex with a person who had been exposed
in a country where transmission of HIV through sexual intercourse is
common, e.g. Sub-Saharan Africa, India
Shared injecting equipment when using recreational drugs?
Received a blood transfusion in the UK before 1991 (blood screening
started in 1991 for hepatitis C) or plasma products before 1985, or
received a blood transfusion in a country were heterosexual
transmission of HIV through sexual intercourse is common
If the injury occurred on an instrument that was contaminated with blood from a
known/identifiable patient, then a staff member (preferably not the exposed person)
should explain about the incident and why the additional enquires and blood tests
are being sought. In the majority of cases you will have to arrange for the patients
GP to take the blood sample. The GP or Health and Wellbeing Service will organise
for the patient to receive a pre-test discussion and to give informed consent for a
blood sample to be taken for HIV, HBV, HCV testing. For further information please
click the following link. SERCO
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Recording of sharps injuries
All sharps injuries and significant splashes however minor must be recorded in an
"accident book". In order to comply with Data Protection Regulations 1998 accidents
must be recorded on separate forms. These forms have an identification system,
which allows for a chronological record keeping. Once completed, they must be
stored securely and in such a way that the confidentiality of the person concerned is
protected. They must be kept for a minimum of three years.
In the event of a significant occupational exposure to HIV infection or hepatitis B/C
you may have to report the incident to RIDDOR as a "dangerous occurrence" or if
HIV infection occurs as a "disease ". (See www.riddor.gov.uk ).
Clinical governance and accident risk assessment
Reviewing your clinical procedures and undertaking risk assessments is an
important component of clinical governance and the learning from such incidents
informs future training requirements. It is important that the healthcare manager
creates an environment where his/her team members feel confident to inform them
that something might or has gone wrong. The circumstances that lead up to an
adverse incident should be identified and steps taken to prevent a recurrence.
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Spillages
Key Points
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All spillages must be cleaned up promptly
Clearly define Nurse / Cleaning staff responsibilities
Proper protective clothing should be worn
Specific action depends on the nature of the spillage
Warning about dangers of chlorine
Separate arrangements for mercury spillages
Introduction
For the purpose of this policy a spillage is defined as a leak or spill of blood or other
body fluid from a patient, equipment, specimen, container or cadaver. All spillages
present a potential infection hazard so they must be dealt with promptly.
Cleaning of Spillages
Responsibility for spillage cleaning:
Co-operation and flexibility between groups of staff in the removal of spillages is
essential. However, the following staff should be responsible for spillage clearance in
these areas:
 Nursing Staff: clinical areas, clinics and patient treatment areas
 Cleaning staff or Non-nursing: all of the healthcare settings corridors
and public areas
Equipment Required:
 Disposable cloths and towels or incontinence pads
 Yellow plastic sack
 Appropriate chemical disinfectant
 For all BLOOD spills, (and any spillage from a patient suspected of
being infected by HIV, HCV or HBV), a Chlorine Releasing Agent
*Chlorine fumes will be released when Chlorine-releasing (e.g. Haztab, or
Presept) granules are used so ensure the area is well ventilated. If possible,
stay away from the spillage while the disinfectant is acting. Do not put granules
on urine spills until they have been mopped up.
Action Required:
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Move patients and other workers away from the spillage while using a
Chlorine Releasing Agent
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Don protective clothing before handling the spillage and chemical
disinfectant; use domestic gloves
Cover the spillage with the appropriate disinfectant; leave to act for a
minimum of 5 minutes
Mop up the spillage using disposable cloths or wipes until the area is
visibly clean
Dispose of wipes and protective clothing in yellow plastic sack; seal
sack; label with biohazard tape if appropriate and send for incineration
Wash and dry hands thoroughly
Ensure a "spot" clean of the area with general purpose detergent
Note that chlorine solutions tend to leave floors slightly sticky or slippery
Ensure there is a warning sign is in place when the floor is wet
Carpets
Clean up spillage as far as possible using paper towels. Arrange to steam clean
carpet as soon as possible. Move patients away from the area. (Chlorine releasing
preparations will bleach carpets).
Accidents or Incidents
If an accident (e.g. cut) occurs whilst dealing with the spillage, follow the SHARPS
policy: Ensure that First Aid is received locally. Complete an incident form and report
the incident to your manager.
19
Personal Protective Equipment
Background
Personal protective equipment (PPE) such as protective clothing, eyewear and
disposable gloves are worn as a barrier to prevent the transmission of
microorganisms between patients and the healthcare team. The type of protective
clothing required will depend upon the potential risks associated with the planned
task. Legally it is the health care worker's responsibility to assess this risk and decide
upon the necessary clothing as appropriate. However, the employer must ensure
suitable PPE is freely and readily available for use.
Plastic Aprons
Clear plastic aprons may be worn to protect the carers clothing from moisture,
splashing or soiling. Aprons used for these purposes must be discarded after contact
with each patient.
Aprons must be removed and discarded appropriately. Aprons used for healthcare
interventions or that have been contaminated with blood or body fluids should be
discarded immediately into an orange clinical waste bag.
Face Protection
Goggles and visors must be worn to prevent splashing of body fluids into the eye
when performing risky procedures. The healthcare team must protect their eyes and
those of the patient against splatter, aerosols and foreign bodies such as amalgam
fragments.



Goggles or visors should be worn during all types of healthcare
treatment where there is a risk of splashing of blood or body fluids or
when manually cleaning instruments prior to sterilisation
Choose goggles or protective glasses with side protection that conform
to standard BS EN 166:1988
Goggles should be decontaminated according to the manufacturer's
instructions e.g. alcohol based surface disinfectant or hypochlorite 1000
ppm available chlorine followed by thorough rinsing in water
Masks
Waterproof surgical masks may be considered if there is a risk of splashing during a
procedure.
Masks are recommended for all dental procedures
20





Masks are single use items. They should be changed after every
patient and not reused
Try to avoid touching the outer surface of the mask, which may be
contaminated
Remove the mask by breaking, undoing the straps or lifting over the
ears
Mask should be disposed of as hazardous clinical waste
Clean your hands after removing the mask in order to prevent
contamination of your face and the surgery environment
Respirator type masks
Respirator type masks offer a higher degree of personal respiratory protection
compared to a standard facemask. They filter out airborne particles as the air is
breathed in through the mask. However, they are not intended to filter out gases.
Such masks are recommended for healthcare workers for use whilst treating patients
with tuberculosis or other infections that are spread via aerosols e.g. influenza.
In appearance they resemble moulded surgical facemasks. They are made to
defined national standards, which differ between the USA and Europe. Only
respirators with CE markings that conform to the European standard EN149: 2001
should be worn. The standards define the performance parameters of the respirator
mask including filtration efficiency. The European Standard EN149: 2001 FFP2 (94%
filtering efficiency) and the approximately equivalent USA type N95 respirator (filters
at least 95% of airborne particles) is recommended for use with patients with active
tuberculosis and respiratory viral infections.




When fitted and worn correctly, they seal firmly to the face thus reducing
the risk of leakage
Beards and stubble interfere with the fit and seal of the respirator
Instructions for fitting and the leak tests to be carried out by the wearer
differ slightly with each product and are supplied by the manufacturer
Avoid touching the outer surface of the respirator mask once it is fitted.
Always wash hands after handling the mask
Masks with higher filtering efficiency are recommended by the Health Protection
Agency (European Standard EN149: 2001 FFP3 [98% filtering efficiency]) for
suspected or probable cases of avian flu. (http://www.hpa.org.uk/infections/topics)
but are only for use following advice by the Health Protection Unit or the Infection
Prevention and Control Teams. These are generally only advocated whilst
performing aerosolisation producing procedures (i.e suctioning of oral
secretions or where a cough is likely to be induced.)
21
The Role of Gloves: 



To provide a barrier to protect the wearer from contamination with bodily
fluids
To reduce the risk of transmission of microbes from healthcare worker to
patient
Gloves should be worn for all routine healthcare interventions where
there is a risk of contamination and discarded between patients
Gloves do not prevent sharps injuries but the wiping effect of the glove
reduces the risk of contamination
Safe use of gloves in the healthcare setting:






Hands must be washed before donning gloves. Never consider gloves
to be an alternative to hand washing
Never re-use single use disposable gloves
Changing your gloves between patients prevents cross infection
between patients and contamination of hard surfaces in the healthcare
setting.
Gloves must only be worn whilst treating the patient and removed at the
end of the procedure. Dispose of as hazardous waste. Remember
hands are not necessarily clean because gloves have been worn. When
removing gloves the patient's microorganisms can be transmitted from
the external surface of the glove to the healthcare workers hands and
need to be removed by hand hygiene
Regular changing of gloves can prevent excess sweating and this
reduces the risk of dermal infections or inflammation
It is advised that all healthcare settings move to latex free products to
reduce the risk to staff and patients suffering latex allergies
Choosing a suitable glove for the task





Use non-sterile gloves for routine healthcare interventions
Use sterile surgical gloves for some minor and oral surgery, periodontal
work, wound dressings, catheterisation and implant procedures
Gloves should be powder-free and have the lowest levels possible of
extractable proteins and chemical accelerators (the recommended
levels are < 50 m g/g of latex proteins and levels of < 0.1%w/w for
residual accelerators)
Always choose a glove that fits you correctly.
Do not use disposable clinical gloves for scrubbing
instruments. To help protect the hands from sharps injuries use heavy
duty, lined household gloves for washing instruments and general
22
environmental cleaning. These gloves are reusable, wash whilst on the
hands and dry. They need to be checked regularly for small tears, and
discarded accordingly
If you develop an allergy to Natural Rubber Latex (NRL) gloves
Reports of latex sensitivity amongst health care workers (and patients) have risen to
6-18% paralleling the increased clinical use of latex gloves. Sensitivity is particularly
common amongst healthcare staff, and can develop even after successfully wearing
NRL gloves for many years. Sensitivity occurs via inhalation of airborne antigens or
through damaged skin. The risk of allergic reactions is triggered not only by latex
gloves but also by other latex containing devices e.g. rubber dam, syringe and
medication vial bungs, prophylaxis cups, orthodontic elastics etc.
Alternative to NRL gloves that have similar physical properties, i.e. do not impair
dexterity and are not prone to splitting and are impermeable to blood borne viruses
include:


Nitrile (acylonitrile) /polychloroprene (Neoprene)
Tactylon (multipolymer synthetic styrene-ethylene-butadine-styrene)
Staff sensitised to natural rubber latex (NRL) gloves must be supplied with
appropriate alternatives by the employer.
All staff should be trained to recognise the symptoms both in themselves and
patients so that they can avoid the use of latex gloves and devices.
23
Clinical Waste
Disposal of Waste and Sharps
Key Points





All clinical waste must go in a orange waste sack
The household waste must go in black bags
Ensure that all hazardous or medicine waste are disposed of in the
appropriate colour bags for your waste contractor
Waste bags must not be overfilled
Bags are tied securely and labelled with the postcode of the healthcare setting
for traceability
Responsibility
The person -charge of any clinical area is responsible for making sure that the
following policies are enacted.
Bag / Waste Colour Codes
Display the colour coding chart for waste disposal in a prominent place and on sackholder lids.
Do not tie up bags, use label ties which indicate source of the waste.
Black: Domestic waste (not infected or contaminated)
Orange: Clinical/offensive or infected waste
Waste



Dispose of waste in the clinical area according to the colour code
Do not use orange bags for non healthcare intervention generated domestic
waste
They are expensive and need to be incinerated
Disposal of Sharps



All sharp instruments, blades, knifes, needles and glass ampoules must be
discarded in the approved Sharps containers supplied
It is sensible to take a Sharps bin to the patient when an invasive procedure
(e.g. phlebotomy) is being undertaken
Do not carry used Sharps around in receivers
24







Used needles must not be re-sheathed; they must not be left for others to
clear up
Sharps boxes should be attached to the dressing trolleys or to the wall
They must not be left on the floor where they are a risk to inquisitive children
Do not overfill Sharps bins; seal and put them out for collection when threequarters full. Write on the box the source healthcare setting, date and the
name of the person who assembled and sealed the box
Larger broken glass items should be discarded into a labelled cardboard box
Healthcare setting labels or clips should be available to stick onto or to seal
plastic bags, and to Sharps Bins so that the source can be identified if there is
any problem about contents
Do NOT put sharps of any kind or glass into plastic bags. If you do this, you
are putting yourself and others at risk
25
MRSA Screening & Management
Key Points




Use diligent hand hygiene to prevent the spread of MRSA
Patients are routinely screened on emergency/elective admission to hospital
Post discharge screening maybe required as a continuation of the MRSA care
pathway
Where patients are confirmed as positive to carriage of MRSA, decolinsation
is attempted in accordance with national guidance
Introduction
MRSA stands for Meticillin Resistant Staphylococcus aureus. It is a variety of a
common germ called Staphylococcus aureus. Staphylococcus aureus (S aureus) live
completely harmlessly on the skin and in the nose of about one third of the
population. It is more common on skin that is broken – such as a cut, a sore, or a
rash such as eczema. Occasionally in severe cases patients may die from
overwhelming sepsis due to Staph aureus, when it has entered the blood stream and
causes a systemic infection. The most likely mode of spread is by indirect contact via
a staff member acting as a transient carrier of Staph aureus on the hands,
transferring the organism from one patient to another. Many more patients and staff
are colonised with Staph aureus than have overt infections. Hand carriage of MRSA
is temporary and easily removed by carrying out effective hand hygiene. It is
possible for staff, patients or visitors transmit the organism to susceptible patients
without being aware that they are carriers. Therefore, meticulous hand hygiene
before patient contact is essential to prevent transmission.
A patient with MRSA will be identified in the laboratory because a specimen (often a
wound swab) has been sent from the healthcare setting. The healthcare setting and
medical staff will be notified of the results by the Infection Control Team.
Limiting the impact of MRSA and other resistant organisms in the healthcare
environment
Each member of the Health Care Team is responsible for protecting patients from
infection by:

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


Clear guidance to all staff on the principles of control of cross infection
Inform patient of objectives
Use Patient Information Leaflets (PILs)
Alcohol gel at each point of care
Keep handwashing areas clean and keep solutions topped up
26





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

Place waste disposal receptacles for gloves and aprons in convenient
sites to prevent staff from having to walk around wearing or carrying
used PPE
Treatment preparation areas and trolleys for aseptic techniques to be
kept clean and wiped with 70% isopropyl alcohol before tasks
Good communications with domestic staff to facilitate schedules and
spot cleaning
A thorough cleaning regime
Establish cleaning regimens for large pieces of clinical equipment such
as BP machines, ECG Machines and other commonly used items
Keep treatment rooms and storage racks and cupboards clean and tidy,
do not overstock items
Keep sluice and dirty areas clean and tidy
Keep treatment/decontamination areas and notes clean and tidy
Screening Patients for MRSA
Screening for MRSA is not 100% sensitive. A carrier may have undetectably low
carriage which manifests itself only after antibiotic treatment or stress such as
surgery. It is, however, considered worth screening before major surgery in order to
be able direct chemoprophylaxis and therapy for post operative infection. Some
patients may be colonised and be unaware of this, which is why it important to use
standard precautions.
NOTE: Screening will not detect all carriers of MRSA
How do I screen a patient for MRSA?

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
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
Take swabs from nose only; moisten swabs with transport medium;
swab nose (one swab to both nostrils)
Send with one request form which states "MRSA NOSE SCREEN"
Swab any WOUNDS AND LESIONS; send with a separate Request
Form requesting "culture and sensitivity"; (these will be processed for
any significant bacteria)
Other sites may be screened for study purposes including or indwelling
devices
Screening must not be done while the patient is on a 'MRSA Topical
Decolonisation Protocol'
Repeat screening of nose and wounds is only done after attempted
MRSA decontamination (no sooner than 48 hours after stopping the
protocol), otherwise, it should be assumed that a patient colonised
MRSA remains so for the duration of an admission
Repeat screening of MRSA patients should be 7 days apart on patients
who are not currently receiving the topical decolonisation therapy
Three consecutive sets of negative screens would imply that the patient
may have cleared the organism
27
Management of Patients found to have MRSA
What if a patient is found to be colonised MRSA?


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
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General Practitioners will be advised to prescribe and course of topical
decolonisation therapy if a patient is wound/urine/indwelling device
positive or if the screen was taken pre operatively. This course should
continue for a 5 day period. 2 days without any topical decolonisation,
then the patient should be re screened on day 8 of the regime
Patient information leaflets and topical decolonisation therapy charts can
be found by clicking the following links
o Wound positive Topical decolonisation Therapy Chart
o Urine Positive Topical decolonisation Therapy Chart
o MRSA Patient Information Leaflet
Remember the importance of regular hand hygiene in preventing
infection
Use alcohol gel (or alcoholic chlorhexidine hand rub), or perform hand
washing before and after attending to the patient
Wear an apron if there is a likelihood of clothing / uniform becoming
contaminated by a procedure
Wear gloves if there is a risk of hands becoming contaminated by the
procedure
There should only be three attempts at topical decolonisation therapy
(unless otherwise advised by microbiology Consultant or Infection
Prevention and Control Nurse) to reduce the risk of Mupirocin resistance
Staff found to have MRSA
Each member of the Healthcare Team is responsible for protecting patients from
infection by:



Healthcare staff with skin conditions such as psoriasis, eczema or
dermatitis should not look after these patients. They should discuss the
risks of working in a clinical environment with SERCO
Screening for staff should not be undertaken without the instruction from
the Consultant Microbiologist, and involves taking proper specimens
from the nose and any wounds or skin. Members of staff are advised not
to screen themselves for MRSA without the knowledge of ICN or
Somerset Health and Wellbeing Service
On any request form, please state the area in which the staff member is
currently working. Results will be confidential and returned to Somerset
Health and Wellbeing Service
28



Staff members will be given a prescription for the preparations as per
guidance and follow the MRSA Topical Decolonisation Protocol
Staff should not stay away from work during this time but nasal carriers
with colds will be more likely to shed bacteria and should stay away from
clinical areas until the cold is better
The decontamination protocol is to be followed for 5 days, and then staff
will be re-screened at least 2 days after stopping all treatment and then
twice more at weekly intervals. If carriers remain positive after following
the protocol, special advice will be given depending on sites of
persistent carriage
MRSA topical decolonisation therapy charts
For wound positive patients
For urine positive patients
Cleaning Procedures
How do I clean the room after a patient colonised with MRSA has left?

Once a patient with MRSA leaves the room, ensure you clean the
treatment couch and/or chair with general detergent product and water.
Outbreaks of MRSA
Two or more cases in a residential setting where MRSA is unusual or with an
unusual strain constitutes an outbreak so patient and staff screening may be
required, advice will be given by the Infection Prevention and Control Nurse, Health
Protection Unit or the Infection Control Doctor.
For further information on Panton Valentine Leukocidin Producing toxin please click
on the following link Information on PVL (Panton Valentine Leukocidin)
For further information on the topical antimicrobial wound dressings please click the
following link. Antimicrobial wound dressing Policy
29
Clostridium difficile Management
Key Points




Clostridium difficile is an infection often brought on following several courses
of antibiotics
C. difficile can be found within healthcare settings and also within the
community
Risk factors include courses of antibiotics, age, immunosuppression, proton
pump inhibitors, frequent admissions to hospital
All patients with diarrhoea should be nurse in Source Isolation
For further information on the management of a patient with C.difficile please click
the following link
Investigation and Management of Clostridium difficile in Primary Care
Clostridium difficile (C. difficile) is a spore-forming anaerobic bacterium acquired by
the ingestion of spores after contact with the contaminated environment, other
patients or the hands of staff. C.difficile is found both within healthcare settings and
within the community. Some strains produce toxins. C. difficile disease is associated
with the use of antibiotics which may result in disruption of the "normal bowel flora".
C. difficile acquisition may result in asymptomatic carriage, loose stools or profuse
diarrhoea which can result in life-threatening pseudo-membranous
colitis. C. difficile infections are most common in people over the age of 65 years but
any age group may be susceptible.
Antibiotics Likely To Increase Risk of Clostridium difficile
High Risk
Cephalosporins
Quinolones
Clindamycin
Medium Risk
Low Risk
Amoxicillin
Co-amoxiclav
Tazobactam with
piperacillin
Clarithromycin
Meropenem
Gentamicin
Penicillin
Doxycycline
Metronidazole
Trimethoprim
Vancomycin
Control of C.difficile infection focuses on:





Isolation of patients who have symptoms of infection
Handwashing with soap and water to decontaminate hands
Adherence to antibiotic prescribing policies
Keeping the environment clean
Ensuring compliance with all aspects of the policy and associated
guidance
30
Diagnosis of Clostridium difficile
Infection with C.difficile is now routinely diagnosed by detection through Glutamate
dehydrogenase enzyme immunoassays (GDH) followed by Toxin enzyme
immunoassays (EIA) testing of a stool specimen. This two stage test is as per
National Guidance published by the Health Protection Agency 2012. Loose stools
from patients over 65 years will be tested for C. difficile toxins (CDT) routinely as part
of the National Healthcare Associated Infection Surveillance programme. In all other
patients, specimens of diarrhoeal stool will only be tested if specifically requested.
Stools from children below 1 year are not normally tested for this organism.
C.difficile toxin tests should be requested in patients with diarrhoea in the following
situations:




The patient is on or has been on antibiotics in the past 6 weeks
There is severe diarrhoea, fever, bloody stools or severe abdominal
cramps
When previous cultures of stools are negative, but symptoms persist.
The patient developed diarrhoea whilst there was an existing case
nearby
Clearance and repeat specimens
There is no need to send further specimens once C. difficile has been
diagnosed.
Surveillance for Clostridium difficile
C.difficile constitutes part of the mandatory surveillance for healthcare associated
infection. As such, each case is reported nationally and objectives are in place to
reduce the numbers of patients contracting this infection. Advice is provided directly
to primary care practitioners when a patient is identified as C.diff positive, and a
primary care management protocol and patient information leaflet provided by the
Infection Prevention and Control team.
Root cause analysis is undertaken for each case to determine the appropriateness of
previous antibiotic therapy, opportunities to avoid infection and to inform future
clinical practice.
31
Patient Management
Following identification of C. difficile infection the following infection control measures
must be implemented:


Immediate isolation of the patient in a single room (if care home
resident). An en-suite bathroom is preferable. Patients who do not have
access to en-suite facilities must have a commode dedicated for their
use
Patients should be provided with an information leaflet on C. difficile
Clinical patient management
For information on the management of patients with C.diff infection in a primary care
setting please click the link to the NHS Somerset protocol

Patients who develop diarrhoea following a period of being symptom
free may have been re-infected or relapsed. These patients must be
isolated immediately. There is no need to send a further stool specimen
as the bowel can remain colonised with C.difficile for up to 6 months
To review the NHS Somerset prescribing formulary please click the link
The Bristol stool chart can be found at
http://www.nursingtimes.net/Journals/1/Files/2009/3/31/Stool%20Chart%20O4.pdf
For further information on the management of C.difficile please click the following
Department of Health C diff how to deal with the problem (2008)
32
Legionella Control and Management
Key Points

Legionellosis is transmitted by inhalation of contaminated water when fine
droplets are created in respirable water spray or aerosols (3 micron)

Legionellosis can colonise in water storage tanks, hot water cylinders,
pipe work and certain materials used incorrectly in plumbing can favour
growth

Legionellosis may be found in large industrial cooling towers if not
correctly treated

Legionella bacteria are common in natural water courses such as rivers
and ponds. It may contaminate and grow in other water systems such as
water cooling towers and hot and cold water systems. They survive in low
temperatures, thrive at temperatures between 20⁰ to 45⁰C if conditions are
right, supply of nutrients to aid growth. High temperature kills Legionella
bacteria
Introduction
“Legionnaires’’ disease is a potentially fatal form of pneumonia which can affect
anybody, but which principally affects those who are susceptible because of age,
illness, immunosuppression, smoking etc.
The first recorded outbreak was at the Bellevue Stratford Hotel, Philadelphia in 1976
at an American Legion Convention. 29 died attending the conference and 5 died
who were in the vicinity of the hotel. The main source of the outbreak was identified
as the water cooling tower, part of the air conditioning system.
The number of individuals being reported as having legionellosis has shown an
increase year on year, for example between 200-300 cases in 2005, between 3,200
– 4,800 cases in 2009, fatality rate of 10 – 14%. Transmission is by the inhalation of
contaminated water droplets and is, therefore, only likely to occur when clouds of
fine droplets and particles are created, for example in respirable water sprays or
aerosols. However larger droplets of contaminated water may be reduced by
contact with hard surfaces, for example sanitary fitments, or by evaporation to a size
small enough to breathe in. Equipment perceived to be of high risk are:







shower heads
spray taps on basins
cold water services/pipe work and tanks
hot water services/pipe work and storage cylinders
spa baths and pools
water systems incorporating cooling towers
dental equipment, due to aerosols
33

any system which produces aerosols that may exceed a temperature of
20⁰C
Certain groups of people are known to be at a higher risk of contracting
legionnaire’s disease, for example males appear to be more susceptible than
females, as do those who are over 45 years of age, smokers, diabetics or those with
cancer or chronic respiratory or kidney disease. Incubation period is between 2 –
10 days (usually 3 – 6). There is no evidence of person to person spread.
Sampling for legionella and testing for the presence of legionella bacteria is not
usual. However, if a new building/extension is completed initial testing is
recommended.
Testing is also recommended in areas where patients with high risk, for example
cancer or chronic respiratory disease or kidney disease are treated.
Duties under the Health & Safety at Work Act extend to risks from Legionella
bacteria, which may arise from work activities as they affect staff, patients or
members of the public. All properties, including healthcare settings, have a duty of
care and responsibility to control the risk of legionella in their water systems. These
are covered in the Statutory Documentation:





Health & Safety at Work Act 1974
Control of Substances Hazardous to Health (COSHH)
Health & Safety Approved Code of Practice and Guidance L8 Control of
legionella bacteria in Water Systems
Water Supply/Water Fittings Regulation 1999
The Notification of Cooling Towers and Evaporative Condensers
Regulations 1992
Plus other non-statutory documents (Guidance)



Health Technical Memorandum 04-01 – NHS Codes of Practice
Water Regulations Guidance
Primary Care Trust’s Legionella Policy
Managing the Risk





Each site needs to appoint an individual to take responsibility for
managing the scheme you have in place
If you employ 5 or more people you must have a risk assessment of the
cold and hot water installation
If you employ contractors to work on your system you must ensure they
are competent and aware of the issues when dealing with this service
Water should be stored and circulated at the correct temperatures
All maintenance work carried out both to the water services or local air
conditioning units should be recorded
34





All outlets which are used infrequently must be flushed three times a week
and recorded for inspection. Records to be retained for 5 years
Water outlets which are not used regularly should be considered for
removal
Equipment which has aerosols should be considered as high risk and
managed accordingly, for example dental equipment
Ensure equipment which uses water is changed regularly and the correct
‘distilled water’ is used in equipment, for example sterilisers
All paperwork is retained in appropriate place for inspection
For further information on Legionella please follow the following links
http://www.hse.gov.uk/legionnaires/
Legionaries disease a guide for employers
Legionnaires' disease. The control of Legionella bacteria in water systems.
Approved Code of Practice and guidance
Essential information for providers of residential accommodation
35
Specimens for Clinical Laboratories
Key Points






Ensure all specimens are labelled correctly
The freshness of the specimen determines its usefulness, so get all
specimens to the laboratory as soon as possible
All specimens are potentially dangerous so should be bagged and must be
transferred to laboratories in proper rigid containers
Contaminated and unlabelled specimens will be discarded
Label specimens 'HIGH RISK' when appropriate
Ensure that legible clinical details are including antibiotics taken on all
microbiology specimens
Quality
The usefulness of a specimen collected for laboratory investigation depends on the
appropriateness of the specimen and the time it takes to reach the laboratory.
Members of staff in the laboratories are always happy to give advice about
specimens required for investigations and once taken every effort must be made to
ensure that the specimen reaches the appropriate laboratory as soon as possible.
UNLABELLED SPECIMENS WILL NOT BE PROCESSED.
SPECIMENS SHOULD BE LABELLED WITH THE PATIENT'S NAME
IMMEDIATELY AFTER THEY HAVE BEEN TAKEN.
Specimens must be sent in a plastic bag, preferably with the request form attached
and should be transported in a rigid container. There are strict regulations about the
packing of specimens for postage so this must be done in the laboratory. The
request forms at Musgrove Park Hospital carry an integral plastic bag designed to
contain the specimen safely. Please use only these forms and follow the sealing
instructions carefully. Make sure that no request form is ever in contact with a
specimen and that only the specimens appropriate to that patient are placed into the
bag. Do not use pins or staples to hold forms together.
All the relevant information requested on the forms must be given to ensure
specimens are correctly processed.
Infection Hazards
All samples in all laboratories are treated as containing virulent organisms.
Specimens from patients known to have blood borne virus infections must be
labelled "High Risk" (Guidance in "HIV and the Practice of Pathology". Royal College
of Pathologists, 1995). It is most important that specimens are transported safely.
Lids should be firmly tightened. Ensure that forms are completed appropriately and
36
place the specimen in the plastic wallet attached to the form. All leaking or
contaminated or broken specimens will be discarded. The greatest danger of
infection to laboratory staff comes from the specimens. This danger stems largely
from specimens that have had clinical material spilt on the outside of the container,
which may have been wiped "socially" clean. This may remove evidence of
contamination but does not remove the risk of infection. When clinical material
contaminates the outside of a specimen container, the specimen should be
discarded on the ward. Inevitably occasional specimen containers will leak. They
should not be sent to the laboratory as this may lead to contamination. Leaking
specimens that arrive in the laboratory, except in very exceptional circumstances,
will always be discarded without immediate consultation. Further specimens will be
requested, but this will result in a delay for the patient.
Haematology and Biochemistry
Specimens for haematological and biochemical investigations will be almost
exclusively blood specimens.
Bacteriology
Specimens for bacteriological investigations must be adequate. Delays in reaching
the laboratory may result in death of some organisms or multiplication of others so
that the number found in the specimen is meaningless. This is particularly important
for urine specimens.
When aspirated pus, body fluids or faeces are available, do not use swabs. It is
always better to send the original specimen in a sterile pot.
Always place a swab in appropriate transport medium. The transport media for
bacteria and viruses is different. When in doubt about which to use, please consult
the laboratory.
Virology
Specimens for Virology fall into three types:


Culture and isolation of viruses: Special viral transport medium (VTM) is
available. This preserves the viability of viruses but contains antibiotics to kill
bacteria and fungi. VTM is useful for sensitive enveloped viruses (e.g. herpes
viruses) but not necessary for enteroviruses in stools, which can be sent
untreated
Antigenic and morphological identification of viruses: Clotted blood
samples, faecal samples, fluids from ulcers or vesicles are required. Please
consult the laboratory
37

Serology: Serum samples (clotted blood) are required. Please use the
correct request forms and send one form for each request. The serum sample
will be divided in the laboratory
Summary









Always get specimens to the laboratory as soon as possible after
collection
When delay is unavoidable, urine and sputum specimens must be
refrigerated at 4o C
Swabs for gonorrhoea must NOT be refrigerated
Always use the correct transport medium
Never use a swab when faeces, fluids or pus is available
Use only the correct request forms with an integral specimen bag or
place the specimen in a separate plastic bag. Place only one specimen
in each, and please complete the request form or computer entry fully
Never send leaking specimens anywhere. Discard them
Never wipe clinical material from the outside of a specimen container
and then send it to the laboratory
Whenever you wish to collect an unusual specimen, or you have a query
about safety or you need advice, please consult the laboratory staff
Health and Safety





Do not overfill containers
Throw out contaminated containers
Transport in plastic bags
NO NEEDLES OR SYRINGES PLEASE
Ensure "HIGH RISK SPECIMENS" are labelled as such
How to take specimens
For laboratory guidance on how to take specimens please click the following
links
Swabs
Urine
Chlamydia
Availability of Microbiology Results

Day of receipt: Microscopy results and some antigen or antibody tests
38





After overnight incubation and reading time: First day culture results,
printed and sent to requesting departments. Telephoned results
normally available after 10.30am
Second day: Identification of organisms and antibiotic sensitivities from
first day isolates. Anaerobic culture results, first reading
Third to tenth day: further reports may follow especially for anaerobes
and fungi
Mycobacterial cultures are continued for 8 or sometimes 12 weeks.
Positive results are always telephoned
The following results will be telephoned directly to the requesting or duty
doctor:
o Virulent organisms (e.g. Streptococcus pyogenes)
o Any positive culture from a normally sterile site (Blood, CSF, etc)
39
Environmental Cleaning & Disinfection
Disinfection Guidelines
Key Points




Cleaning is the key to disinfection
Clean using detergents in the first instance
Chemical disinfection is rarely needed in hospitals
Single use devices must never be reprocessed or re-used
Availability of Antiseptics and Disinfectants
Disinfectants and antiseptics are expensive and often ineffective so they tend to be
used excessively and ineffectually. The most effective means of disinfection, that is
the reduction of microbial contamination, is thorough cleaning. Chemical
disinfectants are ineffective in the presence of dirt. They may be inactivated by dirt,
biological fluids or by rubber. They may destroy certain substances, particularly
rubber and metal. Antiseptics may reduce bacterial counts on the surface of the skin
or a wound but rarely enhance and more likely will interfere with healing.
Domestic Cleaning Agents










General purpose detergent (G.P.D.)
Cream cleanser (C.C.)
Floor maintainer
Floor polish
Floor stripper
Toilet descaler
Carpet cleaner
Glass cleaner
Metal polish
Chewing gum remover
Decontamination of Equipment Prior to Service or Repair ("Permit to Work"
Procedure)
Key Points


Contaminated medical equipment must be made safe before service or repair
There is a duty of care to inform engineers and others whether equipment is
safe or unsafe
40
Introduction
Anyone who inspects, services repairs or transports medical, dental or laboratory
equipment within a healthcare setting has a right to expect that the equipment has
been appropriately treated to minimise the risk of infection. Documentation is
required to indicate the contamination status of the item.
This procedure refers to medical equipment from clinical areas sent for repair,
servicing or decontamination to the following departments:





District Supplies
Works/Estates
Outside contractors or manufacturer
Medical Physics
Medical Electronics
The procedure is designed to protect personnel handling the equipment from the risk
of acquiring infection. This includes all staff working within the healthcare setting and
also those working for outside manufacturing commercial companies who are
entitled to request a certificate of decontamination before accepting equipment for
servicing.
The procedure does not apply to the processing of SSD instruments or linen. These
will continue to be dealt with in the usual way.
The relevant advice is contained in the Medicines and Healthcare Products Agency
Device Bulletin MHRA DB 2003(05): Management of Medical Devices Prior to
Repair, Service or Investigation (June 2003). All reusable medical devices and
equipment to be inspected, serviced, repaired, returned to the lending organisation
or disposed of should undergo decontamination. The devices and equipment should
not expose the recipient to a biological, chemical or radio-active hazard.
Failure to comply with the legislative requirements could leave your healthcare
setting open to prosecution.
National Patient Safety Agency - The national specifications for cleanliness in
the NHS: Guidance on setting and measuring performance outcomes in
primary care medical and dental premises
41
Aseptic Non Touch Technique and Wound Management
Key Points



Know how to prevent wounds from getting infected
Know the wound management products available
Know how to carry out Aseptic Non Touch Technique
Introduction
Infection of surgical wounds may be a serious complication leading to prolonged
hospital stay, readmission, prolonged morbidity and occasional death. Wound
dressings should be performed using the Asceptic Non Touch Technique (ANTT).
For further information on Aseptic Non Touch Technique for wound
management please click the following link. ANTT
Prevention
Wound infection may be prevented by:
 Preventing a patient acquiring virulent or resistant hospital flora (e.g.
MRSA)
 Aseptic techniques in surgery
 Judicious use of antibiotic prophylaxis
 Proper post-operative wound management
 Use of Aseptic Non Touch Technique (ANTT) on dressing changes
Wound Care
The choice of dressing depends on wound type, position and size, and patient
factors (e.g. allergy). Follow manufacturers' guidelines. Do not mix chemical
products. Most infections become apparent around day 10 after surgery (although
usually preceded by a period of non-specific fever) and may require re-exploration of
the wound to drain pus and remove foreign objects such as stitch material.
Antibiotics are poorly effective.
It is important to remember that patients who are diabetic or immunosuppressed do
not always show the same inflammatory response as those who are not. A wound
swab should be taken on all non healing acute wounds and also on wounds
(including chronic) which show clinical signs of infection. Referral to the Tissue
Viability Nurse Specialist may be required for acute non healing wounds.
MRSA Wound Management
For further information on the management of MRSA in wounds please click the
following:
42
Antimicrobial Dressing Protocol for Adult Inpatient Wounds Critically
Colonised or Infected with Meticillin Resistant Staphylococcus Aureus
(MRSA)
43
Handling & Storage of Vaccines
Vaccination programmes in the UK are well developed and have led to a large
reduction, and in some cases eradication, of disease. It is important therefore that
confidence in the immunisation programme is not compromised.
The vaccination cold chain refers to all the materials, equipment and procedures
involved in maintaining vaccines under the required storage conditions from
manufacturer to administration.
For vaccines to be effective, it is important that they are stored within the
temperature range recommended by manufacturers [+2°C to +8°C] to ensure that
they remain potent.
The maintenance of the cold chain in the delivery of vaccines in the UK is subject to
a very vigorous and robust procedure. In the unlikely event of a break in this cold
chain during the delivery process, vaccines can be traced and recalled, and
individual patients who have received them can be identified within a matter of hours
using tested recall procedures.
Once vaccines have been delivered to providers however, the maintenance of the
cold chain and the storage of vaccines becomes the responsibility of that provider.
It is therefore important for those working in primary care to be able to assure the
safety and efficacy of vaccines they offer.
A summary of the existing recommendations for the storage of vaccine
(Department of Health. Immunisation against infectious disease – ‘The Green
Book’.
Third edition. DH, London. (2006).
• Local practice should be in accordance with national policy for the ordering,
storage, stock control, distribution, transport and disposal of vaccines
• Each practice should have one trained individual, with at least one trained deputy,
responsible for the receipt and storage of vaccines and the recording of
refrigerator temperatures
• Vaccines should be stored in the original packaging at +2°C to +8°C and
protected from light
• Vaccine stocks should be monitored by the designated person(s) to avoid overordering or stockpiling
• Surgeries should have no more than two to four weeks’ supply of vaccines at any
time
• Vaccines must be refrigerated immediately on receipt and must not be left at room
temperature
• Specialised refrigerators are available for the storage of pharmaceutical products,
and must be used for vaccines and diluents. Ordinary domestic refrigerators must
not be used. Food, drink, and clinical specimens must never be stored in the
same refrigerators as vaccines
• The accidental interruption of the electricity supply can be prevented by using a
switchless socket or by placing cautionary notices on plugs and sockets
• An approved cool box or alternative refrigerator should be used to store vaccines
during defrosting of the main refrigerator
44
• The temperature with the vaccine refrigerator must be continually monitored with a
maximum-minimum thermometer
• Temperatures in the refrigerator must be monitored and recorded at least once
each working day, and documented on a chart for recording temperatures
• Arrangements should be in place for back-up facilities to be available in the event
of the refrigerator failing or breaking down
Vaccine stability
Whilst storage of vaccines outside of manufacturer’s recommendations is clearly not
best practice, some vaccines are particularly susceptible to becoming inactive if
stored below +2°C. Conversely, stability data suggests other vaccines stored outside
recommendations may continue to be used in specific circumstances.
Details of the effect of temperature on vaccine stability have been investigated in
detail and are published in the World Health Organization report Temperature
sensitivity of vaccines.
For practical day-to-day guidance on the use of UK-licensed medicines and vaccines
when the cold chain has been broken, UK Medicines Information (UKMi) maintains a
database that collates published and unpublished information from manufacturers.
This is known as ’The Fridge Database’. It recommends action designed to prevent
wastage for 237 medicines and 50 vaccines. Access can be obtained by contacting
your regional medicines information centre (contact details at the front of the British
National Formulary).
Medicines information services
Information on vaccine stability can be obtained from regional and district medicines
information services. Details regarding the local services provided within your region
can be obtained by telephoning the following number.
England Bristol (0117) 342 2867
Whilst product use following a break in the cold chain may be appropriate in certain
circumstances for individual products, it will usually be outside the terms of the
product licence and use remains at the discretion of individual practitioners.
References
The Green Book Immunisation against infectious disease (DH, 2006) provides
general information on vaccines and immunisations
Information can also be found on the NHS Immunisation Information website
Slide set vaccine ordering and storage. Health Protection Agency
For further guidance on vaccine handling and storage please refer to the Vaccine
Handling Policy for NHS Somerset Commissioned clinics, hospitals, community
pharmacies and GP Practices
Health Protection Agency presentation on Vaccine Storage
45
Dental Decontamination
Local Decontamination Units (LDUs)
Studies undertaken in GP and GDP surgeries have shown evidence of failure to
adequately clean and sterilize medical and dental equipment. As a consequence, the
prevailing view from Department of Health Estates & Facilities Directorate is that
Central Sterile Services Department ( CSSD) provide a superior service for the
reprocessing (cleaning, sterilisation and packaging) of re-useable instruments
compared to local decontamination units in surgeries. Local reprocessing should be
the exception rather than the norm for the reprocessing of reusable surgical
instruments in primary and acute care. However, if the use of central processing
units (CSSD) is not achievable, then all reprocessing of surgical instruments should
be undertaken outside of the clinical environment wherever possible, and that
automated washing methods (e.g. thermal washer disinfectors) are preferred to
manual cleaning, and should conform to HTM 01-05 essential practice standards,
and have a plan in place to work towards meeting the best practice standards.
HTM 01-05
HTM 01-05 self assessment tool
The overarching aim of the Government is to raise and harmonise the standards of
decontamination and infection control across the whole spectrum of primary and
acute care in order to reduce the associated infection risks to patients and
healthcare workers. Recommended protocols based on those published by
Department of Health Estates & Facilities Directorate, MHRA and the BDA are
described in the following section of the Guidelines.
Therefore the Chief Dental Officer has recommended that local decontamination of
instruments should continue in dental practice, but that dentists should implement
high quality standards in line with national recommendations for good practice
(National Standards, Local Action 2004, www.dh.gov.uk/publications), and ensure
that they conform to HTM 01-05, essential practice elements and be working towards
the Best Practice elements. All dental practices should have an action plan to show
that they are working towards compliance with HTM 01-05.
In essence good practice comprises:



Instrument decontamination should be performed away from the patient
treatment area (preferably in a dedicated room)
Automation of instrument cleaning (wherever possible) or validated
manual cleaning
Commissioning, validating, monitoring and maintaining of sterilizers
46


Segregation of dirty instruments and procedures from clean by zoning
and work flows patterns
Enhanced training of dental staff in instrument decontamination
Dedicated decontamination room or decontamination area
According to advice from the Department of Health Estates & Facilities Directorate
whenever possible decontamination should be carried out in a separate dedicated
room, although it is appreciated that many practices do not have sufficient space to
build or house a dedicated local decontamination unit. Under those circumstances
an area in the surgery should be specifically designated for decontamination.
This is to ensure quality standards and enhanced staff safety in line with:




The Medical Devices Regulations 2002 and the HSC 1999/179 Controls
Assurance in infection control: decontamination of medical devices,
HTM 2010, HTM 2030
Department of Health report on combating healthcare associated
infections "Winning ways "
Compliance with the standards set out in the national decontamination
strategy, which are outlined in the above Regulations is required by April
2007
Compliance with the HTM 01-05
Layout of Decontamination room /area
The decontamination area or dedicated decontamination room should be divided into
two physically separate sections so that there is a one- way flow through of traffic
from the "dirty- scrub section" to the "clean" section for handling of sterile
instruments. There should be a dedicated deep sink with a second sink nearby for
cleaning instruments that is not used for hand hygiene. Automated methods are
recommended as these are safer and can be validated, so the use of a thermal
washer disinfector rather than manual cleaning is preferred. One way flow from dirty
to clean with a single run of sealed, easily cleaned worktop with (in order):
Dirty zone contains:
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a setting down area for dirty instruments
Secure storage containers for dirty instruments
Ultrasonic bath
Thermal washer disinfector (part of HTM 01-05 best practice standards)
Automated pre-sterilisation dental handpiece cleaning machines
(optional)
47

A dedicated sink for instrument cleaning with a separate sink for rinsing
the instruments (essential practice standards within HTM 01-05)
Clean zone contains:

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A setting down area for machine-washed or manually disinfected
instruments, with task lighting for inspection (for visible contamination
and functionality/damage), instrument wrapping (if using a vacuum
sterilizer)
Sterilizer (preferably a vacuum sterilizer)
Shelving or cupboards for storing sterilized instruments in trays,
cassettes or pouches
Sterile supplies
Storage area for PPE (personal protective equipment)
Airflow should be from the clean zone to the dirty zone
Dedicated decontamination room (LDU)
If you are planning a major refurbishment or new build then you should comply with
the requirement for a dedicated decontamination room or local decontamination unit
(LDU) designed with a hand-through hatch (for the delivery of dirty sets of
instruments and equipment). Instruments should be transported to and from the
clinical area in a clean box with a secure lid. If you would like any infection
prevention and control advice on any new builds then please contact the Infection
Prevention and Control Team at NHS Somerset or the Dental Lead.
Like the dedicated decontamination area there should be a one-way flow of
instruments from the "dirty zone"- reception and instrument cleaning area, which is
separated from the clean zone that contains the instrument inspection area, sterilizer
and storage areas. The clean zone should be physically separated from the dirty
zone and fitted with readily cleanable shelving and cupboards. In the clean zone
sterile instruments and equipment that is sterilized unwrapped can be packaged and
stored. The room should be well ventilated (8-10 air changes per hour) and any
extraction ventilation should be sited in the dirty zone so that the air flows from the
clean to the dirty area i.e. the reverse traffic flow to that of the instruments.
Sources of information and web sites
Sterilizer purchase, use, validation and maintenance:

MHRA (Medical Devices Agency) Device Bulletin: MDA DB 2002(06)
Benchtop steam sterilizers - Guidance on the purchase, operation and
maintenance. (A comprehensive guide to the use of benchtop steam
sterilizers in general practice). Available at http://www.mhra.gov.uk/
48


A guide to the decontamination of reusable surgical instruments.
NHS Estates. 2003. Available at www.dh.gov.uk
HTM 01-05 - Decontamination in primary care dental practices
Instrument Decontamination and vCJD
Decontamination of instruments used on patients with TSE (Transmissible
Spongiform Encephalopathies)
Key points:





Dental procedures are classified as low risk for transmission of CJD or vCJD
In order to prevent cross infection and onward transmission of vCJD via
endodontic instruments these instruments should be single use only
Patients identified at risk or their relatives should not be refused routine dental
treatment
Ensure that satisfactory standards of decontamination are observed
Information about patients who are at risk of vCJD is included in any referrals
for surgery and recorded in your records
Dentistry and vCJD
The risk of transmission of CJD or vCJD from dental instruments is thought to be
very low, provided that best practice guidelines for infection control and national
standards on decontamination are followed.
The current advice issued by the Department of Health is that reusable instruments
used on known, suspected or at risk patients with CJD (see table 13) or their
relatives can be re-processed using standard, optimal decontamination
procedures and returned to use ( as outlined in these Guidelines). No additional
infection control precautions are required when treating these patients for routine
dental treatment.
Therefore there is no reason why any categories of patient defined in table below or
their relatives should be refused routine dental treatment. Such people can be
treated in the same way as any member of the general public. It is most unlikely that
a confirmed case of sporadic CJD or vCJD would present at a Dental surgery due to
the dehabilitating nature of the disease. Therefore the cross infection risk arises in
relation to unidentifiable asymptomatic carriers of the vCJD and those who are at
potentially at an increased risk of the disease due to iatrogenic exposure from vCJD
contaminated blood transfusions and plasma products.
49
Prevalence of vCJD in the UK
Transmissible Spongiform Encephalopathies (TSE) is a group of rare, fatal
degenerative central nervous system infections, which occur as sporadic, familial or
acquired disease. The TSEs are caused by prions (infectious protein particles),
which are an abnormal pathogenic form of a human cell surface protein known as
PrP. The commonest TSE is the sporadic form of Creutzfeldt-Jakob disease (CJD)
with an incidence of 1 in a million /population per annum. TSEs have a long
asymptomatic incubation period lasting a decade or more before the appearance of
clinical disease.
In the UK, vCJD was first diagnosed in humans in 1996 and was linked to the
consumption of meat products tainted with bovine Spongiform Encephalopathy (BSE
or "mad cow disease"). vCJD differs from sporadic CJD in that it affects younger
people, has a shorter incubation period, with prominent early psychiatric and
behavioural manifestations and persistent parathesias. Up to June 2006, the total
number of reported cases of confirmed or probable vCJD in the UK is 161 patients of
which 6 are still alive. The exact number of people incubating the disease is
unknown. A study reporting in 2004 examined tonsils and appendices removed
during surgery on over 12,000 patient’s resident throughout the UK, demonstrated
abnormal prion protein in 3 cases, which after extrapolation gives an estimated 3,800
preclinical cases across the UK. Theoretically, during the preclinical stage of the
disease vCJD carriers could transmit infection to other patients via inadequately
decontaminated surgical instruments.
Iatrogenic transmission CJD and vCJD
Available epidemiological evidence suggests that normal social or routine clinical
contact with a patient suffering from any type of CJD (Creutzfeldt-Jakob disease)
including v CJD does not represent a risk to healthcare workers. However, a number
of cases of iatrogenic CJD have been associated with the administration of
hormones prepared from human pituitary glands and dura mater grafts and three
cases have been reported associated with corneal grafts. Transmission has also
been identified following neurosurgical procedures with inadequately
decontaminated instruments.
Blood components and plasma products
Two reports of possible transmission of vCJD through blood transfusion were
announced in December 2003 and July of 2004. The cases had received blood from
donors who were well at the time of donation but later died of vCJD. The second of
these patients died of causes unrelated to vCJD but the post-mortem revealed vCJD
50
in the spleen, indicating that the patient had been infected with vCJD. The possibility
that vCJD can be transmitted through blood raises concern about the possible
infectivity of blood components and plasma products. Certain patients with bleeding
disorders (e.g. haemophilia, Von Willebrand disease and antithrombin III deficiency)
and a small number of others who were recipients of specific plasma products (e.g.
clotting factors and antithrombin sourced between 1980 and 2001) have been
identified and will be informed by their doctor that from a public health safety
standpoint, they are deemed to be at an increased risk of vCJD. This group of
patients have been asked to notify their dentist of their risk status. The dentist will
then be able to ensure that satisfactory standards of infection control are used.
Dentists are recommended to include this information in referral letters for invasive
surgical procedures to specialists such as maxillofacial surgeons as additional
infection control procedures are required for surgery that could involve the lingual
tonsil or other organs and tissues potentially infected with vCJD, but as far as dental
treatment is concerned such patients can be managed in the same way as any other
member of the public and should not be refused routine care in dental
practice. However, the possibility of transmission via blood transfusion does
emphasize the need for every precaution must be taken to ensure optimal standards
of infection control and instrument decontamination are employed in the practice.
Single use of endodontic files- Position statement from SEAC
Prions may not be inactivated by standard sterilisation procedures nor can they can
they be reliably destroyed by prolonged sterilisation times (18 minutes at 134 o C).
Hence, expert advice suggests that effective cleaning of instruments prior to
sterilisation is of the utmost importance in reducing the risk of transmission of prions
via surgical procedures. This is because the first round of cleaning of an instrument
reduces contamination by approximately 100-1000 times.
Variant CJD have been recovered from brain, trigeminal ganglion, and tonsil in the
examined post-mortem cases. Abrasion of the lingual tonsil is considered a highly
unlikely event during routine dental treatment but could occur during maxillo-facial
procedures. Fortunately, to date there are no published cases or epidemiological
evidence directly linking vCJD or other TSEs to dental treatment.
Evidence suggests that the files and reamers used in endodontic procedures
continue to be reused and are difficult to reliably decontaminate, it is stated in HTM
01-05 that these should be single use items. Appreciable quantities of residual
material remain adherent to the surface after normal cleaning and sterilisation. Thus,
there is potential for transfer of dental pulp between patients undergoing endodontic
procedures.
51
There is evidence to suggest that individuals infected with the vCJD agent may
remain in a subclinical infection carrier state instead of developing vCJD. They could
over the course of their lives be potential sources of numerous secondary infections
arising from invasive medical or dental procedures. Residual dental pulp on
endodontic files and reamers is considered to be transferred relatively efficiently to
patients on reuse. There is reason to believe that dental pulp is as infective as
peripheral nerve tissue for v CJD in this subclinical vCJD carrier population. So
potentially a self-sustaining vCJD epidemic arising from endodontic surgery is
plausible.
Interactions between this and other routes of secondary transmission, such as blood
transfusion and hospital surgery, would make a self-sustaining epidemic more likely.
Risk Reduction Measure
Therefore restricting endodontic files and reamers to single use would prevent
potential secondary transmission via these instruments
Risk groups for CJD and vCJD
Fulfil the diagnostic criteria for definite,
probable or possible CJD or vCJD
Symptomatic patients
Patients with neurological disease of
unknown aetiology, but where the
diagnosis of CJD is actively considered
Patients with 2 or more blood relatives
affected by CJD or a relative with a
genetic mutation indicative of familial
CJD
Asymptomatic patients at risk from
familial forms of CJD linked to genetic
mutations
Patient shown by genetic testing to be at
significant risk of developing CJD or
other prion disease
Recipients of hormones derived from
human pituitary gland e.g. growth
hormone, gonadotrophin, or received
dura mater graft before August 1992 for
spinal surgery for a tumour or cyst
Asymptomatic patients potentially at risk
from iatrogenic exposure
Patients contacted as potentially " at
risk" because of exposure to instruments
or to blood, plasma derivatives, organs
or tissue from patients who later
developed CJD or vCJD
52
Disinfection of Equipment, Instruments and Dental Impressions
Definition of disinfection
Disinfection is a process used to reduce the number of viable microorganisms but
may not inactivate certain viruses and bacterial spores. Disinfection should be limited
to equipment, which cannot be reprocessed using other methods and is strongly
discouraged in dental practice as a form of sterilisation, as most equipment can be
steam sterilized or is available as single use disposable items.
When selecting a disinfectant for heat sensitive equipment, check that it is active
against bacterial spores, M. tuberculosis and viruses including HIV, HCV and HBV.
The disinfectant must be compatible with the instrument or equipment and not
corrode, damage or have a deleterious effect on its function. Always check first with
the manufacturer before using a new disinfectant. Finally, read the disinfectant's
Safety Data Sheet, as some disinfectants require special conditions for use such as
exhaust ventilation in order to prevent adverse reactions occurring e.g. skin
hypersensitivity or asthma. An example is Glutaraldehyde which is NOT suitable for
general dental practice as it is an irritant and sensitises the skin, eyes and
respiratory tract.
You will need to prepare a written COSHH assessment on all disinfectants used in
the practice.
Procedure for chemical disinfection of heat sensitive equipment











Instruments and equipment must be cleaned before disinfection
When preparing disinfectants staff must wear appropriate PPE
(Visor/goggles, mask, heavy duty gloves, plastic apron)
Room used for disinfection must be well ventilated
Receptacles used for chemical disinfectant solutions must be cleaned
and steam sterilized before use
Make up the disinfectant at the correct concentration according to
manufacturer's instructions
Disinfect for the recommended contact time (use a timer)
Devices that can be submerged should be completely immersed in the
disinfectant to ensure contact with all internal and external parts
Remove using an aseptic technique
Rinse thoroughly in sterile water
Dry using a sterile non linting cloth
Inspect for cleanliness
53
Disinfection of dental impressions and impression trays
Dental impressions become contaminated with saliva, blood and oral bacteria. Less
commonly they may become contaminated with respiratory pathogens, which are
coughed up into the mouth from the lungs. For example, impressions taken on a
patient previously diagnosed with tuberculosis were found to harbour the causative
agent Mycobacterium tuberculosis.
Dental impressions:







All impression must be cleaned and disinfected before being sent to the
laboratory
Wear gloves, mask, goggles /visor and disposable plastic apron
All impressions should be rinsed thoroughly in running water to remove
all visible signs of contamination
Use a disinfectant that is compatible with impression material. Immerse
the impression in the disinfectant for the specified time. Avoid spray
disinfectants, which are less effective and may create an inhalation risk.
Rinse off the disinfectant with water
Impression trays
Commercially manufactured plastic impression trays are for single
patient use only. Do not clean or reprocess then for subsequent reuse.
After single use they should be disposed of as clinical waste by the
practice or the dental laboratory
Metal impression trays are reusable and should be thoroughly cleaned,
immersed in an ultrasonic bath or processed in a thermal washer
disinfector and then steam sterilized
Equipment to be sent for service or repair
Equipment, which has been contaminated with blood/body fluids, or has been
exposed to patients with a known infectious disease, must be decontaminated before
being sent to third parties for inspection, service or repair (see DB 2003 (05) June
2003). The device or equipment should not expose the recipient to biological,
chemical or radiation hazards. Specific advice on decontamination procedures
should be obtained from the manufacturer. All equipment to be inspected, serviced
or repaired must be assessed and a declaration of contamination status form
completed. Sample forms and further guidance can be obtained from the MHRA
website. The contamination status form should state whether the item:

Is contaminated with blood, body fluids, pathogens or hazardous
chemicals
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


Has been cleaned and /or decontaminated
The method used for cleaning, disinfection or sterilisation
Signed and dated to declare that "the item has been prepared to ensure
safe handling and transportation"
If equipment cannot be decontaminated (for example if device needs to be
dismantled by an engineer), the repair organisation should be contacted and asked if
they will accept an item that has not been decontaminated. If accepted, then it
should be labelled with its contamination status and packed and dispatched for
service/repair. Please note that it is illegal to send contaminated items through the
post. If the repair organisation will not agree to the dispatch of the device, then
quarantine the item, label with its contamination status and arrange a site visit to the
practice by the service/ repair organisation.
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Staff Health & Immunisation
Immunisation
On employment, checks should be made to ensure that staff are immunised
according to current national guidelines. All clinical staff (including Nurse
Practitioners, GPs, Practice Nurses, HCA’s, Dentists, Dental Nurses (DCPs),
Therapists and Hygienists) should have received vaccinations against hepatitis B,
rubella, tetanus, polio, tuberculosis (and varicella, if non-immune). Annual
vaccination in the autumn against seasonal influenza is strongly recommended.
Written documentary evidence that they and their employees have been immunised
against hepatitis B must be held by the practice.
Record the following (Check this with someone who would know)




Completion date of the hepatitis B vaccination course
Post vaccination antibody levels (with date of blood test)
Record immune response (categories -non-responder <10 iu/ml; poor
responder 10-100iu/ml, good responder >100iu/ml)
Date for booster vaccination
Nominate a person within the practice to co-ordinate staff health and keep a written
confidential record of immunisation schedules and antibody test results.
Permission (written consent) must be first gained from the team members before
requesting any confidential information from their GP. A letter can then be written to
the GP requesting the appropriate information. Put in place markers or an alerting
system to help the practice keep their records contemporary and ensure that all
members of the dental team are up to date with booster vaccinations.
Who should be immunised against hepatitis B?
All staff who are likely to have contact with blood/body fluids, clinical waste and
sharps in the course of their duties should have received and completed a hepatitis
B immunisation course.
Their antibody response should be measured 1-2 months after the completing the
course of immunisation to ensure that they have mounted an adequate antibody
response.
A single booster vaccine is recommended at 5 years. People who produced an
adequate immune response after the initial course of immunisation and who have a
needle stick injury within 1-5 years of completing the course of vaccine may be
offered a booster vaccine. If this occurs there is no requirement for a second booster
dose at 5 years.
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Vaccinations against Hepatitis B are available via the SERCO Telephone Number
01278 450870 their website is
http://intranet.sompar.nhs.uk/services/central_services/human_resources/staff
_occupational_health.aspx or professionals can follow the link on
http://intranet.sompar.nhs.uk/default.aspx
Further information and a fact sheet for staff can be obtained from www.dh.gov.uk
Health Clearance
It is current policy in the NHS to screen all new entrants to the Health Service
including students for:



Evidence of tuberculosis disease/immunity
To offer hepatitis B (HBV) immunisation, with post-immunisation testing of
response
The offer of testing for hepatitis C (HCV) and HIV, within the context of
reminding them of their professional responsibilities in relation to serious
communicable diseases
Most routine dental and minor oral surgical (MOS) procedures are classified as EPP.
Healthcare workers who are known to be infectious carriers of HCV, HBV (HBe Ag
positive) or HIV seropositive or are found to be so following testing are not allowed to
perform EPPs. Hepatitis C infected healthcare workers who have a sustained
virological response to antiviral therapy will be allowed to perform EPPs six months
after cessation of antiviral therapy.
Staff who are HBeAg positive and those HBsAg positive carriers who are HBe Ag
negative but who have a significant viral load (>1000 genome equivalents /ml) will
not be allowed to perform exposure-prone dental procedures. HBe Ag negative
infected health care workers whose viral load is < 1000 genome equivalents /ml may
continue to perform EPPs but should receive appropriate occupational health advice.
Such persons will require re-testing every 12 months and if the viral load rises above
the specified level or there is evidence of transmission from the dental healthcare
worker to a patient then they must cease performing EPPs.
Staff do not routinely perform exposure prone procedures but a risk assessment
should be undertaken to determine whether the individual’s specific duties pose a
risk to patients or other members of staff and whether they would need to be
redeployed within the practice. (See Maintaining Standards)
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Dentistry
Dentists currently registered with the GDC who believe that they may have been
exposed to blood borne viruses such as HIV, Hepatitis B (HBV) or Hepatitis C (HCV)
e.g. via unprotected sexual activity, occupational exposure, blood transfusions etc.
(see risk factors for HIV transmission) are under a legal, professional and ethical
obligation to promptly seek and follow confidential advice on testing for BBV (blood
borne viruses) and national guidelines on practising restrictions.
General Practice
Healthcare workers must not rely on their own assessment of the risk they may pose
to patients. Confidential advice on testing for BBV can be obtained from your local
Director of Public Health of Primary Care Trusts. Failure to do so may breach your
duty of care to patients under the Health and Safety at Work Act and the COSHH
regulations (see HIV infected healthcare workers: Guidance on management and
patient notification July 2005. Department of Health paragraph 4.7). This guidance
applies to all those working in the NHS and the independent sector. All medical
information and records held on staff must be kept strictly confidential and the
confidentially must be protected and respected at every stage. For further
information on your obligations and the correct procedures to follow see the
Department of Health website for guidance relating to HIV and for information
relating to HBV.
Varicella immunisation
Chickenpox is caused by the virus Varicella zoster virus (VZV) and is highly
infectious. VZV is spread via respiratory droplets or direct contact with the blisters
and contaminated clothing. The infection can occur at any age but is more common
in children. However, disease in adults tends to be more severe.
New recommendations for varicella vaccination
Following advice from the Committee on Vaccination and Immunisation, varicella
immunisation is now recommended for non-immune members of the healthcare
team who have direct patient contact. Approximately 10 % of the population have no
immunity to chickenpox. Vaccination is recommended to protect both susceptible
healthcare workers and to protect vulnerable patients from acquiring chickenpox
from an infected member of staff. Members of the healthcare team with direct patient
contact who have no previous history of chickenpox or shingles should have a blood
test to check their immunity. Staff with a definite history of chickenpox or shingles
can be considered to be immune. Those who are seronegative (with no antibody
evidence of immunity) will be recommended the vaccine. Non-immune staff should
58
receive 2 doses of the live attenuated vaccine 4-8 weeks apart. Additional
information and a fact sheet for staff can be obtained from www.dh.gov.uk/cmo.
Invasive Devices
Guidance on the insertion and management of invasive devices can be obtained on
the following link:
http://www.wales.nhs.uk/sites3/Documents/739/RCN%20infection%20control.doc.p
df
59