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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 1 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: 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) 2 Designated Infection Control Lead The Infection Control Lead is responsible for the organisation of infection control management and structure within the practice. This includes: 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: 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 3 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] 4 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 5 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 6 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 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 7 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 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 8 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 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 9 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: Keep sleeves rolled above the wrist Wear a name badge Do not wear a wrist watch or jewellery Keep hair neat and tidy; long hair must be tied back Keep fingernails short and no false nails or varnish are permitted 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. 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 10 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: 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 11 Measures that reduce the exposure of patients, the healthcare team, laboratory staff, maintenance engineers, waste contractors and the general public to infection include: 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 12 Management of Sharps Key points: 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. 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 13 Sharp safe working: 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: 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 14 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 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 15 Assessment of significance of injury - Factors that increase risk of transmission of blood borne viruses 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 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 16 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. 17 Spillages Key Points 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: Move patients and other workers away from the spillage while using a Chlorine Releasing Agent 18 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: 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 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? 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? 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: 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: 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 54 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. 55 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. 56 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) 57 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