Download 2.5 trust policy and procedures for blood and body fluid spillage

2.5 TRUST POLICY AND PROCEDURES FOR BLOOD AND BODY
FLUID SPILLAGE
Reference Number
Version 2.1
CL-RM/2013/051
Status
Final
Author:
Forrest
Helen
Job
Title
Lead
Nurse
Infection
Prevention
and
Control
Version / Amendment History
Version Date
Author
Reason
2
October
2012
J.
Toplass
Reviewed and
Updated
2.1
June
2016
H.
Forrest
Review and updated
Intended Recipients: All medical and clinical staff, Associate Directors, Service
Managers, Divisional Nurse Director, Clinical Governance Facilitator, Matrons.
Training and Dissemination: Dissemination via the Trust Intranet. Included in
Infection Control Mandatory Training
To be read in conjunction with: Trust Policy for Standard Infection Control
Precautions; Trust Policy and Procedure for Hand Hygiene; Trust Policy for Personal
Protective Equipment; Trust policy for the management of inoculation incidents, Trust
Waste policy. Trust policy for Cleaning and Disinfection
In consultation with and Date: Health and Safety (June 2016) Infection Control
Operational Group (27.06.16), Infection Control Committee (28.06.16)
EIRA stage one Completed Yes
Stage two Completed N/A
Procedural Documentation Review Group Assurance
Approving Body and Date Approved
Infection
Control
Committee 28.06.16
Management
Executive 12.07.16
Date of Issue
July 2016
Review Date and Frequency
May 2019 (then
every 3 years)
Contact for Review
Lead
Nurse
–
Infection Prevention
and Control
1
Executive Lead Signature
Chief Nurse
Approving Executive Signature
Chief Nurse
2
Contents
Section
1
Introduction
2
Purpose and Outcomes
3
Managing the Policy for Blood and Body Fluid Spillage
3.1
General Principles
3.2
Methods of Treating Blood and Body Fluid Spills.
3.2.1
Blood, high risk body fluids and body fluids with visible blood
present:
3.2.2
Vomit, diarrhoea, infective urine, no visible blood present. (Fluids
potentially infectious but not known to contain blood borne viruses).
3.2.3
General body fluid spillages – (spillages of urine and faeces, which
do not appear to have blood present):
3.2.4
Carpeted areas
3.2.5
Soft Furnishings
4
Definitions Used
5
Key Responsibilities
6
Monitoring Compliance and Effectiveness
7
References
3
1
Introduction
Contamination of the environment / equipment with blood and body
fluids may provide a reservoir of pathogens, which could result in
cross-infection to patients, staff and visitors.
2
Purpose and Outcomes
As part of standard infection control precautions all staff should be
aware of the procedure for cleaning of blood and body fluid spillages,
to prevent cross-infection
Any staff responsible for decontamination of spillages and equipment
has a duty, under the Health and Safety at Work Act, to do so safely
and correctly to ensure the workplace is free from hazards.
Adherence to this policy will result in a safe clean environment
following a blood / body fluid spillage.
3
Managing the Policy for Blood and Body Fluid Spillage
3.1
General Principles
Body fluid spillages must be cleaned up promptly following the
methods outlined below. If the member of staff is unable to do this
immediately, then the area must be made safe, including the use of a
floor safety sign and it must be reported urgently to an appropriate
person to be actioned. Disposable gloves and aprons must be worn
and fresh solutions in clean containers should be used and discarded
after each use.
Mop buckets if used should be washed with detergent and water and
stored dry after use. Mop heads should be changed after each use.
Spillages onto linen/ curtains etc must be managed in line with the
Trust linen policy.
3.2
Methods of Treating Blood and Body Fluid Spills.
3.2.1. Blood, high risk body fluids and body fluids with visible blood
present:
Cleaning agents: 1% Sodium hypochlorite (10,000ppm av. Chlorine) and
detergent
1. Collect protective personal equipment and other equipment (mop,
bucket, paper towels, offensive / infectious waste bags etc.)
2. Put on personal protective equipment, protect eyes and mouth with
goggles/visor and mask or full face visor if splash or spray is
anticipated.
3. Soak up excess spillage with paper towels and discard into offensive
waste bag according to waste policy.
4
4. If there is broken glass in the spillage DO NOT pick it up with your
fingers – use a scoop of cardboard or dust pan and brush and dispose
of into Sharps container (a large container will be needed for dustpan
and brush).
5. Wipe spillage area with undiluted 1% sodium hypochlorite (10,000ppm
available chlorine) using disposable paper towels.
6. Wash off with hot water and detergent, dispose of the towels offensive
waste (infectious waste if patient is known or suspected to have an
infection) according to the waste policy.
7. Leave the spill area clean and dry.
8. Remove apron and gloves and discard offensive waste bag according
to waste policy.
9. Wash hands.
3.2.2. Vomit, diarrhoea, infective urine, no visible blood present. (Fluids
potentially infectious but not known to contain blood borne viruses).
Cleaning agent: Actichlor plus (1,000ppm av. Chlorine)
1. Collect protective personal equipment and other equipment (mop,
bucket, paper towels, infectious waste bags etc.)
2. Put on personal protective equipment, protect eyes and mouth with
goggles/visor and mask or full face visor if splash or spray is
anticipated
3. Soak up excess spillage with paper towels and discard into infectious
waste bag according to waste policy.
4. If there is broken glass in the spillage DO NOT pick it up with your
fingers – use a scoop of cardboard and dispose of into Sharps
container.
5. Clean the area using Actichlor plus diluted to 1000ppm av. Chlorine,
(this does not need rinsing off).
6. Leave the spill area clean and dry.
7. Remove apron and gloves and discard into infectious waste bag
according to waste policy.
8. Wash hands.
3.2.3 General body fluid spillages – (spillages of urine and faeces, which
do not appear to have blood present):
Cleaning agent: neutral detergent
1. Collect protective equipment and equipment (mop, bucket, offensive waste
bags etc.)
2. Put on personal protective equipment, protect eyes and mouth with
goggles/visor and mask or full face visor if splash or spray is anticipated
3. Soak up excess spillage with disposable paper towels; discard into
offensive waste bag according to waste policy.
4. Clean area with detergent and hot water, dry thoroughly.
5. Remove apron and gloves and discard into offensive waste bag.
6. Wash hands.
5
3.2.4 Carpeted areas
Where a spillage has occurred in a carpeted area, treat according to the type
of spillage outlined above. Contact the facilities help desk as soon as possible
in order that the carpet can be domestically cleaned after the spillage has
been treated. If the carpet is unable to be cleaned then the carpet must be
replaced/discarded.
3.2.5 Soft Furnishings (cushions, floor mats etc)
Soft furnishings are not recommended for use in clinical areas. Infection
Prevention and Control must be contacted prior to purchase of such items to
determine their suitability. If such items are present and become soiled advice
must be sought from the infection prevention and control team regarding
decontamination. Items that cannot be decontaminated will be discarded.
Definitions Used
Pathogens
Micro-organisms with the ability to cause disease.
High Risk Body Fluids
Blood, breast milk, cerebral spinal fluid, amniotic
fluid, pleural fluid, semen, vaginal secretions,
synovial fluid, body fluids containing visible blood,
saliva associated with dentistry, wound exudates.
Low risk Body Fluids
Vomit, diarrhoea, urine, with no visible blood
present
5
Key Responsibilities/Duties
5.1
Infection Prevention and Control Team

Will review and update the policy in line with up to date guidance

Will provide on-going support and advice as required

Will ensure blood spillage procedure is covered in Mandatory
training.

Will ensure COSHH data sheets are provided to divisions when
new products are introduced.
5.2
Divisional Nurse Directors / Clinical Governance Facilitators/
Matrons/Clinical Leads / Sisters / Charge Nurses
 Will ensure all staff are aware of and adhere to this policy.
 Will ensure that COSHH data sheets are easily accessible to all
staff.
 Are responsible for ensuring adequate stock levels of appropriate
disinfectants are available in clinical areas.
 Are responsible for ensuring any equipment purchased is
compatible prior to purchase with the procedure to manage a blood
spillage.
 Will ensure staff are released to attend appropriate training.
6
5.3
Employees
 Are responsible for ensuring their own practice complies with this
policy and for encouraging others to do so.
6
Monitoring Compliance and Effectiveness
Monitoring Requirement :

The IPCT and Facilities Management will monitor
compliance with Environmental cleanliness

Any non compliance issues will be reported to the
divisional Matron / Head of Nursing as appropriate.
Monitoring Method:
Environmental cleanliness and the presence of blood /
body fluids spillages will be monitored as part of the
annual infection control audit programme, individual
area cleanliness auditing and by the Patient Led
Assessment (PLACE) Team.
Report Prepared by:
Lead Nurse – Infection Prevention and Control
Monitoring
presented to:
Report
Frequency of Report
7
Non-compliance will be reviewed through the Infection
Control Operational Group
As required
References
Department of Health (1992) Management of Health and Safety at
Work Regulations.
Department of Health (1998) Guidance for clinical health care workers:
protection against infection with blood-borne viruses.
Recommendations of the Expert Advisory Group on AIDS and the
Advisory Group on Hepatitis.
7