Download Standard Precautions for the Prevention and Control of Infection Policy

Policy No:
IC03
Version:
6.0
Name of Policy:
Standard Precautions for the Prevention and
Control of Infection
Effective From:
30/06/2016
Date Ratified
Ratified
Review Date
Sponsor
Expiry Date
Withdrawn Date
14/06/2016
Infection Prevention and Control Committee
01/06/2018
Director of Nursing, Midwifery and Quality/DIPC
13/06/2019
Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that
this is the most up to date version
This policy supersedes all previous issues.
.
Standard Precautions for the Prevention and Control of Infection v6
Version Control
Version
Release
Author/Reviewer
Ratified
by/Authorised
by
Date
1.0
February
2002
2.0
Changes
(Please identify page no.)
April
2006
L Orr
IPCC
20/01/2006
3.0
November
2008
Head of Infection
Prevention &
Control
IPC Policy
Approval
Meeting
29/10/2008
4.0
20/01/2011
L Flude
IPCC
26/11/2010
Summary of changes
circulated
4.1
28/08/2012
L Flude
IPCC
27/07/2012
Audit revision and
appendix 2 added
5.0
01/08/2013
A Cobb
IPCC
30/05/2013
Format: Trust
re-branding
Small changes have been
made to the policy
6.0
30/06/2016
J Storey/ L Caisley
IPCC
Standard Precautions for the Prevention and Control of Infection v6
14/06/2016
Small changes have been
made to improve flow
and update references
and practices
2
Contents
Section Page
1
Introduction .................................................................................................................................. 4
2
Policy scope .................................................................................................................................. 4
3
Aim of policy ................................................................................................................................. 4
4
Duties (Roles and responsibilities) ............................................................................................... 4-6
5
Definitions .................................................................................................................................... 6
6
Standard Precautions ................................................................................................................... 6-9
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
6.10
Hand Hygiene .................................................................................................................. 6
Skin .................................................................................................................................. 6
Gloves .............................................................................................................................. 7
Aprons and Long Sleeved Gowns .................................................................................... 7
Eye Protection ................................................................................................................. 7
Masks............................................................................................................................... 7
Sharps and Needlestick Injury ......................................................................................... 7-8
Conjunctivae/Mucous Membranes ................................................................................. 8
Spillages ........................................................................................................................... 8
Waste............................................................................................................................... 9
7
Training ......................................................................................................................................... 9
8
Equality and diversity ................................................................................................................... 9
9
Monitoring compliance with the policy ....................................................................................... 9
10
Consultation and review .............................................................................................................. 9
11
Implementation of policy (including raising awareness) ............................................................. 9
12
References .................................................................................................................................... 9
13
Associated documentation (policies) ........................................................................................... 9
Appendices
Appendix 1 : Personal Protective Equipment (PPE) Risk Assessment for ................................................ 11
Patient Care and Specimen Manipulation
Appendix 2 : Ward Quality Ward Measures Audit Tool ............................................................................ 12-16
Standard Precautions for the Prevention and Control of Infection v6
3
1
Introduction
This policy aims to fulfil the criteria set out within national guidance The Health & Social care Act
2008 (2015). This policy incorporates EPIC3 Guidelines (2014), which suggest a non-discriminatory
approach to infection prevention and control practice.
Health care workers who come into contact with blood, body secretions/excreta may be exposed to
pathogens like Meticillin Resistant Staphylococcus aureus (MRSA), Clostridium difficile, TB bacteria,
new multi-resistant organisms and blood borne viruses such as HIV, hepatitis B and C. Healthcare
workers are at risk of developing infection and spreading infection between patients. It is
impossible to identify all colonised or infected patients at any given time. Therefore, it is
recommended that all body fluids be regarded as potentially infectious and standard precautions
are to be strictly followed at all times.
The most common means of transmission is direct contact, particularly via hands. Blood borne
infections are most likely to be transmitted by direct percutaneous inoculation of infected blood via
a sharps injury. Blood contact with broken skin or mucous membranes also provides a route of
transmission.
2
Policy scope
This policy applies to all employees of Gateshead Health NHS Foundation Trust, all students, visiting
health professional, locum and agency staff.
3
Aim of policy
All requirements with this policy require equal attention and compliance. The policy aims to reduce
the risk to staff and service users from infection whilst minimising the disruption to the
organisation.
4
Duties (Roles and responsibilities)
Staff listed all have a duty to assist the Trust in the achievement of national standards for infection
prevention and control by compliance with this policy and all other Infection Prevention and
Control policies. All staff have a responsibility to disseminate good practice. Specific responsibilities
are outlined as follows:
Trust Executive Board of Directors
The Board of Directors, through the Chief Executive and the Medical Director, will delegate to the
Joint Directors of Infection Prevention and Control (DIPC) responsibility for supporting and
encouraging compliance of this policy by:
•
•
•
Regarding lapses in compliance with this policy as a serious issue.
Supporting education for all staff and appropriate updates for staff involved in direct patient
contact.
Ensuring that appropriate facilities are provided for the management of patients with infections.
Involving the Infection Prevention and Control Team (IPCT) in the planning process for new
construction and refurbishment work, so that advice can be given on appropriate isolation facilities
as emphasised by ‘Infection Control in the Built Environment’ (NHS Estates, 2013) and the Health
and Social Care Act 2008 - Code of Practice on the prevention and control of infections and related
guidance (DH 2015).
Standard Precautions for the Prevention and Control of Infection v6
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Chief Executive - The Chief Executive has overall responsibility for ensuring that the Trust has the
necessary management systems in place to enable the effective implementation of this policy and
overall responsibility for the health and safety of staff, patients and visitors.
All Staff - All Trust staff have a responsibility to adhere to Trust policy and ensure that appropriate
measures are taken to reduce risks associated with infection. All Trust Staff have a responsibility to
ensure they receive annual education for Infection Prevention and Control.
Head of Infection Prevention and Control - Has a duty to provide expert infection control advice
and support to the Director of Infection Prevention and Control, the Infection Control Team and
other service users.
Consultant Microbiologist/Infection Control Doctor - Provide expert advice in line with Trust
infection control needs and national policy to the Infection Control Team, Director of Infection
Prevention and control and service users.
Director of Infection Prevention and Control (DIPC)
The DIPC has executive responsibility for ensuring systems are in place to facilitate nursing staff
awareness of this Policy, and to ensure appropriate support is given to enable staff in delivering
practice as outlined in this policy.
The DIPC have executive responsibility for IPC delegated by the CEO for:
•
•
•
•
•
•
Overseeing IP&C policies and their implementation.
Responsible for IP&C team.
Report directly to the Chief Executive and Trust board.
Challenge inappropriate hygiene practice and antibiotic prescribing.
Assess impact of plans/policies/strategies on IP&C practice.
Member of clinical governance and patient safety structures.
The Infection Prevention and Control Team (IPCT):
•
•
•
•
Will provide advice against this policy and ensure that it is updated in line with current
national guidance via the nominated IPC lead.
The IPCT will support clinical staff in explaining results to patients if required and provide
appropriate advice and support until their discharge from hospital.
Provide relevant training for all clinical staff.
Develop patient and public literature and assist with communications relating to IP&C.
The Waste Manager - is responsible for:
•
•
•
•
•
•
•
•
•
•
Ensuring that the Trust manages waste disposal in accordance with its Waste Management
Policy.
The revision of this procedure on a bi-annual basis or more frequently if required. The
provision of necessary training and regular updates throughout the Trust.
The promotion of good waste reduction processes throughout the Trust.
The carrying out of audits in conjunction with the Infection Prevention and Control team.
Duty of Care inspections to companies employed by the Trust.
The keeping of all waste control transfer notes and records.
The premise notification required under the Hazardous Waste Regulations.
Administration of the waste disposal contract.
Contingency planning in the event of an emergency.
The keeping of a waste register of all contractors used by the Trust.
Standard Precautions for the Prevention and Control of Infection v6
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Associate Directors/ Service Line Managers (AD & SLM)/Identified leads
Each business unit is responsible for:
•
•
Ensuring a process in place for all relevant staff to complete IP&C mandatory training and
updates.
have a duty to ensure compliance with Trust policy.
Managers are responsible for ensuring all staff complete mandatory training for Infection
Prevention and Control and that those non-attendees are followed up in accordance with the
Trust Mandatory Training Policy (PP25)
Modern Matron - Matrons are responsible for the reduction of Healthcare associated infection.
They monitor adherence to Infection control policy via clinical presence/expertise and the Infection
Control Audit tool. Ensure that Infection Prevention and Control Link staff are released to attend
study sessions and perform audits for their areas which will provide the Trust with evidence of
compliance in infection control.
Occupational Health Department - Provide support and direction to Trust staff for individual and
outbreak infection control issues. Lead on implementation of safer sharps and systems to reduce
sharps injuries. Liaise with Health and Safety Advisor if post exposure testing results means that an
incident becomes RIDDOR reportable. Ensure that appropriate management of sharps injuries
sustained by Trust employees, visiting health professionals, agency / locum staff and students.
Infection Prevention and Control Link Persons - Perform Infection Prevention and Control audits as
directed by the IPCT/Modern Matron. Attend Link group meetings and cascade information to the
ward manager and ward teams
Ward Manager or Nurse in charge of ward - ensure that adequate personal protective equipment
is made readily available for staff use. Compliance of practice is audited weekly with the use of the
Ward Quality Ward Measures audit tool (see appendix 2) and the results are saved via the Safecare
dashboard.
5
Definitions
Standard infection prevention and control precautions should be applied by all healthcare
practitioners for the care of all patients. They are designed to prevent cross infection from
recognised and unrecognised sources of infection. The sources of (potential) infection include blood
and other body fluid secretions or excretions and any equipment or items in the environment
which are likely to become contaminated.
6
Standard Precautions
6.1 Hand Hygiene
Hand hygiene must be carried out in accordance with the World Health Organisations
Recommendations for hand hygiene (2008). This includes immediately before and after use of
protective clothing (glove usage IS NOT a substitute for hand hygiene), between patient contacts,
after contact with blood and body fluids, before and after invasive procedures, before handling
food or medications and after contact with the patient’s environment.
All clinical staff must have induction/training in correct hand washing technique and alcohol gel
use. See IC04 – Hand Hygiene Policy, which includes a guide for good hand washing technique.
Standard Precautions for the Prevention and Control of Infection v6
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6.2 Skin
Cuts and abrasions in any area of exposed skin should be covered with a dressing that is
waterproof, breathable and is an effective viral and bacterial barrier. Correct drying of hands after
hand washing will prevent skin becoming dry, cracked and sore. If any local reactions to hand soap
or alcohol hand sanitizer refer to Occupational Health.
6.3 Gloves
Seamless, Nitrile should be worn whenever there is a risk of exposure to body fluids,
secretions/excretions, non-intact skin or mucous membranes and when handling sharp or
contaminated instruments. (EPIC 3, 2014).
Sterile gloves are required for invasive procedures or contact with sterile sites. See Policy IC02 –
Personal Protective equipment in Clinical Practice Policy, for more details. To safe guard patients
and staff from latex allergy the Trust has changed to provide non-latex gloves.
6.4 Aprons and Long Sleeved Gowns
Disposable plastic aprons or water impermeable gowns should be worn whenever the potential of
splashing of clothes or uniform with body fluids is anticipated. See policy IC02 - Personal Protective
equipment in Clinical Practice Policy.
Disposable long sleeved gowns should be worn when caring for patients with active Clostridium
difficile and GDH diarrhoea, see IC26 – Clostridium Difficile Policy.
Disposable long sleeve gowns should be worn for patients with scabies and symptomatic patients
during a period of pandemic flu.
6.5 Eye Protection
Visors, goggles or safety spectacles should be worn whenever there is a possibility of splashing with
body fluids or flying contaminated debris/tissue is anticipated. Visors, goggles and masks with
visors are available via supplies. See policy IC02 - Personal Protective equipment in Clinical Practice
Policy.
6.6 Masks
Fluid repellent surgical face masks and eye should be worn when there is a risk of body fluid
splash/spray to the face.
For the care of patients with suspected or smear positive respiratory tuberculosis (TB), high
efficiency filter masks (FFP3) are worn during cough induction, bronchoscopy and for prolonged
contact. See policy IC02 – Personal Protective equipment in Clinical Practice Policy.
Please see appendix 1 for PPE flow chart
6.7 Sharps and Needlestick Injury
Take care during the use and disposal of sharps.
Do not re-sheath sharps.
Do not disassemble needles and syringes prior to disposal.
Standard Precautions for the Prevention and Control of Infection v6
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Dispose of all sharps at the point of use into an approved sharps container.
Do not overfill containers. See IC09 – Waste Disposal and Recycling Policy.
In the event of a sharps or needlestick injury:
Encourage bleeding from the wound.
Wash area thoroughly with soap and water.
Cover with a waterproof dressing.
If known, note the name of the patient.
Report to Occupational Health if the injured is a member of staff. Contact A+E out side of
normal working hours and attend Occupational Health the next working day.
Notify Line Manager, document the incident and a Datix report must be completed.
If the patient is thought to be HIV positive, Post Exposure Prophylaxis (PEP) may be required.
This should be given as soon as possible after injury within 72 hours. Staff must be familiar
with local PEP guidance. See sharps policy IP07.
6.8 Conjunctivae/Mucous Membranes
If blood or body fluids are splashed onto a mucous membrane (eyes, nose, mouth or open skin
lesions) irrigate with copious amounts of water immediately. This incident should be reported to
Occupational Health (or A+E if outside of normal working hours).
Notify Line manager and document the incident as per sharps policy IC07.
6.9 Spillages
When cleaning spillages an apron and non-sterile Nitrile gloves should be worn. Facial protection
should be considered if aerosol spray production is likely. Absorb any liquid using paper towels.
Clean the area with detergent and warm water and dry, refer to IC15 - Cleaning and Disinfection
Policy IC15.
All waste to be disposed of according to Policy IC09 Waste Disposal and Recycling
All body fluids should be regarded as potentially infected and spillage requires cleaning with a
hypochlorite 1,000 parts per million (ppm) solutions. The trust currently uses a combined detergent
and 1,000ppm chlorine solution Chlorclean. However, TB infection needs to be inactivated with a
5,000 ppm solution and for blood spills apply 10,000 ppm (1%) hypochlorite solution. Haz tablets
should be used for these potential infection risks. For known CJD patients obtain 20,000 ppm
hypochlorite solution (2% Milton) from the emergency drug cupboard.
6.10
Waste
All waste to be discarded as per Policy IC09 Waste Disposal and recycling.
Standard Precautions for the Prevention and Control of Infection v6
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7
Training
Infection Prevention and Control Policy IC01 to be read by all staff during induction.
Staff involved with providing patient care should be aware of their local arrangements regarding
patient isolation and also the management of infected/potentially infected patients.
All staff receives annual mandatory infection prevention and control training, addressing the
principles of Evidence Based Practice for Infection Control (EPIC3 2014).
8
Equality and diversity
The Trust is committed to ensuring that, as far as reasonably practicable, the way we provide
services to the public and the way we treat our staff reflects their individual needs and does not
discriminate against individuals or groups on the grounds of any protected characteristic (Equality
Act 2010).
9
Monitoring compliance with the policy
Standard/process/issue
Standard Precautions
Policy
Monitoring and audit
Method
By
Committee
Frequency
Weekly Audit
with Ward
Quality
Measures Tool
Ward/clinical
teams
Results are recorded
electronically via the
Dash Board to all
clinical teams
Weekly
10
Consultation and review
The policy has been circulated to members of the Infection Prevention and Control Committee
(IPCC) prior and agreed by the committee
11
Implementation of policy (including raising awareness)
On ratification of this policy a Trust electronic e-mail will be sent via OD& Training to alert Trust
personnel of the updated policy
12
References
EPIC 3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS
Hospitals in England, The Journal of Hospital Infection (2014), Loveday et al.
http://www.epic.tvu.ac.uk/
World Health Organisation (2008) 5 moments for hand hygiene (WHO, 2008)
Health and Social Care Act 2008: Code of practice on the prevention and control of infections and
related guidance. DOH (July 2015).
13
Associated documentation
This policy should be read in conjunction with the following Policies available on the intranet:
http://pandora/docs/policies/DOCUMENTS%20POLICIES/Forms/Infection%20Control.aspx
Standard Precautions for the Prevention and Control of Infection v6
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IC02 - Personal Protection Equipment in Clinical Practice Policy
IC04 - Hand Hygiene Policy
IC06 - Isolation Policy
IP07 - Sharps Policy
IP09 - Waste disposal and Recycling Policy
IC15 - Cleaning and Disinfection Policy
IC26 - Clostridium difficile and Infective Diarrhoeal Illness policy
Appendix 1:
Appendix 2:
Personal Protective Equipment (PPE) Risk Assessment for Patient Care and Specimen
Manipulation
Quality Ward Measures Audit Tool
Standard Precautions for the Prevention and Control of Infection v6
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Appendix 1
Personal Protective Equipment (PPE)
Risk Assessment for Patient Care and Specimen Manipulation
For patients known to have an infection refer to Isolation Policy as additional considerations may
be necessary
Is there a risk of potential contact with body fluids?
YES
Wear a disposable apron and gloves
Is there risk or potential risk of:
Spray Splash Spill?
YES
Wear an apron, (gown if appropriate) gloves and
facial protection
(Mask and goggles* or facial shield)
Prescription spectacles are not adequate*
Standard Precautions for the Prevention and Control of Infection v6
11
Appendix 2
Ward Quality Measures Performance Indicators for Infection Prevention & Control
Date:
Location:
Name of person completing audit including designation: ___________________________________
Please note: if you have a score of 75% or below for two consecutive weeks for any of the elements
below please inform your IPCN and Modern Matron. Commence daily measures for each element of
non-compliance until you are able to achieve 100% for 5 consecutive days.
1.Uniform/Work Attire Policy:
This week
Last week
Max score
Observe 8 members of staff* who are on duty and indicate
below how many of each of the groups have been included
in this audit.
Please reflect a mix of staff.
o Nurses
o Doctors
o Allied Health Professional
o Ward Clerks
o Housekeepers
*Adjust staff group to match your population ie. Radiographers
1.1 All staff wearing their uniforms appropriately in the
clinical area eg. No lanyards, ties tucked in, bare below the
elbow
1.2 All staff compliant with hand hygiene requirements
eg. Short finger nails, no nail varnish or false nails, no wrist
watch in the clinical setting
1.3 All staff are wearing minimal jewellery eg. No more
than a single metal band, one set of stud earrings or as per
Work Attire Policy for non-clinical working
1.4 Staff hair is neat, tidy and if providing clinical care
should be tied up with no hair hanging below the collar
with minimum fastenings.
25%
Total score
100%
2. Standard Precautions
25%
25%
25%
This week
Last week
Max score
Observe 8 members of staff as described in section 1 above
2.1 All staff are wearing an apron and gloves if performing
direct patient care where exposure to body fluids or
known/suspected infection eg. Carrying body fluids,
administration IV medications, venepuncture/cannulation,
wound or device care
2.2 Hand hygiene is performed before and after donning
apron, gloves and other items of personal protective
equipment (PPE)
2.3 Correct facial protection (masks and/or eye protection)
worn for known or suspected respiratory infection eg. TB,
Influenza, multi-resistant organism in sputum
2.4 Look in 3 household (BLACK) waste bins – ensure there
are no PPE items in the bin such as gloves, aprons, masks
Total score
Standard Precautions for the Prevention and Control of Infection v6
25%
25%
25%
25%
100%
12
3. Hand Hygiene
This week
Last week
Max score
3.1 using the Hand Hygiene audit template below
Hospital:
Ward:
Date:
Number of hand hygiene opportunities observed:
Before low risk
contact
After low risk
contact
Start time:
End time:
Observer:
Before high risk
contact
After high risk
contact
Doc
Opp
Soap
Alc
u/k
Nurse
Opp
Soap
Alc
u/k
AHP
Opp
Soap
Alc
u/k
Comments:
Compliance:
Total S+A before contact =
Total Opp before contact =
Compliance before:
%
Total S+A after contact =
Total Opp after contact =
Compliance after:
%
Total S+A low risk =
Total Opp low risk =
Compliance low risk:
%
Total S+A high risk =
Total Opp high risk =
Compliance high risk:
%
Total Soap + Alc use =
Total Opportunities =
OVERALL COMPLIANCE =
Standard Precautions for the Prevention and Control of Infection v6
%
13
4. Intravenous Cannula management
Score 20% if you are fully compliant for each
cannula in each of the elements indicated
Score 0% if any one cannula is non-compliant
o
o
This week
Last week
Max score
Number of peripheral cannula currently in situ =
Number of central venous access devices
(CVAD)currently in situ =
4.1 All patients on your ward with a cannula or CVAD in situ
are registered on Vital pack system
In areas where vital pack system is not in use the Cannula
care standard 25C is in place and/ or care standards 25A &
25B for The care of the patient with CVAD
20%
4.2 VIP scores are recorded and actioned as appropriate
during AM, PM & Night shifts for each patient’s cannula?
20%
4.3 The reason for the cannula, date and initial insertion
site, cannula size and the name of the person inserting is
recorded for each cannula
20%
4.4 The date the cannula was removed is registered on vital
pack or is recorded on the care standard
The cannula was removed within 72 hours of insertion
20%
4.5 The cannula is safely secured using a transparent
dressing
20%
Total score
5. Indwelling Urinary catheter
Score 25% if you are fully compliant for each
catheter in each of the elements indicated
Score 0% if one catheter is non-compliant
o
o
100%
This week
Last week
Max score
Number of long term urinary catheters currently
in situ =
Number of short term urinary catheters currently
in situ =
5.1 Are all the urinary catheter care documents fully
completed with aseptic insertion & date, reason for
catheterisation & sterile bag changes in line with
manufactures recommendations? (7days for sterile
bag changes). If catheter in situ from the community
is the reason & date of insertion documented?
5.2 Is the catheter drainage bag (including the drainage
tap) above the floor but below the bladder level to
prevent reflux or contamination?
5.3 Is there DAILY documented evidence that urinary
catheter care has been performed?
5.4 Is there ongoing DAILY documented evidence for the
need of the short term catheter and prompt removal
of the catheter when no longer required?
Total score
Standard Precautions for the Prevention and Control of Infection v6
25%
25%
25%
25%
100%
14
6. Equipment is clean and maintenance/cleaning
records are up to date
This week
Last week
Max score
Observe 5 individual items of equipment & score 20% if
the item is clean.
This should give an overall score of 100% if 5 individual
items of equipment are clean and the equipment record is
up to date
Substitute with 5 key pieces of equipment relevant to your
area of practice
6.1 Thermometer& Dynamap equipment
20%
6.2 Commodes/ shower chairs
20%
6.3 Blood glucose machine / urinalysis machine
20%
6.4 Linen trolleys
20%
6.5 Hoist
20%
Total score
7. Diarrhoea management
o
o
100%
This week
Last week
Max score
No patients with suspected/ known infective
diarrhoea =
No patients with DAMP record =
7.1 DAMP record page 1 assessment is fully completed,
dated and signed - including patient’s usual bowel habit,
duration of diarrhoea and the date stool sample was sent &
result if known
7.2 DAMP record page 2 implementation of precautions
sections 1 and/or section 2 are fully completed as
appropriate
7.3 Bristol stool chart is maintained daily & accurately
records the type and frequency of stools or a record of no
BA
7.4 Patients are isolated and door signs in place, if unable
to isolate the appropriate section is completed in the
DAMP record on page 2 & precautions implemented
Score 0 if patient is not isolated and no additional
precautions are in place at bedside
7.5 There is evidence of blue long sleeved gowns in use,
alcohol hand foam removed from end of bed and/or signs
in place over wall mounted dispensers, sporacidal (red)
wipes in use at the bed side
Score 0 if one of these elements is not implemented
Total score
Standard Precautions for the Prevention and Control of Infection v6
20%
20%
20%
20%
20%
100%
15
WQM
exception
section
no.
Outline improvement measures initiated
Date
implemented
Date of
review
Reviewer
1.
2.
3.
4.
5.
6.
7.
Additional comments and issues to note
Standard Precautions for the Prevention and Control of Infection v6
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