Download Hand Decontamination

Cardiff School of Nursing and Midwifery Studies
BN (Hons)
Common Foundation Programme
Module 1 – Clinical Skills
Standard Precautions
for prevention and control of infection
Guided Study
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Instructions
This guided study must be completed before the first clinical skills session to ensure
you have the relevant knowledge to maximize the potential of the practical learning
opportunity. It will take approximately 2 hours to complete. The guided study
offers some information and some questions/activities for you to complete for which
you will need to access other material. Some sources (identified in bold) are
suggested to assist you; at the end of the guided study you will find both references
and a list of other relevant sources i.e. indicative sources. Additional sources may
also be used. Particularly if you access other sources, reference your answers and
keep a full record of the source.
The guided study is a brief introduction to the substantial and very important topic of
prevention and control of infection. It will help you fulfill your responsibilities in
preventing the spread of infection by developing your knowledge and understanding
of standard precautions. “By applying standard precautions at all times and to all
patients, best practice becomes second nature and the risks of infection are
minimized”(RCN,2005.3).
Throughout the 3-year programme various aspects of this topic will be studied and
you will be assisted in correctly applying your knowledge and understanding of the
subject in both clinical skills laboratories and in clinical placements.
We hope you will find completing this guided study useful and enjoyable.
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Introduction
A healthcare-associated infection (HCAI) is an infection that occurs as a result of
contact with any aspect of a healthcare system(WHAIP 2007) Statistics published by
the National Audit Office(2000) indicated 9% of hospital patients have a nosocomial
infection at any one time and 5000 patients die as a result of hospital acquired
infection(HAI) each year. Other patients with an HAI experience a range of effects
in addition to illness; for example, anxiety and/or loss of earnings. Their families
also suffer consequences. For the health service, there are less obvious consequences
such as increased financial costs. You will all have heard about methicillin resistant
Staphylococcus aureus (MRSA) but Clostridium difficile (often referred to as c-diff)
and glycopeptide-resistant enterococci(GRE) are two other disease-causing bacteria
which are of particular current concern.
The Department of Health(2001) acknowledges that not all infection is avoidable but
emphasizes that a significant proportion is preventable. Although there are many
contributory factors to hospital-acquired infections, it is believed that up to 30% could
be avoided through better application of knowledge(WHAI 2007). To address the
problem, central and devolved government policies and guidance documents have
been published, for example, Infection Control Prevention of Healthcare-Associated
Infections in Primary and Community Care(NICE 2003) and Healthcare Associated
Infections: a strategy for hospitals in Wales(WAG 2004). Employers, industry and
professional organisations also provide policies and resources, for example; each NHS
Trust, the Infection Control Nurses Association(ICNA), and the Royal College of
Nursing(RCN).
There are three main aspects of standard precautions:

Hand Decontamination

Personal Protective Equipment

Safe disposal of Sharps and Waste
Each aspect will now be considered separately. The clinical skills sessions will
enable you to apply these within the context of working with and caring for people.
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The diagram below shows the chain of infection. You will note that without a means
of transmission, the infectious agent cannot be passed on; this includes each one of us
– you could be the means of transmission.
Remember, without a means of transmission, the infectious agent cannot be passed on
i.e. you have a key role in preventing the spread of infection.
DDirect and indirect contact transmission accounts for most hospital-acquired Direct
Direct and indirect contact transmission accounts for most HAIs.
Direct contact transmission requires body-to-body surface contact in which microorganisms are transferred between a susceptible host and an infected or colonized
person.
Indirect contact transmission involves contact of a susceptible host with a
contaminated go-between, an object that transfers the micro-organisms.
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Hand Decontamination
The aim of routine hand hygiene in the hospital ward or primary care setting is to
break the chain of infection, removing transient micro-organisms from the hands
before they can be transferred to susceptible patients (Gould 2002).
Aim:
An introduction to the principles and practice of hand washing and its importance in
the prevention of cross infection.
Learning outcomes:

To identify the major routes in the transmission of infection.

To describe the importance of hand washing in the prevention of hospital
acquired infection.

To explain the evidence base underpinning the essential principles of good
hand washing.

To describe the recommended hand washing method.
Introduction
Hand washing is a simple but effective means of protecting patients from infections.
It is universally considered to be an imperative measure in infection control and
therefore attention to hand washing is crucial in all healthcare settings(Kerr 1998).
The cleanyourhands campaign has been designed to improve compliance with hand
hygiene and therefore improve the quality of care(National Patient Safety Agency
2004). Access literature which focuses on hand hygiene, for example Storr and
Clayton-Kent(2004) and Gould(2002) and consider the following:
Activities
1. There are two main groups of micro-organisms that can be found on hands.
What are they?
How do they differ?
2. Hand washing is commonly categorised into three main types.
What are the three types?
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What are the differences between each type?
3. Nurses perform many essential and specialist activities in their every-day practice.
When should nurses wash their hands during a typical day? Identify at least four
occasions/activities.
Why should rings and wristwatches be removed?
What cleaning solution should be used and why?
Hand decontamination method
Many studies have contributed to a universal defined method of washing hands. The
technique requires at least 15 seconds to complete. After washing, the hands should
be rinsed thoroughly to avoid residual soap irritating the skin. However the
technique is much more important than the cleansing solution used(RCN 2005a).
4. Access, for example, Camm(2004) to answer the following:
When washing, which areas of the hands are commonly missed?
List the six-step decontamination technique which aims to ensure all surfaces are
cleansed:
1.
2.
3.
4.
5.
6.
Within the Clinical Skills Labs you will have the opportunity to test the effectiveness
of your hand washing technique.
Hand drying
A variety of methods are available for drying hands, but it is imperative that hands are
dried thoroughly as moisture support the living organism. The friction created whilst
drying the hands further assists the removal of organisms (Kerr 1998). Furthermore,
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failure to dry hands properly can lead to cracked skin; a potential portal of entry for
bacteria. Related to this is the importance of caring for your skin by using a good
hand cream.
5. Why are material / cloth towels not recommended for hand drying?
What is the preferred method for drying the hands and why?
6. Why is the application of alcohol hand rub encouraged following the hand
washing?
Identify at least one other occasion when it would be appropriate to use alcohol gel.
Jeanes(2005c) is a useful source to consider these points.
The National Patient Safety Agency(2004) recommends the availability of alcohol gel
at the point of care. This is not always appropriate, for example, in some child and
mental health settings. In such circumstances you will have access to personal clipon alcohol rub.
Personal Protective Equipment (PPE)
Aim:
To explore the use and role of personal protective equipment: gloves, aprons, and face
masks/visors when handling and/or in direct contact with blood and bodily fluids.
Learning outcomes:

To explain the appropriate use of gloves, aprons and face masks/visors.

To differentiate between sterile and non-sterile gloves and the indications for
their use.

To discuss the importance of hand washing before and after the use of
protective equipment.
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As you now know, hand washing is the single most effective method of preventing the
spread of infection. In addition to hand washing, in certain circumstances, protective
equipment is used to help prevent transmission of micro-organisms.
The route of transmission determines the specific equipment used.
Gloves
Gloves are worn to protect hands from contamination and to reduce the risks of
transmission of micro-organisms to patients and staff. Therefore, in deciding
whether to wear gloves or not, it is necessary to assess the risk of potential exposure
to bodily fluids, and whether the activity will involve contact with non-intact skin or
mucous membranes.
Gloves can be sterile or non-sterile:
Clean non-sterile gloves are worn when touching blood, bodily fluids, secretions,
excretions, and contaminated items e.g. sheets. Sterile gloves are worn when
carrying out aseptic procedures.
Gloves are made from various materials, for example, vinyl, latex and nitrile.
N.B. If you are allergic to latex you must inform staff prior to clinical skills
sessions and wherever you practice. Latex-free gloves are available.
Face masks and visors
These are worn when there is a risk that splashes or sprays of body fluids may come
into contact with eyes or mucous membranes.
Aprons
Non-sterile disposable aprons protect your clothing from contamination while giving
care or undertaking activities which may present a risk of contamination, for example,
helping a patient with bathing or making a bed.
Aprons also protect patients from possible contamination from your clothing, for
example, while assisting a patient during a meal.
Aprons are available in different colours. White is universally available and in some
NHS Trusts this colour is worn for all activities requiring an apron. Other employers
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may provide different coloured aprons for different activities. At the beginning of
each placement you will need to find out what protocol applies.
Activities
1. For each activity, consider what precautions would be appropriate. Tick each
relevant box.
Activity
Preparing a
Baby’s bottle
Bathing a patient
Talking to a patient
Removing a bed-pan
Feeding a patient
Making a bed
Wiping-up a spillage
Hand-washing
Gloves
Apron
Mask/visor
Now consider when it would be appropriate to wear sterile gloves or non-sterile
gloves. Again, tick the relevant box.
Activity
Removing a used sputum pot
Changing a baby’s nappy
Re-dressing a wound
Cleaning a patient’s mouth
Sterile gloves
Non-sterile gloves
2. If gloves offer both the nurse and the patient protection, why is it necessary to
wash the hands before and after using gloves? Identify at least three reasons for
washing the hands after removal of gloves.
N.B.
All protective equipment is removed and disposed of safely as soon as the activity has
been completed.
Safe disposal is considered in the final section of this guided study.
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Safe disposal of sharps and waste
Aim:
To increase awareness of the importance of safe handling and disposal of sharps and
waste.
Learning outcomes:

To identify different types of waste (clinical and non-clinical) and sharp items.

To discuss the risks and the individuals at risk when disposing of sharps and
clinical waste.

To identify and discuss the relevant health and safety and infection control
policies in relation to the safe handling and disposal of waste and sharps.

To describe safe handling and disposal of sharps and clinical waste.
It is important to differentiate between clinical and non-clinical waste as these present
different levels of risk to handlers and the public. The cost of disposing of clinical
waste is also significantly greater than non-clinical waste. As you are aware,
management of waste is a significant problem for both central and local government.
Therefore government recommendations exist to provide a framework for effective,
efficient and economic management of healthcare waste(DoH 2006) The guidance is
not mandatory therefore, as long as healthcare organisations comply with relevant
legislation, different systems may be in place. In addition, you may encounter the
recommendations being implemented over a period of time. Therefore, this guided
study will refer to both the ‘old’ and the ‘new’ recommended colour-coded
segregation systems.
N.B. Wherever you practice you must find out what system is in use and, if in doubt
as to the appropriate way to dispose of a particular item, always seek the advice of
your Mentor or other staff.
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Disposal systems
Waste is segregated into clinical and non-clinical waste. For many years staff have
differentiated between categories of waste through different coloured bags or rigid
containers: yellow for clinical waste and black for non-clinical waste.
The DoH(2006) best practice recommendations introduced a new category – that of
offensive/hygiene i.e. non-infectious (human hygiene waste such as nappies, sanitary
protection) disposed of into a yellow bag with a black stripe.
The remainder of
‘clinical waste’ i.e. infectious or potentially infectious waste is disposed of into an
orange bag.
The table below, hopefully, clarifies these two systems:
‘old’
waste type
‘new’ colour
black
domestic waste e.g. paper hand-towels
black
yellow
infectious or potentially infectious e.g. infected
orange
colour
wound dressing
yellow
offensive/hygiene waste e.g. used incontinence pad
yellow with black
stripe
The DoH(2006) guidelines also address all other clinical waste e.g.medicines. For
further information, access the full text.
Laundry is also segregated as follows:
Ordinary soiled laundry into a cloth bag.
Infected laundry or laundry soiled with bodily fluids into red plastic bag.
Laundry infected with particular organisms e.g. Hepatitis B into clear alginate bag.
The alginate bags dissolve in a high temperature wash therefore contents do not have
to be handled by laundry staff.
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Activities
1. When disposing of the following, which colour bag would you place the waste
into? N.B. Don’t be afraid to say “it depends” but justify (explain) your answer.
Waste type
A patient’s newspaper
‘old’ colour
‘new’ colour
A soiled incontinence pad
Used apron and gloves
Soiled dressing from infected wound
Sweet wrapper
Infected laundry
Used paper towels
Sharps present a different risk in that a plastic bag offers no protection to a handler,
therefore sharps are disposed of in rigid plastic boxes or bins. Sharps must be
disposed of by the user as near to the point of use as possible. Prior to the publication
of the 2006 DoH guidelines all sharps were placed in yellow sharps boxes. The
guidelines recommend segregation as follows: partially discharged sharps are placed
into a yellow sharps box; sharps not contaminated with medications or which are fully
discharged are placed into a yellow sharps box with an orange lid.
And finally…within the clinical skills laboratories and in your clinical placements you
will see posters reminding everyone of the principles of standard precautions. To
help you consider the broader application of good infection prevention and control
practice access Patel(2005) for some consideration of environmental cleaning and
Parker (2004) in which personal hygiene and some aspects of essential patient care
are discussed.
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References and Indicative Sources
Baillie L(ed.) (2005) Developing Practical Nursing Skills (2nd Edition) London:
Arnold.
Barber J (2000) Clinical Care Manual For Children’s Nursing. Dinton:Quay.
Beckford-Ball J (2004) The control and prevention of hospital-acquired infections
Nursing Times 100 ( 29) 28-29.
Bennett G Mansell I (2004) Universal precautions: a survey of community nurses’
experience and practice Journal of Clinical Nursing 13 413-421
Camm J (2004) What does it take to ensure effective hand decontamination by
nurses? Professional Nurse. 19 (12) 26–28.
Chambers C Straub M (2006) Standard principles for preventing and controlling
infection Nursing Standard 20 (23) 57-65
Cochrane J (2003) Infection control audit of hand hygiene facilities.
Nursing Standard. 17 (18) 33-38.
Cole M (2007) Should nurses take a pragmatic approach to hand hygiene? Nursing
Times 103 (3) 32-33
Collins F Hamprton S (2005) Handwashing – MRSA British Journal of Nursing 14
(13) 703-707
Department of Health (2006) Environment and sustainability Health Technical
Memorandum 07-01: Safe Management of healthcare waste London: The Stationery
Office
Department of Health (2001) The epic project: developing national evidence-based
guidelines for preventing healthcare associated infections phase 1: guidelines for
preventing hospital-acquired infections
Available at www.dh.gov.uk/en/publicationsandstatistics
Duncan C Dealey C (2007) Patients’ feelings about hand washing, MRSA status and
patient information British Journal of Nursing 16 (1) 34-38.
Godfrey K (2001) Sharp practice Nursing Times 97 (2) 22-24.
Gould D (2001) Practical Procedures No.1 Handwashing Nursing Times Supplement.
93, 37.
Gould D (2002) Hand decontamination Nursing Times 98 (46) 48-49.
Gould D (2005) Infection Control: the environment and service organization Nursing
Standard 20 (5) 57-65
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Hall S (2007) Infection control: implementing principles in primary care Practice
Nurse 33 (3) 47-51
Huband S and Trigg E (2000) Practices in Children’s Nursing; Guidelines For
Hospital and Community Edinburgh: Churchill Livingstone.
Jeanes A (2005a) Keeping hospitals clean: how nurses can reduce health –careassociated infection Professional Nurse 20 (6) 35–37.
Jeanes A (2005b) Handwashing Nursing Times 101 (27) 28–29
Jeanes A (2005c) Using alcohol handrubs Nursing Times 101 (28) 28-29
Jeanes A (2005d) Putting on gloves Nursing Times 101 (29) 28-29
Kerr J (1998) Handwashing Nursing Standard 12 (21) 35-39.
May D Brewer S (2001) Sharps injury: prevention and management Nursing
Standard 15 (32)45-52.
National Audit Office (2000) The management and control of hospital acquired
infection in acute NHS trusts in England London: Stationery Office
National Institute for Clinical Excellence (2003) Infection Control Prevention of
healthcare-associated infections in primary and community care.
Available at www.nice.org.uk
Nicol M Bavin C Bedford-Turner S Cronin P and Rawlings-Anderson K (2004)
Essential Nursing Skills (2nd Edition) Edinburgh: Mosby.
Parker L (2004) Infection control: maintaining personal hygiene of patients and
staff British Journal of Nursing 13 (8) 474-478
Patel S (2005) Minimising cross-infection risks associated with beds and
mattresses Nursing Times 101 (8) 52-53
Pellowe C Pratt R Loveday H Harper P Robinson N and Jones S (2004) The epic
project: updating the evidence-base for national evidence-based guidelines for
preventing healthcare-associated infections in NHS hospitals in England: a report with
recommendations British Journal of Infection Control 15 (6) 10-16
Pellowe C (2006) Hands up: how clean are your hands? Nursing in Practice (28) 3437
Pellowe C (2007) Implementing EPIC2 infection control guidelines Nursing Times
103 (33) 30-31
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Pratt RJ (2007) epic 2: National evidence based guidelines for preventing HCAI in
NHS hospitals in England Journal of Hospital Infection 65S:S1-S64
Rankin A Kean L (2005) Application of standard precautions in the community
setting British Journal of Community Nursing 10 (1) 503-506
Royal College of Nursing (2005a) Good Practice in Infection Prevention and
Control Guidance for Nursing Staff London: Royal College of Nursing
Available at www.rcn.org.uk
Royal College of Nursing (2005b) Guidance on uniforms and clothing worn in the
delivery of patient care London: Royal College of Nursing
Available at www.rcn.org.uk
Storr J Clayton-Kent S (2004) Hand Hygiene Nursing standard 18 (40) 45-51.
Tavolacci M Merle V Pitrou I (2006) Alcohol-based hand rub: influence of healthcare
workers’ knowledge and perception on declared use Journal of Hospital Infection 64
(2) 149-155
Trim J C (2004) Raising awareness and reducing the risk of needle stick injuries
Professional Nurse 19 (5) 259-264.
Ward D (2003) Improving patient hand hygiene Nursing Standard 17 (35) 39-42.
Weaving P (2007) Conducting a campaign to improve hand hygiene in non-acute
health care British Journal of Infection Control Feb 8 (1) 12-13.
Welsh Assembly Government (2004) Healthcare Associated Infections: a strategy for
hospitals in Wales Cardiff: WAG
Available at www.nphs.wales.nhs.uk
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Recommended web sites:
N.B. To access some information and e-learning programmes you will have to register
with the particular web-site.
www.clean-safe-care.nhs.uk
This is a Department of Health website dedicated to supporting the delivery of clean
and safe care. This offers an e-learning infection control programme.
www.handhygiene.co.uk
www.hpa.org.uk
This is the website of the Health Protection Agency. You may find the fact sheets on
infections useful at this stage.
www.infectioncontrol.nhs.uk
This offers information and various links including to www.clean-safe-care.nhs.uk
www.icna.co.uk
This is the website of the Infection Control Nurses Association
www.nphs.wales.nhs.uk
This is the website of the National Public Health Service and gives access to Health of
Wales Information Service (HOWIS), Health Protection Agency and Welsh
Healthcare Associated Infection Programme (WHAIP). The frequently asked
questions (FAQ) area of the WHAIP is a good starting point.
Via WHAIP you can also link to www.hai-champions.wales.nhs.uk for information
on the current campaign and an e-learning programme: Healthcare Associated
Infection Champion
and www.nes.scot.nhs.uk to access an e-learning module: Promoting Hand Hygiene
in Practice. At the time of writing, this module was not available but we are assured
it will be!
www.npsa.nhs.uk
This is the website of the National Patient Safety Agency. Useful resources are
available in the ‘cleanyourhands’ campaign area.
www.rcn.org.uk
This is the website of the Royal College of Nursing.
www.saferhealthcare.org.uk/IHI/Topics/InfectionControl
www.saferneedlesnow.net
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Glossary
Alcohol gel/handrub
A hand cleaning substance containing alcohol designed to reduce the number of
micro-organisms on the hands.
Decontaminate hands
Reduce the bacterial count on hands by cleaning with plain soap and water or an
alcohol based handrub.
Hand hygiene
A general term that applies to hand washing, antiseptic handwash, antiseptic handrub
or surgical antisepsis.
Hand washing
Washing the hands with an unmedicated detergent and water (or water alone) to
remove dirt and loose transient flora in order to prevent cross-infection.
Healthcare-associated infection (HCAI)
An infection that occurs as a result of contact with any aspect of a healthcare system –
health care or community setting.
Hospital-acquired infection (HAI) or nosocomial infection
An infection that develops 48 hours or more following hospital admission. An
infection which develops within 48 hours of admission is referred to a communityacquired infection; it is assumed the infection was acquired in the community(WHAIP
2007).
Micro organism
An organism too small to be seen with the naked eye. The term includes bacteria,
fungi, protozoa, viruses and some algae.
Personal protective equipment(PPE)
Clothing or equipment used to protect yourself and your patient from the risks of
cross-infection.
Sources:
www.npsa.nhs.uk/cleanyourhands
www.rcn.org.uk
www.nphs.wales.nhs.uk
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