Download infection prevention and control guidelines for general practices

INFECTION PREVENTION
AND CONTROL
GUIDELINES FOR GENERAL PRACTICES
Date Issued:
Review Date:
November 2010
November 2012
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NHS Stoke on Trent Infection Prevention and Control Team 2010
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INFECTION PREVENTION AND CONTROL
GUIDELINES FOR GENERAL PRACTICES
CONTENTS
PAGE
1.
1.1
1.2
INTRODUCTION
The Health and Social Care Act 2008 and Code of Practice
Roles and responsibilities
7
7
10
2.
LOCAL SOURCES OF ADVICE
13
3.
WHY INFECTION PREVENTION AND CONTROL IS IMPORTANT
14
4.
THE CHAIN OF INFECTION
15
5.
5.1
5.2
5.3
STANDARD INFECTION PREVENTION AND CONTROL PRECAUTIONS
What are standard infection prevention and control precautions?
Hand hygiene
Personal protective equipment (PPE)
17
17
18
21
6.
6.1
6.2
6.3
6.4
25
26
26
29
33
6.5
6.6
6.7
TRANSMISSION BASED (DISEASE SPECIFIC ) PRECAUTIONS
Service user placement/Isolation facilities
Meticillin Resistant Staphylococcus Aureus (MRSA)
Clostridium difficile
Extended spectrum beta lactamase producers (ESBLs,)
Glycopeptide resistant enterococci (GRE) and other
resistant micro organisms
Influenza
Creutzveldt-Jakob Disease
Other infections
7.
7.1
7.2
7.3
7.4
7.5
OUTBREAKS
General
Suspected food poisoning
Closure of premises
Further advice
Viral outbreaks of diarrhoea and vomiting
39
39
39
41
41
41
8.
8.1
8.2
8.3
SURVEILLANCE AND DATA COLLECTION
Infection records
Root Cause Analyisis for MRSA and Clostridium difficile
Notifiable diseases
42
42
42
43
9.
9.1
9.2
9.3
9.4
PREVENTION OF OCCUPATIONAL EXPOSURE TO INFECTIONS
Blood borne viruses and sharps
Post exposure prophylaxis
Other immunisations
Protection against tuberculosis
44
44
47
48
49
10.
10.1
10.2
10.3
ASEPTIC TECHNIQUE
What is an aseptic technique?
Principles of asepsis
Procedure
49
49
49
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CONTENTS
PAGE
11.
11.1
11.2
WOUND CARE
Aseptic dressing technique
Clean dressing technique
51
51
12.
INVASIVE DEVICES
51
13.
VENEPUNCTURE
51
14.
14.1
14.2
14.3
MINOR SURGERY
Definition
Facilities for minor surgery
Infection prevention and control practices
53
54
54
56
15
15.1
15.2
15.3
15.4
15.5
15.6
STORAGE AND HANDLING OF VACCINES
Vaccine refrigerators
Vaccines
Administration of vaccines
Disposal of vaccines
Training
Further information
58
59
59
60
60
60
60
16.
16.1
16.2
16.3
16.4
16.5
SPECIMEN COLLECTION AND TRANSPORT
Specimen collection
Handling specimens
Transport of specimens
Disposal of specimens
Further information
60
61
62
62
62
62
17.
17.1
17.2
17.3
17.4
17.5
17.6
17.7
17.8
17.9
CLEANING THE ENVIRONMENT
General
Floors and other hard surfaces
Curtains, blinds and soft furnishings
Cleaning equipment and materials
Colour coding
Cleaning schedules
Management of body fluid spillage
Deep cleaning
Key points when cleaning.
63
63
63
63
64
64
65
65
66
68
18
18.1
18.2
18.3
18.4
18.5
DECONTAMINATION OF CARE EQUIPMENT (MEDICAL DEVICES)
Good practice
Purchase of equipment
Methods of decontamination
Single use items
Decontamination of items sent for inspection/repair
68
68
68
68
72
72
19.
19.1
19.2
19.3
19.4
WASTE DISPOSAL
Legislation
Waste categories
Storage of clinical waste
Disposal of sharps
73
73
73
78
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PEST CONTROL
78
21
ADMISSION, DISCHARGE AND TRANSFER OF SERVICE USERS
79
22.
ANTIMICROBIAL PRESCRIBING
79
23.
UNIFORMS AND WORK WEAR
79
24.
24.1
24.2
24.3
24.4
24.5
OCCUPATIONAL HEALTH
Occupational health advice
Immunisations
Exclusion from work
Inoculation/needle stick injuries
Skin and soft tissue infections
80
80
81
82
82
82
25.
NEW BUILD, REFURBISHMENT AND SERVICE DEVELOPMENT
82
26.
INFECTION PREVENTION AND CONTROL TRAINING
83
27.
BIBLIOGRAPHY
83
APPENDICES
Appendix 1
Appendix 2
Appendix 3
Appendix 4
Appendix 5
Appendix 6
Appendix 7
Appendix 8
Appendix 9
Appendix 10
Appendix 11
Appendix 12
Appendix 13
Appendix 14
Appendix 15
Appendix 16
Appendix 17
Appendix 18
Appendix 19
Appendix 20
Appendix 21
Appendix 22
Appendix 23
Appendix 24
Appendix 25
Appendix 26
Appendix 27
Appendix 28
Definitions from the Health and Social Care Act 2008
Checklist for Health and Social Care Act 2008
Policy template
Statements for job descriptions
Infection Control Audit Tools
Role profile and objectives for an Infection Control Link Person
Standard precautions information leaflet
5 Moments for hand hygiene
Six stage hand washing technique
MRSA information leaflet for care workers
MRSA leaflet for service users and visitors
MRSA screening leaflet
Clostridium difficile information leaflet
Medicines which can produce diarrhoea
Bristol stool Chart
E. Coli 0157
Pulmonary TB
Chickenpox and Shingles
Scabies
Norovirus - Diarrhoea and vomiting leaflet
Flowchart- Action to take following a sharps/inoculation injury
Checklist to assess risk following a sharps/inoculation injury
Sharps poster
Action to take following sharps find
Aseptic technique poster
Antimicrobial guidelines 2010
National Patient Safety Agency Colour Coding
Example of a cleaning schedule
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119
121
139
143
145
147
149
151
153
155
157
159
161
163
165
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169
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1.
INTRODUCTION
Infection prevention and control is an essential element of high quality care. Having
effective infection prevention and control measures in place contributes to the safety
of the environment for service users, care workers and others.
These guidelines provide information that will support general practices to put in
place all the reasonable infection prevention and control measures that are required
to protect service users and care workers from infection and enable general
practitioners to meet the requirements of the Health and Social Care Act 2008.
The Health and Social Care Act 2008 can be accessed at:
www.dh.gov.uk/publications
To be consistent with the Health and Social Care Act 2008 these guidelines use the
same terms and definitions.
Service user is used to describe patients, residents and clients.
Registered providers are all organisations that provide health and social care and
include both NHS and independent healthcare providers.
Care Worker is used to refer to any employee whose normal duties involve
providing direct care to service users.
More definitions used in the Health and Social Care Act 2008 and these guidelines
can be found in Appendix 1.
1.1
The Health and Social Care Act 2008 and Code of Practice
The Health and Social Care Act 2008, Code of Practice for health and adult social
care on the prevention and control of infections and related guidance (Department of
Health 2009) requires all organisations which provide health and adult social care to
have policies, procedures and protocols in place which minimise the risk of infection.
This Act came into force in April 2009 for NHS care providers. Independent health
and adult social care will be brought into registration under the Health and Social
Care Act 2008 from October 2010.
The Code is currently being revised to cover health care providers in primary care.
Primary care providers will, as part of the registration requirements, be required to
comply with the Health and Social Care Act 2008 and Code of Practice from April
2012.
The Code of Practice is used by the Care Quality Commission (CQC) to assess
compliance with the registration requirements on „cleanliness and infection
prevention and control‟.
The Code and related guidance sets out how the Care Quality Commission will
assess compliance with the registration requirement „Cleanliness and infection
prevention and control‟ and describes how providers of care may meet the
registration requirements related to the prevention and control of infections. There
are 10 criteria that providers of adult health and social care are required to meet.
Table 1
Compliance Criteria for the Health and Social Care Act 2008
Compliance
What the registered provider will need to demonstrate
criteria
1
Systems to manage and monitor the prevention and control of infection.
These systems use risk assessments and consider how susceptible service
users are and any risks that their environment and other users may pose to
them.
2
Provide and maintain a clean and appropriate environment in managed
premises that facilitates the prevention and control of infections.
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Compliance
What the registered provider will need to demonstrate
criteria
3
Provide suitable accurate information on infections to service users and their
visitors.
4
Provide suitable accurate information on infections to any person concerned
with providing further support or nursing/medical care in a timely fashion.
5
7
Ensure that people who have or develop an infection are identified promptly
and receive the appropriate treatment and care to reduce the risk of passing
on the infection to others.
Ensure that all staff and those employed to provide care in all settings are
fully involved in the process of preventing and controlling infection.
Provide or secure adequate isolation facilities.
8
Secure adequate access to laboratory support as appropriate.
9
Have and adhere to policies, designed for the individual‟s care and provider
organisations, that will help prevent and control infections.
Ensure so far as is reasonably practical, that care workers are protected
from exposure to infections that can be caught at work and that all staff are
suitably educated in the prevention and control of infection associated with
the provision of health and social care.
6
10
A check list to help care providers assess their progress against these requirements can be
found in Appendix 2.
All providers of care must comply with other relevant legislation, such as the Health and
Safety at Work Act 1974 and the Control of Substances Hazardous to Health Regulations
(2002).
The Infection Prevention and Control Team of NHS Stoke on Trent have developed these
local guidelines to support general practices meet the requirements of the Code. By
following these guidelines general practices will ensure that they are taking all reasonable
steps to protect service users, care workers and others from acquiring infection.
In developing these guidelines the Infection Prevention and Control Team of NHS Stoke on
Trent would like to acknowledge the guidelines produced by the South West Health
Protection Agency in 2007 and those produced by NHS Highlands in 2008.
Tools to support and help organisations to effectively manage and prevent infection have
been published and should be used. The tools include Saving Lives for acute health care
settings and Essential Steps to Clean, Safe Care for non acute settings.
Both of these were published by the Department of Health in 2006 and 2007 and are
available from the Department of Health website www.dh.gov.uk
Managers and care workers in all sectors of health and social care, whether statutory or
voluntary, must be aware of their local infection prevention and control arrangements and
whom they can contact for advice, guidance or in the event of an incident. It may be that
they employ their own infection prevention and control specialist or team, or may have a
contract or informal arrangements with the local Primary Care Trust (PCT), hospital team or
Health Protection Unit.
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Many infection prevention and control problems and outbreaks can be resolved quickly if
action is taken at the earliest opportunity and advice is received from the appropriate
specialists.
Ensuring that the principles of infection prevention and control are incorporated into all
service and building developments will result in the provision of the best possible
environment for the prevention and control of infection.
Accessible policies will inform care workers and managers, of infection prevention and
control precautions and the actions that need to be taken in the event of an incident such as
a needle-stick or inoculation injury. This will also be underpinned by infection prevention
and control training.
Infection knows no boundaries and draws no distinction between service users, care
workers, professional groups or institutions. By ensuring that everyone practices a good
standard of infection prevention and control at all times they will all play their part in
reducing infection. Health care providers and their managers have a responsibility to
ensure all the elements of an infection prevention and control programme with appropriate
infrastructures are in place in their own organisation. This is a requirement of The Health
and Social Care Act 2008.
The programme should include:
The infection prevention and control measures needed in the service;
The policies, procedures and guidance that are needed and how they will be kept up to
date and how compliance is monitored;
The initial and ongoing training that care workers will receive.
The infrastructure should:
Be a record of the names and contact details of sources of expert infection prevention
and control advice;
Include guidance for care workers about the circumstances in which contact should be
made.
New guidance, legislation and regulations that have implications for control of infection are
published and updated frequently and will need to be referred to in conjunction with these
guidelines.
All care workers must have access to a written infection prevention and control policy (see
Appendix 3 for Policy template) and receive training in infection prevention and control.
The infection prevention and control responsibilities for all care workers should be included
in their job descriptions (Appendix 4) and in personal development plans.
Registered providers will need to report an annual statement/report which provides a review
of:
Any outbreaks/incidents of infection and the action taken following these;
Audits undertaken;
Risk assessments undertaken for prevention and control of infection;
Training received by care workers;
Review and update of policies, procedures and guidance.
In all care settings which deliver healthcare there should be a programme of audit of
infection prevention and control practices. (Examples of Audit tools can be found in
Appendix 5).
In case of difficulty or problem not covered by these guidelines please contact those listed
under „Local Sources of Advice‟ in Section 2 or refer to NHS Stoke on Trent Policies at
www.stoke.nhs.uk
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1.2
Roles and responsibilities
1.2.1 The Registered Provider
The owner/s of the practice are responsible under health and safety legislation for
maintaining an environment which is safe for service users, care workers and others
alike. Suitable arrangements and procedures for prevention and control of infection
will form part of the health and safety requirements.
1.2.2 The Practice Manager
The practice manager should have access to advice on infection prevention and
control from a suitably qualified and competent individual and is responsible for
ensuring that there are effective measures in place for the prevention and control of
infection which include:
The provision of up to date policies, procedures and guidelines which are
approved by local infection control specialists. These should be readily
available, understood by all members of staff and used within the practice.
Infection prevention and control training for all staff that is appropriate to their
role both at induction and on a regular basis and training records kept.
Monitoring the implementation and effectiveness of infection prevention control
policies and procedures at least annually by using standardised audit/quality
improvement tools approved by the local infection prevention and control
specialists
Designating an Infection Prevention and Control Lead for the practice.
1.2.3 The Director of Infection Prevention and Control (DIPC)
The DIPC in an organisation providing health care has overall responsibility for
infection prevention and control and is accountable to the registered provider of care.
This role is usually in NHS providers of health care.
1.2.4 The Infection Prevention and Control Lead for the organisation. (IPC lead)
The role of the IPC lead in primary care will depend on the organisational structures
and the complexity of the care provided and their role is similar to the DIPC in health
care.
Both the DIPC and the IPC lead are responsible for producing an annual
report/statement on infection prevention and control which should include:
information on incidents and outbreaks of infection;
risk assessments;
training and education of staff;
infection prevention and control audits; and
the actions that have been taken to rectify any problems
1.2.5 The Care Quality Commission (CQC)
The CQC aims to ensure that better care is provided for everyone, whether in
hospital, care homes, people‟s own homes, or elsewhere. It regulates health and
adult social care services, whether provided by the NHS, local authorities, private
companies or voluntary organisations. It also protects the rights of people detained
under the Mental Health Act. Their work brings together independent regulation of
health, mental health and adult social care. Before 1 April 2009 this work was
carried out by the Healthcare Commission, the Mental Health Act Commission and
the Commission for Social Care Inspection. These organisations no longer exist.
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1.2.6 The Health Protection Units (HPU).
The Health Protection Teams/Units (HPUs) are part of the Health Protection Agency.
The HPUs are responsible for the control of infectious disease and environmental
hazards within a county. The HPUs are comprised of Consultants in Communicable
Disease Control (CCDC) and Health Protection Nurses (HPNs)/Infection Prevention
and Control Nurses (IPCNs) and other supporting staff.
Outbreaks and incidents of infection in the community will be monitored and
investigated by the HPU and they will initiate and co-ordinate any necessary action
to limit further spread.
1.2.7 Consultants in Communicable Disease Control (CCDC) and/or Consultants in
Health Protection (CHP)
The CCDC and the CHPs are employed by the Health Protection Agency. CCDCs
are responsible for the control of communicable disease within their locality. They
may advise the local community and infection prevention and control teams on
communicable disease control including the management of outbreaks.
They are appointed as the Proper Officer of the Local Authority, which has statutory
duties and powers relating to communicable disease control.
1.2.8 Health Protection Nurses (HPN)
The HPNs are employed by local HPUs and are able to provide specialist advice on
infection prevention and control in the community when outbreaks and other
incidents occur. The local HPU is to be informed of any suspected outbreak of
infection in the community and will provide and lead the investigation and
management of the outbreak.
1.2.9 The Community Infection Prevention and Control Nurse (CIPCN)
The CIPCN is usually employed by the primary care trust (PCT) and provides advice,
education, training, policy development and audit functions to the care providers in
the PCT. The level of support given to general practices by the CIPCN will be
dependent on local service level agreements.
1.2.10 Hospital Infection Prevention and Control Teams provide an infection prevention
and control service for the hospitals. The hospital infection prevention and control
teams are comprised of an Infection Prevention and Control Doctor, who is usually a
consultant microbiologist, and Infection Prevention and Control Nurses.
1.2.11 The General Practitioner (GP)
The GP is responsible for the diagnosis and treatment of all those registered under
their care. The GP has an ethical responsibility to consider the implications of a
diagnosis of an infectious disease for the health of the public. Liaison with the
CCDC/local HPU is important in infectious disease control; the GP is responsible for
notifying the CCDC/local HPU of certain infectious diseases (see section 8.3
Notifiable Diseases).
The GP has a responsibility to prescribe appropriate antibiotics and be mindful of the
link between antibiotic prescribing and Clostridium difficile infection, for following the
local antimicrobial prescribing policy and being aware of advice from the local
Medicines Management Team, which includes the PCT pharmacy advisors.
1.2.12 Environmental Health Officers (EHOs) work for local authorities. They advise on
food safety and kitchen design, pest control and waste disposal. They are
responsible for the control of pollution and other nuisances. Their duties include the
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inspection of food premises to enforce the requirements of the Food Safety Act
1990. They investigate complaints about food and collaborate with the HPU in the
investigation of outbreaks, particularly of food or water-borne illness. They will coordinate the collection of samples and delivery to the laboratory during an outbreak
to speed the outbreak investigation.
1.2.13 Infection Prevention and Control Link Person is an employee working in a health
care setting and who has received some additional training in infection prevention
and control and is appointed by their manager to act as a link between the Infection
Prevention and Control Nurse or Health Protection Nurse and the workplace. A role
profile is available in Appendix 6.
1.2.14 Practice Staff/Care workers
Infection prevention and control is the responsibility of everyone working within the
practice although the management of this will be shared by the management team
and the designated IPC lead. All staff/care workers have a responsibility to ensure
that they:
Are aware of the location, how to access and be able to demonstrate an
understanding of the practice policies on the prevention and control of infection.
Follow the infection prevention and control policies of the practice and to work in
such a way that the infection risk to service users, themselves and others is
minimised.
Receive infection prevention and control training appropriate to their role.
Report any recurrent skin, soft tissue and other infections that may be
transmittable to service users to their line manager and occupational health
advisor.
1.2.15 Informal carers look after their partners, spouses, relatives, friends, and neighbours
on an informal basis. They often have no formal training in care, but practice staff
should be able to provide information about any care procedures they will undertake.
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2.
LOCAL SOURCES OF ADVICE
NHS Stoke on Trent
Head of Infection Prevention and Control and Infection Prevention and Control Specialist
Nurses
NHS Stoke on Trent
London House 4th Floor
Hide Street
Stoke-on-Trent
ST4 1NF
Tel: 01782 401039
Mobile : 07515190001
Mobile : 07850299914
Health Protection Unit
Health Protection Unit
West Midlands North
Crooked Bridge Road
Stafford
ST16 3NE
Tel: 01785 221158
Consultant in Communicable
Disease Control
Tel: 01785 221158
Health Protection Nurses
Tel: 01785 221158
Consultant Microbiologist
University Hospital of North Staffordshire
Pathology Laboratory
Tel: 01782 554666 (General Office)
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3.
WHY INFECTION PREVENTION AND CONTROL IS IMPORTANT
Many infections have the potential to spread in the health care environment and both
service users and care workers are at risk. In general practice activities are
undertaken which may increase the risk of infection. Infections acquired in primary
care may have serious consequences for service users, they may worsen underlying
medical conditions and in some instances may be life threatening.
Service users receiving care may have an increased susceptibility to infection due to
a number of risk factors:
Age;
Immune status;
Poor nutrition;
Underlying medical conditions such as cancer, diabetes, heart problems;
Antibiotic and other medications;
Incontinence;
Surgical procedures;
Indwelling medical devices such as urinary catheters or gastric feeding tubes ;
Breaks in the skin.
In recent years infection prevention and control has also become more of a
challenge across all health care settings due to complexity of care and the increasing
numbers of organisms that have become resistant to treatment with antibiotics.
Resistant organisms that have increased include:
meticillin resistant Staphylococcus aureus (MRSA)
Extended Spectrum Beta Lactamase producers (ESBLs).
Glycopeptide resistant enterococci (GRE).
There has also been an increase in the numbers of cases of Clostridium difficile
infection and the emergence of relatively new organisms such as E. coli 0157.
As well as the challenge posed by the emergence of resistant micro organisms many
general practices have extended their activities to include interventions that may
carry an increased risk of infection to service users e.g. carrying out minor surgical
procedures. It is essential that appropriate infection prevention and control
measures are in place to provide a safe environment that minimises the risk of
infection to all.
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4.
THE CHAIN OF INFECTION
In order for infection to occur several things have to happen. This is often referred to
as the Chain of Infection. The six links in the chain are:
The source of the micro organism – Link 1
The main types of micro organism causing human infection include bacteria (e.g.
salmonella), viruses (e.g. hepatitis A, B or C), fungi or yeasts (e.g. candida).
Infected individuals may act as a source of infection for others because the micro
organisms that are found on the skin and in body fluids could be passed on to
others.
Reservoirs for micro organisms – Link 2.
These are places where micro organisms may live and survive. Reservoirs can
include people, animals, the environment, food or water. Contaminated food may
act as a reservoir, for example if it is contaminated with salmonella or
campylobacter. If the meat is not thoroughly cooked, those eating it may become
infected. Other examples of reservoirs for micro organisms include articles such as
towels, flannels, wash bowls, bed pans, contaminated equipment etc.
The way micro organisms leave the body – Link 3
Sometimes termed “portal of exit”, this can occur in a number of ways. For example,
Clostridium difficile leaves the body in the faeces and, if diarrhoea is present, high
numbers of C difficile micro organisms and spores are excreted and can contaminate
the environment and equipment.
The method of spread of micro organisms from person-to-person – Link 4
Micro organisms are spread in several ways. These include direct or indirect contact
(including ingestion, sexual contact, mother to foetus, injection or inoculation) and
some infections are airborne and are inhaled, e.g. influenza and pulmonary
tuberculosis.
Unwashed hands are the most common way to spread infection.
Micro organisms may be present in any body fluids (excretions and secretions). If
hands come into contact with body fluids they may become contaminated and carry
micro organisms from one person to another if hands are not washed. In addition
the micro organisms can be spread from person-to-person via a contaminated
environment (e.g. dust) or equipment.
Some infections may be spread via the air, such as the cold and influenza viruses.
The infection may be spread in droplets or aerosols produced by coughs and
sneezes. Some childhood illnesses are also spread in this way.
Micro organisms enter into the body. - Link 5
This is sometimes referred to as the “portal of entry”. In order for micro organisms to
cause an infection they must gain entry into the body. Different micro organisms
have different ways of entering our bodies. For example, salmonella needs to be
ingested (eaten), others may cause infection if they are inhaled e.g. influenza.
Others, such as hepatitis B, enter the bloodstream via broken skin, injection or
sexual intercourse.
A susceptible person (person at risk of infection) - Link 6
Once micro organisms have gained entry to the body they will only cause infection if
the person is susceptible to infection. In many cases the body‟s defence
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mechanisms will prevent infection occurring. People may develop infections if the
body‟s natural defences are breached and the micro organisms are in sufficient
numbers to cause illness. Immunity to some infections can be developed after being
infected (e.g. chickenpox) or after immunisation (e.g. hepatitis B and influenza).
Certain people are more susceptible or at greater risk of infection for a variety of
reasons. People who are very young or the very old are more at risk because their
immune system may not be developed or may be less efficient. In addition, some
medications, such as steroids and cytotoxic agents can damage the immune system
and increase the infection risk as can underlying diseases such as diabetes, blood
disorders, cancer and HIV.
The Chain of Infection
Link 1
Source
Link 2
Reservoir
Link 6
Person at
risk
Link 5
Way into
the body
Link 4
Method of
spread
Link 3
Way out of
the body
Breaking the chain of infection
Breaking the chain of infection by targeting one or more links can prevent the spread
of infection. This usually involves:
Eradicating the source of infection through appropriate antimicrobial therapy;
Preventing the method of spread through infection prevention and control
measures;
 such as hand and personal hygiene;
 use of Personal Protective Equipment ;
 environmental cleaning;
 decontamination of equipment;
 disposal of waste.
Protecting the individual at risk by immunisation;
Preventing micro organisms from entering the body by:
 wearing protective clothing;
 using an aseptic technique when handling invasive devices or dressing
wounds;
 covering wounds and insertion sites with sterile dressings etc.
It will not be possible to identify all service users who have an infection. Some diseases are
infectious before any signs develop. Some infections may not show any signs or
NHS Stoke on Trent Infection Prevention and Control Team 2010
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symptoms, such as hepatitis B or HIV. Some people may carry a micro organism without
developing the infection themselves, e.g. salmonella or MRSA.
For this reason it is important for everyone to follow standard precautions at all times to
help protect service users, care workers and others from infection.
5.
5.1
STANDARD INFECTION PREVENTION AND CONTROL PRECAUTIONS
What are standard infection prevention and control precautions?
The aim of standard infection prevention and control precautions is to break “The
Chain of Infection” and they are the core measures that should be used at all times,
in all care settings, by all care workers. They are based upon the assumption that
every individual could be carrying potentially harmful micro organisms and that there
is the potential for transmission of infection.
The underlying principle of standard infection prevention and control precautions is
that:
All body fluids must be treated as potentially infectious therefore standard
infection prevention and control precautions must be followed at all times
In all situations the care worker must assess the risk of the task that they are doing,
and assess both the risks to and from the service user to themselves and others.
The two key elements of standard precautions are hand hygiene and the use of
personal protective equipment.
A staff information leaflet for standard precautions can be found in Appendix 7.
5.2
Hand hygiene
Good hand hygiene is the most important way to prevent the spread of infection. An
intact skin provides an efficient waterproof barrier; therefore everyone should look
after their skin and cover any breaks in the skin with a waterproof plaster. If skin
becomes contaminated with body fluids these should be washed off as soon as
possible.
5.2.1 What are your hands carrying?
Micro organisms found on hands may be categorised as either “resident” or
“transient”.
Resident micro organisms are:
Deep seated;
Difficult to remove;
Part of the body‟s natural defence mechanism;
Associated with infection following surgery or invasive procedures, especially
those involving implants and invasive devices.
Transient micro-organisms are:
Superficial;
Transferred easily to and from the hands;
A significant cause of cross infection;
Easily removed with good hand hygiene.
5.2.2 When should you decontaminate hands?
The point of care as the crucial moment for hand hygiene
The point of care refers to the service user‟s immediate environment in which the
care worker has contact with the service user or when treatment is taking place. This
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may be the treatment room, consulting room, or the service user‟s home. This time
represents the point when the risk of transfer of micro organisms is greatest.
To assist care workers The World Health Organisation (WHO) has identified “five
moments for hand hygiene”:
1.
2.
3.
4.
Clean your hands before touching a service user.
Clean your hands after touching a service user and the immediate surroundings.
Clean your hands immediately before an aseptic technique.
Clean your hands immediately after an exposure risk to body fluids (and after
glove removal).
5. Clean your hands after touching any object or furniture in the service user‟s
immediate surrounding when leaving – even if the service user has not been
touched.
(National Patient Safety Agency 2008)
A poster demonstrating “five moments of hand hygiene” can be found in Appendix 8.
5.2.3 Hand hygiene facilities
Hand wash facilities that include as a minimum a hand wash basin, supplied with hot
and cold water, liquid soap and disposable paper towels should be available and
easily accessible at all hand wash basins that are used by care workers for hand
washing.
A lack of appropriate facilities should be brought to the attention of the manager and
the Infection Prevention and Control Lead for the practice.
Hand wash basins used by care workers for clinical procedures should be
designated as such and have mixer taps that are wrist, sensor, elbow or foot
operated. These hand wash basins should not be used for any other purpose.
In situations where paper towels and liquid soap are not available e.g. in the service
user‟s own home there should be a portable system in place for care workers to use
e.g. a toolbox equipped with paper towels, liquid soap, aprons and gloves or a hand
hygiene kit. Hand hygiene kits are available from some companies.
5.2.4 Hand hygiene products
The products chosen must be acceptable to the users, and not have a detrimental
effect upon the skin of care workers.
Liquid soap
In most care settings, hand washing with liquid soap (preferably one that contains an
emollient) and water is all that is required.
There is no need to use antibacterial soaps.
Liquid soap dispensers should be provided. These should be wall mounted, kept
clean and maintained regularly. The dispenser should have single use cartridges that
are discarded when empty to reduce the risk of accidental contamination and cross
infection.
Soap dispensers must not be refilled or topped up.
Paper towels
Soft user-friendly paper towels should be provided for drying hands. These should
be provided in wall mounted holders that are easy to use and clean.
Cloth towels must not be used.
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Alcohol hand rubs
Alcohol hand rubs should be available for use at the point of care.
They are available in wall mounted, portable and small personal dispensers. The
most appropriate way of delivering the alcohol hand rub should be chosen and will
depend on the needs of both service users and care workers.
Alcohol hand rubs are useful in many situations especially when delivering
domiciliary care and are recommended for use to compliment hand washing with
soap and water as and when appropriate.
Alcohol hand rubs provide a quick and effective method of disinfecting clean hands
when hand washing facilities are limited.
They should be applied using the illustrated six stage technique (Appendix 9) until
the hands are dry. After using on a maximum of five consecutive occasions hands
should be washed with soap and water to prevent a build up of residue on the hands.
They are not suitable for use on hands that are soiled or during outbreaks of
diarrhoeal illness (Clostridium difficile and norovirus) when washing with soap and
water is necessary.
Alcohol hand rubs used following hand washing with soap and water can be used to
achieve hand disinfection prior to carrying out aseptic procedures including minor
surgery.
Hand wipes
Impregnated hand wipes are not as effective as hand washing or the use of alcohol
hand rub and should not be used as a substitute.
5.2.5 Hand Hygiene procedures
Hand hygiene procedures can be considered as:
Routine hand hygiene
Hand disinfection
Surgical hand hygiene
Routine hand hygiene
Ensure that the wrists and forearms are exposed by removing any items of clothing
that may hinder thorough hand hygiene.
Effective hand washing involves four stages:
Preparation – requires wetting hands under warm running water before applying
liquid soap. The solution must come into contact with all surfaces of the hands.
Washing – using soap and water and applying the recommended six stage
technique (Appendix 9).
Rinsing – under warm clean running water.
Drying – with good quality disposable paper towels.
Hands should be washed by systematically rubbing all parts of the hands and wrists
being particularly careful to include the areas of the hand which are most frequently
missed – i.e. the finger tips, finger webs and thumbs.
1. Turn on the taps using elbows if possible.
2. Wet hands before applying liquid soap. Wash hands thoroughly with liquid soap
and running water, following the recommended six-stage technique (Appendix
9). The solution must come into contact with all surfaces of the hand.
3. Rinse hands under running water, holding the hands down.
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4. Turn off the taps using the elbows. If elbow operated taps are not available, use
a paper towel to turn off the tap.
5. Dry hands thoroughly using a good quality paper towel (cotton hand towels may
harbour bacteria and should not be used). Correct hand drying is essential to aid
the removal of transient micro organisms and to protect the integrity of the skin.
Hands not dried properly may become dry and cracked leading to an increased
risk of harbouring micro organisms. Dispose of towels in a foot-operated bin
(never lift the bin lid by hand to avoid re-contamination of hands).
6. Nail brushes should not be used for routine hand washing. Nail brushes can
damage the skin leading to an increased risk of harbouring micro organisms or
dispersing skin scales. If a nail brush is necessary it must be single-use and
disposed of immediately after use.
Hand disinfection
This process should be carried out after contact with a service user with a known or
suspected infection or before contact with particularly susceptible service users. It
involves the application of an alcohol hand rub after the procedure for routine hand
hygiene described above.
Surgical hand hygiene
This process results in the destruction of transient micro organisms and a reduction
in the numbers of resident micro organisms and should be carried out:
Before invasive and aseptic procedures e.g. minor surgery, insertion of intra
uterine contraceptive devices.
Surgical hand hygiene can be achieved in two ways:
Wash hands using soap and water using the 6 stage technique and then apply
two applications of 5ml alcohol hand rub/gel. Each application should be applied
using the 6 stage technique and allowed to dry.
Wash hands using the 6 stage technique with an antiseptic hand scrub solution.
Lather well and wash all surfaces of the hands and wrists for 2 minutes, before
rinsing and drying with paper towels.
5.2.6 Hand and skin care
An intact skin is a natural barrier to infection consequently all care workers need to
be aware of the potentially damaging effects of frequent hand washing and the use
of alcohol hand rubs. Care workers should protect and maintain their skin integrity
and minimise the risk of skin irritation by observing the following:Always wet hands before applying soap.
Rinse hands thoroughly after washing to remove all traces of soap.
Use good quality paper towels to dry hands thoroughly, including the area
between the fingers.
Regularly use aqueous based hand creams to keep the skin moist and supple.
Do not wear gloves for any longer than is necessary for the task.
Always wash hands thoroughly after removing gloves.
Always wear gloves when handling blood, body fluids, secretions and excretions,
or chemicals.
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Any care worker who develops a skin irritation or allergy that may be due to the use
of hand hygiene products should report this to the care home manager, their
occupational health advisor and their GP.
5.2.7 ‘Bare below the elbow’
A “Bare below the elbow” initiative has been recommended and endorsed by the
Department of Health and has been widely adopted across the NHS. This requires
all care workers that have direct contact with service users, their equipment and
environment:
To have short sleeves;
Not to wear wrist watches, jewellery on the hands or arms other than a plain
band;
To keep nails short and clean;
Not to wear artificial nails, nail polish or nail jewellery.
Jewellery and wrist watches may become contaminated with and harbour micro
organisms, consequently care workers providing care should ensure that prior to
commencing a shift all wrist and hand jewellery apart from a plain band is removed.
5.2.8 Respiratory hygiene/ Cough etiquette
Hand hygiene is an important part of respiratory hygiene and cough etiquette. The
following measures will assist good practice –
When coughing, sneezing, wiping or blowing the nose, cover the nose and
mouth with disposable single use tissues. Dispose of used tissues immediately
into the appropriate waste stream.
Wash hands after coughing, sneezing wiping or blowing the nose, or after
contact with respiratory secretions.
5.2.9 Involving service users.
Service users must be educated on the importance of hand hygiene to reduce the
risk of cross infection to themselves and others and should ensure that care workers
responsible for delivering care have decontaminated their hands prior to any contact.
Service should be provided with information and advice on the correct six stage hand
hygiene technique (see poster in Appendix 9).
5.3
Personal protective equipment
The use of personal protective equipment (PPE) is essential for health and safety,
and offers protection both to service users and care workers. PPE is worn in
addition to normal work clothes, whether these are the care workers own or a
uniform.
Inevitably, the clothes that the care worker wears will become
contaminated with micro organisms in the course of the day. However, if PPE is
utilised when appropriate then there is little evidence that contamination of clothing
plays a major role in the transmission of infection.
PPE includes:
Gloves
Aprons
Face, mouth/eye protection, e.g. masks/goggles/visors.
Water repellent gowns
In considering what protective clothing might be necessary in any situation it is
necessary to carry out a risk assessment. This means asking whether the task that
is about to be performed gives rise to any possibility of contact or contamination with
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blood or other body fluids. If the answer is yes, then appropriate protective clothing
is necessary.
5.3.1 Risk assessment for protective clothing (Gloves, aprons and eye/face
protection).
Table 2
Low Risk
No risk of contact with
blood and body fluids
PPE not required
Moderate Risk
High Risk
Risk that clothing or skin will
be contaminated with blood
and body fluid
Apron and gloves
Risk that eyes, clothing or skin
will get splashed with blood
and body fluids
Eye and face protection, water
repellent gowns and gloves
5.3.2 Gloves
The need for gloves and the selection of appropriate ones must be based on a
careful risk assessment (refer to Table.3). This will involve consideration of the
actual task to be carried out, and the potential risks to both the service user and care
worker. Gloves should only be worn if there is a possibility that hands will have
contact with:
Blood
Body fluids
Secretions
Excretions
Mucous
Hazardous substances
An intact skin provides a natural barrier to infection. During any service user contact
considered to be “social” where there is no contact with the above, gloves are not required
and hand hygiene using the six stage technique is sufficient. The following flow chart and
table can be used to carry out a risk assessment to decide on the most appropriate glove
for the task.
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Table 3
Are gloves really necessary?
Gloves are NOT required for
procedures where there is minimal
risk of cross infection between
service user and care worker.
E.g. basic care procedures where
there is no contact with blood and
body fluids, taking recordings (BP,
temperature and pulse)
Gloves ARE required for procedures
where there is a risk of cross infection
between service users and care workers
and further risk assessment should be
undertaken
Is there a risk of exposure to blood and
body fluids?
No
Yes
Do not wear gloves
Non sterile vinyl
Is a sterile field required?
Yes
Sterile examination glove
should be used for aseptic
procedures:
Dressing surgical wounds
Inserting urinary catheters
Manipulating
Sterile surgical gloves
should be used for surgical
procedures.
Minor surgery
Insertion of intra uterine
contraceptive devices.
No
Non sterile nitrile or a
synthetic glove with
equivalent properties
should be used for:
Venepuncture
Taking Smears
Contact with blood and
body fluids
Handling specimens
Cleaning P.E.G sites
Dressing chronic wounds
e.g. – leg ulcers and
pressure sores
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Table 4
Selection of appropriate gloves
Procedure to be performed
1 Invasive
procedures
which
involve
breaking the skin involving contact with
blood or body fluids, e.g. surgery, for which
high levels of protection for the service user
and care worker are required.
2 Non-invasive procedures involving
exposure to blood or body fluids, or
exposure to excreta, such as urine, faeces,
vomit, and where there is little likelihood of
exposure to hazardous or corrosive
substances.
3 General cleaning procedures
4 Handling chemicals or other hazardous
substances.
5 Food handling
Suitable gloves
Sterile, non-powdered
surgeons‟ glove.
examination
or
For those who are sensitised to natural
rubber latex (service users and care
workers), synthetic materials must be
available e.g. vinyl, nitrile or neoprene.
Non-sterile, non-powdered well fitting
examination gloves
For those who are sensitised to natural
rubber latex, synthetic materials must be
available e.g. vinyl, nitrile or neoprene.
Polythene gloves must not be used for
clinical care.
Flock-lined household, nitrile or vinyl
gloves
If contact with blood or body fluid is likely,
wear a glove that is comparable with (2) as
outlined above.
A glove that offers the necessary
protective qualities, e.g. latex for high
resistance to water-based chemicals and
nitrile for resistance to solvents and oil
based chemicals.
Polythene if necessary
Key points for glove use
Gloves must not be re-used or washed. Liquids may penetrate through microscopic
holes in the glove, and the glove may also be damaged if it comes into contact with oils
or silicone based lotions, disinfectants or alcohol gel.
Wear gloves only when necessary. Unnecessary or overuse of gloves may result in
adverse reactions in some susceptible individuals.
Gloves must not be used as a substitute for hand washing/hand hygiene.
There is a growing incidence of latex allergy, and latex glove use is the single biggest
risk factor. Alternatives to latex must therefore be provided.
Never use gloves that contain powder, as this increases the risk of allergy.
Gloves should be changed after contact with each service user and at the end of each
procedure.
Bear in mind that it may be necessary to change gloves between tasks on the same
service user to prevent cross-contamination.
Gloves worn for a specific task must be removed before touching uncontaminated
areas, or for example, writing in notes.
Hands must be washed after gloves have been removed.
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Removing gloves
The wrist end of the glove should be held and the glove pulled down gently over the
hand, turning it inside out whilst doing so. Dispose of the gloves immediately into a
pedal operated disposal bin and dispose of in correct waste stream. (See section 19
Waste).
Wash hands immediately after removing gloves.
5.3.3 Aprons
Plastic disposable aprons should be worn whenever there is a possibility that
clothing or uniforms may be contaminated with blood or body fluids or when caring
for service users with certain infections.
A separate apron should be worn for each occasion of care given to each individual
service user. Never reuse or wash single-use disposable aprons. To prevent cross
infection change aprons between caring for different service users and between
different tasks for the same service user.
Aprons and gloves should be stored in a clean area to avoid contamination.
Removal of aprons
Remove the apron promptly after use by turning the outer contaminated side inward
and rolling into a ball. Dispose of immediately into a pedal operated bin and wash
hands.
Colour coding
It is a good idea to use different coloured aprons for different types of tasks. For
example, use white ones when required for clinical procedures, and another colour
can be worn for non clinical procedures e.g. cleaning activities. For more information
on colour coding refer to section 17.5.
This is especially important when the same care worker is undertaking different
types of tasks.
5.3.4 Face mouth and or eye protection
It is unlikely that face, mouth and or eye protection will be required routinely in the
general practice setting. One possible exception to this is the use of masks during a
flu pandemic.
Face and eye protection e.g. visors should be worn if there is a risk that blood or
body fluids may splash into the eyes.
Visors should be washed with general purpose detergent and warm water after use.
5.3.5 Water repellent gowns
It is unlikely that water repellent gowns will be required in general practice and
should only be worn if there is a risk of splashing of blood and body fluids e.g. during
home deliveries.
6.
ISOLATION OF SERVICE USERS WITH AN INFECTION
(TRANSMISSION BASED PRECAUTIONS/ISOLATION PRECAUTIONS)
In some situations it may be necessary to use additional infection prevention and
control precautions known as transmission based precautions. Guidelines related to
these circumstances are outlined in this section.
Appropriate advice can be obtained from the Health Protection Unit or the
Community Infection Prevention and Control Nurses.
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6.1
Service user placement/Isolation facilities
This is about ensuring that individual service users with specific infections are
segregated appropriately so that the risk of infection to other service users is
minimised e.g. in waiting or communal areas. This is not usually an issue in general
practice as the risk of infection is minimised by the implementation of standard
precautions, however there may be situations where a service user may be a risk to
others e.g. a child with chickenpox or a service user with influenza during a
pandemic influenza outbreak. In these circumstances arrangements should be
made to see the service user in their own home or in a separate area of the practice
away from other service users. Further advice can be obtained from the Community
Infection Prevention and Control Nurse (CIPCN).
6.2
MRSA
6.2.1 What is MRSA?
MRSA is an abbreviation for Meticillin Resistant Staphylococcus aureus. MRSA is a
strain of Staphylococcus aureus which is resistant to Meticillin or Flucloxacillin.
Staphylococcus aureus is a bacterium which can be carried on the skin; this is
referred to as colonisation. Approximately 30% of the population is thought to be
colonised with S.aureus. In these individuals the common sites of carriage are the
nose, axilla (armpit), perineum, groin, skin folds or the umbilicus. It is normally
harmless and these individuals are said to be colonised. If the micro organism gains
access to tissues it may cause infections ranging from boils and abscesses to
bronchopneumonia and septicaemia.
MRSA causes the same range of infections as non-resistant strains of
Staphylococcus aureus, but they may be more difficult to treat.
6.2.2 What is colonisation?
Colonisation with MRSA occurs when the micro organism is present e.g. in the nose,
skin folds, the axillae (armpits), groin or perineum, without any signs of infection.
The bacterium may also colonise around indwelling devices, such as urinary
catheters and Percutaneous Endoscopic Gastrostomy (P.E.G) tubes. Chronic
wounds such as pressure sores, and leg ulcers may also be colonised without
causing any invasive infection. The wound may continue to heal while colonised
with MRSA.
Healthy people are unaffected by colonisation with MRSA and may be unaware of its
presence, however should a person develop an infection it may be that the
colonising strain is responsible for the problem.
6.2.3 What is infection?
Infection occurs when the micro organism (MRSA) enters the body and causes a
host (person) response, such as pain, pyrexia, inflammation, or tissue damage.
MRSA has the potential to cause a range of infections including minor skin
infections, surgical site infections and bacteraemia. The severity of the infection will
vary depending on a number of risk factors including the individual‟s general health
and the area of the body infected.
6.2.4 The impact of MRSA in the community
Service users who are colonised with MRSA will not be aware of its presence; a
proportion however may develop an infection which requires treatment.
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MRSA may be no more dangerous or virulent than Meticillin sensitive
Staphylococcus aureus (MSSA), but it is more difficult to treat and continues to
evolve into new potentially dangerous strains.
6.2.5 MRSA in Hospitals
In UK hospitals, approximately 40-50% of all S. aureus strains from clinical
specimens are MRSA positive. MRSA is therefore endemic in the hospital setting
and may be a risk to vulnerable or debilitated older service users particularly those in
the acute stages of illness, following surgery and those with indwelling medical
devices such as vascular or urinary catheters and enteral feeding tubes.
6.2.6 How is MRSA Spread?
MRSA can be spread in two ways:Endogenous (Spread from one part of the body to another in the same person)
A service user colonised with MRSA may transfer the bacteria from one part of
the body to another through touch.
Exogenous (Spread from person to person)
This may occur via the following routes:Directly, during healthcare treatment.
Indirectly via communal shared equipment or the environment.
Service users with MRSA may contaminate objects and the environment through
aerosols or skin scales which may transfer to other service users either directly
or via care workers hands and shared equipment.
Service users may also acquire antibiotic resistant strains as a result of antibiotic
exposure.
6.2.7 Who is at risk?
Service users with the following are at greatest risk of infectionIntravenous devices;
Surgical wounds;
Chronic wounds e.g. pressure sores, leg ulcers;
Repeated hospital admissions;
Immunocompromised;
Complex medical conditions;
Multiple courses of antibiotics;
Indwelling medical devices e.g. lines, catheters, and enteral feeding tubes.
6.2.8 How should service users with MRSA be cared for?
Carriage of MRSA should not prevent discharge from hospital to a service user‟s
own home, or to a care home.
If simple hygiene measures are followed, service users colonised or infected with
MRSA are not a hazard to relatives, care workers or other service users.
The practice of Standard Infection Prevention and Control Precautions in the
care of all service users will prevent most cases of transmission of MRSA.
Good hand washing/hygiene is the most important method of preventing the
spread of infection.
Sores or wounds should be covered with an appropriate dressing which is
regularly changed. (An appropriate dressing is one that is impermeable such as
a hydrocolloid, or a vapour permeable film or membrane).
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6.2.9 Is MRSA a risk to care workers and others?
MRSA does not usually pose a risk to care workers unless they have risk factors for
infection, for example they may be immunocompromised or have skin conditions
such as dermatitis or eczema. Care workers should report any dermatological
problems to their Occupational Health Advisor and their GP.
The family and friends of affected service users should be encouraged to undertake
thorough hand hygiene; they do not need to take any special precautions and should
not be discouraged from normal social contact or from contributing to care packages.
6.2.10 Additional precautions in residential care settings
Service user‟s may share a room as long as neither they nor the person they
share with has open sores or wounds, a urinary catheter or other invasive
devices.
Service users may receive visitors and go out of the home to visit their family and
friends and for other social activities.
Service user‟s may join others in communal areas such as sitting or dining rooms
provided any wounds are covered with an appropriate dressing.
Complete procedures for other service users before attending to service users
with MRSA.
Perform dressings and clinical procedures on a service user with MRSA in the
service users room/treatment room with the door closed.
Seek advice from the CIPCN if the service user has a postoperative wound,
productive cough, urinary catheter, PEG or other invasive device.
6.2.11 Admission to hospital and outpatient appointments.
If admitted to hospital, the receiving ward/department must be informed of the
service user‟s MRSA history, even if not currently positive.
Inform the hospital staff if the service user is to attend the hospital as an
outpatient or day case.
If an ambulance is required the service should be informed but there is no
requirement for ambulance personnel to take any precautions other than
standard precautions.
6.2.12 MRSA Screening
The Department of Health recommends screening all service users that are admitted
to hospital.
It is estimated that 7% of all those who are admitted to hospital have the bacterium
on their skin or in their nose, even though they feel quite well and have no signs of
infection. MRSA screening involves testing all service users who are admitted to
hospital or attending the day case department, so that those who do carry the
bacterium can be identified. The MRSA bacterium is more likely to cause an
infection in people who are unwell, which is why it is so important to identify the
carriers before they develop an infection or before MRSA is spread to others.
By identifying those service users who are carrying MRSA when they are admitted to
hospital, they can be offered the best and most appropriate care and treatment in a
timely manner.
Care worker screening should never be undertaken except on the advice of the
Health Protection Team.
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6.2.13 Treatment and decolonisation
Skin decolonisation is the process by which the MRSA organisms that are
multiplying on the skin are removed or the number of organisms is reduced.
Topical regime for skin decolonisation of MRSA
Antiseptic body wash
The treatment should be applied daily for five days.
Wet skin before application.
Antiseptic wash should be applied neat as a liquid soap/shampoo.
Using approximately 30mls of solution, apply to the skin using a disposable cloth.
Wash vigorously from head to toe paying particular attention to known carriage
sites such as the axillae (armpits), groin, and buttock areas.
The solution should remain on the skin for at least one minute before being
thoroughly rinsed (preferably in a shower if possible).
Hair should be washed twice within the 5 day course of treatment if the service
user‟s condition allows. (N.B. Hibiscrub can change the colour of hair dyes).
Dry thoroughly using clean towels.
Towels should be laundered daily and cloths discarded after use during the
course of treatment.
Clean clothing, bedding and towels should be used after each body and hair
wash during the course of treatment.
If any treatment causes irritation, stop immediately and contact the CIPCN.
Mupirocin sensitive MRSA
Apply Mupirocin (Bactroban) Nasal using a cotton wool bud to both nostrils 3 times
per day for five days.
Mupicocin resistant MRSA
Apply Naseptin (Chlorhexidine 0.1%) cream to both nostrils four times a day for ten
days in combination with antiseptic wash for five days.
MRSA information leaflets are found in Appendices 10 - 12.
6.3
Clostridium difficile
6.3.1 What is Clostridium difficile?
Clostridium difficile is an anaerobic bacterium (i.e. does not grow in the presence of
oxygen). It is found in the large intestine and is carried asymptomatically in about
5% of healthy adults. It is also common in babies - up to two thirds of infants have it
in their intestines, but it rarely causes problems. It is estimated that as many as 20%
(one in five) of service users over the age of 65 carries C. difficile.
Individuals can be colonised with C difficile, that is carrying the organism without any
signs or symptoms of infection. C difficile colonisation is usually controlled by
healthy or “good” bacteria in the intestine which have a protective effect.
Individuals may develop illness as a result of C difficile infection and this is referred
to as CDI.
6.3.2 What are the signs and symptoms of CDI?
C. difficile is the major cause of antibiotic associated diarrhoea and colitis.
Symptoms include:Type 5-7 stool (Bristol Stool Scale Appendix 15) or stool which takes on the
shape of its container, for which no other explanation can be given;
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Fever or low grade pyrexia;
Nausea and /or loss of appetite;
Abdominal pain and tenderness;
Raised white cell count or raised levels of C- reactive protein;
Acute rising Creatinine levels;
The presence of Clostridium difficile toxins A & B in the stool sample;
Pseudomembranous colitis is seen on endoscopy.
C difficile infection can result in severe colitis leading to bleeding and ulceration of
the intestine, megacolon and at worst perforation of the bowel.
6.3.3 What causes CDI?
CDI is nearly always linked to and triggered by the use of antibiotics. The effect of
antibiotics, however, may not immediately be apparent and CDI can occur up to six
weeks after treatment.
Other factors that increase the risk are gastric
surgery/interventions, tube feeding and medications that inhibit gastric acid
production and gastric motility e. g .PPIs (proton pump inhibitors).
6.3.4 Who is at greatest risk of CDI?
Acutely ill service users in hospital who are receiving or who have had multiple
courses of antibiotics.
Any service user treated with broad spectrum antibiotics, most commonly elderly
service users with serious underlying disease.
6.3.5 How is CDI diagnosed?
Clostridium difficile infection should always be considered as a diagnosis in its own
right, not a side effect of other treatments. The following should be used to confirm or
refute the diagnosis.
An episode of diarrhoea, type 5 – 7 on the Bristol Stool Scale (Appendix 15), or
stool which takes on the shape of its container, and which cannot be attributed
to any other cause. Other causes should include dietary considerations,
any medications which may alter bowel habit, (see Appendix 14), and any
chronic bowel disease.
If no other cause can be found a stool sample should be submitted to the
laboratory. Please do not send samples of formed stool to the lab as they will not
be processed.
If the first sample is negative but symptoms persist and the service user appears
unwell send a second sample 24 hours later.
The following basic principles shown in the table below apply when CDI is
suspected. These principles comply with specific duties of the Health and Social
Care Act 2008.
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Table 5
S
I
G
H
T
Suspect that a case may be infective where no alternative cause for diarrhoea
can be identified
Isolate the service user while determining the cause of the diarrhoea.
Gloves and aprons must be used for all contacts with the service user and their
environment.
Hand washing with soap and water will be carried out before and after each
contact with the service user and their environment.
Test the stool for toxin.
6.3.6 How is Clostridium difficile spread?
A service user who has C. difficile associated diarrhoea may excrete large numbers
of micro organisms and spores in their liquid faeces. These can contaminate the
environment, surfaces and equipment used by and in the immediate vicinity of the
service user. Spores can survive in the environment for long periods and are a
potential source of hand to mouth (faecal oral) infection in other service users
particularly those receiving antibiotics.
6.3.7 What can be done to prevent the spread of Clostridium difficile?
Preventing spread relies upon six important components;
Prudent antibiotic prescribing;
Isolation of symptomatic service users;
Thorough hand hygiene with soap and water;
Appropriate use of personal protective equipment (PPE);
The use of service user specific equipment, and thorough cleaning of equipment
and the environment;
Where possible reduce the use of broad spectrum antibiotics.
In health care environments such as care homes and hospitals the service user with
C difficile associated diarrhoea should be cared for in a single room or cohort ward.
Thorough hand hygiene is essential. After caring for a service user with C. difficile
associated diarrhoea, hands must be washed with soap and water using the
recommended six stage technique (Appendix 9), alcohol alone is not sufficient.
Alcohol hand rub can be used to compliment hand washing. Always use the
recommended six stage technique immediately before each and every episode of
direct service user contact or care. (NICE 2003).
Always use gloves and aprons for direct care with the affected service user and for
other tasks carried out in the affected service user‟s immediate environment. This is
especially important when dealing with faeces or items that may be contaminated
with faeces.
6.3.8 Does CDI require treatment?
A laboratory result documenting the presence of C. difficile toxin should prompt a
service user re-assessment; however service users who do not have symptoms of
CDI will not require treatment.
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Treatment should always be based on assessment of the service user not just
the laboratory report.
Treatment should aim to control symptoms and restore normal bowel flora.
Any antibiotics that the service user is taking should be reviewed by the GP. In
mild cases of infection just stopping the antibiotics may be sufficient for the
person to recover.
Other medication such as laxatives and other drugs that may cause diarrhoea
should also be reviewed.
Anti-peristaltic agents such as Loperamide should not be prescribed.
If possible medication which inhibits stomach acid production such as proton
pump inhibitors should be reviewed and if possible discontinued.
Sometimes it is necessary to prescribe special antibiotics. The first line of
treatment is Metronidazole which has high activity against anaerobic bacteria
and may be used for up to fourteen days. For very sick service users or for
treatment failure oral Vancomycin may be used.
Ensure that fluid intake is recorded, and that it is adequate.
Use a stool chart to record all bowel movements.
If the service user‟s condition does not improve after 7 days treatment the GP
should seek advice from the consultant microbiologist.
6.3.9 Do probiotics prevent C.difficile?
The evidence for the use of probiotics is inconclusive, imprecise and has been linked
to rare but reported adverse side effects.
6.3.10 Can the service user attend hospital for diagnostic tests?
The risk of spread arises from contact with faecal material.
If the diagnostic test is not urgent it would be best to delay it until the service user no
longer has symptoms.
6.3.11 Will the presence of C. difficile delay discharge or transfer?
The service user must be free from C. difficile diarrhoeal symptoms for at least 72
hours prior to transfer to another hospital or care home. Following transfer the
service user should be monitored for a re-occurrence of diarrhoeal symptoms which
may occur in 20-30% of cases.
Service users can be discharged to their own home when they are clinically well.
6.3.12 Are repeat stool specimens required?
Repeat stool specimens for clearance are not required. The service user is not an
infection risk once the diarrhoea has ceased.
Clostridium difficile toxin may be present for many weeks after recovery from
symptoms. The laboratory will not undertake C. difficile toxin testing within four
weeks of the first positive specimen collection date.
6.3.13 Care of a service user with C.difficile infection (CDI)
All service users in a care home or hospital setting with diarrhoea should be isolated
until they have had no symptoms for a minimum of 48 hours and have passed a
formed stool/stool that is normal for them.
Standard infection prevention and control precautions should be followed by all
care workers at all times.
Remember to assist service users to wash their own hands after using the
toilet/commode/bedpan.
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In addition to standard infection prevention and control precautions:
Care workers should wear disposable gloves and aprons when carrying out any
care (i.e. not only when contact with blood and/or body fluids is anticipated).
If the affected service user does not have their own en-suite toilet, use a
dedicated commode (i.e. for their use only) which can remain in their room until
they are well.
Treat all linen as infected, and place directly into a water-soluble bag prior to
removal from the room.
Pay special attention to daily cleaning of the environment. Routine cleaning with
warm water and detergent is important to physically remove any spores from the
environment.
After cleaning with warm water and detergent, wipe all hard surfaces with a
chlorine based disinfectant (1000ppm). This is obtained by diluting Milton 1:10
or household bleach 1:100.
Ensure that visitors wash their hands at the beginning and end of visiting
It is important to ensure that you have adequate stocks of liquid soap, paper
towels, disposable gloves and plastic aprons.
Hand washing with soap and water is necessary when caring for service users
with C difficile as alcohol gel will not inactivate the spores.
6.3.14 When can these extra precautions be stopped?
It is not necessary to send further stool samples to the laboratory to check whether
the service user is free from infection. Additional precautions can be stopped when
the service user has been completely free from symptoms for 48 hours and a normal
formed stool/normal for that service user has been passed. The additional isolation
precautions can also be stopped at this time.
Symptoms may recur in about one in five people, so if this happens, inform the GP
and recommence all precautions.
An information leaflet for Clostridium difficile can be found in Appendix 13
6.4
Extended spectrum beta lactamase producers (ESBLs), Glycopeptide resistant
enterococci (GRE) and other resistant/ multi resistant micro organisms
Over recent years there has been an increase in the number of micro organisms that
are becoming resistant to antibiotics. These include extended spectrum beta
lactamase producers (ESBLs) and Glycopeptide resistant enterococci (GRE).
Glycopeptides are a group of antibiotics which include vancomycin and tiecoplanin.
Although these micro organisms have the ability to cause infection most service
users identified with them will be colonised rather than infected and will not require
treatment.
The infection prevention and control measures are similar to those for MRSA.
6.4.1 What is an ESBL?
ESBL an abbreviation for extended spectrum beta lactamase. ESBLs are not
organisms in their own right, but are the name given to a number of bacteria that
release enzymes which make the bacteria resistant to antibiotics. The types of
bacteria commonly associated with ESBL production are organisms which normally
inhabit the bowel such as Escherichia coli or klebsiella. The bacteria are then
referred to as an ‟ESBL producers‟. ESBLs are resistant to nearly all antibiotics and
treatment options are very limited.
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6.4.2 Glycopeptide-resistant enterococci (GRE)
GRE are bacteria that are commonly found in the faeces of humans and animals.
Two main types may cause disease in humans: Enterococcus faecalis and
Enterococcus faecium. In recent years some species of enterococci have become
resistant to certain antibiotics, especially glycopeptides.
In the past these organisms were known as Vancomycin-resistant enterococci (VRE)
but today they are known as Glycopeptide-resistant or GRE. These organisms tend
to cause colonisation rather than infection, though some, more vulnerable people
may develop more serious infection such as urinary tract infection and bacteraemia
(blood infections).
Infection is often linked with the presence of invasive devices such as catheters and
intravenous (IV) lines. Antibiotics are available to treat these infections. GRE can
live harmlessly in the gut of healthy and sick people. Its presence doesn‟t
necessarily need treatment with antibiotics. People who are more at risk of acquiring
and becoming infected with GRE include service users needing intensive care, those
with immunosuppression (oncology, haematology and transplant patients), those
undergoing abdominal or cardiovascular surgery or renal dialysis and those with
invasive devices such as IV lines and urinary catheters.
6.4.3 How are ESBLs, GREs and other resistant micro organisms spread?
They may be passed from person to person by direct contact with a person who has
an infection or carries the bacteria in their gut or on their skin. They may also be
transmitted by contact with equipment and environmental surfaces that have been
contaminated with the bacteria.
As many of these resistant organisms live in the gut, service users who are
incontinent may be a greater risk to others.
6.4.4 How can spread be prevented?
In residential settings and hospitals, service users with resistant micro organisms
should have their own room.
The simplest but most effective measure in preventing the spread of
infection is thorough hand hygiene.
In addition to standard precautions aprons and gloves should be worn for contact
with the service user and their immediate environment. Wear gloves and aprons
for handling body fluids, excreta, stomas, linen, waste etc. Discard on leaving the
service user and wash hands.
Hands must be washed after giving any care or after handling linen and waste.
Alcohol hand rubs should be used following hand washing with soap and water.
Dispose of urine or faeces promptly and with care.
Use of a washer/disinfector for cleaning bedpans and commode pans.
Use an aseptic technique when dealing with invasive devices (e.g. Hickman
lines), catheters etc.
Maintain high standards of environmental cleanliness.
Clean equipment after each and every episode of use.
Designate equipment for the colonised/infected service user.
No special precautions are needed with crockery and cutlery.
If the service user is admitted to hospital or another residential setting, inform the
care worker about the resistant micro organism so they can take appropriate
precautions.
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6.4.5 Who is at risk of acquiring resistant micro organisms?
Frail service users in hospital or care homes particularly those with long term
indwelling devices such as a urinary catheter are most at risk. The device may
become colonised with bacteria creating a potential reservoir for infection. The
following factors further increase the risk:Old age;
Multiple courses of antibiotics;
Prolonged hospital stays or intensive care admissions;
Prolonged illness or complex medical conditions e.g. renal dialysis service users;
Those in long term residential care.
6.4.6 Are care workers at risk of acquiring resistant micro organisms?
Care workers may pick up these micro organisms on their hands and clothing when
caring for a colonised or infected service user. By following standard precautions the
risk of care workers becoming colonised is minimised and these micro organisms are
readily removed by hand washing and laundering.
Healthy people are not at risk from these micro organisms.
6.4.7 Will the service user require treatment?
Service users who are colonised with no signs of infection will not require any
treatment.
In care homes and in the community, the risk of serious infection from resistant
micro organisms is very small and treatment is rarely needed.
The GP should contact the microbiologist to carry out a risk assessment for each
affected service user
6.4.8 Does the service user require isolation?
In residential care settings the service user does not need to be confined to their
room. All clinical procedures should be carried out in the service user‟s room. It is
important that urine and faeces can be managed and contained and that standard
infection prevention and control precautions are followed. Any spillages should be
cleaned away immediately (i.e. clean with general purpose detergent, followed by
wiping over with hypochlorite solution).
6.5
Influenza
6.5.1 What is influenza?
Influenza is a viral respiratory infection that tends to occur during the winter months.
The two main types of influenza causing disease in the UK are influenza type A and
B, but new strains and variants of the virus emerge each year. The incubation
period is 2-3 days and cases are infectious from 1 day before the onset of symptoms
and for up to 5 days after the onset. Outbreaks may occur in communities and
communal settings such as schools and care homes.
When the number of cases exceeds that normally expected, this is defined as an
epidemic. If a completely new strain of influenza virus emerges, to which the
population has no previous immunity, it may result in a global outbreak, known as a
pandemic, which can affect large numbers and have a high death rate.
The onset of influenza is sudden with a high fever (> 38.9 0C), dry cough, headache,
aches and pains in the joints and muscles, chills and a general feeling of tiredness.
Fever usually reduces after the second day and the nose may become stuffy and a
sore throat may develop. People with influenza should stay at home and rest, drink
plenty of fluids and may find symptom relief with painkillers, cough mixture etc.
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Antibiotics are not required unless there is also a bacterial infection.
6.5.2 Who is at risk?
Most people recover from influenza within a few days. However, influenza may be
serious in newborn babies, people aged over 65 years and people of any age with
existing chronic diseases.
High-risk conditions include people with cardiac,
respiratory, renal and liver disease and those with impaired immune systems.
Bronchitis and secondary bacterial infections such as pneumonia can result in
hospital admission and can be life-threatening.
6.5.3 How is influenza spread?
Influenza is highly infectious and is one of the most difficult infectious diseases to
control because the virus spreads rapidly and easily from person to person. This is
through two routes:
Direct via droplets expelled from infected people (coughing, sneezing and
talking) which land on the mucous membranes of other people and enter the
body.
Indirect via hands touching contaminated surfaces, and then touching the nose,
mouth or eyes.
The infection spreads easily within households and settings such as care homes and
other institutions where individuals live or work in a shared environment.
The good news is that careful hand hygiene and environmental cleaning can easily
deactivate the virus.
6.5.4 How can influenza be prevented?
Each year a new influenza vaccine is developed which provides immunity against
the strains of influenza circulating that year. Every autumn the vaccine is offered to
anyone aged over 65 years, people with a high-risk condition and their carers,
people residing in care homes and front-line health and social care staff. Antiviral
drugs can be offered to at-risk groups when influenza is circulating in the community.
Health and social care teams should report any suspected cases in their care to the
GP and any clusters to the Health Protection Team.
6.5.5 How can the spread of influenza be avoided?
People with influenza should:Try to stay away from contact with others during the infectious period;
Stay in their own room, if living in a care home;
Use disposable tissues and wash hands after coughing and sneezing.
Carers should:
Wash their hands after giving care, handling used tissues or items contaminated
with respiratory secretions;
Keep the environment clean.
6.5.6 Pandemic flu – what is it?
Pandemic flu is when there is a worldwide outbreak of flu. This happens when a
new flu virus that is able to spread easily from person to person emerges. Because
the virus is new, the human immune system will have no pre-existing immunity, and
the majority of the population will therefore be susceptible. This makes it likely that
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people who contract pandemic flu will experience more serious disease than that
caused by seasonal flu.
There were three worldwide flu pandemics in the last century in:
1918/1919 “Spanish flu”
1957/1958 “Asian flu”
1968/1969 “Hong Kong flu”.
These pandemics were caused by new subtypes of flu that were probably formed by
a combination of genes from both avian (bird) and human flu viruses. There is
concern that the currently circulating strain of avian influenza/bird flu (H5N1) may
combine with another strain, or adapt to the human body and result in a pandemic.
Pandemics of the previous century spread around the globe in six to nine months,
but because of the speed of international travel today, it would probably reach all
continents within three months or less
6.5.7 Swine Flu
H1N1 Is a new sub type of influenza that emerged as a result of changes to the
swine flu virus that had been circulating in the United States. These changes have
meant that it is now able to infect humans and can spread easily from person to
person.
As it is a new sub type very few people have been exposed or have developed
immunity to it so large numbers of the population will be susceptible and it is for this
reason and extent of spread across the globe that the World Health Organisation
declared a Pandemic in 2009.
All front line care workers and those at greatest risk were offered swine flu vaccine.
6.5.8 What can be done to prepare?
As a provider of community care, it is important that you have a plan prepared in the
event of an outbreak of pandemic influenza.
If a vaccine is available for the strain of flu causing the pandemic both service users
who are perceived to be at a greater risk and care workers will be offered vaccine.
All care workers who have direct contact with service users should be encouraged to
have the vaccine. This should minimise the impact of the pandemic on the service
provided by the practice.
The service will have to be managed with fewer care workers, as it is expected that
in a pandemic, healthy younger people will also be infected. Over the course of the
pandemic up to 50% of the population may become ill, and care workers will be off
work, either because they are ill themselves, or because they are caring for relatives.
The plan should include how to cope with this situation. Identify which aspects of the
service are essential and must carry on, and which might be stopped if necessary.
How many care workers do you need to do the basics?
Other very practical issues are:
Health and Safety - you still have a duty to protect your employees;
Training and education - for care workers who may be asked to take on
alternative roles;
Staff welfare - e.g. sick leave policy, protecting those most at risk such as
pregnant women;
Parents - what to do if schools close.
Identify a person within the practice that can start writing your plan.
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A wealth of guidance has been published nationally and regionally is updated
regularly and is available at:
www.dh.gov.uk/
In the event of future pandemics guidance will be issued at global, national and local
levels for all health care providers including those in general practice.
6.6
Creutzfeldt Jakob Disease (CJD)
6.6.1 What is CJD?
CJD is rare and fatal degenerative brain disease. It is thought to be caused by
infectious proteins known as prions, which are very resistant to conventional
disinfection and sterilisation processes. It has a long incubation period, up to 25
years, and causes sponge-like gaps to appear in the brain tissue. CJD cannot
spread by normal contact.
There are 4 types of CJD:Variant CJD (vCJD) generally affects younger people and early symptoms
include personality changes and psychological symptoms.
It has been
associated with exposure to the prion agent responsible for Bovine Spongiform
Encephalopathy (BSE).
Sporadic CJD is currently the commonest form of CJD occurring randomly in
the community and affecting about 50 people per year. It usually affects people
over 45 years of age.
Familial CJD is responsible for about 15% of cases and is inherited. It is caused
by mutation in the prion protein gene.
Iatrogenic CJD is acquired during medical treatments, particularly in the 1970s,
such as grafts of human dura mater and corneas, administration of human
pituitary derived growth hormone and the use of contaminated instruments
during surgery.
The long pre-clinical phase is followed by clinical features, which vary depending
upon the type of CJD. The symptoms are progressive and there may be rapid
deterioration.
CJD can attract a great deal of media interest, so service user confidentiality is
essential.
Symptoms commonly include:Personality changes and loss of intellect and memory;
Sensory and motor neurological deficits;
Myclonic jerks, chorea, or dystonia;
Difficulty speaking, swallowing, moving and incontinence;
Coma and death.
6.6.2 Infection prevention and control precautions
In the community there is no risk of the spread of CJD and no special infection
prevention and control measures are required.
Use standard infection prevention and control precautions, e.g. the use of
protective clothing, washing of contaminated clothes and linen, care with sharps
and waste.
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Provide relatives with protective clothing for handling body fluids and information
about the importance of hand hygiene and infection prevention and control.
Health care workers should assess all service users for the risk of CJD prior to
any invasive procedure.
Use single-use, disposable items. This is especially important during procedures
involving the nervous system, such as lumbar puncture, and certain dental
procedures.
After death, place the body in a body bag labelled with a “danger of infection”
sticker. The funeral director should not embalm the body, but may carry out
cosmetic work as usual. Relatives and friends may view the body and touch it as
normal. There are no restrictions on burial or cremation.
Liaise with the Health Protection Unit for more information and support. The HPU
will contact the CJD Incidents Panel re any previous high risk procedures.
6.7
Other infections
Information on other infections that may occur in the community and cause
outbreaks can be found in Appendices16-19.
E Coli 0157
Pulmonary TB
Chickenpox/shingles
Scabies
7.
7.1
OUTBREAKS
General
In the community setting several individuals may become ill with the same infectious
disease. If these cases are linked in time, place and person an outbreak may be
suspected. The GP and other care workers in primary care have important roles to
play in the early detection of such outbreaks and should contact the Health
Protection Agency if an outbreak is suspected so that appropriate action can be
taken at the earliest opportunity to prevent further spread.
7.1.1 General control measures
Different infectious diseases are spread in different ways. By using standard
infection prevention and control precautions outlined in section 5, the risk of
transmission of infection from body substances (such as blood, faeces, urine etc.) is
very much reduced.
7.1.2 What is an outbreak?
An outbreak is defined as two or more linked cases of the same infection. These
cases may be connected in time, place or person.
Practice staff should be aware of the micro organisms that have the potential to
cause outbreaks such as norovirus, salmonella, E. coli 0157 and influenza.
Care workers should also be aware that a potential outbreak does not depend on
having received positive laboratory results; the presence of similar symptoms in two
or more connected cases is sufficient. Seek advice promptly rather than worrying
about „false alarms‟.
7.1.3 Action to take if an outbreak is suspected
If a general practitioner suspects an outbreak they should inform the Health
Protection Agency and the PCT Infection Prevention and Control Nurse. In
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community settings The Health Protection Team will advise on any infection control
measures that need to be taken to manage the outbreak and prevent further spread.
7.2
Suspected food poisoning
Gastro-intestinal illnesses which result in diarrhoea and or vomiting may have many
causes including viruses, bacteria, toxins and chemical contaminants. Causative
infective micro organisms include campylobacter, Clostridium difficile,
cryptosporidium, E coli 0157, giardia, Norovirus, salmonella, shigella, etc. The
symptoms vary depending upon the cause of the infection. Some cause mainly
vomiting whereas others cause mainly diarrhoea. Other possible symptoms may
include abdominal pain, nausea or fever and bloody diarrhoea. Infections may have
an incubation period of a few hours, or several days. Some infections resolve
without treatment whilst others need to be treated.
Micro organisms that are most likely to cause food poisoning are:
Campylobacter
Salmonella
E Coli 0157(Information on E coli 0157 can be found in Appendix 16)
Clostridium perfringins
Staphylococcus aureus
7.2.1 How is food poisoning spread?
Food poisoning can be spread in the following ways:
Many raw foods such as meat, poultry and raw eggs contain harmful micro
organisms or toxins. These are destroyed during cooking and it is only if the
food is not going to be cooked further or eaten raw that the micro organisms and
toxins will not be destroyed and may cause illness.
A food handler with a gastrointestinal disease, or who does not practice good
hygiene, can spread micro organisms onto the food.
Humans and animals can also be sources of infection and infection can spread
by contact with infected diarrhoea or vomit; or indirect contact with the
contaminated environment - the micro organisms being passed to the mouth and
ingested.
If it is suspected that the outbreak may be a result of food poisoning the General
Practitioner must inform the Health Protection Unit and the Proper Officer of the
Local Authority, usually the CCDC (see section 8). The Health Protection Unit will
make an initial assessment to see whether the suspected outbreak is likely to be due
to a viral infection or food poisoning. Any of the following should be reported as a
suspected outbreak of food poisoning:
Any service user diagnosed as having salmonella, campylobacter or other food
related infection.
Diarrhoea and/or vomiting in two or more cases in the same environment e.g.
place of work, school or care establishment.
Any service user diagnosed by a doctor as having food poisoning.
It is much better to be cautious, and to report early, rather than to wait until there is a
major problem.
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7.3
Closure of premises
In the event of an outbreak of any gastro-enteritis, food poisoning or other
communicable disease in the community the Health Protection Unit will be
responsible for the investigation and management of the incident. The HPU will
advise on the infection prevention and control measures required. If the outbreak
occurs in a residential care home the HPU will advise them to stop admissions, day
care and transfers to other homes or hospitals.
If the outbreak is associated with other institutions or premises e.g. schools, hotels,
farms, the HPU will advise whether or not premises should be closed whilst
investigations are in progress. The Health Protection Unit will declare when any
outbreak is over.
7.4
Further advice
Further advice about any infectious disease can be obtained from the Health
Protection Unit, during normal office hours.
On-call Public Health Specialists may be contacted for emergency infectious disease
matters out of normal working hours (See section 2 for contact details).
The Health Protection Agency website provides up to date information about a wide
range of infections and diseases. Visit http://www.hpa.org.uk.
In addition, the local authority Environmental Health Teams may have a range of
information leaflets available on food-related illnesses.
7.5
Viral outbreaks of diarrhoea and vomiting
Outbreaks of vomiting and diarrhoea caused by viruses, usually norovirus, have
unfortunately increased substantially in recent years.
These infections can occur in all settings especially where individuals live and work
in a shared environment. In hospitals they can cause a major disruption to activities.
Outbreaks have been reported in:
Hospitals and other care facilities
Schools and nurseries
Prisons
Cruise ships
Hotels
To identify outbreaks of diarrhoea and vomiting specimens should be sent if the
service user has diarrhoea that is not attributable to any known cause e.g. aperients,
P.E.G feed, other medications (Appendix 14).
Norovirus is highly infectious. It can be spread by the faecal oral route, via aerosols
that are produced when people vomit, and by touching surfaces and objects that are
contaminated with virus particles that are excreted in vomit and faeces.
The incubation period is 12 to 48 hours and the disease normally resolves within 48
hours. Elderly service users may suffer more adverse effects and may develop
problems with hydration and nutrition.
7.5.1 Symptoms of norovirus infection
Vomiting, which may be projectile;
Nausea;
Diarrhoea;
Headache;
Fever;
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Muscle aches;
Service users and care workers affected.
The illness usually lasts for between 24 and 48 hours, and treatment is directed
mainly at ensuring that service users do not become dehydrated.
7.5.2 Prevention of Spread
Particular attention to good hygiene measures is essential and during outbreaks
of norovirus it is important to wash hands with soap and water as alcohol rubs
alone are ineffective. Alcohol rub can be used to complement washing with soap
and water.
Use of PPE
Enhanced environmental cleaning with a hypochlorite (bleach) solution (see
section 17).
Individuals with symptoms should remain off work/school until they have been
symptom free for 48 hours.
In care homes and other residential settings service users should stay in their
own rooms until they have been symptom free for 48 hours.
7.5.3 Hospital Admission
Having a diagnosis of noroviris is not an indication for admission to hospital. There
is no specific treatment for norovirus and most people will recover within 24-48
hours.
The only indication for admission from a care home setting is if the service user‟s
specific needs cannot be addressed.
If service users develop problems with nutrition and hydration the community matron
should be contacted and they may be able to provide advice and support that will
prevent unnecessary admission to hospital thereby reducing the risk of further
spread.
8.
8.1
SURVEILLANCE AND DATA COLLECTION
Infection Records
Although there is no statutory requirement for GPs to keep infection records it is
good practice to keep a record on the number of cases of service users with specific
infections such as MRSA, Clostridium difficile and other multi resistant organisms.
This will help the practice identify any trends within their service user population and
may be included in the annual report/statement of the Infection Prevention and
Control Lead for the practice.
8.2
Root cause analysis (RCA) for MRSA and Clostridium difficile infections
Mandatory reporting requires that the organisation reports all MRSA bacteraemias
and new cases of Clostridium difficile infection (CDI) to the Department of Health;
this is undertaken by UHNS Pathology Laboratory on behalf of Combined Healthcare
and the North Staffordshire PCTs.
All MRSA bacteraemias are classed as Serious Untoward Incident (SUI) and are
reported to the Strategic Health Authority, each case has to be investigated to
determine the possible cause of the bacteraemia. Patients admitted to the UHNS
who are admitted with or develop the bacteraemia within 48 hours of admission are
considered to be community acquired and will be investigated by primary care staff.
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All MRSA bacteraemia and new cases of CDI must be investigated within 10 days of
notification using the Root Cause Analysis (RCA) process. The person undertaking
the investigation should be the clinician responsible for the service user or a senior
member of the clinical team. Within a community setting this may be the general
practitioner, matron, ward manager or district nursing caseload holder.
The nominated member of staff undertaking the investigation must use this standard
documentation pack provided by Combined Healthcare and the North Staffordshire
PCTs. The documentation facilitates the summary of information and prompts the
questions which may assist in identifying the possible cause of the bacteraemia or
CDI.
8.3
Notifiable Diseases
Doctors (usually the GP) attending service users with certain infectious diseases
(see the list below), whether confirmed or suspected, are obliged to notify the Health
Protection Unit using a standard form available from the Health Protection Unit.
Cases of other infectious diseases, which are not statutorily notifiable, (e.g. scabies
and influenza) should also be reported when an outbreak is suspected.
Prompt notification and reporting of cases of infectious disease is essential for the
monitoring of infection and assists with investigation and outbreak control.
Under the Public Health (Control of Disease) Act 1984 and the Public Health
(Infectious Disease) Regulations 1988, certain diseases are notifiable to the Proper
Officer of the Local Authority, usually the CCDC at the Health Protection Unit.
Statutory Notifiable Diseases (to Local Authority Proper Officers) under the Public
Health (Infectious Diseases) Regulations 1988 are:
Acute encephalitis
Acute poliomyelitis
Anthrax
Cholera
Diphtheria
Dysentery
Food poisoning
Leptospirosis
Malaria
Measles
Meningitis
Meningococcal septacaemia (without meningitis)
Mumps
Ophthalmia neonatorum
Plague
Rabies
Relapsing fever
Rubella
Scarlet fever
Smallpox
Tetanus
Tuberculosis
Typhoid fever
Typhus fever
Viral haemorrhagic fever
Viral Hepatitis (Hepatitis A, B or C)
Whooping cough
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Yellow fever
Leprosy is also notifiable, but directly to the HPU
It has been agreed that although the following diseases are not statutorily notifiable,
nevertheless, the Consultant for Communicable Disease Control should be informed
of their occurrence:
AIDS
Psitticosis
Legionnaires‟ Disease
CJD
Listeriosis
9.
PREVENTION OF OCCUPATIONAL EXPOSURE
All practices should have policies/procedures in place to ensure that care workers
are protected from occupational exposure to micro organisms, particularly those that
may be found in blood and body fluids. Service users must also be protected from
any communicable diseases that care workers may have.
9.1
Blood borne viruses
In NHS settings, sharps injuries are one of the most common types of injury to be
reported to occupational health departments.
Blood borne viruses can be
transmitted when blood or body fluid from an infected person comes into contact with
tissue/body fluids of another person. Of main concern are those agents that persist
in the blood of a carrier who may be unaware and be without symptoms, the main
agents are blood borne viruses including Hepatitis B (HBV), Hepatitis C (HCV) and
Human Immunodeficiency Virus (HIV), which can be the cause of Acquired Immune
Deficiency Syndrome (AIDS).
Body fluids, which may pose a risk of Blood-borne Virus Infection if significant
occupational exposure occurs, are:
Amniotic fluid
Cerebrospinal fluid
Human breast milk
Pericardial fluid
Peritoneal fluid
Pleural fluid
Saliva in association with dentistry (likely to be contaminated with blood, even
when not obviously so)
Synovial fluid
Unfixed human tissues and organs
Any other body fluid if visibly bloodstained
Exudate or other tissue fluid from burns and skin lesions
Semen
Vaginal Secretions
9.1.2 Risk of Infection to health care workers
Hepatitis B & C
The Hepatitis B and C virus is transmitted by blood and body fluids from an infected
person and may enter through the eyes, mouth or breaks in the skin. It is
recommended that care workers who have, or are likely to have, contact with blood
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and body fluids, secretions and excretions, are immunised against the Hepatitis B
virus.
There is no vaccine available for protection against Hepatitis C
Human Immunodeficiency Virus (HIV)
HIV is less transmissible than HBV/HCV but is transmitted in the same way.
Acquired Immune Deficiency Syndrome (AIDS) is an alteration in the cellular
immune system of a previously healthy person, causing the person with the disease
to become susceptible to infection.
9.1.3 Sharps and Inoculation Injury
Inoculation injuries are the most likely route for the transmission of blood borne
viruses and other infections in the health care setting.
A sharps/inoculation injury is when someone‟s blood or body fluid gains access to
another person‟s blood or tissue. This may be caused by:A cut or puncture of the skin by a contaminated sharp;
Splashes to the eyes, nose and mouth from blood or body fluids;
Contamination of a care worker‟s broken skin e.g. scratches, cuts, eczema by a
service user‟s blood or body fluid;
Bites which break the skin and draw blood.
Most cases of occupationally acquired HIV have arisen following injury from hollow
needles, and great care must be taken when handling ALL sharps.
Body fluids splashed into the eye or mouth may also transmit infection.
Remember – all sharps injuries are potentially preventable
Sharps include items such as needles, blood glucose lancets, ampoules, sharp
surgical instruments, used razor blades and disposable razors that may be
contaminated with blood or other body fluids.
9.1.4 Reducing the risk of sharps/inoculation injuries
Use of personal protective equipment (refer to section 5) will reduce contamination of
skin and clothing with blood and body fluids. The greatest risk of a blood borne virus
(BBV) being transmitted is as a result of a sharps injury, especially those resulting
from injury with a hollow bore needle where blood may remain. Transmission of
BBVs may also result from contamination of mucous membranes with splashes of
blood/body fluids. There is no evidence that BBVs can be transmitted through
intact skin.
9.1.5 Sharps containers
Sharps containers must be of a type UN approved, correctly assembled and never
be over-filled, i.e. above the manufacturer‟s fill line, or ¾ full. The container must be
puncture resistant and leak proof. It must be stable and provided with a handle and
an aperture which will inhibit the removal of the contents, but will ensure that it is
possible to dispose of items safely.
It is the responsibility of the person using the sharp to dispose of it correctly.
9.1.6 Safe use of sharps
The safe handling and disposal of sharps is paramount in reducing the risk of
exposure to blood borne viruses and extreme care must always be taken when using
and disposing of sharps.
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Avoid using sharps, including pen injecting devices when administrating
medication to service users, wherever possible (e.g. use a system such as
Vacutainer for venepuncture or Unistix for finger pricking).
Wear disposable gloves when handling sharps.
Always request assistance when using sharps with an uncooperative service
user and use safe needle devices.
Assemble containers following manufacturer‟s instructions.
Label sharps containers when assembling them.
Sharps containers must comply with UN3291 and BS7320: 1990.
Sharps containers must be kept off the floor, away from children, and
inaccessible to unauthorised persons. Do not place them on the floor, window
sills or above shoulder height.
Secure containers using brackets attached to the wall or a trolley.
Place sharps containers of a suitable size on a level surface in each location
where sharps are used.
Discard all sharps into a sharps container at the point of use.
Never leave needles or any other sharps lying around.
Never walk about with unguarded sharps.
Do not pass an exposed sharp to another person.
Clinical sharps should be single-use only.
Needles must not be resheathed.
The user of sharps must discard them directly into a sharps container.
When carrying a sharps container, or whenever the container is left unattended,
use the temporary closure to prevent spillage or tampering.
Carry sharps containers by the handle or on a tray, do not hold them close to the
body.
Do not dispose of wrappers, cotton wool, etc in sharps boxes as this may
prevent the sharps being dropped in directly, and may cause an injury if
someone tries to force a sharp in.
Do not attempt to retrieve items from a sharps container.
Do not attempt to press down upon sharps to make more room.
For more information on the disposal of sharps containers see section 19.4.
9.1.7 Assessing the risk following an inoculation injury
In a healthcare setting, the risk of acquiring a blood borne virus as the result of a
sharps or inoculation injury from a source known to be infected has been estimated
as follows:Hepatitis B - around 1 in 3;
Hepatitis C - around 1 in 30;
HIV - around 1 in 300.
The degree of risk should be assessed immediately after the incident has occurred
and should be determined by the injured care worker and their immediate
supervisor/line manager using the Risk Assessment Check List found in
Appendix 22.
A Significant exposure is defined as:
Percutaneous Injury – breaks in the skin e.g. from needles, instruments, bone
fragments or a significant bite.
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Exposure of broken skin – e.g. due to eczema, cuts, abrasions or injury.
Exposure of mucous membrane including the eye.
Injury with an unused/clean sharp
No risk of infection, (except from the micro organisms on your own skin).
Record incident, but no further action.
Injury with a used/dirty sharp – also human bite/scratch/mucous membrane
splash from a source that is known or unknown.
During normal working hours seek professional advice from the Occupational Health
Service, or Accident and Emergency Department at the University Hospital of North
Staffordshire. This should be within one hour of the incident having taken place. Out
of hours the injured care worker must attend the A and E Department.
Injury from a used/dirty sharp from a person known or strongly suspected to
be HIV positive.
During normal working hours contact the Microbiologist on call at the UHNS. If the
incident occurs out of hours the injured care worker must attend the A and E
Department at the local hospital immediately.
The risk of acquiring an HIV infection from a sharp or inoculation injury in a low risk
population when the infection status of the source is unknown is very small.
9.1.8 Immediate action to take in the event of a sharps/inoculation injury:Bleeding from a small wound should be promoted for a few seconds by gently
squeezing the surrounding skin. Do not suck or scrub.
Wash the wound with warm running water and liquid soap.
Cover the wound with a waterproof dressing.
If the eyes are contaminated irrigate for 2 minutes with normal saline or running
water. If contact lenses are worn, irrigate both before and after removal.
Contaminated mucus membrane (e.g. the nose or mouth) should be washed with
plenty of water.
Report the injury to the person in charge who should carry out a risk assessment
using the checklist in Appendix 22.
Record the incident following the usual procedure.
A poster and flow chart summarising the action to take in the event of a sharps or
splash injury and the action to take following a sharps find can be found in
Appendices 21-24.
9.2
Management of needle stick/inoculation incidents and post exposure
prophylaxis (PEP).
Human immuno deficiency virus (HIV)
The Department of Health has issued guidelines on HIV post-exposure prophylaxis
(PEP) for health care workers. Although HIV PEP is recommended for health care
workers following „high risk‟ incidents, the risk of transmission is very small and
requires the inoculation of a significant volume of infected body fluid. The side
effects of the treatment may also outweigh any potential benefit.
Following incidents where the source of the injury is thought to be high risk for HIV
(using the check list in Appendix 22) the injured person should attend the A and E
department at the University Hospital of North Staffordshire immediately where a
PEP pack is kept. The decision to administer PEP will be taken by the A and E
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consultant in consultation with the Medical Microbiologist or the Infectious Diseases
Consultant.
If recommended, a course of PEP should be started as soon as possible after the
incident. Ideally this would be within one hour if there were a high risk of exposure to
HIV. However, PEP may be commenced up to 2 weeks after the injury if
circumstances change, for example if the source of the injury is subsequently found
to be HIV positive. The PEP specialist should advise pregnant women, who may
have been exposed to HIV, regarding the risks and benefits of HIV PEP.
Hepatitis B
If the source of the injury is known, or suspected to be, hepatitis B positive,
occupational health or the care workers GP should check the hepatitis status of the
injured care worker and if appropriate consider starting a course of hepatitis B
vaccine and or giving immunoglobulin. This should be administered ideally within 48
hours of the injury, though it can be given up to 7 days after the incident if necessary.
Hepatitis C
Where possible an attempt should be made to assess the HCV status of the source.
An initial blood sample should be taken from the injured person and sent to the
laboratory to be stored. If the source is found to be positive, the injured party should
also be investigated for subsequent sero-conversion and appropriate referral made.
There is currently no vaccine available for hepatitis C.
Following all exposure incidents a review of the event should be undertaken in order
to identify if a similar injury could be avoided in future.
9.2.1 Hepatitis B immunisation
Hepatitis B immunisation is recommended for all care workers who may have direct
contact with a service user‟s blood, blood-stained body fluids or tissues.
All care workers of residential and other accommodation for those with learning
difficulties should also be offered immunisation as higher rates of hepatitis B carriage
has been found in this group of people.
When immunisation is required, the cost must be borne by the employer.
There are no vaccines which protect against hepatitis C or HIV.
9.3
Other immunisations
It is regarded as good public health practice for everyone to be fully immunised.
Care workers should be asked to consult their occupational health advisor to ensure
that they are up-to-date with all immunisations and arrange boosters if necessary.
The Department of Health recommends that all those involved in delivering front line
care to vulnerable groups should be immunised annually against influenza. This is
the responsibility of the employer to arrange and fund. Care workers should be
encouraged to be immunised, for the following reasons:
They personally benefit, as they reduce their chances of becoming ill.
The organisation benefits because there is reduced absenteeism, and last but
not least.
Service users benefit because they are doubly protected.
The Occupational Health Service will advise on the immunisations that care staff will
require.
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9.4
Protection against tuberculosis
Care worker‟s history of TB and or BCG vaccination should be checked at pre
employment. Please contact the Occupational Health Advisor or the TB clinic if
advice on this is required.
If care workers are in contact with a service user with infectious TB the care workers
will be followed up in the normal way.
More information on TB can be found in Appendix 17.
10.
10.1
ASEPTIC TECHNIQUE
What is an aseptic technique?
The term aseptic means „without micro organisms‟. The aseptic technique refers to
the practice used to prevent the risk of infection. There are two aims of an aseptic
technique: first, to protect susceptible sites on the service user from contamination
by pathogenic organisms during care and nursing interventions and secondly, to
protect the care worker from being exposed to potentially infectious blood and body
fluids.
Aseptic technique will be used for surgical and other procedures such as undertaking
wound dressings or performing an invasive procedure such as inserting a urinary
catheter or when managing any invasive device.
Susceptible sites include:Normal body orifices (openings) such as urethra, vagina, mouth, eyes etc.
Artificial orifices such as surgical and other wounds, tracheostomy sites, insertion
sites for invasive devices such as urethral catheters or intravascular catheters
etc.
The principles of aseptic technique involves:Hand hygiene;
Personal protective equipment;
Sterile materials, equipment and fluids for invasive procedures;
Separation of sterile/clean equipment from contaminated items;
Avoiding direct contact with susceptible sites;
A technique to avoid introducing potentially harmful micro organisms into wounds
and susceptible body sites.
There are two types of aseptic technique:Surgical technique used when undertaking procedures or handling equipment that
breach the body‟s normal defences such as surgery, insertion of catheters,
intravenous devices, tracheostomy etc.
Non-touch or clean technique may be used when the risk of contamination comes
from micro organisms on the skin on carer‟s hands e.g. dressing chronic wounds,
mouth care, eye care, emptying catheter bags, endotracheal suctioning etc.
10.2 Principles of aseptic technique
10.2.1 Hand hygiene
The removal or reduction of micro organisms from carers‟ hands prior to aseptic
procedures is essential.
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Invasive procedures - hand disinfection using skin disinfectant such as alcohol
hand rub or antiseptic solution.
Clean procedures - routine hand hygiene with soap and water is usually
adequate unless the service user is particularly at risk of infection.
10.2.2 Protective clothing
This is worn for two purposes:
Protect the service user from micro organisms on the care worker‟s skin and
clothing;
Protect the care worker from micro organisms on the service user‟s body.
Gloves are recommended for using an aseptic technique:
Sterile gloves for a surgical technique.
Non-sterile gloves for a clean technique.
Gloves can give the wearer a false sense of security and they may touch
contaminated equipment, environment or skin sites during an aseptic procedure.
If hands touch a contaminated object or part of the body during an aseptic
procedure, the gloves should be removed, alcohol hand rub applied to the hands and
a new pair of gloves worn.
Aprons are recommended for procedures where there is a risk of splash from body
fluids or to protect open wounds from contamination from micro organisms on the
clothing or uniform, e.g. during wound care.
Eye/face protection should be worn if there is a risk of splash from blood and body
fluids to the face.
10.2.3 Equipment
Sterile, single-use equipment is recommended for an aseptic technique. Ensure
sterile packs are not damaged and are used before the expiry date. Keep sterile and
non-sterile equipment/devices separate. If sterile equipment/devices are
contaminated during an aseptic technique they should be replaced immediately.
It is illegal to re-use single-use items and they must not be reused. Single use
items are marked:-
If the contents of single use packs e.g. dressing packs are partially used the unused
contents must be discarded.
Dressing trolley or surface
A dressing trolley or tray may be used when carrying out aseptic procedures. The
trolley/tray should be cleaned at least daily and when soiled. They should be
cleaned with detergent and warm water and dried with disposable paper towels.
Sterile dressing aids/packs are often used for dressing wounds etc. The polythene
bag can be used to arrange the sterile items on the sterile field and then to remove
the soiled dressing. The care worker places a clean hand into the bag to arrange the
items on the packaging, which acts as a sterile field. The bag can be used to
remove the dressing, and inverted to contain the soiled dressing. The bag can be
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attached to a trolley, or laid on a surface, to act as a disposal bag for other discarded
items.
Avoid carrying out aseptic procedures immediately after activities that may have
raised the level of airborne micro organisms, such as bed making and cleaning.
Delaying for 30 minutes or so will allow the micro organisms to settle on surfaces
and help to prevent contamination of open wounds from airborne micro organisms.
10.3
Procedure
Equipment required
Clean dressing trolley;
non-sterile gloves;
sterile gloves;
dressing pack;
appropriate dressings;
fluids for cleaning/irrigation;
hypoallergenic tape;
sterile scissors;
clinical waste bag (orange).
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Explain the procedure to the service user.
Wash hands using the six stage hand wash technique.
Clean trolley surfaces with detergent and dry with paper towels.
Gather equipment for the procedure and place on the bottom of the trolley.
Ensure the service user is comfortable and their privacy and dignity is
maintained.
Put on a clean disposable apron and disinfect hands with alcohol gel.
Check sterility and expiry dates of equipment used.
Open the outer cover of the pack and slide contents on to the trolley.
Open the sterile field using only the corners of the paper, being careful not to
touch the inner surface of the sterile wrapping. This will now be your sterile field.
Disinfect hands with alcohol.
Put on clean disposable gloves and remove dressing.
Dispose of dressings and gloves into the clinical waste bag.
Disinfect hands with alcohol hand rub and apply sterile gloves using appropriate
sterile technique. DO NOT contaminate the sterile field by dropping the glove
packet onto it. Use another clean, at surface to put it on before applying sterile
gloves.
Carry out procedure i.e. clean wound and apply new dressing as necessary.
Make sure protective apron and waste materials are disposed of as clinical
waste (orange bag).
Clean trolley if it has become contaminated during procedure.
Wash hands after procedure.
A poster demonstrating Aseptic technique can be found in Appendix 25.
11.
WOUND/ULCER CARE
The presence of a wound or ulcer can increase the risk of the individual developing
infection or becoming colonised, for example with MRSA. It is therefore important to
try to prevent wounds, such as pressure ulcers, if possible, and to prevent infection
in existing wounds.
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The key measures that can help to prevent wound infection/colonisation include:Hand hygiene before handling wounds or dressings;
Wearing gloves when handling wounds;
Using a wound dressing that is appropriate to the wound;
Changing dressings when indicated and whenever the barrier-effect has been
impaired (e.g. wet);
Selecting a dressing that will promote healing;
These principles apply regardless of whether an aseptic technique or a clean
technique is used.
11.1
Aseptic dressing technique
Must be used for acute wounds such as surgical wounds, recent trauma, burns and
scalds and for chronic wounds in service users who are at greater risk of infection,
e.g. those who are immuno-compromised, have circulatory problems or diabetes.
For aseptic technique sterile gloves, sterile irrigation fluids and sterile equipment and
dressing are used in addition to hand hygiene.
11.2
Clean dressing technique
May be used for chronic wounds, such as leg ulcers and pressure sores in service
users with normal infection risk.
Clean gloves and equipment and tap water may be used in addition to hand hygiene.
However care should still be taken to avoid introducing micro organisms into the
wound.
For further details on wound management refer to local wound management
guidelines or the PCT Tissue Viability Team.
12
INVASIVE DEVICES
Invasive devices such as urinary catheters, infusion devices, tracheotomies and
P.E.Gs are increasingly being used by service users in the community. These
devices will increase the risk of a service user developing an infection and the
practice should have procedures in place for the management of these devices. The
use of the device and the reason for its use should be documented in the service
user‟s notes/care plan. The use of all devices must be reviewed and the review
documented in the service user‟s notes. The device should be removed as soon as
it is no longer required. The service user should be monitored for signs of infection
associated with the device.
To reduce the risk of infection an aseptic or clean non-touch technique should be
used when managing these devices.
In the community service users with invasive devices will normally be cared for by
the specialist teams e.g. continence, nutrition, respiratory and “hospital at home” and
any queries regarding care and management of these devices should be discussed
with the appropriate team/nurse specialist.
13.
VENEPUNCTURE
A safe system of work is recommended for handling blood in order to protect both
the patient and the healthcare worker. Vacuum blood collection systems have been
shown to reduce injuries in care workers and are recommended for use wherever
possible. They consist of a plastic holder, which contains or is attached to a doubleended needle or adaptor. A vacuumed tube is pushed onto the holder and blood
drawn off. An aseptic technique should always be used.
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It is impossible to know of all service users infected with a blood-borne virus;
therefore standard infection control precautions are important whenever taking
blood.
Factors that increase the risk of skin contamination with blood include:
• A service user who is difficult to bleed;
• A service user who is receiving anti-coagulation therapy;
• A service user who is restless and un-cooperative;
• A practitioner with broken skin or a cut etc;
• A practitioner who is inexperienced;
Infection control measures
• Collect equipment, including a sharps container.
• Use disposable tube-holders to avoid re-sheathing and prevent cross infection.
• Decontaminate hands prior to the procedure and wear disposable gloves.
• If the skin is socially clean, it is not necessary to disinfect the skin. Soap and
water is adequate otherwise. If spirit swabs are used ensure the alcohol has
evaporated and the skin is dry before taking the blood.
• Allow the skin to dry and avoid touching the disinfected area.
• Use a vacuum blood collection system in accordance with manufacturer‟s
guidelines and local procedures.
• When the needle is fully removed apply a swab to the insertion site and apply
pressure to stop the bleeding (the service user may be able to do this).
• Discard the needle and tube-holder directly into a sharps container.
• Remove gloves and decontaminate hands.
• Label the sample and laboratory request forms with relevant clinical details and
attach a bio-hazard/danger of infection sticker if necessary.
Never force blood from a traditional syringe and needle into a vacuumed tube.
This can damage the sample, produce aerosols and separate the syringe from
the needle.
14.
MINOR SURGERY
There is little written guidance for general practitioners or others such as podiatrists
undertaking minor surgery and the following guidelines are the consensus of
accepted good practice. A number of factors may be involved in post surgical wound
infection and little is written on infection risks that occur from surgery carried out in
general practice. Further information may be found at:
http://primarycare.nhsestates.gov.uk/secure/content.asp.
However, the principles of asepsis apply to both primary and secondary care
settings.
The Primary Care Trust is involved in establishing arrangements for the provision of
services for minor surgery and for monitoring their safe and effective provision.
It is essential that the facilities used and the practices implemented for carrying out
minor surgery are of the highest possible standards to:
Minimise the risk of infection to service users by the application of infection
prevention and control measures
Protect care workers by the application of standard precautions.
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14.1
Definition of minor surgery
Minor procedures are those that are carried out under local anaesthesia and do not
involve procedures below the deep fascial plane.
The operative site is usually limited in size by whether it can be anaesthetised
locally. Some podiatry procedures and the debridement of leg ulcers are included in
this category.
Some general practices have contracts to do more complex procedures such as joint
injections, joint aspirations and vasectomies. For these procedures where there is a
greater risk of infection consideration should be given to the provision of
mechanically ventilated operating facilities.
14.2
Facilities for minor surgery
The room
Minor surgery should take place in a designated minor surgery or treatment room
(which may or may not be used for other clinical activities).
The room should be of a sufficient size with a floor area of 18-20 metres 2. A clinical
hand wash basin with lever-operated mixer taps, wall mounted liquid soap, antiseptic
hand solution, alcohol hand rub and paper towels should be available.
Furniture and equipment should be kept to the minimum which will allow care
workers to work unhindered and facilitate cleaning. The furniture, fixtures and fittings
should be made of/or covered in material that is impervious, can be wiped clean and
in a good state of repair.
Ventilation
For most minor surgery naturally ventilated rooms are acceptable. Where more
complex procedures /or procedures where the risk of infection is increased
mechanical ventilation should be considered especially if refurbishment or new build
projects are planned. Advice can be sought from infection prevention and control
specialists.
Electric extractor fans and vents should be inspected on a monthly basis and
cleaned on a 3 monthly basis to prevent the build up of dust.
Ceilings
Ceilings should be made from non-porous material that can be easily cleaned and
which will withstand regular cleaning. They should be of solid construction i.e. not a
suspended ceiling and be free from cracks and visible defects.
Walls
Plasterwork should be smooth, free from cracks and visible defects and made from
non-porous material or painted with a product that can be easily cleaned and that will
withstand regular cleaning. They should be of solid construction i.e. not tiled.
Walls only need to be cleaned when visibly soiled (usually every 6 months) by using
detergent and water. Blood splashes should be removed as soon as possible.
Work surfaces and splash backs
Work surfaces and splash backs should be made of smooth, impervious material.
Work surfaces should be made of material that will withstand chemical disinfection
e.g. stainless steel. They should have rolled edges and all joints should be sealed.
There should be separate work surfaces for clinical and non clinical activities.
Surfaces should be clear of extraneous items.
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Windows
Natural ventilation - the presence of opening windows is acceptable but they must
be fitted with a fly screen.
Mechanical ventilation - windows must not be opened during surgery.
To maintain service user privacy obscured glass is preferred.
Curtains should be avoided where minor surgery is carried out. If present, they
should be washed on a regular basis (usually every 6 months) or when visibly soiled.
Vertical wipe clean blinds are the most appropriate choice.
Doors
These should be self-closing with a vision panel to facilitate observation of
procedures and avoid unnecessary movement in and out of the operating room.
Floors
Floors should be impervious, durable, non slip with welded seams and made of
material that can be easily cleaned. They should have continuous coving which
extends a short height up the wall. Floors should be cleaned at least daily using
detergent and water; this should take place at the end of the day or session. Blood
splashes should be removed and the area cleaned as soon as possible.
Fixtures and fittings must be in good condition and of a design and material that
can be easily cleaned.
Treatment /Examination Couches
The covering should be made of wipe clean impervious fabric. Covers should be
intact. The couch should be protected with disposable paper which is changed
between each service user. The couch should be cleaned with general purpose
detergent and hot water between each service user.
Privacy screen/curtains
The use of curtains should be avoided where possible. Washable or disposable
curtains should be used and changed at least every 3 months or sooner if visibly
soiled or contaminated with blood and body fluids.
Screens that can be wiped clean should be used.
Hand wash sinks/Scrub-up facilities
These may be within the designated room and should comply with current standards.
Taps should be non-hand operated.
Taps and basins should conform to HTM 64 with no plugs or overflows and the
waste outlet offset from directly below the tap.
Sink should be large enough to avoid splashing.
Liquid soap in single use wall mounted dispensers.
Alcohol hand rub and or antiseptic hand scrub solution.
Single use paper towels in a wall mounted dispenser.
Foot or sensor operated bins with close fitting lids.
If nail brushes are used they must be single use disposable.
Sterile pack storage
There should be adequate space with due regard to the range of procedures
carried out and the throughput of service users.
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Packs and instruments should be stored in a clean area away from possible
contaminants and above floor level.
The design should minimize the collection of dust including appropriate racking
or shelving.
Sterile packs and instruments should only be laid up as required and not in
advance.
Prior to use sterile packs should be checked for integrity, sterility and expiry
dates.
Room conditions (e.g. temperature)
These should be within the standard range, i.e. 18 - 22o C, unless clinical
considerations deem otherwise.
Lighting
This should be adequate for the task to be undertaken in the facility. The light fittings
should be of a suitable construction that allows easy cleaning and does not allow a
build up of dust. The light fitting should be cleaned at the end of each day using
detergent and water and at the end of any procedure where the operator has to
adjust the light fitting.
Lighting used for patient examination/minor surgery must be fitted with a heat filter.
Fittings and illumination should be in accordance with BS EN 12464-1.
Specimen storage/transport
There should be adequate facilities and space for the collection and storage of
specimens.
Electrical services
An uninterrupted power supply is required for minor procedures to avoid loss of
lighting, and any other essential electrical equipment. A battery back-up is adequate
for non-hospital facilities.
Electrical sockets
These should be splashproof and placed 1 metre above the floor.
Central heating radiators
These can quickly accumulate high levels of dust so it is important that they are of a
design that can be easily cleaned. They should be cleaned at a frequency that
prevents build up of dirt and debris. Radiators should be painted with paint that will
withstand regular cleaning.
14.3 Infection Prevention and Control Practices
14.3.1 Hand hygiene
Surgical hand disinfection
Prior to minor surgery and other aseptic procedures the operator should carry out
surgical hand disinfection. This procedure will result in the removal and destruction
of transient micro organisms and can be achieved in two ways:
Wash hands using soap and water using the 6 stage technique and then apply
two applications of 5ml alcohol hand rub/gel. Each application should be applied
using the 6 stage technique (Appendix 9) and allowed to dry.
Wash hands using the 6 stage technique with an antiseptic hand scrub solution.
Lather well and wash all surfaces of the hands and wrists for 2 minutes, before
rinsing and drying with paper towels.
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Reusable towels must not be used.
If the hands of the operator are not visibly dirty, alcohol hand rubs or equivalent
may be used between cases. However, surgical hand disinfection/scrub is
indicated at the start of a list, i.e. before the first case or procedure.
14.3.2 Protective Personal Equipment (PPE)
PPE is worn by those carrying out minor surgical procedures to protect themselves
and the service user from infection. A new disposable plastic apron and sterile
gloves are the minimum PPE required for minor procedures and must be changed
between cases. After use protective clothing should be disposed of as clinical
waste.
However, full precautions, including a sterile gown, are required if a sterile device is
being implanted, or if there are other factors predisposing to infection.
Masks are not usually required except when a sterile device is being implanted or
there are other issues predisposing to infection. However, visors/face protection
should be worn by care workers if splashing is likely.
14.3.3 Aseptic Technique
All operators whether surgically trained or not must be assessed as competent in
aseptic procedures and in the knowledge and understanding of the facilities that are
provided.
14.3.4 Pre operative skin preparation
Operation skin sites should be disinfected prior to surgery. The aim is to remove
transient bacteria and reduce the number of resident bacteria. The preparation used
should be fast acting and have a prolonged antibacterial effect. Antiseptic
preparations that are suitable and most frequently used are those containing
chlorhexidine gluconate or povidone-iodine in either an aqueous or alcohol base.
Skin reactions may occur with some products.
The solution should be liberally applied to the operation site and surrounding area
and then allowed to dry. Skin disinfection should be carried out immediately prior to
surgery.
Hair removal is not always necessary and should be avoided. If required use a
depilatory cream or electric clippers rather than a razor to avoid trauma to the skin
which increases the risk of post operative infection.
14.3.5 Surgical instruments.
There are rigorous national and local requirements in place for the decontamination
of surgical instruments which are difficult to comply with outside a specialist Central
Sterile Services Unit (CSSU). For this reason local reprocessing of surgical
instruments should not take place in general practice.
In primary care settings all surgical instruments must be managed in either one or a
combination of the following:
Single use sterile instruments
Single use sterile instruments supplied by or sterilised by Central Sterile Services
Unit that complies with the Medical Devices Directive (MDD) 93/42 EEC and is
registered with an MHRA approved notified body to provide services for a third party.
If reusable instruments are supplied by a CSSU they must be handled safely after
use. All sharps and tissue should be removed. The used instruments should be
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wrapped in the original packaging and stored in clearly identifiable, secure, leak
proof, lidded container whilst awaiting collection.
Instruments should not be washed prior to return to a CSSU.
Where instruments are supplied by a CSSU the traceability system employed by the
CSSU should be used for example, packs supplied by the UHNS have a two part
label with identical bar codes on each part. One bar code stays with the pack and
the other bar code should be placed in the service users notes. This allows total
traceability of the pack which is one of the DOH requirements for decontamination.
14.3.6 Organisation and work flow
In the clinical area work flows should be from clean to dirty areas, with clean and
dirty procedures clearly defined. The areas should be arranged to reduce the risk of
cross contamination. Ideally „clean‟ and „dirty‟ activities should be carried out in
separate rooms.
14.3.7 Cleaning the environment and general equipment
Cleaning must be undertaken at frequencies that prevent build up of dust, dirt and
debris. The frequency may range from after each use, daily to weekly depending
upon the nature and volume or work undertaken in the room.
Cleaning with general purpose detergent, warm water and disposable paper or
cloths will be suitable for most surfaces. Detergent wipes may be used for
equipment where use of water could be hazardous.
Equipment and surfaces that have been contaminated with splashes of blood or
body fluids may need to be disinfected with a hypochlorite (bleach) solution after
cleaning.
The cleaning schedule should outline the items to be cleaned, the frequency and the
method.
More information on cleaning the environment and equipment can be found in
Section 17
14.3.8 Clinical waste
Clinical waste should be placed in a foot operated waste bin. Clinical waste bags
should be removed at the end of each session/day and placed in a secure
designated holding area for clinical waste that complies with the latest guidelines.
A separate secure area, inside or outside the operative facility, e.g. a lockable bin,
should be provided. Further information can be found in Section 19 and in the Stoke
on Trent Primary Care Trust Waste Policy
14.3.9 Records must be maintained using an operations register, both for audit purposes
and as a safeguard for medico-legal reasons. It should include details of the date
and time of operation, Service user‟s name and address, names of surgeon,
procedure performed, if local anaesthetic was administered, name of assistant and
whether histology or other specimens were sent.
15.
STORAGE AND HANDLING OF VACCINES
Vaccines are substances that lose their effectiveness if they are transported or
stored at the incorrect temperature.
It is important that the correct temperature between 2oC and 8oC (the Cold Chain) is
maintained during transport and storage
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A designated individual (and deputy) should be responsible for ordering and storing
vaccines.
Reception staff should ensure that vaccines are handed over to the responsible
person as quickly as possible when delivered, and know what to do if this person or
their deputy is unavailable.
If there is any question regarding the maintenance of the Cold Chain or transit time
(more than 48 hours), the delivery should be refused and returned to the supplier.
The date and time of dispatch should be noted.
To retain potency vaccines must be stored in appropriate conditions:
15.1
Vaccine refrigerators
Medical refrigerators are generally of a higher specification than domestic varieties.
They should be validated prior to use by checking the temperature with either a
thermometer or a temperature probe.
The vaccine fridges should:
• Be a medical fridge that is lockable;
• Be large enough for routine stock levels plus seasonal needs e.g. flu vaccine;
• Be large enough for air to circulate and maintain constant temperature;
• Be fitted with an electric lead that is fitted into a spur point that is fused but not
switched to prevent inadvertent break in electricity supply.
• Have to hand guidelines on action to be taken in the event of power failure
including who to contact.
• Be fitted with a maximum and minimum thermometer.
• Have the temperature monitored daily with recordings of maximum and minimum
temperatures which should be between 2oC and 8oC. Record the details of
minimum and maximum temperature, time and date of recording on a chart
attached to or beside the fridge. Temperature records should be retained for one
year.
• Have the thermometer reset after each recording.
• Be self defrosting or defrosted every month ensuring that the Cold Chain is
maintained by use of another fridge/cool box.
• Be kept clean and dry.
• The vaccine fridge should be used to store only vaccines and drugs (no food,
drink or specimens).
• Have certain shelves designated for specific vaccines and list them on the
outside of the door to minimise the time the door is kept open.
• Have the stock rotated.
• Have items stored in accordance with manufacturer‟s instructions (e.g. some are
sensitive to light).
• Not be over stocked.
15.2
Vaccines
• Must be placed in the vaccine fridge immediately after they are received.
• Must not be left out of the fridge. Remove them just before use or transfer to a
cool box if a busy session is planned
• Must be returned in a cool box to the fridge as soon as possible. Note the time
they were out of the fridge and use them first.
• Do not allow vaccine ampoules/vials to come into direct contact with ice packs in
cool boxes.
• Have good stock control systems in place.
• Must not be used past the expiry date.
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15.3
Administration of vaccines
• Vaccines should not be prepared in advance of an immunization session as this
increases the risk of administering the wrong vaccine and may affect the
temperature.
• Reconstituted vaccine must be used according to the manufacturer‟s
recommendations, usually within 1-4 hours.
• Vaccines should only be removed from the fridge for the minimum length of time
before administration and any opened in error must be discarded.
• Oral polio vaccine (OPV) should not be allowed to remain at room temperature
awaiting or following an immunisation as this may decrease the potency of the
vaccine.
• Multi-dose vials may be used for one session only. Any remaining vaccine must
be discarded at the end of the session
Skin Preparation
If the skin is socially clean, it is not necessary to disinfect the skin prior to injection.
Soap and water is adequate otherwise. If spirit swabs are used ensure the alcohol
has evaporated and the skin is dry before administering the vaccine.
Some live vaccines may be inactivated by alcohol.
15.4
Disposal of vaccines
At the end of a vaccination or immunisation session any prepared or opened
vaccines must be destroyed. Place the vaccines in a sharps box, for incineration.
Expired vaccines must also be disposed of in a sharps box.
15.5
Immunisation training
National standards and a core curriculum have been developed for immunisation
training courses. All care workers involved with distribution, handling, storage and
administration of vaccines should have received appropriate training.
15.6
Further Information
• From the UK Guidance on Best Practice in Vaccine Administration, available
from the Vaccine Administration Taskforce, Shire Hall Communications, PO Box
31580, London W11 4YZ and
• Stoke on Trent Primary Care Trusts Vaccine Procedure 3.19.1, The Safe
Distribution, Storage, Handling and disposal of Vaccines Procedure.
16.
SPECIMEN COLLECTION, HANDLING AND TRANSPORT
Specimens are an important element in care, providing information both for
diagnosis and treatment. Clinical specimens include any substance, solid or liquid,
removed from the service user for the purpose of analysis. It is important that care
workers are trained to handle specimens safely and have appropriate immunisation
cover which is regularly updated.
All staff managing specimens are responsible for ensuring that the information
supplied is
• Legible
• Logical
• Accurate
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• Includes all the necessary information
• Complies with the requirements of information governance.
The care worker taking the specimen should provide the service user with an
explanation of why the specimen is being taken.
16.1
Specimen collection (for microbiological investigations)
Specimens for microbiological investigations must only be taken if there are
signs and symptoms of clinical infection. Bear in mind, for example, that any
wound will be colonised with many organisms, and if swabbed in the absence of
clinical infection, the culture result may lead to unnecessary treatment with
antibiotics.
The signs and symptoms of infection vary depending upon the nature of the
infection, but include:
Wound infection - cellulitis, pain, redness, pus, fever.
Chest infection - fever, cough, sputum that may contain pus or blood.
Urinary infection - fever, pain on passing urine, blood or pus in urine, offensive
odour, malaise.
Eye infection - redness, pain on moving the eyelid, discharge.
Enteric (gut) infection - diarrhoea, vomiting, abdominal pain, fever, blood or
mucous in faeces.
The aim when collecting a microbiology specimen is to collect an adequate amount
of tissue/fluid, uncontaminated by micro organisms from any outside source, but
preserving any micro organisms that may be present. When obtaining specimens for
microbiological investigation it is important to:Use the appropriate container; if unsure, check with the laboratory at your
local hospital.
Label the specimen container with the service user‟s details and date prior
to collection.
Wash hands before and after taking the specimen.
Collect an adequate amount in order to increase the possibility of detecting
the micro organism. Where pus is present a sample of pus is preferable to a
swab.
Moisten the bacteriology swab used for dry wounds/surfaces with sterile
water or saline to allow for optimum pick-up of micro organisms.
Ensure that the specimen is not contaminated during collection, either by
equipment or an individual‟s normal flora (the normal skin bacteria).
Obtain specimens prior to the commencement of antibiotic therapy.
If therapy has already commenced, specify the antibiotic on the request
form.
Complete all details on the laboratory request form in legible hand writing
and include: Details of the service user (name, DOB and NHS number);
 GP name and number
 Details of sample sent, including the site from which the sample was
taken if the sample is a wound swab;
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 Nature of the signs and symptoms;
 Date (and time if appropriate) of specimen;
 Duration of illness;
 Tests required.
 Recent antibiotic therapy or travel history;
 Whether the case is part of a cluster or outbreak of similar cases;
 Biohazard/danger of Infection label;
 Signature of the person requesting the specimen;
The service user‟s details must be entered on both the container and the
request form, the container placed in a plastic transport bag and the
accompanying request form put into a separate pouch provided.
16.2
Handling and storage of specimens
Non-sterile gloves should be worn for handling specimen containers especially
those brought in by service users.
Specimens must be in appropriate, robust leak proof containers.
The specimen container should be in a separate pouch to the request card.
The outside of the specimen container should be clean and free from
contamination.
Where the sample is known or suspected to be high risk a bio hazard or "danger
of infection” label must be attached to both the specimen and the request form.
Hands should be washed after handling specimens and there should be a hand
wash basin adjacent to the specimen reception area.
There should be a spillage kit in specimen reception area.
Specimens must be stored away from food, drink and drugs to prevent cross
contamination.
Specimens awaiting collection should be stored in a clean, leak proof lidded
container which is washed daily with general purpose detergent and warm water,
rinsed and dried.
16.3
Transport
Send specimens to the laboratory as soon as possible after collection in order to
prevent overgrowth of non-pathogens and the death of pathogenic micro
organisms.
The specimen transport carrier used for carrying specimens to the GP/hospital
pathology laboratories must be secure and conform to guidelines set out in the
Health and Safety at Work Act (1974).
Other regulations that apply are the Carriage of Dangerous Goods
(Classification, Packaging and Labelling) and the use of Transportable Pressure
Receptacles Regulations 1996.
16.4
Disposal of Specimens
All specimens are clinical waste and must be disposed of safely.
Urine specimens tested in the practice should be disposed of via a sluice facility
or if this is not available a toilet may be used.
Specimens MUST not be disposed of via a hand wash sink.
16.5
Further Information
More detailed information on the collection of specimens can be obtained from the
laboratory handbooks on the UHNS website at www.uhns.nhs.uk
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17
17.1
CLEANING THE ENVIRONMENT
General
The practice environment should be visibly clean, free from dust and debris to be
acceptable to service users, care workers and visitors. Regular and efficient
cleaning is necessary to maintain the appearance and function of the premises.
In general, it is considered that the environment has a relatively low role in the
transmission of infection however the environment is known to play an important role
in cross infection during outbreaks.
In treatment rooms used for clinical procedures and minor surgery accumulations of
dust, dirt and liquid residues will increase infection risks and must be reduced to the
minimum. This can be achieved by regular cleaning and by using good design
features in buildings, fittings and fixtures. The local PCT Infection Prevention and
Control Team can be contacted for advice.
A good standard of cleaning will control the microbial population and prevent the
transfer of potentially infectious material. It is important that the chosen method of
cleaning should remove the contamination, and not merely redistribute it.
An audit programme for monitoring the standard of hygiene should be in place in all
health care premises.
17.2
Floors and other hard surfaces
Hard floors should be durable, of good quality, washable and smooth-finished with
welded seams. They should be intact, impervious to fluids and should not allow the
pooling of liquids.
Carpets are not recommended in treatment rooms or other clinical areas. If carpets
are provided (in non clinical areas) there should be procedures or contracts in place
for regular cleaning and for dealing with spillage.
Generally, for hard surfaces wet cleaning methods are preferable to dry ones, as
with dry methods there is risk of dispersal into the air of micro organisms. Moist
surfaces encourage bacterial growth, and thorough drying is part of the cleaning
process. Impervious flooring should be washed using a neutral general purpose
detergent and a mop with a detachable head that can be laundered. Mop heads
used should be changed daily and laundered. Mop buckets must be washed daily
after use, and stored clean, dry and inverted.
If dry dusting of floors is carried out it must be with a dust attractant mop to ensure
no dispersal of dust and micro organisms.
Vacuum cleaning (with filters) is suitable for carpets and other soft furnishings.
Work surfaces should be smooth-finished, intact, washable, durable and impervious
to fluids. Cleaning with neutral general purpose detergent and hot water remains the
most effective method of removing contamination including micro organisms, and
therefore damp dusting with disposable paper towels/cloths should be the norm for
all hard surfaces. Do not use refillable spray cleaners as they provide a breeding
ground for micro organisms.
17.3
Curtains, blinds and soft furnishings
Curtains should be laundered or cleaned when soiled or periodically (e.g. six
monthly) and an adequate supply of curtains purchased to facilitate this.
Blinds/screens should be of a type that can be wiped clean.
Upholstered furniture should be covered in impermeable fabrics that can be wiped
clean.
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Pillows if used should be in sealed plastic covers that can be wiped clean. If the
covers are damaged the items should be replaced.
17.4
Cleaning equipment and materials
Disposable, non-shedding cloths or paper roll should be provided for cleaning
purposes. Equipment and materials used for general cleaning should be kept
separate from those used for the cleaning of body fluid spillage. Fresh cleaning
solutions should be used and changed for each room. Do not leave cloths or mops
stored in disinfectants or buckets.
There has been an increase in the use of micro fibre cleaning systems in health care
settings. These systems reduce the time required for cleaning and minimise the use
of detergents and other cleaning products. When used guidance and advice should
be sought from the suppliers/manufacturers.
Cream cleaner or a hard surface cleaner is usually suitable for cleaning hand
washbasins and general-purpose detergent is recommended for other environmental
cleaning. Follow manufacturer‟s instructions. Detergent wipes can be used for
those items that cannot be immersed e.g. electrical equipment. A COSHH
assessment is required for any cleaning materials used.
The following table shows the cleaning and disinfectant products recommended for
use by the Infection Prevention and Control Team at NHS Stoke on Trent.
Table 6
Recommended cleaning products and disinfectants
Products
Examples of Products
Use
Neutral general purpose
detergent
Hospec
Fairy
Routine cleaning of equipment
and environmental surfaces,
Detergent wipes
Routine cleaning of equipment
and environmental surfaces ,
Cream cleanser
Cif
Stubborn marks or stains in
sanitary or kitchen areas
Chlorine releasing
agents:Sodium Hypochlorite (Na
CIO)
Milton /Domestos
For blood spillage on hard
surfaces DO NOT USE ON
URINE SPILLS the fumes
released are harmful
Presept /haz tabs
Sodium
Titan/ Sanichlor
dichloroisocyanurate
(NaDCC)
17.5
Colour Coding
Colour coding of cleaning equipment has been adopted in many NHS settings, and
practices may wish to consider adopting this. It is especially useful when care
workers work across other care providers both in the independent care sector and in
the NHS.
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All cleaning items, for example, cloths (re-usable and disposable), mops, buckets,
aprons and gloves, should be colour coded as outlined in the table below and
Appendix 27.
Table 6
NATIONAL COLOUR CODING SCHEME FOR CLEANING
EQUIPMENT (NATIONAL SERVICE USER SAFETY AGENCY)
MATERIALS
BLUE
Day rooms, wards and general areas.
RED
Sanitary areas and body fluid spills.
GREEN
Kitchens and food preparation
(Kitchen cleaning equipment should be stored separately).
YELLOW
Isolation Rooms.
17.6
AND
Cleaning Schedules
A written cleaning schedule should be devised, based on a risk assessment, which
includes the management of spillage of body fluids and regular removal of dust by
damp dusting high and low horizontal surfaces. This should specify those persons
responsible for cleaning (especially in the cleaner's absence), the frequency of
cleaning and methods used and the expected outcomes.
For suggested methods and frequencies of cleaning the environment and
equipment, refer to cleaning schedule in Appendix 28.
17.7 Management of the spillage of blood and body fluids
17.7.1 Spillage of high risk body fluids
Spillages of blood and high-risk body fluids must be dealt with quickly and effectively.
Disposable gloves and an apron must be worn for cleaning body fluid spillage and
the contaminated debris treated as clinical waste.
Chlorine-releasing agents can be a hazard especially if used in large volumes, in
confined spaces or mixed with other chemicals or urine. Protective clothing must be
worn and the area well ventilated.
A risk assessment and COSHH assessment must be carried out for dealing with
these spillages both in terms of the chemicals used and the likelihood of infection.
Following a risk assessment and depending upon the products available, spillage
may be dealt with by any of the following methods.
Commercial companies produce spillage kits with instructions that would be useful in
areas such as specimen reception.
Sodium dichloroisocyanurate (NaDCC) method (not carpets
furnishings) using sanitising powder or granules
Wearing protective clothing, cover spillage with NaDCC granules.
Leave for at least two minutes.
Scoop up the debris with paper towels and/or cardboard.
Wash the area with detergent and water and dry thoroughly.
Dispose of all materials as per clinical waste.
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Clean the bucket/bowl with fresh soapy water and dry.
Discard protective clothing and wash hands.
Hypochlorite (Milton or bleach) method (not carpets and soft furnishings)
Wearing protective clothing, soak up excess fluid using disposable paper towels.
Remove organic matter using the towels and discard as clinical waste.
Clean area with detergent and water and disinfect the area with towels which
have been soaked in 10,000 (Milton undiluted) parts per million of available
chlorine (e.g. Milton or Haz Tabs) and leave for at least two minutes and then
rinse and dry thoroughly.
Clean the bucket/bowl in fresh soapy water and dry.
Discard protective clothing and wash hands.
Detergent and water method (for soft furnishings and carpet)
Steam clean or
Wearing protective clothing mop up organic matter with paper towels or
disposable cloths.
Clean surface thoroughly using a solution of detergent and water and paper
towels or disposable cloths.
Rinse the surface and dry thoroughly.
Dispose of materials as clinical waste.
Clean the bucket/bowl in fresh hot, soapy water and dry.
Discard protective clothing and wash hands.
17.7.2 Spillage of low-risk body fluids (urine, faeces, vomit etc)
Wearing protective clothing mop up organic matter with paper towels or
disposable cloths.
Clean surface thoroughly using a solution of detergent and water and paper
towels or disposable cloths.
Rinse the surface and dry thoroughly.
During outbreaks of viral gastroenteritis disinfect surfaces using 1000 ppm (1
part Milton to 10 parts water or bleach 1 part bleach to 100 parts water) chlorine
solution after cleaning.
Dispose of materials as outlined in Section 17.
Clean the bucket/bowl in fresh hot, soapy water and dry.
Discard protective clothing and wash hands.
17.8 Deep cleaning
17.8.1 What is deep cleaning?
Deep cleaning is not routine environmental cleaning that is undertaken daily within
the care environment but is additional cleaning that should be undertaken in special
circumstances. In care facilities providing residential care such as hospitals and
care homes this would be:Following outbreaks and would involve cleaning - the whole environment.
Post discharge, transfer or death of individual service user – single room and
en suite.
When isolation of a service user with a known infection is no longer required –
single room and en suite.
Following refurbishment and building work.
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Periodic cleans to thoroughly clean the environment. The frequency will depend
on the type of room and its use.
The last two of these categories are the ones that would apply to general practices.
Each care establishment should have a written cleaning schedule for both routine
and deep cleaning that ensures that all areas of the premises are cleaned to a
satisfactory standard.
Deep cleaning is the thorough cleaning of all surfaces, floors and soft furnishings
and reusable equipment.
This will include:
Skirting boards, picture and dado rails;
Window sills and frames;
All ledges, shelving and storage cupboards.
All horizontal surfaces;
Soft furnishings including curtains and blinds;
Curtain rails and tracks;
Floors and carpets ;
Light fittings and lamp shades;
Equipment;
Furniture and fittings;
Radiators;
Sinks, toilets, baths and showers plus taps, flush and door handles;
Soap and towel dispensers.
Deep cleaning is essential to ensure that a safe environment is maintained for
service users, care workers and others by minimising the risk of cross contamination.
17.8.2 What equipment is required for deep cleaning?
Care workers and housekeeping staff that are carrying out deep cleaning should
wear disposable plastic aprons and household or disposable gloves.
The routine use of disinfectants is not recommended. The physical removal of dirt
and micro organisms by wiping or scrubbing is more important than the type of
cleaning agent used.
If a disinfectant is required this will be advised by the local Infection Prevention and
Control Nurses.
Deep cleaning should be undertaken using:
Clean bucket;
Clean hot water and general purpose detergent;
Disposable cloths;
Floor mop with disposable or washable mop head;
Vacuum cleaner fitted with a HEPA filter;
Steam cleaner or carpet shampooer.
17.8.3 Deep cleaning procedure
Wear personal protective clothing (at least disposable gloves and apron).
Water and detergent solutions, disposable cloths and mop heads used for
cleaning should be changed for each episode of cleaning when moving from one
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environment to another (room to room) and when the water is visibly dirty or
contaminated.
Remove/dispose of unwanted items.
Take down curtains and send to the laundry.
Clean, all furniture and fittings
The „Golden Rule „for cleaning is to work from the cleanest to the dirtiest areas
starting at the higher levels and working down.
Curtains should be laundered.
Carpets should be vacuumed (vacuum cleaners should be fitted with a HEPA
filter) and then steam cleaned or shampooed.
Discard waste and clean waste bin.
Clean all cleaning equipment and leave to dry.
Wash hands.
Restock room with clean supplies.
17.9
Key points when cleaning:
Wear protective clothing, i.e. apron and gloves;
Prepare a fresh cleaning solution appropriately diluted for each task;
Make up only the quantity required in a clean container;
Some cleaning products are incompatible; only mix if advised by manufacturer;
Change the solution frequently to prevent a build-up of soil or micro organisms
which would recontaminate surfaces;
Dispose of cleaning solution promptly in a sluice or dirty utility area;
Ensure that equipment is stored clean, dry and in the designated place;
Remove protective clothing and wash hands before carrying out other duties;
Do not use disinfectants routinely.
18.
18.1
DECONTAMINATION OF CARE EQUIPMENT AND MEDICAL DEVICES
Good practice
All equipment must be clean, fit for purpose, and in a good state of repair;
All equipment must be stored in an appropriate area;
If there are items of equipment that are not routinely cleaned on a daily basis,
there should be a written cleaning schedule and records kept of cleaning
undertaken.
Most general equipment can be cleaned safely using warm water and general
purpose detergent.
Chemical disinfection using chlorine based disinfectants may be used following
cleaning if items have been contaminated with blood and high risk body fluids.
All reusable medical devices that need to be sterile at the point of use should be
supplied as single use disposable items or supplied by an accredited CSSU.
18.2
Purchase of equipment
Before purchasing any new equipment, it is important to know how it can be
decontaminated. Manufacturers should be able to provide written instructions on this
and equipment should only be purchased if appropriate decontamination facilities are
available.
18.3
Methods of Decontamination
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Equipment can be categorised according the risk of infection it poses to the service
user. The choice of process depends on a number of factors:The type of equipment;
The organisms involved;
The time available for decontamination;
The risk to service users and care workers.
Table 7 summarises the decontamination processes that should be used based on
risk.
Items that are not in direct contact with the service user or in contact with intact
skin are classed as low risk and should be cleaned.
Items in contact with mucous membranes (eyes, mouth or rectum) are classed
as medium risk and should be single use or cleaned and disinfected (or
sterilised) between uses.
Items that enter the body or have contact with broken skin, broken mucous
membranes or with the vagina are classed as high risk and must be single use
or cleaned and sterilised
Table 7
Risk assessment for decontamination of equipment
Risk
Application of Item
Low
Items not in direct contact
with service user or in
contact with healthy skin.
Recommended
Method
Cleaning with general
purpose detergent and
drying.
Medium Items in contact with mucous
membranes or contaminated
with virulent or readily
transmissible micro
organisms (body fluids) or
prior to use on
immunocompromised service
users.
Single use items.
High
Items used in the
vagina must be single
use or sterilised.
Items in contact with a break
in the skin or mucous
membrane or for introduction
into sterile body areas .
Clean item and then
disinfect or sterilise
(item does not need to
be sterile at the point
of use).
Examples
Floors and ceilings,
walls, surfaces,
examination couches,
trolleys, toilets, wash
hand basins, furniture
and fittings.
Suction catheters,
aurasccopes,
thermometers,
ambubags , masks,
respiratory equipment
Surgical instruments,
urinary catheters,
dressings, needles
and syringes.
Sterilisation in a sterile
services department
or single use and use
item sterile
(Adapted from the Medical Devices Agency 2005)
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18.3.1 Cleaning
Thorough cleaning with general purpose detergent and warm water (body
temperature) will remove large numbers of micro organisms from a surface. A
further reduction in numbers occurs as the surface dries. Reusable medical devices
cannot be effectively disinfected or sterilised without having first been thoroughly
cleaned and dried. Cleaning will not be effective if surfaces are damaged or rusty.
An automated method such as a thermal washer/disinfector is the most effective
cleaning method and is recommended for cleaning many reusable medical devices
e.g. surgical instruments prior to sterilisation.
Manual cleaning
Reusable surgical instruments and medical devices that require disinfection and
sterilisation should not be cleaned manually they should be sent to a CSSU for
reprocessing.
Manual cleaning is an acceptable method for cleaning the environment and low risk
equipment e.g. If any manual cleaning is undertaken there must be a risk
assessment and records of agreed procedures must be in place to ensure that a
consistent method is employed by all care workers. There should be a deep sink
designated for the purpose and PPE (disposable gloves, apron and eye and face
protection) available.
How to clean care equipment.
Clean the item in an area designated for cleaning.
Wear protective clothing, i.e., apron, gloves and eye and face protection.
Prepare a fresh cleaning solution appropriately diluted for each task.
Make up only the quantity required in a sink designated for cleaning
equipment/not a hand wash sink.
Some cleaning products are incompatible; only mix if advised by manufacturer.
Use warm water, a general purpose detergent and disposable cloths or
disposable paper towels. It is not necessary to use cleaning products that
contain disinfectants and other antibacterial agents.
Avoid generating splash by immersing the item where possible. If splash is
unavoidable wear protective eyewear.
After cleaning, rinse and inspect the equipment. If the item remains soiled,
repeat the cleaning process.
Change the solution frequently to prevent a build-up of soil or micro organisms
which would recontaminate surfaces.
Ensure the item is dried as quickly as possible either using paper roll or by
inverting to air-dry. Air drying is acceptable for large surfaces, but small areas
should be dried with clean disposable paper towels/cloths.
Dispose of cleaning solution promptly in a sluice or dirty utility area.
Remove protective clothing and wash hands before carrying out other duties.
18.3.2 Disinfection
Disinfection is a process used to reduce the number of micro organisms to a level
that is considered safe, but which may not necessarily destroy some viruses or
bacterial spores. Disinfection is usually acceptable for devices that pose a medium
risk of infection if these devices cannot be effectively sterilised. Disinfection can be
achieved in a number of ways including the use of heat and chemical disinfectants.
Both methods have their drawbacks and it is often safer and more convenient to use
a single use disposable device instead.
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Disinfection is a process additional to cleaning. It does not kill all micro organisms,
but reduces their number to a level which is not harmful to health.
Disinfection is necessary when items:are contaminated by blood or body fluids, and/or
come into contact with mucous membrane.
How to disinfect
There are two common methods of disinfection; moist heat and chemical
disinfection. Moist heat is used for example in CSSU for cleaning surgical
instruments prior to sterilisation and in domestic items such as dishwashers and
washing machines.
Moist heat disinfection
Dishwashers, washing machines and washer-disinfectors are effective methods for
disinfecting equipment because they clean the item and then expose the items to hot
water for the required time to achieve thermal disinfection.
65oC for 10 mins
71oC for 3 mins
80oC for 1 min
90oC for 1 sec
Washer-disinfectors
Thermal washer-disinfectors physically clean devices and kill micro organisms by
applying hot water at disinfection temperatures. They are used for cleaning
instruments, bedpans and other devices. They must have a contract for planned
preventive maintenance and must be cleaned and maintained in accordance with
Health Technical Memorandum (HTM 2030).
Chemical disinfection
Chemical disinfection is normally used for cleaning heat labile equipment such as
flexible endoscopes and this must be carried out in a facility designed for that
purpose.
Chemical disinfectants are also used to disinfect equipment and surfaces after
contamination with blood and body fluids and during outbreaks.
Chlorine
preparations are recommended following blood spillage, during outbreaks and when
caring for service users with C difficile diarrhoea.
Chlorine preparations
There are two widely used chlorine releasing agents, suitable for use on equipment
and environmental surfaces:
NaDCC (sodium dichloroisocyanurate) –e.g. Presept or Haz-tabs.
NaCIO (sodium hypochlorite) –e.g. Milton or bleach.
NaDCC is available as tablets, granules or powders, and some also contain a
compatible detergent. It is preferred to NaCIO because it is:Easier to prepare and store;
Slightly more efficacious;
Less damaging to surfaces.
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Different concentrations are required in different circumstances, and it is usual to
describe the required concentration in “parts per million”, abbreviated to “ppm”. See
Table 8.
Examples: Haz Tabs, Actichlor, Precept, Sanichlor, Milton
Table 8
Dilution of NaDCC and NaCIO
Blood spills
Parts per million
10,000ppm
Environment
1,000ppm
Catering
125
NaDCC
2 x 5.0g tabs in
500mls water
2 x 0.5g tabs in
500mls water
1 x 0.5g tabs in 2
litres of water
NaCIO
Milton 1% use
undiluted
Milton 1% diluted
1: 10
Milton 1% diluted
1:80
Chlorine releasing agents should be diluted with cold water. Once prepared, the
solution should be used within 24 hours or discarded.
After disinfection the item/surface should be rinsed and then dried using a paper
towel.
18.3.4 Sterilisation
Sterilisation is a process used to remove and destroy all microorganisms.
It is recommended that sterile equipment should be obtained pre-sterilised from a
manufacturer or via a Central Sterile Supplies Unit (CSSU).
In general practice when sterile or disinfected items are required single use
disposable items are recommended.
18.4
Single use and single patient use items
Items labelled as „Single-use‟ are intended by the manufacturer to be used once and
discarded. The manufacturer considers that the item is not suitable for use on more
than one occasion or that there is insufficient evidence to ensure that this would be
safe (MHRA 2000).
Single-use items may alternatively be labelled as „Do not re-use‟ or as per
international standards symbol for „do not re-use‟, which is the figure 2 with a line
drawn through it.
Certain devices, e.g., nebulisers, may be used a number of times by the same
service user and are described as being appropriate for “single patient use”. These
items should be cleaned after each use by the service user following the
manufacturer‟s instructions.
18.5
Decontamination of health care equipment prior to repair, service or
investigation
Equipment that has been contaminated with blood and other body fluids, or exposed
to service users with a known infectious disease, should not be sent to third parties
without being correctly decontaminated first. If in doubt, contact the third party in
advance. After decontamination and before dispatching the item it should be
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labelled with a declaration of its decontamination status that states the method of
decontamination used, or reasons why this was not possible.(Medicines and
Healthcare products Regulatory Authority-MHRA, 2003).
Some equipment cannot be effectively decontaminated without being dismantled by
an engineer. In addition decontamination may sometimes remove evidence of a
fault or hinder an investigation. In these situations the manufacturer, repair
organisation or investigating body should be contacted for advice regarding
packaging and transportation. A “decontamination status” label should be attached
to the item, the certificate completed accordingly and the recipient advised on
protective measures required.
19.
19.1
WASTE DISPOSAL
Legislation
The Environmental Protection Act 1990 applies to waste disposal. This legislation
places a duty of care on all those producing waste to safely manage the handling
and disposal of the waste in the correct and proper manner from its production to
final disposal. The following information will help meet the duty of care. Healthcare
waste must be managed in accordance with current legislation and national
guidelines.
All healthcare organisations should have a waste policy in place, which is owned by
the senior managers and supported by training and audit. This guideline does not
cover the topic in detail so it is advisable for managers to refer to the original source
documents in developing local policy and discuss local policy with their waste
manager or Contractor. For more information see HTM 07-01: Safe Management of
Healthcare Waste which can be accessed at:http://www.dh.gov.uk/assetRoot/04/14/08/93/04140893.pdf
and the Environment Agency at:
http://www.nhsestates.gov.uk/sustainable_development.index.asp
Recent legislative changes that include the Hazardous Waste (England and Wales)
Regulations 2005 and the Lists of Waste Regulations 2005 have resulted in
substantial changes in the way waste is defined.
Waste that is produced as a result of healthcare activities is classified as healthcare
waste in section 18 of the European Waste Catalogue (EWC).
19.2 Waste Categories
19.2.1 Clinical waste
This is defined as:
Any waste which consists wholly or partly of:
Human or animal tissue;
Blood or other body fluids;
Excretions;
Drugs or other pharmaceutical products;
Swabs or dressings;
Syringes, needles or other sharp instruments; which unless rendered safe may
prove hazardous or infectious to any persons coming into contact with it.
And:
Any other waste arising from medical, nursing, dental, veterinary, pharmaceutical
or similar practice, investigation, treatment, care, teaching or research, or the
collection of blood for transfusion, being waste which may cause infection to any
person coming into contact with it.
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19.2.2 Hazardous/non hazardous waste
The new national guidelines HTM07-01 further classify waste as “hazardous” and
“non hazardous” waste.
Table 9
Types of hazardous and non hazardous waste
Examples of hazardous waste:
Examples of non hazardous waste
Infectious waste
Medicines
Amalgam
Chemicals
Batteries
Offensive/hygiene waste
Domestic waste
Food waste
Packaging
Recyclates (paper, glass, aluminium)
Infectious waste has two categories for the purposes of transport legislation:
Category A: An infectious substance which is transported in a form that, when
exposure to it occurs, is capable of causing permanent disability, life threatening or
fatal disease in humans or animals. Highly infectious waste includes waste arising
from exotic infectious diseases and laboratory cultures;
Category B: An infectious substance which does not meet the criteria for inclusion in
Category A.
19.2.3 Offensive waste /non-infectious waste (dressings, incontinence pads)
This is non-infectious waste arising from healthcare, which does not require
specialist treatment but may cause offence to those coming into contact with it; i.e.
human hygiene waste, incontinence products, sanitary waste, nappies, plaster casts
etc.
Where the waste products of healthcare are assessed as non-infectious; i.e. noninfectious wound dressings, incontinence pads etc, the waste should be discarded
as “offensive/hygiene waste” in a yellow bag with black stripe.
Some contractors may use orange bags for disposal of offensive waste.
19.2.4 Medicinal waste
Medicinal waste has two categories:
1. Cytotoxic and cytostatic;
2. Medicines others than cytotoxic and cytostatic.
Cytotoxic waste arising from care must be placed into an appropriate yellow
container with purple stripe or purple lid. Community healthcare workers involved in
the administration of cytotoxic drugs should use the waste disposal arrangements of
their Trust. If service users self-administer the cytotoxic drugs the container should
be returned to the hospital or GP surgery as agreed locally.
Care workers must assess waste as it is produced to identify its infectious, chemical
and medicinal properties and segregate appropriately for disposal.
National guidelines produce useful flowcharts.
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19.2.5 Household/domestic waste
Pedal-operated bins with lids are recommended.
Any waste that is not covered under the clinical waste groupings is classed as
household domestic waste, e.g. wastepaper, cans, bottles.
This waste must be disposed of through the normal household waste stream i.e.
black bin liners or dustbins collected by the Local Authority. Where possible,
recycling options should be considered.
Household waste and clinical waste must be kept separate at all times.
Reducing waste can save money and help to improve the environment.
Table 10
Segregation and disposal of clinical waste
Type of waste
Examples
Containers Disposal
Infectious
waste
(Category A)
Anatomical waste: placenta, tissues, organs etc,
and laboratory waste. Waste from highly
infectious diseases, e.g. Ebola virus
Yellow rigid
lidded bin
or bag
Hazardous
waste for
incineration
Infectious
waste
(Category B)
Assess for infection risk.
Infectious: dressings, swabs, bandages, pads,
suction liners, stoma bags, catheter bags, plastic
disposable instruments (not sharps).
Non-infectious: treat as offensive / hygiene waste
Not contaminated with medicinal products OR
Fully discharged sharps contaminated with
medicinal products
(NOT cytotoxic or cytostatic medicines)
Partially or undischarged sharps (NOT cytotoxic
or cytostatic medicines)
Orange
lidded bin
or bag
Licensed or
permitted
treatment
facility or
incineration
Incineration
or alternative
treatment
facility
Hazardous
Waste for
incineration
Clinical
sharps
Clinical
Sharps
Cytotoxic and
cytostatic
waste and
sharps
All contaminated waste. Soft waste: including
gloves, swabs, packaging etc Sharps waste:
needles, syringes, ampoules etc,
Offensive/
hygiene
waste
Non-infectious dressings, swabs, drains,
incontinence pads, suction liners, stoma bags,
catheter bags, plastic disposable instruments
(not sharps).
Unused drugs and other pharmaceutical
products. Never discard them into the drainage
system.
Controlled drugs: comply with local procedures.
Medicines
(Not cytoxics
or cytostatic)
Orange
lidded
sharps
container
Yellow
lidded,
liquid-proof
sharps
container.
Yellow bag
or lidded
bin with
purple
stripe.
Yellow
sharps bin
with purple
lid
Hazardous
waste for
incineration
Yellow bag
with black
stripe
Deep landfill
Yellow rigid
lidded box
for liquids
or solids
Hazardous
waste
incineration
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Table 11
Waste packaging and colour coding (from HTM 07-01)
Waste receptacle
Waste type
Example of
contents
Dressings, tubing
etc. from treatment
involving low level
radioactive
isotopes
Indicative treatment
disposal
Licensed incineration
facility
Infectious waste
contaminated with
cytotoxic and/or
cytostatic medicinal
products
Dressings/tubing
from cytotoxic or
cytostatic treatment
Incineration
Sharps contaminated
with cytotoxic and
cytostatic medicinal
products
Sharps used to
administer cytotoxic
products
Incineration
Infectious and other
waste requiring
incineration including
anatomical waste,
diagnostic specimens,
reagent or test vials
and kits containing
chemicals
Partially discharged
sharps not
contaminated with
cyto-products
Anatomical waste
from theatre
Incineration
Syringe body with
residue medicinal
product
Incineration
Waste type
Example of
Healthcare waste
contaminated with
radioactive material
„Over stickers‟ with the
radioactive waste
symbol may be used on
yellow packaging
Solid Bag Container
(No Images currently
available)
Extra robust containers
used for needle
exchange programmes
May be black
Receptacle must be UN
approved for liquids
Waste receptacle
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Medicines in original
Packaging
contents
Waste in original
package with
original closures
disposal
Incineration
Medicines NOT in
original packaging
Waste tablets not in
foil pack or bottle
Hazardous waste
incineration
Segregate aerosols
i.e. asthma inhalers
Infectious waste,
potentially infectious
waste and autoclaved
laboratory waste
Soiled dressings
Licensed/permitted
treatment facility
Offensive/hygiene
waste
Human hygiene
waste and noninfectious
disposable
equipment, bedding
and plaster casts
Deep landfill
Domestic waste
General refuse
Paper, cardboard,
cans, household
flowers, plastic
wrappers, food
scraps, office
waste, paper
towels, kitchen
waste, etc.
Excluding glass
and sharp objects
Landfill
Note; wheeled waste
containers may remain
yellow but marked and
tagged as orange
stream waste. Due to
cost of replacements.
Clinical Waste (Containers may vary in size and design dependant on manufacturer)
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19.3
Storage of clinical waste
Foot pedal operated or hands free bins must be available where clinical waste is
generated.
Bins must be lined with the appropriate coloured liner.
Clinical waste bags must be removed when they are three-quarters full or at the
end of the day, as appropriate.
Bags should be tied securely per local arrangements using tape, clips or tying in
a swan-neck before removing them from the bin.
Clinical waste bags and sharps boxes must be labelled with the address of
where the waste was produced. This may be using labelled tape or clips, or
simply by writing the address or post code in permanent marker pen onto the
bag prior to use.
Bags must be held by the neck and must not be thrown.
Clinical waste should be stored in a designated waste collection point or wheeled
bin away from residential and food preparation areas. Ideally in a lockable fixed
bin awaiting collection.
Bins provided for clinical waste must be kept in a secure locked location away
from public access that is well-lit, ventilated and marked with warning signs.
Waste must be collected by a registered carrier at regular intervals e.g. weekly.
Waste contractors are under no obligation to remove waste if it does not
adhere to the duty of care, e.g. packaged and labelled correctly.
19.4
Disposal of sharps
See section 9.1.4 for safe use of sharps.
Sharps containers must comply with UN3291 and BS7320: 1990.
Lock the sharps container prior to disposal.
Discard when three-quarters full or after 3 months. Lock the container using the
closure mechanism.
Place damaged sharps containers inside a larger container, lock and label prior
to disposal.
If sharps are spilled from the container use a safe technique to retrieve them,
e.g. a dust pan and brush, and carefully place inside the container.
Never put a sharps container inside a clinical waste bag
20.
PEST CONTROL
Pests can be found in any property but with appropriate precautions will not pose a
risk to service users and care workers.
Pests include:Insects
ants, flies, cockroaches, fleas, silverfish
Rodents
rats and mice
Birds
pigeons
Feral cats and foxes
Control measures include:Fitting fly screens, bird netting and covering drains;
Being alert for signs of infestation such as droppings, nests and chew marks;
Storing food in pest proof containers.
Inspecting storage areas regularly.
Keeping storage areas clean and cleaning up any spillage promptly.
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Correct waste disposal.
If pests are a problem advice should be obtained from specialist pest control
companies.
21.
ADMISSION AND TRANSFER AND DISCHARGE OF SERVICE USERS
In order to minimise the risk of infection to other service users and care workers the
infection status should be passed on to those providing further support and nursing
or medical care. This is essential at the time of admission or transfer between care
facilities to ensure the provision of optimum care and prevent further transmission of
infection. Likewise when service users are discharged home from hospital details of
infection status should be passed on to the primary care team.
22.
ANTIMICROBIAL PRESCRIBING
Inappropriate use of antimicrobial agents has led to a significant increase in the
numbers of antibiotic resistant micro organisms. In addition to this the use of broad
spectrum antibiotics has increased the risk and spread of Clostridium difficile
infection.
All antimicrobial prescribing should be in accordance with NHS Stoke on Trent‟s
antimicrobial prescribing guidelines 2010, and where ever possible supported by
microbiological evidence. These guidelines have been sent to all prescribers.
Where the service user‟s condition or other factors warrant prescribing outside
the guidelines advice should be taken from the Consultant Microbiologist.
All antimicrobial prescribing should be reviewed and amended if appropriate
when microbiology results are available.
Antibiotics should only be prescribed when there is clinical evidence of bacterial
infection.
The reason for the prescription should be clearly documented in the service
user‟s notes.
Any long term prophylaxis should be discussed with the Consultant
Microbiologist.
A summary of the 2010 guidelines can be found in Appendix 26.
23.
UNIFORMS AND WORKWEAR
Not all care workers are required to wear uniforms. Uniforms are not considered to
be a significant source of infection but the way care workers dress will convey certain
messages to the service users they care for and the public. Both infection
prevention and control and public perception should underpin the organisation‟s
uniform and dress code.
Examples of good and poor practice are shown in the following table
Table 12
Examples of good and poor practice for uniform/dress code
Good Practice
Poor practice
Wear short sleeves when providing care to
enable good hand hygiene.
Go shopping and other public places
whilst wearing uniform
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Change into and out of uniform at work or
cover uniform when travelling to and from
work.
Wear clear name badges so that service
users know who is caring for them.
Change immediately if uniforms become
visibly soiled or contaminated.
Tie long hair back.
Wear soft soled closed toed shoes to
protect feet from sharps and spills
Wear false nails when giving care as
these can harbour micro organisms
damage service users and prevent
good hand hygiene
Wear hand or wrist jewellery
/wristwatches
Wear numerous badges
Wear neck ties other than bow ties for
direct care
Carry pens, scissors etc outside breast
pockets
Wear clothes that are machine washable
Uniforms do not constitute protective clothing and should always be protected from
contamination by the use of disposable aprons.
Care workers should have sufficient uniforms to wear a clean uniform each day.
Ideally they should be made of a fabric that is able to withstand a wash temperature
of 60oC.
If care workers wear their own clothes in the workplace similar hygiene measures
should be followed.
24.
24.1
OCCUPATIONAL HEALTH
Occupational health advice
There must be arrangements in place for occupational health support and advice,
together with appropriate policies for the protection of care workers from infection
through immunisation, the avoidance and management of incidents and training and
compliance with health and safety legislation. Such policies should apply to all
agency and locum staff, and to those on short-term contracts. Each new member of
staff should complete a pre-employment health questionnaire and provide
information about previous immunisation against relevant infections. Service users
and other care workers also need to be protected from care workers infected with a
communicable disease. Occupational health policies should clearly set out the
responsibilities of staff members to report episodes of illness, such as vomiting and /
or diarrhoea to their manager.
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24.2
Immunisations
Any vaccine-preventable disease that is transmissible from person to person poses a
risk to both care workers and service users. Care workers have a duty of care
towards those they provide care to through their work to take reasonable precautions
to protect them from communicable diseases.
Immunisation of care workers may therefore:
protect the individual and their family from an occupationally-acquired infection;
protect service users, including the most vulnerable who may not respond well to
their own immunisation;
protect other care workers and allow for the efficient running of services without
disruption.
The most effective method for preventing infections is the adoption of safe working
practices.
Immunisation should never be regarded as a substitute for good practice, although it
does provide additional protection.
This applies to all care workers who have regular clinical contact with service users
and who are directly involved in patient care and includes doctors, dentists, midwives
and nurses, paramedics and ambulance drivers, occupational therapists,
physiotherapists and radiographers. Students and trainees in these disciplines and
volunteers who are working with service user must also be included.
Routine vaccinations
All care workers should be up to date with their routine immunisations, e.g. tetanus,
diphtheria, polio and MMR. The MMR vaccine is especially important in the context
of the ability of care workers to transmit measles or rubella infections to vulnerable
groups. While healthcare workers may need MMR vaccination for their own benefit,
they should also be immune to measles and rubella in order to assist in protecting
service users.
Satisfactory evidence of protection would include documentation of having received
two doses of MMR or having had positive antibody tests for measles and rubella.
BCG
BCG vaccine is recommended for care workers who may have close contact with
infectious patients. It is particularly important to test and immunise care workers
working in maternity and paediatric departments and who are in contact with service
users who are likely to be immunocompromised, e.g. transplant, oncology and HIV
units.
Hepatitis B
Hepatitis B vaccination is recommended for care workers who may have direct
contact with service user‟s blood or blood-stained body fluids. This includes any care
workers who are at risk of injury from blood-contaminated sharp instruments, or of
being deliberately injured or bitten by patients. Antibody titres for hepatitis B should
be checked one to four months after the completion of a primary course of vaccine.
Such information allows appropriate decisions to be made concerning post-exposure
prophylaxis following known or suspected exposure to the virus.
Influenza
Influenza immunisation helps to prevent influenza in care workers and may also
reduce the transmission of influenza to vulnerable service users. Influenza
vaccination is therefore recommended for front line care workers. Influenza
immunisation should be offered on an annual basis.
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Varicella
Varicella vaccine is recommended for susceptible care workers who have direct
contac with service users. Those with a definite history of chickenpox or herpes
zoster can be considered protected. Care workers with a negative or uncertain
history of chickenpox or herpes zoster should be serologically tested and vaccine
only offered to those without the varicella zoster antibody.
Further information on immunisations for care workers can be obtained from the
Occupational Health Department on 01782 418248 or from the “Green Book” on the
Department of Health website: www.dh.gov.uk
24.3
Exclusion from work
When necessary, care workers may need to be excluded from work until they have
recovered or results of specimens are available. Staff with vomiting and or diarrhoea
should be advised to remain off work until at least 48 hours have elapsed since their
symptoms ceased.
24.4
Inoculation (sharps) injuries and bites
There should also be a clear policy regarding action to be taken in the event of a
blood contamination incident (e.g. needle-stick, sharps, inoculation injury or bite).
Where possible this should be provided in a poster format, as well as written policy,
so an injured party can take action promptly.
24.5
Skin and soft tissue infections
Care workers with recurrent skin and soft tissue infections should report this to their
manager and be referred to the Occupational Health department.
25.
NEW BUILD AND SERVICE DEVELOPMENTS
Department of Health guidelines have emphasised the role of the environment as a
potential source of infection for service users. Therefore it is important that infection
prevention and control principles and issues are considered whenever planning new
or upgraded buildings. Designers, engineers, architects, facilities managers and
planners must collaborate with the local infection prevention and control team to
ensure that infection risks are reduced to a minimum. The infection prevention and
control team should be consulted during the planning process in order to identify and
minimise infection risks. This principle also applies when planning service
developments and new contracts.
Key considerations include:
Size of rooms;
Availability of treatment rooms;
Availability and design of clinical hand wash basins;
Design and features of ancillary areas;
Engineering services;
Storage facilities;
Finishes for walls, floors, ceilings, doors, windows, fixtures, fittings and furniture;
Interior design and designs of fixtures and fittings;
Decontamination facilities;
Kitchen and rest rooms;
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Waste – segregation, storage and disposal;
Changing facilities;
Service lifts
Construction and the role of cleaning.
Further information on all these aspects may be found in the publication:
Infection prevention and control in the Built Environment: Design and Planning. HFN
30.
26.
26.1
INFECTION PREVENTION AND CONTROL TRAINING
Induction
Practice Managers must ensure that all newly employed care workers are introduced
to the infection prevention and control policies and procedures on induction and by
the end of their first week of employment.
26.2
Ongoing training
Care workers must also be updated on an annual basis and / or when new matters
arise. Managers should also periodically undertake an assessment of the infection
risks in their workplace and ensure that everything necessary is in place to manage
those risks.
An infection prevention and control link person should be identified to act as a link
between the infection prevention and control/health protection team and the place of
work.
Infection prevention and control training can be obtained from a variety of sources,
access may vary and a variety of charges apply.
Examples of potential sources of infection prevention and control training include:
BTEC courses;
Distance learning packages;
Health Protection Units;
PCT/Hospital Infection prevention and control Teams;
Local colleges/universities;
NVQ courses;
NHS Core Learning Programmes Unit Infection prevention and control e learning
training programme is available on-line. Further information and a link to the
programme can be found at:
http://www.dh.gov.uk/PublicationsAndStatistics/PressReleases/Press
27.
BIBLIOGRAPHY (FROM THE HEALTH AND SOCIAL CARE ACT 2008)
The following bibliography taken from the Health and Social Care Act 2008
represents current guidance, best practice and legislation that sets the standard of
care that should be applied in the prevention and control of infection in both health
and social care. The bibliography includes current guidance for those providing
health and social care in all settings and across all organisations. This means that
providers of care whether in hospital or community settings can be aware of each
other‟s needs and priorities. It is not expected that carers become experts in both
sectors – only that in the interests of service users‟ safety and high standards a
greater awareness is achieved.
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However, when a medical procedure is carried out in a social care setting, the
relevant healthcare guidance should be consulted.
Procedures should be performed only by carers who have demonstrated the
appropriate competency and who are able to work to standards that may be
indicated in the following publications.
Department of Health guidance on management and organisation for the prevention
and control of infection
Department of Health (2009) The Health and Social Care Act 2008: Code of Practice for
health and adult social care on the prevention and control of infections and related
guidance. London DH. Available from www.dh.gov.uk/en/Publications
Department of Health (2008) Board assurance: a guide to building assurance frameworks
for reducing health care associated infections. London: DH. Available from:
www.clean-safe-care.nhs.uk/ArticleFiles/Files/287717_BoardAssurance.pdf
Department of Health (2008) Board to Ward – how to embed a culture of HCAI prevention
in acute trusts. London: DH. Available from:
www.clean-safe-care.nhs.uk/ArticleFiles/Events/286948-COI-BoardToWard.pdf
Department of Health (2008) Director of Infection Prevention and Control Role Profile.
Available from:
www.clean-safe-care.nhs.uk/ArticleFiles/Files/DIPC_final.pdf
Department of Health (2008). The operating framework for the NHS in England: 2009/10.
London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_091445
Department of Health (2008) Clean, safe care: reducing infections and saving lives.
London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_081650
Department of Health (2006) Essential steps to safe, clean care: reducing healthcareassociated infections. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_4136212
Department of Health (2007) Saving Lives: reducing infection, delivering clean and safe
care. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_078134
Department of Health (2006) Standards for better health. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_4086665
NHS Stoke on Trent Infection Prevention and Control Team 2010
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Department of Health (2004) Towards cleaner hospitals and lower rates of infection: a
summary of action. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyandGuid
ance/DH_4085649
Department of Health (2003) Winning ways: working together to reduce healthcare
associated infection in England. Report from the Chief Medical Officer. London: DH.
Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyandGuidance/D
H_4064682
Department of Health (2002) Getting ahead of the curve: a strategy for combating infectious
diseases (including other aspects of health protection). A report by the Chief Medical
Officer. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyandGui
dance/DH_4007697
Department of Health (1995) HSG (95) 10: Hospital infection control. London: DH.
Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyandGui
dance/DH_4017852
Ambulance guidelines
Department of Health (2008) Ambulance guidelines: reducing infection through effective
practice in the pre-hospital environment. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_087430
Antimicrobial prescribing
BMJ Group and RPS Publishing (2009) British National Formulary. Available from:
www.bnf.org
Health Protection Agency Antimicrobial prescribing template for primary care.
London: HPA. Available from:
www.hpa.org.uk/HPA/Topics/InfectiousDiseases/InfectionsAZ/1197637041219
Department of Health, Specialist Advisory Committee on Antimicrobial Resistance
(2007) Antimicrobial Framework, Journal of Antimicrobial Chemotherapy 60
(Supplement 1). Available from:
http://jac.oxfordjournals.org/cgi/content/full/60/suppl_1/i87
Scottish Medicines Consortium/Healthcare Associated Infection Task Force (2005)
Antimicrobial prescribing policy and practice in Scotland: recommendations for good
antimicrobial practice in acute hospitals. Edinburgh: Scottish Executive. Available from:
www.sehd.scot.nhs.uk/cmo/CMO(2005)8report.pdf
NHS Stoke on Trent Infection Prevention and Control Team 2010
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Department of Health, Standing Medical Advisory Committee, Sub-Group on
Antimicrobial Resistance (1998) The path of least resistance. London: DH. Available
from:
www.advisorybodies.doh.gov.uk/pub/docs/doh/smacrep.pdf
Audit
Infection Control Nurses Association (2005) Audit tools for monitoring infection control
guidelines within the community setting. Infection Prevention Society. Available from:
www.ips.uk.net/PRD_ProductDetail.aspx?cid=9&prodid=22&Product=CommunityAuditTool-Booklet--CD-Rom
Infection Control Nurses Association (2004) Acute audit tools for monitoring infection
control standards. Infection Prevention Society. Available from:
www.ips.uk.net/PRD_ProductDetail.aspx?cid=9&prodid=24&Product=%20AcuteAudit-tools-for-monitoringInfection-Control-Standards-2004
Care of deceased persons
Health and Safety Executive (2003) Safe working and the prevention of infection in the
mortuary and post-mortem room. London: HSE. Available from:
www.hsebooks.com/Books/default.asp
Clinical practice and patient management
National Patient Safety Agency (2008) Patient Safety Alert: clean hands save lives.
London: NPSA. Available from:
www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59848
Department of Health (2008) Ambulance guidelines – reducing infection through effective
practice in the pre-hospital environment. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_087430
Pratt RJ, Pellowe CM, Wilson JA, Loveday HP et al (2007) epic2: National evidence-based
guidelines for preventing healthcare associated infections in NHS hospitals in England.
Journal of Hospital Infection 65 (Supplement). Available from:
www.epic.tvu.ac.uk/epic/notice.html
National Institute for Health and Clinical Excellence (2003) Infection control: prevention
of healthcare-associated infections in primary and community care. London: NICE.
Available from:
www.nice.org.uk/nicemedia/pdf/Infection_control_fullguideline.pdf
Department of Health (2003) Winning ways: working together to reduce healthcare
associated infection in England. Report from the Chief Medical Officer. London: DH.
Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyandGuid
ance/DH_4064682
NHS Stoke on Trent Infection Prevention and Control Team 2010
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Department of Health (2002) Good practice guidelines for renal dialysis/transplantation
units: prevention and control of blood-borne virus infection. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_4005752
Confidentiality
Department of Health (2003) Confidentiality: NHS Code of Practice. London: DH. Available
from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_4069253
National Information Governance Board (2009) The Care Record Guarantee: Our
guarantee for NHS care records in England. London: NIGB. Available from:
www.nigb.nhs.uk/guarantee
National Information Governance Board (2009) The Social Care Record Guarantee: The
guarantee for social care records in England. London: NIGB. Available from:
www.nigb.nhs.uk/social
Control of infections associated with specific alert organisms
Acinetobacter and other antibiotic – resistant bacteria
Health Protection Agency (2006) Working party guidance on the control of multiresistant acinetobacter outbreaks. London: HPA. Available from:
www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1195733753838?
p=1191942145615
Clostridium difficile
Department of Health/Health Protection Agency (2009) Clostridium difficile infection: how to
deal with the problem. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_093220
Department of Health (2005) Infection caused by Clostridium difficile, Professional
Letter from the Chief Medical Officer and the Chief Nursing Officer. London: DH.
Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Professionall
etters/Chiefnursingofficerletters/DH_4124989
Health Protection Agency (2003) National Clostridium difficile Standards Group, Report to
the Department of Health. London: HPA. Available from:
www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947372533
Brazier JS and Duerden BI (1998) Guidelines for optimal surveillance of Clostridium
difficile infection in hospitals, Communicable Disease and Public Health 1(4): 229–230.
Available from:
NHS Stoke on Trent Infection Prevention and Control Team 2010
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www.hpa.org.uk/cdph/issues/CDPHVol1/no4/guidelines.pdf
Diarrhoeal infections
Health Protection Agency (2004) Preventing person-to-person spread following
gastrointestinal infections: guidelines for public health physicians and environmental health
officers, Communicable Disease and Public Health 7(4): 362–84. Available from:
www.hpa.org.uk/cdph/issues/CDPHvol7/No4/guidelines2_4_04.pdf
Chadwick, PR, Beards G, Brown D, Caul EO, et al (2000) Management of hospital
outbreaks of gastro-enteritis due to small round structured viruses, Journal of
Hospital Infection 45(1): 1–10. Available from:
www.ncbi.nlm.nih.gov/pubmed/10833336
Glycopeptide resistant enterococci
Health Protection Agency Glycopeptide-resistant enterococci (GRE) – general information.
London: HPA. Available from:
www.hpa.org.uk/infections/topics_az/enterococci/FAQs.htm
Meticillin-resistant Staphylococcus aureus (MRSA)
Coia JE, Duckworth GJ, Edwards DI, Farrington M, et al, for the Joint Working Party of the
British Society for Antimicrobial Chemotherapy, the Hospital Infection Society, and the
Infection Control Nurses Association (2006), Guidelines for the control and prevention of
meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities, Journal of
Hospital Infection (Supplement): 63 S1–44.
Gemmell CG, Edwards DI, Fraise AP, Gould FK et al, for the Joint Working Party of the
British Society for Antimicrobial Chemotherapy, the Hospital Infection Society, and the
Infection Control Nurses Association (2006). Guidelines for the prophylaxis and treatment
of meticillin-resistant Staphylococcus aureus (MRSA) infections in the UK, Journal of
Antimicrobial Chemotherapy 57(4): 589–608. Available from:
http://jac.oxfordjournals.org/cgi/reprint/dkl017v1
Brown DF, Edwards DI, Hawkey PM, Morrison D, et al, for the Joint Working Party of the
British Society for Antimicrobial Chemotherapy, the Hospital Infection Society and the
Infection Control Nurses Association (2005). Guidelines for the laboratory diagnosis and
susceptibility testing of meticillin-resistant Staphylococcus aureus (MRSA), Journal of
Antimicrobial Chemotherapy 56(6): 1000–18. Available from:
www.ncbi.nlm.nih.gov/pubmed/16293678
MRSA Screening
Department of Health (2008) MRSA screening – operational guidance. London: DH.
Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleaguele
tters/DH_086687
Department of Health (2008) MRSA screening – operational guidance 2. London: DH.
Available from:
NHS Stoke on Trent Infection Prevention and Control Team 2010
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www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleaguele
tters/DH_092844
Department of Health (2006) Screening for MRSA colonisation: a summary of best
practice, Professional Letter from the Chief Medical Officer and the Chief Nursing Officer.
London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Professionalletters
/Chiefmedicalofficerletters/DH_063138
Panton-Valentine leukocidin (PVL) associated and community associated
Staphylococcus aureus
Health Protection Agency (2008) Guidance on the diagnosis and management of PVLassociated Staphylococcus aureus infections (2nd edition). London: HPA. Available
from:
www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/12072083047
10?p=1207208304710
Nathwani D, Morgan M, Masterton R, Dryden M et al for the British Society for
Antimicrobial Chemotherapy Working Party on Community-onset MRSA Infections
(2008). Guidelines for UK practice for the diagnosis and management of meticillinresistant Staphylococcus aureus infections (MRSA) presenting in the community,
Journal of Antimicrobial Chemotherapy 61(5): 976–994. Available from:
http://jac.oxfordjournals.org/cgi/reprint/61/5/976
Respiratory viruses
National Institute for Health and Clinical Excellence (2008) Respiratory tract infections –
antibiotic prescribing. NICE Clinical Guideline 69. London: NICE. Available from
www.nice.org.uk/nicemedia/pdf/CG69FullGuideline.pdf
Department of Health (2006) Immunisation against infectious disease („The Green Book‟).
London: DH. Available from:
www.dh.gov.uk/en/Publichealth/Healthprotection/Immunisation/Greenbook/DH_4097
254
Creutzfeldt-Jakob disease (CJD) and other human prion diseases
Advisory Committee on Dangerous Pathogens TSE Working Group guidance Transmissible
spongiform encephalopathy agents: safe working and the prevention of infection – guidance
from the Advisory Committee on Dangerous Pathogens. London: DH. Available from:
www.dh.gov.uk/ab/ACDP/TSEguidance/index.htm
Tuberculosis
Department of Health (2007) Tuberculosis prevention and treatment: a toolkit for planning,
commissioning and delivering high-quality services in England. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_075621
NHS Stoke on Trent Infection Prevention and Control Team 2010
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National Institute for Health and Clinical Excellence (2006) Tuberculosis: clinical
diagnosis and management of tuberculosis, and measures for its prevention and
control. NICE Clinical Guideline 33. Available from:
www.nice.org.uk/guidance/index.jsp?action=download&o=30018
Viral haemorrhagic fevers
Advisory Committee on Dangerous Pathogens (1996) Management and control of
viral haemorrhagic fevers. ACDP. Available from:
www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947382005
Decontamination of reusable medical devices
Department of Health (2009) HTM 01-06: Decontamination of flexible endoscopes.
London: DH. Available from:
www.spaceforhealth.nhs.uk
Department of Health (2008) HTM 01-05: Decontamination in primary care dental practices.
London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_097678
British Dental Association (2008) Infection control in dentistry, BDA advice sheet A12.
London: DH. Available from: www.dh.gov.uk/assetRoot/04/12/09/05/04120905.pdf
Department of Health (2007) Clarification and policy summary – decontamination of
reusable medical devices in the primary, secondary and tertiary care sectors. London: DH.
Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_074722
Department of Health (2007) HTM 01-01: Decontamination of reusable medical
devices: Part A – Management and environment. London: DH. Available from:
https://publications.spaceforhealth.nhs.uk/
Department of Health HTM 01-01: Decontamination of reusable medical devices. Part B –
Additional management guidance and common elements; Part C –Sterilizers; Part D –
Washer disinfectors and ultrasonic cleaners (was the subject of stakeholder consultation
which closed in May 2009). Available from:
www.dh.gov.uk/en/Consultations/Closedconsultations/index.htm
Medicines and Healthcare products Regulatory Agency (2006) DB 2006 (05): Managing
Medical Devices. London: MHRA. Available from:
www.mhra.gov.uk/Publications/Safetyguidance/DeviceBulletins/CON2025142
Medicines and Healthcare products Regulatory Agency (2006) Sterilization, disinfection
and cleaning of medical equipment: Guidance on decontamination from the Microbiology
Advisory Committee to Department of Health. London: MHRA. Available from:
NHS Stoke on Trent Infection Prevention and Control Team 2010
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www.mhra.gov.uk/Publications/Safetyguidance/Otherdevicesafetyguidance/CON007
438
NHS Estates (2004) HBN 13: Sterile services department. Available from:
https://publications.spaceforhealth.nhs.uk/
Medical Devices Agency (2002) DB 2002 (05): Decontamination of endoscopes.
London: MDA. Available from:
www.mhra.gov.uk/Publications/Safetyguidance/DeviceBulletins/CON007329
Medical Devices Agency (2002) DB 2002 (05): Benchtop steam sterilizers – guidance on
purchase, operation and maintenance. London: MDA. Available from:
www.mhra.gov.uk/Publications/Safetyguidance/DeviceBulletins/CON007326
NHS Estates (1997) HTM 2031: Clean steam for sterilization. Available from:
https://publications.spaceforhealth.nhs.uk/
Education of care workers
National Patient Safety Agency (2008) Patient Safety Alert: clean hands save lives.
London: NPSA. Available from:
www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59848
National Patient Safety Agency. Cleanyourhands campaign website:
www.npsa.nhs.uk/cleanyourhands
NHS Core Learning Unit (2005) Infection control e-learning programme for healthcare
and social care staff. Available from: www.infectioncontrol.nhs.uk
Skills for Care (2005) Common Induction Standards Social Care (Adults, England).
Leeds: Skills for Care. Available from:
www.skillsforcare.org.uk/entry_to_social_care/common_induction_standards/co
mmon_induction_standards.aspx
Skills for Care (2005) Knowledge set for infection prevention and control Social Care
(Adults, England). Leeds: Skills for Care. Available from:
www.skillsforcare.org.uk/developing_skills/knowledge_sets/infection_preventio
n_and_control.aspx
Health Protection Agency (2009) Introduction to infection control in care homes
A series of short films. London: HPA. Available from:
www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/122959419
5568?p=1229594195568
Environmental disinfection
Department of Health/Health Protection Agency (2009) Clostridium difficile infection: how to
deal with the problem. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_093220
NHS Stoke on Trent Infection Prevention and Control Team 2010
91
Department of Health (2003) Winning ways: working together to reduce healthcare
associated infection in England. Report from the Chief Medical Officer. London: DH.
Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyandGui
dance/DH_4064682
Guidance on the environment
Department of Health (2007) Improving cleanliness and infection control, Professional
Letter from the Chief Nursing Officer. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Professionalletters/
Chiefnursingofficerletters/DH_080053
NHS Estates (2006) HBN 26: Facilities for surgical procedures: Volume 1.
Available from:
https://publications.spaceforhealth.nhs.uk/
NHS Estates (2004) A matron’s charter: an action plan for cleaner hospitals.
Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/%20PublicationsPoli
cyAndGuidance/DH_4091506
NHS Estates (2002) HFN 30: Infection control in the built environment: design and
planning. Available from: https://publications.spaceforhealth.nhs.uk/
Cleaning
National Patient Safety Agency (2009) The national specifications for cleanliness in the
NHS: a framework for setting and measuring performance outcomes in ambulance
trusts. London: NPSA. Available from:
www.nrls.npsa.nhs.uk/resources/patient-safety-topics/environment/
National Patient Safety Agency (2009) The revised healthcare cleaning manual. London:
NPSA. Available from:
www.nrls.npsa.nhs.uk/resources/patient-safety-topics/environment/
National Patient Safety Agency (2007) The national specifications for cleanliness in the
NHS: a framework for setting and measuring performance outcomes. London: NPSA.
Available from:
www.nrls.npsa.nhs.uk/resources/patient-safety-topics/environment/
National Patient Safety Agency (2007) Safer practice notice 15: Colour coding hospital
cleaning materials and equipment. Available from: www. NHS Estates (2004) Revised
guidance on contracting for cleaning. London: DH. Available from:
www.nrls.npsa.nhs.uk/resources/patient-safety-topics/environment/
NHS Stoke on Trent Infection Prevention and Control Team 2010
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Building and refurbishment, including air-handling systems
NHS Estates (2008) HBN 04 – 01: Adult in-patient facilities. Available from:
https://publications.spaceforhealth.nhs.uk/
Department of Health (2007) HTM 03-01: Heating and ventilation systems:
Specialised ventilation for healthcare premises. Part A – Design and validation.
Available from:
https://publications.spaceforhealth.nhs.uk/
Department of Health (2007) HTM 03-01: Heating and ventilation systems: specialised
ventilation for healthcare premises. Part B – Operational management and
performance verification. Available from:
https://publications.spaceforhealth.nhs.uk/
NHS Estates (2005) HBN 4: Supplement I: In-patient accommodation: options for choice.
Isolation facilities in acute settings. Available from:
https://publications.spaceforhealth.nhs.uk/
Planned preventive maintenance
NHS Estates (2002) HFN 30: Infection control in the built environment: design and
planning. Available from:
https://publications.spaceforhealth.nhs.uk/
Healthcare waste
Department of Health (2006) HTM 07-01: Environment and sustainability: safe
management of healthcare waste. Available from:
https://publications.spaceforhealth.nhs.uk/
Department of Health (2003) NHS Standard Service Level Specifications.
Service specific specification – waste management. Available from:
www.dh.gov.uk/assetRoot/04/02/10/95/04021095.pdf
Health and Safety Executive (2009) Managing offensive/hygiene waste. London:
HSE. Available from:
www.hse.gov.uk/pubns/waste22.pdf
Pest control
Department of Health (2003) NHS Standard Service Level Specifications.
Service specific specification – pest control version 2. Available from:
www.dh.gov.uk/assetRoot/04/02/11/29/04021129.pdf
Management of water supplies
Health and Safety Executive (2009) Controlling legionella in nursing and residential
care homes INDG253(rev1) Available from:
www.hse.gov.uk/pubns/indg253.pdf
NHS Stoke on Trent Infection Prevention and Control Team 2010
93
Department of Health (2006) HTM 04-01: Water systems: the control of Legionella,
hygiene, “safe” hot water, cold water and drinking water systems. Part A: Design,
installation and testing. Available from:
https://publications.spaceforhealth.nhs.uk/
Department of Health (2006) HTM 04-01: Water systems: the control of Legionella,
hygiene, “safe” hot water, cold water and drinking water systems. Part B: Operational
management. Available from:
https://publications.spaceforhealth.nhs.uk/
British Standards Institution (1997) Specification for design, installation, testing
and maintenance of services supplying water for domestic use within buildings
and their curtilages. London: BSI. Available from:
http://products.ihs.com/cis/Doc.aspx?AuthCode=&DocNum=98868
Food services, including food hygiene and food brought into the organisation by
patients, staff and visitors
Hospital Caterers Association Better Hospital Food programme. Available from:
www.hospitalcaterers.org/better-hospital-food/
NHS Estates (2005) Managing food waste in the NHS. London: DH. Available from:
www.hospitalcaterers.org/library/foodwaste.html
Department of Health (1996) HSG (96) 20: Management of food hygiene and food
services in the NHS. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Healthservicegui
delines/DH_4018215
Health and safety
Health and Safety Executive (2008) Blood-borne viruses in the workplace, Guidance
for employers and employees – INDG342. London: HSE. Available from:
www.hse.gov.uk/pubns/indg342.pdf
Health and Safety Executive (2006) Five steps to risk assessment – INDG163(rev2).
London: HSE. Available from:
www.hse.gov.uk/pubns/indg163.pdf
Health and Safety Executive (2005) COSHH: a brief guide to the Regulations: what you
need to know about the Control of Substances Hazardous to Health Regulations 2002
(COSHH). London: HSE. Available from:
www.hse.gov.uk/pubns/indg136.pdf
Health and Safety Executive (2005) Biological agents: managing the risks in laboratories
and healthcare premises. London: HSE. Available from:
www.hse.gov.uk/biosafety/biologagents.pdf
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Health and Safety Executive (2005) Respiratory protective equipment at work: a
practical guide. HSG53. London: HSE. Available from:
www.hsebooks.com/Books/default.asp
Health and Safety Executive (2003) Health and safety regulation a short guide. London:
HSE. Available from:
www.hse.gov.uk/pubns/hsc13.pdf
Health and Safety Executive (2001) A guide to measuring health & safety
performance. London: HSE. Available from:
www.hse.gov.uk/opsunit/perfmeas.pdf
Health and Safety Executive (1999) Management of Health and Safety at Work
Regulations. Management of health and safety at work. Approved code of practice and
guidance. Statutory Instrument No. 3242. Available from:
www.opsi.gov.uk/si/si1999/19993242.htm
Health and Safety Executive (1999) A guide to the reporting of injuries, diseases and
dangerous occurrences regulations (RIDDOR) 1995. London: HSE. Available from:
www.hse.gov.uk/pubns/books/l73.htm
Health and Safety Executive (1992) Personal Protective Equipment at Work
Regulations. London: HSE. Available from:
www.hse.gov.uk/pubns/indg174.pdf
Health and Safety Executive (1974) Health and Safety at Work etc. Act 1974. London: HSE.
Available from:
www.hse.gov.uk/legislation/hswa.htm
Healthcare workers infected with a blood-borne virus
Department of Health (1993) HSG 93 (40): Protecting health care workers and patients
from hepatitis B. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_4084234
Department of Health (1993) Protecting health care workers and patients from hepatitis B:
recommendations of the Advisory Group on Hepatitis. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_4084234
Department of Health (1996) Addendum to HSG 93 (40): Protecting health care workers
and patients from hepatitis B. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Executiveletters/D
H_4088385
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Department of Health (2000) HSC 2000/020: Hepatitis B infected health care workers.
London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Healthservicecir
culars/DH_4004553
Department of Health (2000) Hepatitis B infected health care workers. Guidance on
implementation of Health Service Circular 2000/020. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Healthservicecir
culars/DH_4004553
Department of Health (2007) Hepatitis B infected healthcare workers and antiviral therapy.
London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_073164
Department of Health (2002) HSC 2002/010: Hepatitis C infected health care workers.
London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Healthservicecir
culars/DH_4004561
Department of Health (2002) Hepatitis C infected health care workers. Guidance on
implementation of Health Service Circular 2002/010. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Healthservicecir
culars/DH_4004561
Department of Health (2005) HIV-infected health care workers: guidance on management
and patient notification. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_4116415
Health and Safety Executive (2008) Blood-borne viruses in the workplace, Guidance for
employers and employees – INDG342. London: HSE. Available from:
www.hse.gov.uk/pubns/indg342.pdf
Immunisation
Health and Safety Executive (2008) Blood-borne viruses in the workplace, Guidance for
employers and employees – INDG342. London: HSE. Available from:
www.hse.gov.uk/pubns/indg342.pdf
Department of Health (2006) Immunisation against infectious disease („The Green Book‟).
London: DH. Available from:
www.dh.gov.uk/en/Publichealth/Healthprotection/Immunisation/Greenbook/DH_4097
254
Health and Safety Executive (2006) Five steps to risk assessment –
INDG163(rev2).London: HSE. Available from:
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www.hse.gov.uk/pubns/indg163.pdf
Isolation of service users with an infection
Department of Health/Health Protection Agency (2009) Clostridium difficile infection: how
to deal with the problem. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_093220
Department of Health (2008) Guide to best practice: isolation of patients. London:
DH. Available from:
www.clean-safe-care.nhs.uk/ArticleFiles/Files/201.pdf
NHS Estates (2005) HBN 4: In-patient accommodation: options for choice. Supplement
1: Isolation facilities in acute settings. Available from:
https://publications.spaceforhealth.nhs.uk/
NHS Estates (2002) HFN 30: Infection control in the built environment: design
and planning. Available from:
https://publications.spaceforhealth.nhs.uk/
Linen, laundry and dress
Department of Health (2003) NHS Standard Service Level Specifications. Service
specific specification – linen. Available from:
www.dh.gov.uk/assetRoot/04/02/11/22/04021122.pdf
Department of Health (1995) HSG (95)18: Hospital laundry arrangements for used and
infected linen. London: DH. Available from:
www.dh.gov.uk/en/PublicationsAndStatistics/LettersAndCirculars/HealthServiceGuid
elines/DH_4017865
Management of occupational exposure to blood-borne viruses and post-exposure
prophylaxis
Health and Safety Executive (2001) Blood-borne viruses in the workplace. London:
HSE. Available from:
www.hse.gov.uk/pubns/indg342.pdf
Department of Health (2008) HIV post-exposure prophylaxis: guidance from the UK Chief
Medical Officers’ Expert Advisory Group on AIDS. 4th edition. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndgui
dance/DH_088185
PHLS Hepatitis Subcommittee (1992) Exposure to hepatitis B virus: guidance on postexposure prophylaxis, CDR Review 2(9): 1–5. Available from:
www.hpa.org.uk/cdr/archives/CDRreview/1992/cdrr0992.pdf
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Ramsay, ME (1999) Guidance on the investigation and management of occupational
exposure to hepatitis C, Communicable Disease and Public Health 4 (4): 258–62.
Available from:
www.hpa.org.uk/cdph/issues/CDPHVol2/no4/guides_hepC.pdf
Health Protection Agency (2005) Reporting of occupational exposure to blood borne
viruses – history and how to report. London: HPA. Available from:
www.hpa.org.uk/infections/topics_ az/bbv/occ_exp.htm
Medical devices directives/regulations
Medicines and Healthcare products Regulatory Agency (2006) Bulletin No 17: Medical
devices and medicinal products. London: MHRA. Available from:
www.mhra.gov.uk/Publications/Regulatoryguidance/Devices/DirectivesBulletins/inde
x.htm
Statutory Instrument 2002 No. 618: The Medical Devices Regulations 2002. Available from:
www.opsi.gov.uk/si/si2002/20020618.htm
Medicines and Healthcare products Regulatory Agency Changes to the registration of medical
devices. Available from:
www.mhra.gov.uk/Publications/Regulatoryguidance/devices/otherdevicesregulatorygui
dance/CON007535
Council Directive 93/42/EEC of 14 June 1993 concerning medical devices. Available from:
http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX:31993L0042:EN:HTML
Microbiology laboratory
Department of Health (2007) Health, safety and security measures for microbiology
laboratories. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_072690
Department of Health (2007) Transport of infectious substances – best practice guidance
for microbiology laboratories. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_075439
Clinical Pathology Accreditation (UK) Ltd (2007) Standards for the medical laboratory.
Sheffield: CPA. Available from:
www.cpa-uk.co.uk/files/pdlabst.pdf
Movement of service users
Department of Health (2008) Clean, safe care: reducing infections and saving lives.
London: DH. Available from:
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www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_081650
Department of Health (2004) Standards for better health. London: DH. Available from:
www.dh.gov.uk/assetRoot/04/08/66/66/04086666.pdf
Department of Health (2003) Winning ways: working together to reduce healthcare
associated infection in England. Report from the Chief Medical Officer. London: DH.
Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyandGui
dance/DH_4064682
Occupational health
NHS Employers (2007) The healthy workplaces handbook. Available from:
www.nhsemployers.org/practice/practice-2468.cfm
Department of Health (2007) Health clearance for tuberculosis, hepatitis B, hepatitis C and
HIV: New healthcare workers. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_073132
Health and Safety Executive (1985) Reporting of Injuries, Disease and Dangerous
Occurrences Regulations (RIDDOR). London: HSE. Available from:
www.hse.gov.uk/riddor/guidance.htm
Health and Safety Executive (2005) Control of substances hazardous to health (Fifth
edition); The Control of Substances Hazardous to Health Regulations 2002 (as amended);
Approved Code of Practice and guidance. London: HSE. Available from:
www.hse.gov.uk/pubns/priced/15.pdf
Outbreaks of communicable infection
Department of Health (2008) Guide to best practice: isolation of patients. London: DH.
Available from:
www.clean-safe-care.nhs.uk/ArticleFiles/Files/201.pdf
Department of Health (2003) Winning ways: working together to reduce healthcare
associated infection in England. Report from the Chief Medical Officer. London: DH.
Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyandGui
dance/DH_4064682
Department of Health (1995) HSG (95) 10: Hospital infection control. London: DH. Available
from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyandGui
dance/DH_4017852
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Prevention of occupational exposure to blood-borne viruses, including the
prevention of sharps injuries
NHS Employers (2007) The healthy workplaces handbook. Available from:
www.nhsemployers.org/practice/practice-2468.cfm
Health Protection Agency (2008) Examples of good and bad practice to avoid sharps
injuries. London: HPA. Available from:
www.hpa.org.uk/infections/topics_az/bbv/good_bad.htm
Department of Health (1998) Guidance for clinical health care workers: protection against
infection with blood-borne viruses. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_4002766
Advisory Committee on Dangerous Pathogens (1995) Guidance on protection against
blood-borne infections in the workplace: HIV and hepatitis. PL CO (95)5. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Professionalletter
s/Chiefofficerlettere/DH_4003606
Provision of information to the patient, the public and other service providers
National Patient Safety Agency (2005) Being open – communicating patient safety
incidents with patients and their carers. London: NPSA. Available from:
www.npsa.nhs.uk/nrls/improvingpatientsafety/patient-safety-tools-andguidance/beingopen/
Renal care
Department of Health (2002) Good practice guidelines for renal dialysis/transplantation
units: prevention and control of blood-borne virus infection. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_4005752
Safe handling and disposal of sharps
Health Protection Agency (2008) Examples of good and bad practice to avoid sharps
injuries. London: HPA. Available from:
www.hpa.org.uk/infections/topics_az/bbv/good_bad.htm
Department of Health (2008) Ambulance guidelines – reducing infection through effective
practice in the pre-hospital environment. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_087430
Pratt RJ, Pellowe CM, Wilson JA, Loveday HP et al (2007) epic2: National evidence-based
guidelines for preventing healthcare-associated infections in NHS hospitals in England.
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Journal of Hospital Infection 65 (Supplement). Available from:
www.epic.tvu.ac.uk/epic/notice.html
National Institute for Health and Clinical Excellence (2003) Infection control: Prevention
of healthcare-associated infections in primary and community care. London: NICE.
Available from: www.nice.org.uk/nicemedia/pdf/Infection_control_fullguideline.pdf
NHS Employers (2007) The healthy workplaces handbook. Available from:
www.nhsemployers.org/practice/practice-2468.cfm
Single-use devices
Medicines and Healthcare products Regulatory Agency (2006) Single-use Medical Devices:
Implications and Consequences of Reuse. Medicines and Healthcare products Regulatory
Agency Device Bulletin DB 2006 (04). London: MHRA. Available from:
www.mhra.gov.uk/Publications/Safetyguidance/DeviceBulletins/CON2024995
Surveillance of HCAI
Department of Health (2008) Changes to the mandatory healthcare associated infection
surveillance system for Clostridium difficile infection (CDI) from 1 January 2008.
Professional Letter from the Chief Medical Officer and the Chief Nursing Officer. London:
DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Professionalletters/
Chiefmedicalofficerletters/DH_082107
Department of Health (2007) Changes to the mandatory healthcare associated infection
surveillance system for Clostridium difficile associated diarrhoea from April 2007.
Professional letter from the Chief Medical Officer and the Chief Nursing Officer. London:
DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Professionalletters
/Chiefmedicalofficerletters/DH_073767
Department of Health (2005) Mandatory surveillance of methicillin resistant Staphylococcus
aureus (MRSA) bacteraemias. Professional Letter from the Chief Medical Officer and the
Chief Nursing Officer. London: DH. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Professionalletters/
Chiefnursingofficerletters/DH_4112589
Department of Health (2003) Surveillance of healthcare associated infections,
Professional Letter from the Chief Medical Officer and the Chief Nursing Officer.
London: DH. Available from: www.dh.gov.uk/assetRoot/04/01/34/10/04013410.pdf
Brazier JS and Duerden BI (1998) Guidelines for optimal surveillance of Clostridium
difficile infection in hospitals, Communicable Disease and Public Health 1(4): 229–30.
Available from:
www.hpa.org.uk/cdph/issues/CDPHVol1/no4/guidelines.pdf
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Uniform and dress code
Department of Health (2007) Uniform and workwear: an evidence base for developing
local policy. Available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGu
idance/DH_078433
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APPENDICES
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APPENDIX 1
DEFINITIONS USED IN THE HEALTH ACT 2008
Adult Social Care
Social care includes all forms of personal care and other practical assistance provided for
individuals who, due to age, illness, disability, pregnancy, childbirth, dependence on alcohol
or drugs or any other similar circumstances, are in need of such care or assistance (Refer
to section 9 of the Act). For the purposes of the CQC, it only includes care provided for, or
mainly for, adults in England.
Alert organism surveillance
Alert organism surveillance is used widely to detect and prevent outbreaks of infection.
These organisms are reported to infection prevention and control teams on a regular basis
to identify possible outbreaks of infections and serious infections. The organisms that are
surveyed will depend on the local epidemiology of infection. Examples of alert organisms
may include Meticillin Resistant Staphylococcus aureus (MRSA), Clostridium difficile and
other antibiotic resistant organisms.
Antimicrobials
Antimicrobials are substances which are used in the treatment of infections caused by
bacteria and viruses.
Aseptic technique
This describes the clinical procedures that have been developed to prevent contamination
of wounds and other susceptible body sites.
Assurance framework
A system for informing third parties that a process of due diligence is in place to assure
safety and quality exists in that setting.
Audit
Audit is a quality improvement process that aims to improve service user care and
outcomes by carrying out a systematic review and implementing change. These are not
necessarily complex and in their simplest form show compliance with a single protocol.
Their value is in showing improvement or maintenance of a high standard.
Blood borne viruses (BBVs)
Organisms such as hepatitis B, hepatitis C and HIV that are potentially transmissible in the
occupational setting via percutaneous (sharp) or mucocutaneous (mucous
membrane/broken skin) routes.
Care worker
Any person whose normal duties concern the provision of treatment, accommodation or
related services to service users and who has access to service users in the normal course
of their work. This term includes not only front-line clinical care and support staff, but also
some staff employed in estates and facilities management, such as cleaning staff and
maintenance engineers.
Care Quality Commission
The Care Quality Commission (CQC) is the new, integrated regulator of health and adult
social care, replacing the Healthcare Commission, the Commission for Social Care
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Inspection and the Mental Health Act Commission. It was established by section 1 of the
Health and Social Care Act, 2008.
CCDC
Consultant in Communicable Disease Control.
Cohort nursing
This describes the physical separation of service users with the same infection or those
displaying similar signs and symptoms of infection in a designated area usually in a hospital
ward or a designated bay on a ward. In a care home this may be in a shared room or
designated location.
Decontamination
The combination of processes (including cleaning, disinfection and sterilisation) used to
make a re-usable item safe for further use on service users and handling by care workers.
Decontamination Lead
The senior member of staff with the responsibility for managing all aspects of
decontamination.
It is expected that this officer will report directly to the chief executive or registered provider.
It is not intended that this post should always be filled by a technically competent individual,
merely that their level of seniority within the organization is sufficient to encompass all
aspects of delivery and thus ensure compliance with best practice.
Director of Infection Prevention and Control (DIPC)
The Director of Infection Prevention and Control who has overall responsibility for infection
prevention and control and is accountable to the registered provider.
Disinfection
A process used to reduce the number of viable infectious agents but which may not
necessarily inactivate some microbial agents such as certain viruses and bacterial spores.
Disinfection does not achieve the same reduction in microbial contamination levels as
sterilization.
Domiciliary care
Homecare that helps people cope with disability or illness and allows them to maintain
independence.
Health and Social Care Act 2008 ('the Act')
The legislation that established the CQC and lays out the framework for its powers and
responsibilities.
ICD
Infection control doctor
ICN/ICP
Infection control nurse/infection control practitioner.
ICT
Infection control team
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Invasive device
A device which, in whole or part, penetrates inside the body, either through a body orifice or
through the skin.
Infection Prevention and Control Lead
The Infection Prevention and Control Lead for an organisation has overall responsibility for
infection prevention and control and is accountable to the registered provider.
Isolation facilities
Separation of a service user with a suspected or confirmed infection from other service
users. In healthcare setting this will usually be a single room with hand washing facilities,
ideally with en-suite lavatory and bath/shower. In some instances, isolation rooms will
require additional special ventilation. In an adult social care setting, a service user can
usually be safely isolated in their own room
LINks
Local Involvement Networks (LINks) aim to give citizens a stronger voice in how their health
and social care services are delivered. Run by local individuals and groups and
independently supported – the role of LINks is to find out what people want, monitor local
services and to use their powers to hold them to account. Each local authority (that
provides social services) has been given funding and is under a legal duty to make
contractual arrangements that enable LINk activities to take place.
Low-risk single (specialty) facility
A provider unit delivering care around a single specialty.
Managed premises
Any premises where regulated activities are delivered, but excluding a service user‟s home
where domiciliary care is provided and, offices used purely for managerial services.
Medical device
A healthcare product other than medicines used for the diagnosis, prevention, monitoring
and treatment of disease, injury or disability. This means everything from artificial hips to
wound dressings, incubators to insulin delivery devices, scanners to scalpels, and
wheelchairs to commodes.
NHS provider
A primary care trust (PCT), an NHS trust where all or most of its hospitals, establishments
and facilities are situated in England, or an NHS foundation trust.
PALS
The Patient Advice and Liaison Service, which has been introduced to ensure that the NHS
listens to service users, their relatives, carers and friends, answers their questions and
resolves their concerns.
Personal care
Physical assistance given to a person in connection with eating and drinking, toileting
(including in relation to the process of menstruation), washing and bathing, dressing, oral
care, or the care of skin, hair and nails; or the prompting and supervision of a person, in
relation to the performance of any of the activities where that person is unable to make a
decision for themselves in relation to performing such an activity without such prompting
and supervision.
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Primary healthcare teams
Health services primarily based in the local community, including community matrons,
district nurses, GPs, pharmacists, dentists, optometrists and podiatrists. This includes
people employed by PCTs and primary medical care contractors.
Registered manager
An individual who is registered with the CQC to manage regulated activity at particular
premises where the registered provider is not in day-to-day control.
Registered person
Any person who is the service provider or registered manager.
Registered provider
Any person, partnership or organisation that provides one or more of the regulated activities
and is registered with the CQC, as a registered provider of that service or those services.
Regulated activities
Broad service areas or types of care that are set out in regulations under section 8 of the
Health and Social Care Act 2008. They will include those health and adult social care
activities that an organisation needs to register with the CQC to provide care or treatment in
England.
Risk assessment
An important step in deciding the policies and practices necessary to protect service users
and care workers from the risks of infection. It requires a careful examination of the service
users‟ environment and the procedures that they may undergo that might cause them harm
to enable an assessment to be made of whether sufficient policies and precautions are in
place to prevent infection.
Serious Untoward Incident (SUI)
The principal definition of a serious untoward incident (SUI) is in general terms something
out of the ordinary or unexpected, with the potential to cause serious harm, and/or likely to
attract public and media interest. This may be because it involves a large number of
people, there is a question of poor clinical or management judgement, a service has failed,
a service user has died under unusual circumstances, or there is the perception that any of
these has occurred. SUIs are not exclusively clinical issues for example; an electrical failure
may have consequences that make it an SUI.
Service user
This covers „patients‟ and users of adult social care e.g. „clients‟.
Single-use device
A medical device that is intended to be used on an individual service user during a single
procedure and then discarded. It is not intended to be re-processed and used on another
service user. The labelling identifies the device as disposable and not intended to be reprocessed and used again.
Specific alert organism
These are micro organisms which have the potential to cause harm and disease in
individuals and which can lead to an outbreak of infection. The organisms which should be
subject to specific surveillance will be selected by local need.
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Traceability
In respect of medical devices, primarily surgical instruments traceability relates to
instrument sets, as distinct from individual instruments, being tracked through use and
decontamination processes and traced in terms of identification of service users with whom
sets have been used. An exception is noted in that traceability of individual instruments or
devices is recommended where these have come into contact with certain tissues (CNS –
brain and posterior ophthalmic), which are classified as carrying a high risk of potential
transmission of prion disease should the infectious agent be present. (Note- this partly
follows the text used in “Coding for Success” a report from the Deputy Chief Medical Officer
– DCMO).
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APPENDIX 2
CHECKLIST FOR HEALTH AND SOCIAL CARE ACT
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APPENDIX 3
TEMPLATE FOR AN INFECTION PREVENTION AND CONTROL POLICY
Introduction and background Information
Why the policy is required
Any relevant legislation
Aims /Purpose of the Policy
What the policy will achieve
Scope
Who the policy applies too
Implementation
Mechanism for dissemination to relevant care workers
Responsibilities
Corporate and Individual responsibilities
Registered provider
Practice Manager
GPs
Practice Nurses
Infection Control Lead
Infection control links
Other staff/employees
Procedural guidance
Any procedure guidance that will need to be followed to implement the policy,
Monitoring and review
How the organisation will monitor and review the policy in accordance with the review date
stated. This section may include data such as external and internal audit reports, local
induction and training figures and key performance indicators.
Monitoring arrangements for compliance and effectiveness i.e. audit, training update and
whose responsibility this is.
Training
Training required to update care workers on the content of the policy. To include frequency
and training records.
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APPENDIX 4
SUGGESTIONS FOR STATEMENT FOR INCLUSION IN JOB DESCRIPTIONS
Suggestion A
Infection Prevention and Control
In accordance with the Health and Social Care Act 2008, infection control is everyone‟s
responsibility. All care workers both clinical and non clinical, are required to adhere to the
(insert name of organisation) Infection Prevention and Control Policies and Procedures and
make every effort to maintain high standards of infection prevention and control at all times
thereby reducing the burden of Infections including MRSA.
All care workers employed by the (insert name of organisation) have the following key
responsibilities:
Care workers must wash their hands or use alcohol gel between each service user
contact.
Care workers have a duty to attend mandatory infection control training provided for
them by (insert name of organisation).
Care workers who develop recurrent skin, soft tissue and other infections that may be
transmittable to service users, have a responsibility to report this to their line manager and
occupational health advisor.
Suggestion B
Infection Prevention and Control
In accordance with the Health and Social Care Act 2008, the post holder will actively
participate in the prevention and control of infection within the capacity of their role. The
Act requires the post holder to attend infection prevention and control training on induction
and at regular updates and to take responsibility for the practical application of the training
in the course of their work. Infection prevention and control must be included in any
personal development plan or appraisal.
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APPENDIX 5
Infection Control Audit Tool – General Practices
(Adapted from the ICNA Audit Tools 2005)
The tool is broken down into four sections:
1
Management and organisation
2
General environment and equipment
2.1
General environment and equipment
2.2
Dirty utility
2.3
Domestics Room
2.4
Staff kitchens/rest room
3
Infection Control Practices
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.9
4
Hand hygiene
Personal protective equipment
Spillages
Disposal of waste
Handling of sharps
Specimen handling
Vaccine handling and storage
Decontamination and disinfection
Clinical procedures
4.1
Aseptic procedures
Scoring: All the criteria should be marked either yes/no or non- applicable. It is not acceptable to
enter a non – applicable response where an improvement in a standard may be achieved.
Add the total number of yes answers and divide by the total number of questions answered (all the
yes and no answers) excluding the non applicable, multiply by 100 to get the percentage
total number of yes answers
x 100 = %
total number of yes and no responses
Compliance Levels:
75% or less
85% and above
Compliant
76 – 84%
Partial compliance
Minimal compliance
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Audit tools
INFECTION CONTROL AUDIT TOOLS
General Practices
Date: ………………………………Practice……………………………………………….
Auditors… ………………………………...
Section 1 – Management and organisation
Standard Statement: There are management structures in place to ensure that all staff throughout the
organisation are engaged to promote and secure the implementation of best practice in the prevention and
control of infection
Yes
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
No
N/A
Evidence/Comments
The Registered Provider and Management
Team accept responsibility for infection
Prevention and control.
There is a designated lead for infection
control within the practice.
The designated lead has received
appropriate training in infection control
Care workers are aware of where to obtain
24 hour infection control advice
There are policies/procedures in place for
infection prevention and control that are
endorsed by local infection prevention and
control specialists
Policies are reviewed and updated every
two years in line with new evidence and
guidance
Roles and responsibilities for infection
control are outlined in the infection control
policy
There are structures in place to ensure
distribution, compliance and monitoring of
infection prevention and control policies to
all care workers.
There is an annual programme of audit of
infection control policies and procedures
Infection control policy is accessible to all
care workers
Care workers are aware of the content of
the policy
GPs are aware of the notification procedure
for notifiable diseases
Infection control is included in induction
programmes for all new staff
All care workers receive annual infection
control training
Records of all infection control training kept
Infection control is included in care workers
job descriptions
Infection control is included in care workers
appraisals
Infection control issues are taken into
consideration at the planning and design
stage of refurbishment /new build
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Yes
19
No
N/A
Evidence/Comments
Infection control advice is sought as
necessary for services that have
implications for infection control (laundry
and waste)
Totals
Comments:
Total number of yes answers
Potential total (Number of Yes and Nos)
Percentage
Status
Review Date
Section 2 – Environment and equipment
Standard Statement: The environment and equipment will be managed appropriately to reduce the risk of
cross infection
2.1
General environment and equipment
Yes
No
N/A
Comments
1
The organisation has access to NHS
document Infection Control in the Built
Environment.
The organisation has comprehensive
procedures for cleaning based on up to
date guidance/best practice (NPSA
2009).
Organisational structures are in place to
ensure compliance and auditing of
cleanliness
Overall appearance of the environment is
tidy and uncluttered with only
appropriate, clean and well maintained
furniture used.
All high and low surfaces are free from
dust and cobwebs
All chairs and stools in clinical/communal
areas are covered in an impermeable
washable materials e.g. vinyl
Furniture, fixtures and fittings are visibly
clean (no body substances, dirt or dust)
and in a good state of repair (surfaces
and fabric intact)
There are rooms designated for clinical
practice/minor surgery
Rooms allocated for clinical practice are
not carpeted
Fabric of the environment and equipment
smells clean , fresh and pleasant
Floor coverings are washable and
impervious to moisture and sealed
regularly
Floors including edges and corners are
free of dust and grit
General environment and equipment
Yes
No
N/A
Comments
2
3
4
5
6
7
8
9
10
11
12
2.1
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13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
(continued)
Curtains and blinds are free from stains,
dust and cobwebs
There is a procedure in place to regularly
clean blinds/change curtains (minimum
yearly)or when soiled.
Fans are clean and free from dust
Air vents are clean and free from
excessive dust
Work station equipment in clinical areas
are visibly clean e.g. phones, computer
keyboards
Furniture that cannot be cleaned is
condemned
Tables and surfaces are tidy and
uncluttered to enable cleaning
Couch covers are covered in impervious,
material, clean and in a good state of
repair.
Disposable paper is used to protect
couches
Where used pillows are sealed in wipe
clean washable covers.
Water coolers are mains supplied, visibly
cleaned and on a planned maintenance
programme.
Soft toys are not available for communal
use
Toys are wipe clean
Toilets are visibly clean with no body
substances, dust, lime scale stains or
smears (check under toilet seat)
Changing mats are wipe clean with wipe
clean covers and free from stains
Baby weighing scales are visibly clean
and lined with disposable paper.
Totals
Comments:
Total number of yes answers
Potential total (Number of Yes and Nos)
Percentage
Status
Review Date
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2.2
Dirty utility
1
A dirty utility is available
2
A separate sink is available for
decontamination of service user
equipment
A sluice hopper is available for the
disposal of body fluids
The integrity of fixtures and fittings are
intact
Totals
3
4
Yes
No
N/A
Comments
Comments:
Total number of yes answers
Potential total (Number of Yes and Nos)
Percentage
Status
Review Date
2.3
Domestics Room
1
Separate hand washing facilities are
available including soap and paper
towels
Floors including edges and corners are
free of dust and grit
Equipment used by the domestic care
workers is clean, well maintained and
stored in a locked area
Vacuum cleaners are clean and fitted
with HEPA filters
Machines used for floor cleaning are
clean and dry
No inappropriate materials or equipment
are stored in the domestic‟s room
Products used for cleaning and
disinfection comply with policy and are
used at the correct dilution
Diluted products are discarded after 24
hours
The floor is clean and free from spillage
2
3
4
5
6
7
8
9
10
11
12
13
14
Yes
No
N/A
Comments
Floors including edges and corners are
free of dust
Cleaning equipment is colour coded
Mops and buckets are stored according
to the local policy
Mop heads are laundered daily or are
disposable (single use)
Shelves and cupboards are clean inside
and out and free of dust, litter or stains
Totals
Comments:
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Total number of yes answers
Potential total (Number of Yes and Nos)
Percentage
Status
2.4
Review Date
Staff Kitchen and rest rooms
1
Separate hand wash basin is available
2
3
Liquid soap and paper towels are
available in wall mounted dispensers
Foot operated waste bin available
4
No evidence of infestation in the kitchen
5
Floor is visibly clean, free of dust and
debris
Cleaning materials accessible and away
from food
Cleaning equipment is colour coded and
stored separately from other cleaning
equipment (green in kitchen)
Drying cloths are disposable (paper roll)
6
7
8
9
10
Opened foods are labelled with name,
date of opening and stored in pest proof
container
Milk is stored in a fridge
11
Food within expiry date
12
Fridge is free from specimens and drugs
13
Hands are washed prior to handling food
14
Cooking appliances are visibly clean
(toaster, microwave, cooker)
There are no inappropriate items in the
kitchen
Totals
15
Yes
No
N/A
Comments
Comments:
Total number of yes answers
Potential total (total Number of Yes and Nos)
Percentage
Status
Review date
3
Infection Control Practices
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3.1 Hand hygiene
Standard Statement: hands will be decontaminated correctly and in a timely manner using a cleansing agent
to reduce the risk of cross infection
3. 1
Hand hygiene
1
The hand hygiene policy/procedure guidance is
available to all care workers.
Hand hygiene is an integral part of induction for all
care workers.
Care workers have received training in hand
hygiene procedures (ask a member of staff)
workers)
Care workers providing care have short nails
which are clean and free from nail extensions and
varnish
Staff are aware of practice “Bare below the elbow”
Short sleeves , no wrist watches, stoned rings or
other wrist jewellery is worn by care workers
delivering “hands on” care
Hand hygiene is encouraged and alcohol rub are
made available for visitors
Posters promoting hand hygiene are available and
on display
Hand wash facilities are visibly clean and intact
(check sinks, taps, splash backs, soap and towel
dispensers)
Hand wash basins are dedicated for that use only
and free from inappropriate items
There is easy access to hand wash basins
2
3
4
5
6
7
8
9
10
11
12
13
14
17
18
Reusable towels are not used by care workers
19
Re usable nail brushes are not used
20
Hands free bins are available close to hand wash
basins
Care workers clean their hands before and after
each care activity. Observe different groups of
care workers
16
21
No
N/A
Comments
Hand wash basins in clinical areas complies with
HTM 64 i.e. no plugs or overflows and the taps
are not directly situated above the plughole
Hand wash basins in clinical areas have mixer
taps that elbow/sensor operated.
Liquid soap is available at each hand wash basin
Liquid soap is in single use wall mounted
dispensers
Alcohol hand rub is available at the point of use.
Portable dispensers acceptable
Soft paper towels in wall mounted dispensers are
available at all hand wash basins
Soap, towel and alcohol dispensers are clean
15
Yes
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22
Totals
Comments:
Total number of yes answers
Potential total (Number of Yes and Nos)
Percentage
Status
3.2
Review Date
Personal protective equipment (PPE)
Standard Statement: Personal protective equipment is available and is used appropriately to reduce
the risk of cross infection
Yes
1
7
The organisation has comprehensive
procedures and a policy for the appropriate
use of PPE
Care workers have received training in the
use of PPE as part of local induction
Sterile and non sterile gloves (powder free)
and conforming to European Community
standards are fit for purpose and available for
care workers
Alternatives to natural latex rubber (NLR) are
available for use by care workers and on
service users with NRL sensitivity
Gloves are worn if there is a risk of exposure
to blood and body fluids, cleaning fluids or
chemicals
Powdered and polythene gloves are not used
for clinical procedures
There are a range of sizes available
8
Gloves are worn as single use items
9
Hands are decontaminated after the removal
of gloves
10
Gloves are stored appropriately
11
Disposable plastic aprons are worn when
there is a risk that clothing or uniforms may
become exposed to body fluids or become
wet
Disposable plastic aprons are worn as single
use items for each clinical procedure or
episode of patient care.
Aprons are stored appropriately
2
3
4
5
6
12
13
14
No
N/A
Comments
Eye and face protection is worn where there is
a risk of splashing into the face and eyes
Totals
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Comments:
Total number of yes answers
Potential total (Number of Yes and Nos)
Percentage
Status
3.3
Review Date
Spillages and or contamination with blood and body fluids
Standard Statement: Body fluid spillage or contamination is dealt with in a way that reduces the risk of
cross infection.
Yes
1
2
3
4
5
6
7
8
9
No
N/A
Comments
There is a policy/procedure for dealing with
spills of body fluids
Care workers have received training in
dealing with body fluid spills
Care workers who come into contact with
body fluid spillages have been immunised
against hepatitis B
Care workers are aware of the action to take
in the event of an inoculation incident
Equipment used to clear body is disposable
Appropriate disinfectants/spillage kits for
cleaning body fluid spillages such as sodium
hypochlorite 10,000 ppm (Milton diluted 1in
10)
Medical Equipment that has been
contaminated with body fluids has been
cleaned appropriately.
PPE is worn to clean up body fluid spillage
Furniture and equipment that has been
contaminated with blood and body fluids and
cannot be cleaned is condemned
Totals
Comments:
Total number of yes answers
Potential total (Number of Yes and Nos)
Percentage
Status
Review Date
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3.4
Waste disposal
Standard Statement: All waste from premises providing health care is segregated and identified at
source, transported and disposed of safely without risk of contamination, infection or injury to care
workers and the general public and in accordance with legislation.
Yes
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
No
N/A
Comments
There is a comprehensive policy/procedure in
place for waste disposal
The practice is registered to generate clinical
waste.
The practice has a contract with a licensed
waste contractor (check records)
Care workers have received training about the
correct and safe disposal of healthcare waste
(check training records)
Waste is correctly segregated (according to
current regulation)
There are posters demonstrating correct
segregation
Correctly colour coded waste containers/bags
are in use
Waste bags are securely sealed and labelled
and dated and no more than 2/3rds full
Clinical waste is not decanted from one
container to another
Waste bags are removed from clinical areas
daily
Waste bins are foot operated, lidded and in
good working order
Waste bins are clean and in a good state of
repair
There is no storage of waste in inappropriate
areas
There is a dedicated area for the storage of
healthcare waste ,which is under cover, free
from vermin and pests, kept locked and
inaccessible to animals and the public
The storage area is clean and tidy
All waste is collected on a regular basis by a
licensed contractor at least once a week
Consignment notes are kept and up to date
The producer of the waste is aware of their
duty of care
Totals
Comments:
Total number of yes answers
Potential total (Number of Yes and Nos)
Percentage
Status
3.5
Review Date
Prevention of blood/body fluid sharp injuries bites and splashes.
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Standard Statement: Sharps/needle stick injuries and splashes involving blood or other body fluids
are managed in away that reduces the risk of injury or infection.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
23
Needles are not resheathed
17
18
19
20
21
N/A
Comments
Yes
No
N/A
Comments
All sharps containers in use are labelled with
date and locality and signed
Sharps containers are available at the point of
use (e.g. small community bins)
Sharps containers are stored safely away
from public access and out of children‟s reach
Sharps containers are not overfilled
22
16
No
The organisation has comprehensive
procedures and a policy for the management
of sharps/needle stick injuries or splashes and
bites in a way that reduces injury or infection
There are arrangements in place to ensure
that care workers who have contact with blood
and body fluids are immunised against
hepatitis B
There are arrangements in place to ensure
that care workers are dealt with appropriately
in the event of needle stick/bite or splash
injury
All care workers have received training in
sharps/bites/splash management and are
aware of the actions to take following an
injury. (ask a member of care workers)
All needle stick/sharps/bites/splash injuries
are recorded
There are appropriate devices to use to
reduce the risk of needlestick injuries,=.
There is a poster displayed for the
management of needle
stick/sharps/bites/splash injuries
Sharps containers comply with BS
7320/UN3291
Sharps containers are correctly assembled
There are no inappropriate items in the sharps
containers
Needles and syringes are disposed of as a
single unit
Syringes with a residue of prescription only
medication are disposed of in line with current
legislation
The temporary closure mechanism is used
when the bin is not in use
Full sharps containers are sealed correctly –
tape or stickers are not used
Sharps containers are not placed in waste
bags prior to disposal
Sealed and locked bins are stored in a locked
facility away from public access
Sharps containers are available for use and
located within easy reach
Sharps containers are visibly clean
15
Yes
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24
The person using the sharps disposes of it
themselves
Totals
Comments:
Total number of yes answers
Potential total (Number of Yes and Nos)
Percentage
Status
Review Date
3.6 Specimen handling
Standard Statement: Specimens are handled in a way that negates the risk of cross infection
Yes
1
2
3
4
5
6
7
8
9
10
11
12
No
N/A
Comments
There is policy/procedure in place for
specimen handling
All staff handling specimens including
reception staff are trained to handle
specimens safely
Specimens are collected in appropriate
containers
Specimens are processed in a CPA
accredited laboratory
Service users are provided with appropriate
containers to collect at home
Specimens are sealed in appropriate bags
(Request card separate from specimen)
Specimens awaiting transport are in a
designated area away from the public and
staff rest areas
Specimens are transported in lidded leak
proof containers
Specimen transport containers are visibly
clean
Specimens tested on site in an appropriate
designated area
Specimens tested on site are discarded in a
toilet or sluice.
Totals
Comments:
Total number of yes answers
Potential total (Number of Yes and Nos)
Percentage
Status
Review Date
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3.7
Vaccine storage and transport
Standard Statement: Vaccines are stored and transported safely.
Yes
1
2
3
4
5
6
7
8
9
10
11
13
Alternative arrangements are in place in the
event of breakdown or repair of the vaccine
fridge
All vaccines are in date
16
17
Comments
There is a validated system for maintaining
the cold chain
Vaccines are not stored in the door or in a
separate drawer at the bottom of the fridge
Storage of vaccines is adequate i.e. up to 50%
15
N/A
There is a procedure /policy in place for the
storage and transport of vaccines
There is a designated person that has overall
responsibility for the safe storage and
handling of vaccines
Vaccines are stored immediately on delivery in
to a dedicated refrigerator
The refrigerator is fit for purpose – not a
domestic fridge
The refrigerator has an uninterrupted electrical
supply
The refrigerator is used for vaccine storage
only
Refrigerator fitted with a thermometer that
shows external and internal temperatures
Temperatures checks are performed and
recorded daily
o
o
The temperature is between 2 C and 8 C
12
14
No
There is a system in place for safe disposal of
expired/surplus or damaged vaccines
Vaccine stocks are rotated and used
according to date
Care workers have attended training which
includes guideline and information on vaccine
use, storage and maintenance of the cold
chain
Totals
Comments:
Total number of yes answers
Potential total (Number of Yes and Nos)
Percentage
Status
Review Date
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3.8
Decontamination of equipment
Standard Statement: Decontamination of re usable medical devices is managed to ensure that the
risk to service users are minimised.
Yes
1
2
3
4
5
13
14
Sterile equipment/packs in date
15
Sterile packs are stored off the floor
16
Instruments are not washed prior to return to
CSSD
Equipment is cleaned before being sent for
inspection and repair and is accompanied by a
declaration of contamination status form
Totals
7
8
9
10
11
12
17
N/A
Comments
There is a procedure /policy in place for the
decontamination of medical devices
There is a designated lead that has overall
responsibility for decontamination
Equipment is decontaminated between
service users.
Deep sink designated for cleaning equipment
There is no evidence of local reprocessing of
sterile items.
(no bench top autoclave, hot air oven).
Care workers are aware of the symbol for
single use
There is no evidence that single use items are
reused.
Check:
cautery probes
sigmoidoscopes
proctoscopes
vaginal speculae
forceps
scissors
If the practice contracts decontamination
services the service provider complies with the
Medical Devices Directive 93/42 EEC and is
registered with a MHRA approved notified
body
Transport containers for used items have a lid,
are leak proof, clean and in a good state of
repair
Inappropriate items e.g. sharps, swabs and
tissue are removed before items are returned
to CSSD.
Workflow system separates clean from dirty
procedures
Effective segregation of clean and dirty
instruments
Appropriate PPE is available
6
No
Comments:
Total number of yes answers
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Potential total (Number of Yes and Nos)
Percentage
Status
Review Date
4
Clinical Practices
Standard Statement: clinical practices will be based on best practice and reflect infection control
guidance to reduce the risk of cross infection to service users whilst providing appropriate protection
to care workers
NB: This section should be undertaken over a period of time to allow for the observation of as many
practice elements as possible.
4.1
Aseptic Technique
Yes
1
2
3
4
5
6
7
8
9
10
No
N/A
Comments
There is a policy/ procedure for aseptic
technique
Hands are decontaminated prior to the
procedure
Exposure of the susceptible site is kept to a
minimum
Sterile/non sterile gloves are used as
appropriate
A clean plastic apron is used for each
procedure
Only sterile equipment comes into contact
with the susceptible site
Sterile packs are in date and undamaged
Care workers are aware of the item for single
use
Single use items are not reused
Dressing trolleys are clean and in a good
state of repair
Totals
Comments:
Total number of yes answers
Potential total (Number of Yes and Nos)
Percentage
Status
Review Date
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INFECTION CONTROL AUDIT
SUMMARY FEEDBACK
GP Practice:
Date of Audit:
Auditors:
Standard audited
1
Management and organisation
2
Environment and equipment
2.1
General environment and equipment
2.2
Dirty utility
2.3
Domestics room
2.4
Staff kitchen
3
Infection control practices
3.1
Hand hygiene
3.2
Personal protective equipment
3.3
Spillages
3.4
Waste disposal
3.5
Handling of sharps
3.6
Specimen handling
3.7
Vaccine Transport and Storage
3.8
Decontamination of equipment
4
Clinical practices
4.1
Aseptic procedures
%
Score
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137
INFECTION PREVENTION AND CONTROL
ACTION PLAN
GP Practice :
Date of Audit:
Auditors:
Criteria of non compliance
Action taken
Completion/review
Date
Managers signature ………………………………………………………
Date completed…………………………………………………………….
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APPENDIX 6
Role Specification for an Infection Prevention and Control Link/Liaison
Person
Role profile
The role of the Infection Prevention and Control Link Person (IPCLP) is to act as a resource in
their organisation and to liaise with the Primary Care Trust Infection Prevention and Control
Nurse (PCT IPCN) and Community Matron. They promote best practice in the prevention and
control of infection by being an informed resource and role model for colleagues. They are not
seen as a substitute for adequately resourced infection prevention and control service.
Summary
To help create and maintain an environment which will ensure the safety of the service users,
care workers and others by sing infection prevention and control knowledge, communication,
clinical, nursing and teaching skills.
Qualifications
They should be a qualified nurse at a senior level within the organisation with the authority to
enable them to implement changes in practice to improve infection prevention and control.
They should have completed additional training in infection prevention and control either an
accredited Infection prevention and control course or training approved by the local Infection
Prevention and Control Nurse Specialists/Practitioners.
Responsibilities
1. To liaise between their clinical area and the PCT IPCN.
2. To be directly responsible for liaising with the PCT IPCN with regard to the working of
infection prevention and control policies and procedures in their organisation.
3. To liaise with the person in charge of the organisation and the PCT IPCN with regard to
the implementation of infection prevention and control policies and procedures.
4. To provide information for care workers concerning infection prevention and control
related problems.
5. To assist in the education of new and existing care workers in the principles of infection
prevention and control as it relates to their organisation.
6. To carry out infection prevention and control audits and feedback results to the
management team and highlight any problems that need to be discussed with the PCT
IPCN.
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7. To participate in the writing, reviewing, updating and auditing of infection prevention
and control procedures and standards in relation to the practice.
8. To inform the PCT IPCN of any alert organisms/conditions/outbreaks to ensure
appropriate infection prevention and control precautions are implemented and to
ensure that there are mechanisms in place to ensure this happens in their absence.
9. To provide teaching for care workers on infection prevention and control.
10. To be knowledgeable regarding the purchase/introduction and use of equipment in
their clinical area in relation to:a)
Infection prevention and control hazards;
b)
Care and maintenance;
c)
Decontamination and storage.
Professional responsibilities
1 To take every opportunity to update and extend his/her knowledge of infection
prevention and control.
2 To meet agreed objectives
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Infection prevention and control Link Person
Objectives
No.
OBJECTIVE
1
Update infection prevention and control
knowledge
2
Agree with the practice manager how infection
prevention and control training and audit are
to be implemented.
3
Ensure all care workers attend infection
prevention and control training on
appointment and annually.
Document attendance and retain records.
4
Train all care workers in hand hygiene,
including correct hand washing technique and
appropriate use of alcohol hand rub at least
annually.
5
Complete:
Essential Steps self assessment
Review self assessment monthly
practice
manager.
Audit I C practice at least annually
Record audit scores, action any non
compliance and highlight problems to practice
manager and community IPCN if necessary.
6
DATE ACHIEVED OR
COMMENTS
Discuss results with the management team.
7
All new care workers must have infection
prevention and control training included in
their induction programme
If you need any help or advice please contact NHS Stoke on Trent Infection
Prevention and Control Nurse on telephone 01782 401039
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APPENDIX 7
Standard Precautions Leaflet
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APPENDIX 8
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APPENDIX 9
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APPENDIX 10
MRSA Information leaflet for Care Workers
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APPENDIX 11
MRSA Information leaflet for Service Users and Visitors
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APPENDIX 12
MRSA Screening Leaflet
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APPENDIX 13
Clostridium difficile leaflet
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APPENDIX 14
Medicines which can produce diarrhoea
Diarrhoea is a common adverse drug reaction with many medications.
Antimicrobials account for about 25% of drug induced diarrhoea. (Lee 2006)
Whilst diarrhoea has been seen with most medicines, the most commonly associated ones
are listed below. Alternative diagnoses for the diarrhoea are important, therefore careful
attention should be paid to the temporal relationship between the time that the medication
was first taken and when the diarrhoea first appears. (DoH & HPA 2008).
Acarbose
Antimicrobials
Biguanides
Bile salts
Colchine
Cytotoxics
Dipyridamole
Gold preparations
Iron preparations
Laxatives
Leflunomide
Magnesium preparations, such as antacids
Metoclopramide
Misoprostol
Non steroidal anti-inflammatory drugs, such as aspirin and ibuprofen
Osalzine
Proton pump inhibitors
Ticlopidine
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APPENDIX15
BRISTOL STOOL CHART
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APPENDIX 16
Escherichia coli (E coli) 0157
What is E Coli 0157?
E. coli 0157 is one of hundreds of strains of the bacterium Escherichia coli. Most strains
are harmless and live in the intestines of humans and animals, but this strain produces a
powerful toxin, which can cause severe illness. Escherichia coli (VTEC) is known as E. coli
0157 is found in the intestines of some cattle and other domesticated animals such as
goats and also in the intestines of infected people.
What are the symptoms of infection with E. coli 0157?
E. coli O157 is often very mild, but some people develop diarrhoea, which can be severe
and bloody, with abdominal cramps. A few cases (especially in children under 5 years of
age and older people) may develop a complication called haemolytic uraemic syndrome,
which is a form of kidney failure. They may need admitting to hospital for renal dialysis.
How is E. coli 0157 spread?
There are 3 main ways in which the infection can be spread to humans.
The bacteria are present in the faeces of some farm animals and this can
contaminate the carcass during slaughter. E. coli 0157 present on the surface of
meat can become mixed into the meat during the mincing process. The bacteria
present in faeces may also contaminate udders and milking equipment and get into
the raw milk.
The infection can be acquired during visits to farms and fields where farm animals
live. Their micro organisms can be found in the general environment (e.g. gates,
fences and soil) or contaminate salads and vegetables being grown in the vicinity.
Faeces may also be picked up on shoes, clothing and fingers. Infection can develop
if the bacteria are able to get into the mouth through poor hygiene or eating poorly
washed salads and vegetables.
The infection can be passed from person to person by direct or indirect contact with
the faeces of people with E. coli 0157 infection. This may happen within families,
households, care homes and nurseries where equipment and the environment may
become contaminated.
Ingestion of a small number of organisms can cause illness.
How can the spread of E. coli 0157 be prevented?
Don‟t eat undercooked meat products, e.g. beef burgers and minced beef.
Thoroughly cook meat until the juices run clear.
Drink only pasteurised milk.
Wash hands before handling food, after using the toilet or changing nappies.
Wash animal faeces from shoes and clothing, followed by hand washing.
Follow recommended precautions for school visits to farms.
In residential care, nurse in a single room with en-suite, or dedicated toilet facilities
until diarrhoea has stopped for 48 hours (may need negative stools see below).
When can people with E. coli 0157 infection return to work/school/playgroup?
Most people must remain away until well and symptom free for 48 hours.
Certain individuals in high risk groups including service users and care workers in
care homes and food handlers must remain away until 2 samples of faeces, obtained
at least 48 hours apart, are negative.
Any household contact in a risk group will need to be tested and excluded from work
or school. The Health Protection Unit will advise if this is necessary.
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APPENDIX 17
Pulmonary Tuberculosis
What is Tuberculosis?
Pulmonary Tuberculosis (TB) is caused by Mycobacterium tuberculosis and Mycobacterium
bovis. It usually affects the lungs, although it can occur elsewhere in the body. TB infection
occurs when the bacteria are inhaled. The bacteria are usually overwhelmed by the body's
immune system, but may become active again later in life. In the UK many of the elderly
may develop TB following an infection earlier in life.
People with TB infection generally complain of a cough lasting more than one month, chest
pain, coughing up sputum that may be blood-stained, loss of appetite, weight loss,
tiredness and weakness and night sweats.
How is TB spread?
Only people with "open" TB infection affecting the lungs are an infection risk to others.
These individuals expel the bacteria into the air during coughing; and others may inhale the
bacteria. Those most susceptible to infection are those who have had prolonged close
contact, particularly members of the same household.
In the care home setting this may include many of the other service users and care workers
with whom they have close contact over a long period of time.
However TB is difficult to catch and the disease develops slowly and may take several
months for symptoms to appear. Many people are immune to TB especially if they have
had BCG vaccination.
Some people are at greater risk of developing TB including children, the elderly, diabetics,
people taking steroids, people taking other drugs affecting the immune system, people
living in overcrowded or poor housing, people who are dependent upon drugs or alcohol,
people with chronic ill health, people with HIV infection or leukaemia.
How is spread prevented?
Care workers should be immunised against TB.
The Health Protection Team and the TB Clinic/Health Visitor are notified of all cases
of TB and ensure that contacts are identified and followed up if necessary. As TB is
slow-growing, follow-up is not a matter of urgency.
Service users with open pulmonary TB should keep to their own room until they have
had two weeks of effective anti-TB treatment.
People with multi drug-resistant TB (MDRTB) should be nursed in a negative
pressure room until they are no longer infectious. This may take some weeks or
months.
A high-efficiency particulate filter mask (respirator) should be worn until the service
user has had two weeks of anti-tuberculosis treatment. This is particularly important
if the service user is coughing.
People with TB should be encouraged to cough into tissues and put their hand over
their mouth to prevent airborne spread and dispose of the tissues carefully,
People visiting countries where TB is endemic for more than one month should be
immunised.
Babies born to parents from countries where TB is endemic should also be
immunised, ideally at birth.
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APPENDIX 18
Chickenpox/Shingles (varicella-zoster virus)
What is it?
Chickenpox is an acute, generalised viral infection, commonly affecting children. The rash
tends to affect central areas of the body, e.g. the trunk more than the limbs, also the scalp,
mucous membrane of the mouth and upper respiratory tract and eye may be affected. It is
infectious from about 2 days before, to 5 days after, the rash appears.
Shingles only occurs in people who have previously had chickenpox infection. Following
chickenpox, the virus remains dormant in the body, usually in a sensory nerve root. In later
months or years the virus reactivates and causes a shingles rash at the skin site supplied
by the nerve. Therefore anyone with shingles must have had chickenpox in the past, even
if they don't remember it. Shingles causes a rash of tiny blisters, usually affecting a clearly
defined area of the body. After a few days, the blisters crust over and form scabs. The
rash is not itchy but it can be very painful. The pain may start a day or so before the rash
appears. It is infectious for about a week after the blisters appear or until 48 hours after the
start of anti viral treatment.
How are they spread?
Chickenpox is spread by contact with infected respiratory droplets or fluid from the blisters.
It is very infectious to people who have not have chickenpox before. Shingles cannot be
spread from person to person. However, the blister fluid contains the varicella virus and
therefore people who have never had chickenpox should avoid contact with cases of both
chickenpox and shingles.
Who is most at risk?
Certain individuals have additional risks if infected, including the immuno-compromised
(e.g. those receiving steroids or cytotoxic drugs), non-immune pregnant women and
neonates. If they have contact with a case during the infectious phase they may need
immunoglobulin. Discuss the situation with occupational health, microbiologist or GP.
Non-immune care workers should be immunised against varicella. Non-immune care
workers, who are exposed to the virus, should be aware of the symptoms which they may
develop 8-21 days after contact with a case (28 days if immunoglobulin has been given).
The risk to the foetus/neonate depends when the mother is infected.
All non immune pregnant care workers who have had contact with a case will be offered
immunogloblulin.
How is spread prevented?
People with chickenpox should stay off work for at least 5 days from the onset of the
rash.
People who are not immune to chickenpox should avoid contact with cases.
In care homes, keep service users with chickenpox/shingles in their room for 5 days
after the onset of the rash.
Wear gloves if applying lotion to the rash.
In residential care settings treat laundry as infected.
Seek medical advice if the rash involves the eye.
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APPENDIX 19
SCABIES
What is Scabies?
Scabies is a condition of the skin caused by a tiny mite called Sarcoptes scabei. Symptoms
are caused by an allergic reaction to the by-products of the mite. Scabies occurs worldwide
and outbreaks in the UK often occur in care homes, elderly care wards, schools and
nurseries.
Most cases of scabies only have around 10 mites on their body. This is known as classical
scabies.
Classical scabies features itching two to six weeks after a first infection or one to four days
after re-infection. The itching is often severe and worse at night or after a bath. A
symmetrical allergic rash appears from the axillae to the calves and around the waist, but
not the upper back.
In individuals with impaired immune systems they can be infected with many hundreds of
mites and this is known as crusted or Norwegian scabies. The features of crusted scabies
are dry, flaky lesions that may be present in many areas of the body. The lesions can flake
off and because they contain hundreds of mites, it is very infectious.
How is scabies spread?
To transmit classical scabies direct, prolonged skin-to-skin contact is required. Holding
hands is a common route.
Bedding and clothing does not contain scabies mite unless the individual has crusted
scabies.
How is spread prevented?
Be aware of the symptoms of scabies and watch out for cases.
Treat all cases and their contacts, ideally on the same day.
Apply lotion to cool, dry skin including under nails and in skin creases.
Leave lotion on skin for 8 - 24 hours. Re-apply to areas of skin that subsequently
become wet e.g. after washing hands or incontinence etc.
Itching can persist for several weeks after treatment.
Wear gloves for contact with a case until treated.
Wash hands and skin after contact.
Crusted/Norwegian Scabies
For crusted scabies more intensive treatment is required, handle bedding etc with gloves,
and place in plastic bag until laundered. Tumble-drying kills the mites. Spread to others is
very common.
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APPENDIX 20
NOROVIRUS LEAFLET
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APPENDIX 21
ACTION IN THE EVENT OF INOCULATION/CONTAMINATION INJURY WHEN BLOOD FROM A
SERVICE USER MAY GET INTO YOUR BLOOD STREAM VIA THE SKIN, EYES & MOUTH
Blood/body fluid splash
Needle stick injury
Bleed it
Wash it
Wash with copious
amounts of water
Do you know the source?
Yes
No
Perform risk assessment of source on service user. Using risk
assessment check list in APPENDIX 22
Consider HIV
Consider other
blood borne
pathogens: e.g.
Hepatitis C
Meningitis
Malaria
CJD
Consider Hep B
Have you been shown
to be immune to Hep B
in the last 5 years?
Source
Source
+ve
-ve
Contact
Medical
Microbiologis
t immediately
worker to
attend A and
E at the UHNS
immediately
Source status unknown
Do risk assessment
(see Appendix 22)
Consent to test the
source for HIV/HBV/HCV
should be sought by the
GP or the person in
charge not the care
worker who had the
exposure incident
Yes
Report to
occupational
Health
01782
418248
Report as an
adverse
incident &
report to
No
Occupational
Health
01782 418248
Mon – Friday
08.30 - 16.30
Report as an
adverse incident and
report to
Occupational Health
01782 418248
Mon – Friday
08.30 - 16.30
Or contact
Microbiologist on
call
Report as an adverse incident
& report to
Occupational Health
01782 418248
Weekends and bank
holidays between 09.00
and 17.00
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APPENDIX 22
SHARPS INOCULATION INJURY CHECKLIST
CONFIDENTIAL
RISK ASSESSMENT CHECKLIST
The manager or person in charge must complete this checklist WITH THE INJURED PERSON
following a needle stick injury, human bite or scratch or body fluid splash to the eyes, mouth or
broken skin.
When completed, the injured person should take the checklist to their Occupational Health
Advisor
Member of Staff injured:
________________________________________________________
Dept: _________________________________DOB: _______________________
Details necessary to assess the risk of HIV exposure.
1.
Is the identity of the source person known?
Yes
No
Source persons name: ________________________________________________
DOB: _________________
Unit No/NHS No: _________________
2.
Has the source ever been tested positive for HIV?
Yes
No
3.
Does the source know that they are HIV positive?
Yes
No
4.
Has the source had sexual contact or shared needles
etc. with anyone known to be HIV positive?
Yes
No
Is there any other reason to suspect that the source
may pose significant risk of HIV infection?
Yes
No
Consent obtained for blood sample from source
to be tested for Hep B, Hep C and HIV necessary
Yes
No
5.
6.
7.
If YES to questions 2,3,4 or 5, or you suspect an increased risk of HIV in the source
THE CONSULTANT MICROBIOLOGIST SHOULD BE CONTACTED
IMMEDIATELY AND THE INJURED CARE WORKER SHOULD ATTEND THE
ACCIDENT AND EMERGENCY DEPARTMENT AT THE UNIVERSITY HOSPITAL
OF NORTH STAFFORDSHIRE.
8.
If no to questions 2, 3, 4, AND 5, there is no need to contact the Consultant
Microbiologist , but you can contact them during normal hours to report the
incident or if any concerns about the exposure incident remains.
9.
Take this completed form to the Occupational Health Advisor.
10.
Complete an Incident report
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APPENDIX 23
IMPORTANT MESSAGE TO ALL STAFF
Action to be taken following a needle stick or sharps injury, human
bite or scratch or body fluid splash to the eyes, mouth or broken skin.
Step 1
Step 2
Step 3
First Aid
Stop what you are doing
Encourage wound to bleed. Do NOT suck.
Wash with soap and running water.
Dry and apply water proof dressing.
Use lots of water to wash away a body fluid splash to the
eyes, mouth or broken skin.
Report Incident to:
Line manager and the person in charge of the area in
which you are working.
Complete the appropriate adverse incident/accident form.
Report the incident to the Occupational Health Advisor
01782 418248. It is not necessary for you to attend A & E
unless your injury requires treatment e.g. suturing
Assess Infection Risk:
The manager or person in charge of the area in which you
are working should carry out a risk assessment at the
time of the incident
A: Used/dirty sharp, human bite/scratch or body fluid splash
to eyes, mouth or broken skin from a patient known or
strongly suspected to be HIV positive. Seek IMMEDIATE
professional advice from:The Accident and Emergency Department at the University
Hospital of North Staffordshire.
B: Used/dirty sharp, human bite/scratch or body fluid splash to
eyes, mouth or broken skin, and your Occupational Health
Advisor within 24 hours.
C: Unused/clean sharp = No risk of infection.
Complete an adverse incident form and report incident
following local protocol
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APPENDIX 24
PROCEDURE FOR A SHARPS FIND
If you find discarded sharps on your premises follow the procedure below.
THE SHARPS FIND KIT FOR ………………………………….IS LOCATED AT/IN
……………………………………….
NEVER ATTEMPT TO PICK UP SHARPS
BY HAND
Needle sheathed for demonstration
Purpose
If you cannot deal with the problem immediately make the
area safe by alerting others to the hazard.
Ensure you have the correct equipment available.
1 x Household gloves (marigold type)
1 x Approved sharps container; correctly assembled
1 x Helping hand (litter picker)
Alternatively long handled dust pan and brush
+
Procedure for Sharps Find.
Wearing the household gloves and using the helping hands
remove the sharps and transfer them to the sharps
container.
Turn the aperture into the closed position (SAFE POSITION).
Please do not lock the container as the contents may be
required for investigation purposes.
Label the container with the location of the find date and time.
Secure the container and return it to a safe location..
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ENSURE IT IS STORED SAFELY AND OUT OF REACH
OF THE GENERAL PUBLIC.
Return your clean up kit to a location known to all care workers.
Inform your Health & Safety Department through the usual
reporting system.
In the event of an inoculation injury of an employee/ contractor
apply First Aid
Encourage bleeding under running water
Wash the wound with warm soapy water
Cover with waterproof plaster
Report the incident following your usual procedure
If a member of the public/contractor receives an inoculation
injury on your premises apply First Aid and Refer to the
Procedure for Sharps Injury as above. Refer to Accident &
Emergency as soon as possible.
HIGH RISK INJURIES!
If the is suspected or known to be contaminated from a HIV positive
source complete the FIRST AID procedure and Risk Assessment
Check List as detailed above.
THEN only if level of risk identified is high the injured person should
visit the Accident and Emergency Department at the University
Hospital of North Staffordshire immediately.
If the sharps find is outside the boundary of your premises contact Environmental Health:
Stoke (City) 01782 232397.
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APPENDIX 25
ASEPTIC TECHNIQUE
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APPENDIX 26
ANTIMICROBIAL PRESCRIBING GUIDELINES
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APPENDIX 27
NATIONAL PATIENT SAFETY AGENCY COLOUR CODING
All cleaning materials and equipment, for example, cloths (re-usable and disposable),
mops, buckets, aprons and gloves should be colour coded.
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APPENDIX 28
EXAMPLE OF A CLEANING SCHEDULE
CLEANING SCHEDULE
Task
Daily
Weekly
Monthly
Quarterly
½ Yearly
Yearly
General areas
Empty/Wipe bins
Clean bins
Clean toilets/sink
Mop hard floors
Check clean
carpets
Vacuum clean
carpets
Wipe furniture
Perimeter dust
High level dust
Replenish soap,
hand towels and
toilet roll etc
Descale W.C’s
Deep clean
Carpets
Scrub/suction dry
hard floors
Damp dust
furniture
Change window
curtains
Clean window
blinds
Change privacy
Curtains
Change window
curtains
Clean cupboards
November
April and
October
Treatment Room
Surfaces and
Equipment
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