Download Healthcare Associated Infection risk management guidance

HEALTHCARE ASSOCIATED INFECTION
RISK MANAGEMENT AND PATIENT SAFETY STANDARDS
Categorised guidance on recommended practice
and legal and professional standards in
Infection Control
1
1
Introduction ............................................................................................................................ 1
2
General Management considerations ................................................................................... 2
3
Training ................................................................................................................................... 9
4
Buildings/service contracts................................................................................................. 11
5
The Environment/Housekeeping ......................................................................................... 12
6
Hand hygiene ....................................................................................................................... 16
7
Personal protective equipment ........................................................................................... 19
8
Safe use and disposal of sharps ......................................................................................... 22
9
Short-term indwelling urethral catheters in acute care ..................................................... 24
10 Long-term urethral catheters in primary and community care ......................................... 26
11 Insertion and maintenance of central venous catheters in acute care............................. 29
12 Care of patients with central venous catheters in community care ................................. 32
13 Peripheral intravenous cannulae ........................................................................................ 35
14 Respiratory support ............................................................................................................. 36
15 Care during enteral feeding (primary care) ........................................................................ 37
16 Intravenous feeding lines (patenteral nutrition) ................................................................. 39
17 Decontamination of instruments and other devices ......................................................... 40
18 Decontamination of Endoscopes ........................................................................................ 42
19 Control and Prevention of MRSA in Healthcare Facilities ................................................. 43
20 Action when patients infected or colonized with MRSA are detected .............................. 50
21 Treatment of MRSA infected or colonised patients ........................................................... 59
22 Temporary, locum or agency staff ...................................................................................... 67
23 Sample processing .............................................................................................................. 68
24 Microbiological support ....................................................................................................... 70
25 Competencies for Directors of Infection Prevention and Control .................................... 71
26 Variant Creutzfeldt – Jakob Disease (vCJD) ...................................................................... 74
27 Blood-Borne Viruses (BBVs) ............................................................................................... 76
28 Blood-Borne Viruses in Renal and Transplantation Units ................................................ 98
29 Management of Outbreaks of Gastro-Enteritis ................................................................ 104
30 Multi-Resistant Acinetobacter (MRAB) Outbreaks .......................................................... 108
31 Control of Tuberculosis ..................................................................................................... 110
32 Pandemic Influenza: Infection Control ............................................................................. 112
33 Standard (Universal) infection control precautions/Aseptic technique ......................... 113
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34 Patient movement .............................................................................................................. 114
35 Anti-microbial prescribing ................................................................................................. 115
36 Occupational Health .......................................................................................................... 116
37 Disposal of Clinical Waste ................................................................................................. 117
38 Isolation of Patients/Patient movement/Ward Closure .................................................... 118
39 Dissemination of Information ............................................................................................ 119
40 Risk Management and Integrated Governance ................................................................ 120
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Introduction
1.1
This document categorises and summarises the key features of the mainstream
infection control guidance available centrally for healthcare institutions. It is not
intended to be a statement of the law or of minimum standards of clinical or nursing
practice. Reference is made to provisions of some legislation which constitutes a
legal standard to be achieved (e.g. the Control of Substances Hazardous to Health
Act Regulations). The remaining guidance quoted may in some circumstances
amount to an expression of the standard of infection control policy and practice that
a healthcare organisation would be expected to achieve as part of the duty of care
owed to its patients, staff and visitors.
1.2
A failure to be able to demonstrate understanding, implementation or adherence to
the recommendations in the guidance on which this document is based may be
construed in Court as evidence of poor infection control practice or found to be a
failure to meet the standards of the Code of Practice for the Control and Prevention
of Healthcare Associated Infection as stipulated under the Health Act 2006. That in
turn could amount to negligence or may be held to be a breach of a statutory duty.
In the event of a breach of statutory duty or of the common law duty of care
compensation could follow. It may alternatively lead to Healthcare Commission
intervention with sanctions under the Health Act.
1.3
The purpose of this document is to serve as a guide for Risk Management
purposes, pulling together the common recommendations found in a wide range of
sources and categorising them under the headings listed above. It is a reference
tool and intended to assist local policy preparation and implementation.
Compiled by:
Simon Lindsay,
Sian Morgan,
Victoria Tucker,
Georgina Shorland,
Marie-Claire Boyle,
Kevin Allard.
With thanks to Dr Peter Wilson, Consultant Microbiologist at University College Hospitals London
Foundation NHS Trust for his help in compiling this document
March 2008
1
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General Management considerations
2.1
So far as is reasonably practicable an NHS Body should provide appropriate care in
suitable facilities consistent with good practice to protect patients, staff and others
from the risks of acquiring healthcare associated infection (‘HCAI’)1.
2.2
So far as is reasonably practicable, an NHS Body should identify promptly and
manage according to good clinical practice any patient who presents with an
infection, or who acquires one during treatment, to reduce the risk of transmission2.
2.3
Infection Control should be a core part of a healthcare organisation’s clinical
governance and patient safety programmes.3 Activities to demonstrate this include:
2.3.1
Regular presentations from the Director of Infection Prevention and
Control / Infection Control Team to the Board
2.3.2
Quarterly reporting to the Board by matrons (or nurses working at
that level) and clinical directors
2.3.3
Review of statistics in the incidence of alert organisms/conditions and
outbreaks, SUIs
2.3.4
Evidence of appropriate actions to deal with infection occurrences
2.3.4
An audit programme to ensure policies have been implemented
2.4
An NHS body must have in place appropriate arrangements to allocate
responsibility to staff, contractors and others concerned with healthcare to protect
patients from HCAIs, including the engagement of senior management to secure
best practice and appointment of leaders at each level of the organisation to do so4.
2.5
These arrangements must include5:
2.5.1
A Board level agreement outlining collective responsibility for
minimising the risks of infection and the general means by which it
prevents and controls such risks.
2.5.2
Designation of a Director of Infection Prevention and Control.
2.5.3
Mechanisms by which resources will be available including
implementation of an appropriate assurance framework, IC
programme and IC infrastructure.
2.5.4
Sufficient training for relevant staff, contractors and others concerned
with patient care.
Code of Practice for the Prevention and Control of Health Care Associated Infection, October 2006 (‘The
Code’), paragraph 1
2 The Code, paragraph 1. See also COSHH Regulations 2002, Reg. 7 (post at paragraph 2.25)
3 See Saving Lives (self assessment and planning tool). The Modernisation Agency has set 9 challenges for
Trust CEOs and their Boards to meet to ensure that senior management engages with and implements
infection control policy. See also the Code at Annex 1 (Assurance Framework)
4 The Code, paragraph 2, see also Saving Lives, Challenges 1 & 2
5 The Code, paragraph 2
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2
2.5.5
A programme of audit, to ensure key policies are being implemented.
2.5.6
A policy addressing movement of infected or colonised patients
between departments and facilities.
2.6
Trusts must adopt national evidence based guidance on infection control6 and
comply with all relevant legislation, e.g. Health and Safety at Work Act 1974 or
Control of Substances Hazardous to Health Regulations7.
2.7
NHS Trust Chief Executives will ensure that the hospital environment is visibly
clean, free from dust and soilage and acceptable to patients, their visitors and staff.8
2.8
Cleaning and disinfecting programmes and protocols for environmental surfaces in
patient care areas will be defined and carefully monitored to ensure high standards
of cleanliness are achieved9.
2.9
Sufficient resources will be dedicated to keeping hospitals clean.10
2.10
The Trust should be able to demonstrate that responsibility for infection prevention
and control is effectively devolved to all professional groups in the NHS body and
clinical specialties and directorates, support directorates or other similar units11.
Trust Boards must be able to demonstrate that infection control is a priority12. This
may be by having hospital acquired infection as a standing item on directorate and
clinical governance meetings.
2.11
A Trust’s leaders should promote a culture of protecting patients from the risks of
infection but also make sure that there are leaders in each clinical area who ensure
that this culture is translated into practice on a daily basis. Local leadership should
be supported with formal systems that establish responsibilities and hold staff to
account for the way in which they discharge their responsibilities, e.g. through
proper audit, training, appraisals, high impact interventions (clean hands
campaigns, fliers, newsletters, notices in wageslips etc) rewards for good
compliance or practice or ‘naming and shaming’ poor performance 13.
2.12
NHS Trusts should embed their assessments of the risks of HCAI within their wider
corporate system to comply with core standards.14
2.13
A Director of Infection Prevention and Control will be designated within each
organisation providing NHS services and will:15
6
Saving Lives: Challenge 4
Introduction to The Code
8 Winning Ways. Working together to Reduce Healthcare Associated Infection in England, DoH 2003. Similar
commitment in ‘A Matron’s Charter: An Action Plan for Cleaner Hospitals’, Department of Health, 4
November 2004: No.2: ‘The patient environment will be well-maintained, clean and safe’.
9 Winning Ways.
10 ‘A Matron’s Charter’ Commitment No.10.
11 The Code, Annex 1
12 Healthcare Associated Infection. What else can the NHS do? Healthcare Commission July 2007
13 HCAI. What more can the NHS do?
14 HCAI. What more can the NHS do? See also Core Standard C1a requiring Trusts to employ systems
which facilitate learning from incidents.
15 The Code, Annex 1. Please also see Competencies for Directors of Infection Prevention and Control,
DOH, May 2004 for further guidance (reproduced at Section 25 below)
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2.13.1
Oversee local control of infection policies and their implementation;
2.13.2
Be responsible for the Infection Control Team within the healthcare
organisation;
2.13.3
Report directly to the Chief Executive and the Board and not through
any other officer;
2.13.4
Have the authority to challenge inappropriate clinical hygiene
practice as well as antibiotic prescribing decisions; (Where the DIPC
is not medically qualified, this may be devolved to consultant
microbiologist)
2.13.5
Assess the impact of all existing and new policies and plans on
infection and make recommendations for change;
2.13.6
Be an integral member of the organisation’s clinical governance and
patient safety teams and structures;
2.13.7
Produce an annual report on the state of healthcare associated
infection in the organisation(s) for which he/she is responsible and
release it publicly.
2.14
Trusts should consider reviewing accountability and reporting arrangements for
DIPCs16.
2.15
There should be an appropriately constituted and functioning Infection Control
infrastructure. This should comprise a mix of nursing and consultant medical
expertise and appropriate support in the case of acute Trusts17. For other
organisations there should be an IC nurse or other designated person. There should
be 24 hour access to a nominated qualified IC Doctor or consultant in
communicable disease18. The contracted sessions per week for the Infection
Control Doctor should be defined and agreed19.
2.16
The infection control programme or policy should be compiled by the ICT in
consultation with relevant external authorities and stakeholders, health
professionals and senior management. It should define roles and responsibilities
and should be agreed by a risk management committee or equivalent body and
approved by the Trust Board20.
2.17
It should set objectives, identify priorities, provide evidence that relevant policies
have been implemented to reduce HCAI and report progress against the objectives
of the programme in the DIPC’s annual report.
2.18
The Trust Board should formally review arrangements for the control of infection
within the Trust at least annually. The review should consider the composition and
functioning of the Infection Control Team and its support staff and resourcing,
16
HCAI. What else can the NHS do?
CNST Standards 7.1.3
18 The Code, Annex 1
19 Winning Ways
20 Winning Ways
17
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including secretarial, IT and audit staff. Trusts should have formally assessed their
infection control staffing needs, particularly adequate medical and nursing cover.21.
2.19
Priorities identified from the infection control programme should be incorporated
within the relevant business plan(s)22.
2.20
The programme should describe how it is to be implemented and audited and by
whom. Audit of the implementation of, and compliance with, selected infection
control policies and procedures should also be outlined within the programme. The
programme, or an abridged version, should be disseminated to all relevant staff,
including those employed by support services.
2.21
Progress on, and improvements in, the infection control programme, and audit
results, should be included in the infection control annual report to the Trust board.23
2.22
Subject to the limitations set out in Appendix 1 of the Code, NHS bodies should
have the following core policies in place24:
2.23
2.22.1
Standard infection control
2.22.2
Aseptic technique
2.22.3
Major outbreaks of communicable infection
2.22.4
Isolation of patients
2.22.5
Safe handling and disposal of sharps
2.22.6
Prevention of occupational exposure to blood borne viruses (BBVs)
including prevention of sharps injuries
2.22.7
Closure of wards
2.22.8
Disinfection
2.22.9
Antimicrobial prescribing – (this is usually in the Pharmacy formulary
rather than the Infection Control Manual)
2.19.20
Reporting to the HPA as directed by the DoH
2.19.21
Control of infections with specific alert organisms taking account of
local epidemiology and risk assessment
Infection control policies for each hospital site should be developed with the
Infection Control Team and approved by the Infection Control Committee, or
equivalent. The sufficiency and suitability of any policy implemented in accordance
with paragraph 10 of the Code must be monitored via the Clinical Governance
system with evidence of a rolling programme of audit, revision and update. Written
21
CNST Standards 7.1.3
Winning Ways. See also The Code, Annex 1 and paragraph 2.10 above
23 CNST Standards 7.1.4
24 The Code, paragraph 10 (guidance on the content of core policies is at Annex 2 of The Code)
22
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policies should be available on all wards and units25 either in printed version or via
the intranet. They should be incorporated into contracts/service-level agreements
and compliance should be monitored. Quarterly reports on operational issues
relating to cleanliness should be made to the Infection Control Committee, or
equivalent.26
2.24
There must be a system in place to ensure that a programme of targeted infection
surveillance is carried out27. The Trust should have agreed objectives and priorities
for surveillance, developed by the Infection Control Team and endorsed by the
Infection Control Committee. These arrangements should include:
2.24.1
Defined methods of surveillance that are in place. Where there are
specific government monitoring programmes and recommendations,
these should be followed and implemented by the Trust. Appropriate
staffing and IT support to undertake surveillance. Reporting of
orthopaedic surgical wound infections to SSISS is mandatory.
2.24.2
Results of the analysis of surveillance, with interpretation and
recommendations, are reported to the Infection Control Committee,
clinicians, nurses, managers and others who need to know, in a
timely manner. Any appropriate action is agreed with the Infection
Control Team.
2.24.3
Robust reporting mechanisms to provide appropriate and timely
information to the Communicable Disease Surveillance Centre and
other appropriate external bodies28. Electronic Co surv reporting to
Health Protection Agency. Mandatory reporting of MRSA bacteremia
and C difficile to HPA and Dept Health.
2.25
Consideration should also be given to some form of post-discharge surveillance of
infections by the Trust.29
2.26
Audits of resources, staff training and infection control measures are suggested but
not required in the NICE guideline but do form part of the assurance framework
made mandatory by The Code (see 2.3 above). Audits of cleanliness standards are
required by the National Standards of Cleanliness for the NHS (see section 5 The
Environment ) and The Revised Guidelines. Hand washing facilities and policies are
required to be part of annual audit programmes by the CNST Standards (see Hand
Hygiene section 6).
2.27
A Healthcare organisation must ensure that it has made a suitable and sufficient
assessment of the risks to patients and staff of infection acquisition30. An NHS body
should also identify the steps needed to reduce or control the risk, record its
25
Sentence added from Revised Guidelines for the Control of Methicillin-Resistant Staphylococcus Aureus
Infection in Hospitals, Department of Health 1998
26 ‘National Standards of Cleanliness for the NHS’, Department of Health, April 2001 Section 3.19
27 See also the Code at Appendix 2(i)
28 Saving Lives requires implementation of a local surveillance programme (Challenge 3) as well as effective
auditing of infection control practices (Challenge 5).
29 Points 1.21 – 1.22 from CNST Standards 7.2.4
30 Control of Substances Hazardous to Health Regulations 2002, Regulation 3
6
findings, implement the steps needed and monitor those risks to know whether
further steps are needed31.
2.28
The Trust as employer and as manager of patient care must ensure that the risk of
employees’ exposure to substances hazardous to health (a definition that includes a
bacterial or viral agent that causes HCAIs) is either prevented or, where this is not
reasonably practicable, it is adequately controlled32.
2.29
An NHS body has a duty, so far as is reasonably practicable, to ensure that its staff,
contractors and others involved in the provision of healthcare co-operate with it, and
with each other, so far as necessary to enable the body to meet its obligations
under the Code33.
2.30
Where it is not reasonably practicable to prevent exposure to a substance
hazardous to health the Trust must comply with this duty by applying protection
measures appropriate to the activity and consistent with the risk assessment,
including, in order of priority;
2.31
2.30.1
The design and use of appropriate work processes, systems and
engineering controls and the provision and use of suitable work
equipment and materials,
2.30.2
The control of exposure at source, including adequate ventilation
systems and appropriate organisational measures, and
2.30.3
Where adequate control of exposure cannot be achieved by other
means, the provision of suitable personal protective equipment
(section 7).34
Adequate control can only be achieved where the following principles of good
practice are applied35:
2.31.1
The control of the working environment, including appropriate
general ventilation,
2.31.2
Design and operate processes and activities to minimise emission,
release and spread of substances hazardous to health,
2.31.3
Take into account all relevant routes of exposure – inhalation, skin
absorption and ingestion – when developing control measures,
2.31.4
Control exposure by measures that are proportionate to the health
risk,
31
The Code, paragraph 3.
Control of Substances Hazardous to Health Regulations 2002. Regulation 7. See also COSHH
Regulations 2004 for the Principles of Good Practice
33 The Code at paragraph 7
34 Control of Substances Hazardous to Health Regulations 2002
35 Control of Substances Hazardous to Health Regulations 2004 (S.I. 2004 3386) amending Regulation 7(7)
of the 2002 Regulations. These principles of good practice are set out at Schedule 2A to the 2004
Regulations
32
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2.31.5
Choose the most effective and reliable control options which
minimise the escape and spread,
2.31.6
Where adequate control of exposure cannot be achieved by other
means, provide, in combination with other control measures, suitable
personal protective equipment,
2.31.7
Check and review regularly all elements of control measures for their
continuing effectiveness,
2.31.8
Inform and train all employees on the hazards and risks from the
substances with which they work and the use of control measures
developed to minimise the risks,
2.31.9
Ensure that the introduction of control measures does not increase
the overall risk to health and safety.
8
3
Training36
3.1
Induction programmes for all healthcare staff, including agency and locum staff,
(see section 22) will include local guidance on infection control policies and the use
of aseptic technique.37 Training on the Trust’s infection control policy should be
repeated annually thereafter.38. Each Trust should have a policy in place for training
on prevention and control of HCAIs39.
3.2
Policies should ensure that all staff can access Occupational Health (OH) Services
and there are OH policies in place for the prevention and management of
communicable infections in healthcare workers (see also section 36 below).
3.3
Audit results and conclusions should be made available to staff.40
3.4
All cleaning staff should have access to accredited training for a nationally
recognised scheme, for example, National Vocational Qualifications (NVQ). There
should be planned and documented training so that staff are competent to carry out
all tasks required of them. A service provider is responsible for training staff
adequately and safely to meet the National Standards of Cleanliness. Cleaning
staff must be familiar with customer service, control of substances hazardous to
health legislation, infection control, manual handling, and basic cleaning techniques.
3.5
Supervisory cleaning staff should be encouraged and supported to undertake the
National Examining Board for Supervisory Management (NEBSM) or a similar
programme in supervisory management.
3.6
Trusts should include specific time within training programmes at induction for all
staff to cover;
3.7
3.6.1
The risks associated with blood and body-fluid exposure (see section
27),
3.6.2
The correct use and disposal of sharps (see section 8),
3.6.3
The use of medical devices incorporating sharps protection
mechanisms.
Training should be provided to staff to with information and training about measures
to reduce the risk of occupational exposure to hepatitis C infection (e.g. safe
handling and disposal of sharps and measures to reduce risks during surgical
procedures)41. Such training should be ongoing, recorded and any responsibilities
36
Un-annotated wording from National Standards. See also RCN ibid. See also Principles of Good Practice
at Schedule 2A of the COSHH Regulations 2004. The Code requires NHS bodies to ensure that policies are
up to date, audit results are fed back with examples of good practice and action needed to correct
deficiencies. Most important is the policy on hand hygiene, a specific requirement of the Healthcare
Commission (see section 6 below for more detail)
37 ‘Winning Ways’. See also Challenge 6 of Saving Lives
38 CNST General Clinical Risk Management Standards 5.2.8. See also Matron’s Charter No. 8,
39 The Code at paragraph 11(c-e)
40 CNST Standards 5.2.8
41 Health Service Circular – “Hepatitis C Infected Health Care Workers” 14th August 2002
9
for infection prevention and control should be reflected in job descriptions,
development plans or appraisals42.
42
The Code, paragraphs 11(d-f). See also Healthcare Associated Infection: What more can the NHS do?
(Healthcare Commission, July 2007) at sections 8 and 9
10
4
Buildings/service contracts
4.1
Infection control requirements will be designed in at the planning stages of
healthcare facilities, including new builds or renovation projects.
4.2
Attention will be given to the prevention of airborne infection by the use of ventilation
in specialist areas and correct engineering and mechanical services43.
4.3
Infection control staff will be part of the teams overseeing plans for rebuilding or
refurbishing work and setting contracts for services such as laundry and cleaning.
4.4
A business plan should be developed to cover one, three and five years. This
should include the adoption of clear, consistent contracts between service providers
and users. It should be continuously monitored and updated as required. While a
contractor may be responsible for service provision, the accountability relating to
that service remains with the Chief Executive and the Trust Board44.
4.5
Service agreements should be based upon the goals set out in the National
Standards of Cleanliness for the NHS, specifying quantitative and qualitative
acceptance criteria for the service and provide thresholds for rejection45. Matrons
have authority and power to withhold payment.46
4.6
All healthcare settings should aim to eradicate pests such as rats, mice, ants,
cockroaches, pigeons and flies.
4.7
Surfaces and furniture will be durable and easily cleaned and carpets will not be
used in clinical areas where there is a risk of spillage.
4.8
Contamination of the water supply in hospitals with bacteria such as legionellae will
be avoided by appropriate building design and maintenance, by cleaning water
storage tanks, maintaining consistently high temperature in hot-water supplies,
keeping cold-water systems cold and minimising water storage. This requires
regular monitoring by the Estates Department or Directorate, especially for older
buildings
4.9
All catering facilities in healthcare settings will comply with current food safety
legislation. This will include catering management, food handlers and premises
from where food is sourced, stored, prepared or served.
4.10
The segregation, handling, transport and disposal of waste will be properly
managed so as to minimise risks to the health and safety of staff, patients, the
public and the environment as set out in the relevant controls assurance standard.
43
PFIs will adhere only to HTM and HBN already published at the time of contract signing or to any other
documents (eg working party reports) highlighted by the microbiologists before the contract signed. Later
documents will only be considered at the Trust’s cost.
44 National Standards, Section 3.5
45 National Standards, Section 1.1, 3.7 & 3.8
46 Last sentence from the ‘Matron’s Charter’ Commitment No. 9. See Housekeeping Section 4 below for
procedure.
11
5
The Environment/Housekeeping
5.1
NHS bodies have a duty to provide and maintain a clean and appropriate
environment for healthcare47. Premises and facilities should be provided in
accordance with best practice guidance48.
5.2
Environmental policies should provide for liaison between the ICT and persons with
overall responsibility for facilities management.
5.3
There should be lead managers designated for cleaning and decontamination of
equipment. There should be effective arrangements for decontamination of
instruments and other equipment.
5.4
All parts of the premises used for providing healthcare should be suitable for
purpose.
5.5
Cleaning arrangements should detail the standards of cleanliness required. A
schedule of cleaning should be publicly available.
5.6
The supply and provision of linen and laundry supply should reflect the
requirements of HSG(95)18. Particular consideration should be given to items of
attire that may come into clinical contact with a patient49.
5.7
Clothing used by staff should be clean and fit for purpose.
5.8
Premises and facilities should be provided in accordance with best practice
guidance. The development of local policies should take account of infection control
advice given by relevant expert or advisory bodies or by the ICT and policies should
address, but not be restricted to: cleaning services, building and refurbishment,
including air handling systems, clinical waste management, planned preventive
waste management, pest control, management of water supplies and food services
including food hygiene and food brought into the organisation50.
5.9
Operational policies for cleaning services for each functional area will be clear,
agreed and well publicised and should include51;
5.9.1
Clear definitions of specific roles and responsibilities.
5.9.2
Clear, agreed and well-publicised cleaning routines.
5.9.3
Provision for consultation with the ICT52.
5.9.4
Clear and measurable outcomes.
47
Items 5.1 to 5.7 are taken from The Code at paragraph 4
The Code at Annex 1
49 The Code at paragraph 4g and Annex 1
50 The Code at Annex 1
51 The Code at Annex 1. See also: ‘A Matron’s Charter’; Key Commitments and S.3.9 of the National
Standards
52 This is especially Important where cleaning services are contracted out – teaching is often performed by
the contractors rather than the infection control team
48
12
5.9.5
Systems that routinely measure these outcomes and report the
results.
5.9.6
Working methods, including equipment, materials and frequencies
that are to be applied;
5.9.7
Responsibility for the cleanliness of equipment such as commodes,
trolleys, keyboards, monitors, patient entertainment systems and IV
stands should be clearly defined in the relevant policies;
5.9.8
There should be sufficient resources dedicated to keeping the
environment clean and fit for purpose.
5.10
Where a piece of equipment is used for more than one patient, e.g. commode, bath
hoist, it must be cleaned following each and every episode of use.53
5.11
Every Trust should have a Board Member who takes personal responsibility for
cleanliness.
5.12
The Board nominee should review progress and objectives at least twice a year with
appropriate senior operational managers and should report back to the Trust Board.
The nominee should also meet regularly with the Patients’ forum. Patients’ views
must be taken into account by the Board and used to evaluate and, where
necessary, amend the Patient Environment Strategy.
5.13
Every Trust should have a written Patient Environment Strategy, which not only sets
out what is to be achieved, but also reports how patient views have been taken into
account. The strategy will be translated into annual action plans to be discussed in
the annual report.
5.14
Ward sisters and matrons should ensure that sufficient resources are spent to
provide high-quality cleaning services. They will monitor cleanliness standards at
ward level and, where standards fall short of what is expected, they will insist that
improvements are made. If they withhold payment an arbitration process will be
initiated and, where a breach of contract has occurred, alternative arrangements will
be put in place as necessary.
5.15
The National Standards encourage all hospitals and cleaning service providers to
undertake a regular internal audit of cleanliness. This process will highlight areas
which fall short of the standards expected and provide an opportunity to negotiate
targets for improvement over a period of time. Records of PEAT inspections help
show if basic standards of cleanliness are achieved although they encompass
general impression more than objective tests
5.16
Three levels of audit are suggested:
5.16.1
Cleaning service provider audits,
5.16.2
Hospital audits, and
53
Un-annotated wording from The epic project: developing national evidence-based guidelines for
preventing health care associated infection. Phase 1: guidelines for preventing hospital-acquired infections.
Journal of Hospital Infection (2001); 47 (supplement): s1–82
13
5.16.3
5.17
Important issues include:
5.18
Frequency:
5.19
5.20
5.18.1
Both the hospital and cleaning service provider must jointly conduct
regular internal audits. They should be followed up according to the
magnitude and location of any problems identified, and lead times
identified for the corrections specified. For example, a problem in the
operating theatres will need to be resolved immediately, while one in
a stationary storeroom may require checking in a week or during the
next scheduled audit. Internal audits may address a small sample of
the hospital, an element e.g. floors or functional areas.
5.18.2
External audits generally occur less frequently but should occur at
least once a year to inform the PAF. But where significant problems
are detected it is recommended that external audits be conducted
more frequently.
5.18.3
Under the NHS Estates revised guidance on contracting for cleaning
all functional areas will have one of four designations: Very high risk,
high risk, significant risk or low risk. These require audit of cleaning
standards once a week, once a month, once every 3 months and
once a year respectively54;
Personnel:
5.19.1
All audit staff are expected to have substantial knowledge of
hospitals and hospital procedures, and to be able to make
discriminating judgements on risk in relation to the areas being
cleaned.
5.19.2
Only experienced auditors should undertake the independent audits.
Contract managers should be knowledgeable about, or must
undertake training in auditing techniques;
Sampling:
5.20.1
5.21
54
External audits.
Random sampling in a range of areas will ensure that areas are more
uniformly cleaned. There should be different sampling cycles for
different areas: high risk areas should be audited more frequently
than low-risk areas;
Scoring:
5.21.1
The regular comprehensive internal audits that cover multiple
elements and functional areas should be scored.
5.21.2
Scoring of audits provides an objective relative assessment of
cleanliness of the hospitals. However, in some circumstances
Revised Guidance on Contracting for Cleaning. NHS Estates 2004
14
purchasers may decide not to score daily or weekly internal audits.
Nonetheless, the outcomes should be retained and used as a
reference for future audits that cover the same area or element.
5.22
5.21.3
The internal auditor (for example the contract manager) should
undertake regular comprehensive audits on a quarterly basis, and
these should be scored.
5.21.4
They should cover a variety of areas within the hospital and cover all
functional areas. The scoring of these audits provides the hospital
with baseline date and an ongoing measurement of the effectiveness
of the cleaning process.
5.21.5
Scoring must be done in the independent audit. For suggested
scoring system see Part C, Section 7 of National Standards of
Cleanliness for the NHS. 55
Action:
5.22.1
55
56
The assessments collected in any audit must be acted upon to
progress the quality improvement cycle.
5.23
An NHS body should have local policies on disinfectant use focused on specific
infection risks. Consideration should be given, where appropriate, to the use of high
level disinfectants56. Disinfection policy usually forms part of the Infection Control
Manual
5.24
For exact cleaning standards and frequencies for functional areas (e.g. operating
theatres) or elements (e.g. windows) please refer to Part B and Part C, Section 8 of
the National Standards of Cleanliness for the NHS and the 2004 Revised Guidance
on Contracting for Cleaning.
5.25
For cleaning of isolation areas please see Section 38 below.
Points 5 – 10 from ‘National Standards’
The Code at Annex 2i
15
6
Hand hygiene57
6.1
As part of their duty to provide and maintain a clean and appropriate environment
for healthcare NHS bodies must ensure adequate provision of suitable handwash
facilities and antibacterial hand rubs58.
6.2
Hands must be decontaminated immediately before each and every episode of
direct patient contact/care and after any activity or contact that potentially results in
hands becoming contaminated.
6.3
Hands that are visibly soiled or potentially grossly contaminated with dirt or organic
material must be washed with liquid soap and water.
6.4
Apply an alcohol-based hand rub or wash hands with liquid soap and water to
decontaminate hands between caring for different patients, or between different
caring activities for the same patient.
6.5
Remove all wrist and ideally hand jewellery at the beginning of each clinical shift
before regular hand decontamination begins. Cuts and abrasions must be covered
with waterproof dressings59. (Non-compliance with this policy is common in medical
staff and some nursing staff)
6.6
The correct hand washing procedure60 involves four stages: preparation, washing,
rinsing and drying. Preparation requires wetting hands under tepid running water
before applying liquid soap or an antimicrobial preparation. The hand wash solution
must come into contact with all the surfaces of the hand. The hands must be
rubbed together vigorously for a minimum of 10-15 seconds. The hands should be
rubbed;
6.6.1
palm to palm;
6.6.2
right palm over left dorsum and left palm over right dorsum;
6.6.3
palm to palm and fingers interlaced;
6.6.4
backs of fingers to opposing palms with fingers interlocked;
6.6.5
rotational rubbing of right thumb clasped in left palm and vice versa;
57
The Code has a mandatory requirement for Hand Hygiene to form part of a policy for standard (universal)
infection control precautions (see Annex 2). The policy should be easily accessible, compliance should be
audited and information on it should be part of induction training. See also Saving Lives ibid and Good
Practice in Infection Prevention and Control (Royal College of Nursing, 2005).
Points 6.2-6.7 above from both ‘The epic Project: Developing National Evidence-based Guidelines for
Preventing Healthcare Associated Infections’, Department of Health 2001 and the NICE Guideline: Infection
Control, Prevention of Healthcare-Associated Infection in Primary and Community Care, June 2003. The
guidelines together cover primary and secondary healthcare providers
58 The Code at paragraph 4e.
59 RCN guidance suggests removal of hand jewellery should be mandatory
60 As detailed in Essential Steps to Safe, Clean Care: Reducing health care associated infection. London:
Department of Health, 2006
16
6.6.6
rotational rubbing backwards and forwards with clasped fingers of
right hand in left palm and vice versa.
Particular attention should be paid to the tips of the fingers, the thumbs and the
areas between the fingers.
6.7
Hands should be rinsed thoroughly prior to drying with good quality paper towels.
6.8
When decontaminating hands using an alcohol hand rub, hands should be free of
dirt and organic material. The hand rub solution must come into contact with all
surfaces of the hand. The hands must be rubbed together vigorously, paying
particular attention to the tips of the fingers, the thumbs and the areas between the
fingers, and until the solution has evaporated and the hands are dry.
6.9
Alcohol-based hand rub to be installed at points of care by April 2005. If the handrub cannot be placed at each bedside, for example in paediatric wards, staff should
be issued with personal dispensers which can be carried in the pocket or clipped
onto clothing. 61
6.10
Pre-operative hair removal should be with a clipper using a disposable head, there
should be no shaving with a razor62
6.11
Conventional hand washing with soap and water is still however more effective
when hands are visibly soiled. Alcohol-based hand rub does not replace the need
for conveniently located sinks in clinical areas.63
6.12
Apply an emollient hand cream regularly to protect skin from the drying effects of
regular hand decontamination. This must be a personal supply, not shared. If a
particular soap, antimicrobial handwash or alcohol product causes skin irritation,
seek occupational health advice.64
6.13
Adequate hand washing facilities, including alcohol hand rub, should be within easy
reach of each bed and patient contact area to encourage good hand hygiene.
6.14
The Trust’s Policy on hand hygiene and hand care should be clear, and the Trust is
actively promoting initiatives and education programmes on hand hygiene.
6.15
All staff should be aware of the Trust’s expectations of them with regard to hand
hygiene. This should be communicated through a specific policy as part of an
agreed and continuing education programme for all staff groups. It may form part of
a broader policy, for example infection control, but the Trust’s expectations in
respect of hand hygiene must be clear.
6.16
The Trust policy should be subject to review at least once every two years.
Initiatives will need to be continuously reinforced and compliance with the Trust’s
61
See Saving Lives: High Impact Intervention 3.
See Saving Lives: High Impact Intervention 3.
63 Patient Safety Alert 2 September 2004, National Patient Safety Agency
64 Taken from ‘The epic Project: Developing National Evidence-based Guidelines for Preventing Healthcare
Associated Infections’, Department of Health 2001 and the NICE Guideline: Infection Control, Prevention of
Healthcare-Associated Infection in Primary and Community Care, June 2003. The guidelines together cover
primary and secondary healthcare providers.
62
17
hand hygiene policy and facilities should be part of each directorate’s annual audit
programme. 65
6.17
Following hand washing, hands should be dried thoroughly using paper towels that
are then discarded in the nearest waste receptacle. Waste bins with foot-operated
lids should be used whenever possible.66
6.18
In addition to the placement of alcohol rub at the point of use (e.g. patient’s
beds/exam rooms and lockers), consideration should also be given to distributing
personal carried alcohol rub to certain groups of transient/migratory staff (e.g.
medical staff in hospitals and community staff performing home visits).67
6.19
All staff, patients and visitors entering and leaving areas where care is delivered
should perform hand hygiene with either soap and water followed by drying, or
alcohol hand rub.68
6.20
Appropriate hygiene measures, including adequate washing facilities should be
available69
6.21
For isolation areas please see Section 38 below.
Points 6.13 – 6.16 from the CNST Standards 5.1.6
Guidance for Pandemic Influenza: Infection Control in Hospitals and Primary Care Settings. Department of
Health. See also section 29: Influenza Pandemic.
67 ibid.
68 ibid.
69 The Control of Substances Hazardous to Health Regulations 2002
65
66
18
7
Personal protective equipment70
7.1
Protective equipment should be available on the basis of an assessment of the risk
of transmission of micro organisms to the patient, and the risk of contamination of
health care practitioners clothing and skin by patients’ blood, body fluids, secretions,
and excretions. The equipment used should always be sterile.71
7.2
Gloves and aprons must be worn for invasive procedures, contact with sterile sites,
and non-intact skin, mucous membranes, and all activities that have been assessed
as carrying a risk of exposure to blood, body fluids, secretions and excretions; and
when handling sharp or contaminated instruments72.
7.3
Gloves should be worn as single use items. Put gloves on immediately before an
episode of patient contact or treatment and remove them as soon as the activity is
completed. Change gloves between caring for different patients, or between
different care/treatment activities for the same patient. (A common fault is to touch
other surfaces eg phones while wearing gloves)
7.4
Gloves must be disposed of as clinical waste and hands should be decontaminated
following the removal of gloves. Hands should be washed following removal.73
7.5
Gloves conforming to European Community (CE) standards and of an acceptable
quality must be available in all clinical areas.
7.6
Sensitivity to natural rubber latex in patients, carers and healthcare personnel must
be documented, and alternatives to natural rubber latex gloves must be available.
7.7
Neither powdered gloves not polythene gloves should be used in healthcare
activities.
7.8
Disposable plastic aprons should be worn when there is a risk that clothing may be
exposed to blood, body fluids, secretions or excretions, with the exception of sweat.
7.9
Full-body fluid repellent gowns must be worn when there is a risk of extensive
splashing of blood, body fluids, secretions or excretions, with the exception of
sweat, onto the skin or clothing of healthcare practitioners (for example when
assisting with childbirth).
7.10
Plastic aprons should be worn as single-use items, for one procedure or episode of
patient care, and then discarded and disposed of as clinical waste.
70
The Code has a mandatory requirement for use of protective clothing to form part of a policy for standard
(universal) infection control precautions (see Annex 2). The policy should be easily accessible, compliance
should be audited and information on it should be part of induction training. Points 7.1-7.12 are taken from
both ‘The Epic Project’ and the NICE Guideline. The guidelines together cover primary and secondary
healthcare providers. See also the Control of Substances Hazardous to Health Regulations. Some of these
points are also referred to in Essential Steps to Safe, Clean Care: Reducing health care associated infection.
London: Department of Health, 2006
71 See Essential steps to Safe Clean Care, ibid.
72 See also RCN ibid.
73 See RCN ibid
19
7.11
Face masks and eye protection must be worn where there is a risk of blood, body
fluids, secretions or excretions splashing into the face and eyes74.
7.12
Respiratory protective equipment, for example a particulate filter mask, must be
used when clinically indicated.
7.13
PPE should be worn to protect staff from contamination with body fluids and thus
reduce the risk of transmission of pandemic influenza between patients and staff
and from one patient to another.75 (See section 32)
7.14
Appropriate PPE for care of patients with pandemic influenza is summarised in the
table below (Standard Infection Control Principles apply at all times);76
Hand hygiene
Entry To Cohorted Close Patient Contact Aerosol
Generating
Area But No Patient (<3 feet)
Procedures
(7.14.1,
7.14.2)
Contact



Gloves
X (7.14.3)
 (7.14.4)

Plastic Apron
X (7.14.3)

X
Gown
X
X
 (7.14.6)
(7.14.5, 7.14.6)
Surgical Mask


X
FFP 3
respirator
Eye protection
X
X

X
Risk Assessment

7.14.1
Examples of aerosol-generating procedures include intubation,
nasopharyngeal aspiration, tracheostomy care, chest physiotherapy,
bronchoscopy, nebuliser therapy, and autopsy of lung tissue.
7.14.2
Whenever possible, aerosol-generating procedures should be
performed in an enclosed environment
7.14.3
Gloves and apron should be worn during certain cleaning
procedures.
7.14.4
Gloves should be worn in accordance with Standard Infection Control
Principles. If glove supplies become limited or pressurised, this
recommendation may need to be relaxed. Glove use should be
prioritised always for contact with blood and body fluids, invasive
procedures and contact with sterile sites.
74
See RCN ibid
Guidance for Pandemic Influenza: Infection Control in Hospitals and Primary Care Settings. Note also that
there is dispute currently as to whether surgical masks or FFP3 masks are required in dealing with
influenza.)
76 ibid
75
20
7.14.5
Consider in place of an apron if extensive soiling of clothing or
contact of skin with blood and other body fluids is anticipated (e.g.
intubation or caring for babies).
7.14.6
If non-fluid repellent gowns are used a plastic apron should be worn
underneath.
7.15
Care in the correct donning and removal of PPE is essential to avoid inadvertent
contamination.77
7.16
All contaminated clothing must be removed before leaving a patient care area.
Disposal or surgical masks being removed last.78
7.17
A surgical mask should be worn by healthcare workers for close patient contact
(within 3 feet). If pandemic influenza patients are cohorted in one area and multiple
patients must be visited over a short time in a rapid sequence, it may be practical to
wear a single surgical mask on entry to the area and keep it on for the duration of
the activity, or until the mask requires replacement. However, other PPE (e.g.
gloves, gown) must be removed between patients and hand hygiene performed. All
contaminated PPE must be removed before leaving the patient care area. Surgical
masks of FFP3 respirators should be removed last followed by thorough hand
hygiene.79
7.18
Surgical masks should;
7.18.1
Cover both the nose and the mouth and not be allowed to dangle
around the neck after use,
7.18.2
Not be touched once put on,
7.18.3
Be changed when they become moist,
7.18.4
Be worn once and discarded in an appropriate receptacle as clinical
waste,
7.18.5
Hand hygiene must be performed after disposal is complete.80
7.19
A disposable respirator providing the highest possible protection factor available
(i.e. an EN 149:2001 FFP3 disposable respirator) should be worn by healthcare
workers when performing procedures which have the potential to create aerosols. If
an EM 149:2001 FFP3 disposable respirator is not immediately available, the next
highest category of respirator available should be worn (e.g. FFP2).
7.20
For isolation areas please see Section 38 below.
77
ibid
ibid
79 ibid
80 ibid
78
21
8
Safe use and disposal of sharps
8.1
An NHS Body should have in place a core policy on the safe handling and disposal
of sharps. It should cover: risk management and training in the management of
needle stick injuries, provision of medical devices incorporating sharps protection
mechanisms; easy access to all groups of staff; auditing of policy and dissemination
of information on policy on induction for all staff groups81.
8.2
All those preparing local policies on the safe handling and disposal of sharps should
carry out a risk assessment in accordance with the Control of Substances
Hazardous to Health Regulations 199982.
8.3
The policy should form part of the written health and safety policy as required under
the Management of Health ad Safety at Work Regulations 1999 and the Health and
Safety at Work Act 1974.
8.4
All sharps injuries should be reported in accordance with the requirements of the
NHS Controls Assurance Standards (Infection Control Standard, Criterion 6) and
local procedures.
8.5
When taking blood samples from small infants, devices should be used that are
specifically intended for that purpose. The "broken needle" technique should not be
used.83
8.6
Sharps must not be passed directly from hand to hand and handling should be kept
to a minimum. 84
8.7
Needles must not be bent or broken prior to use or disposal.
8.8
Needles should not be recapped.
8.9
Used sharps must be discarded into a sharps container (conforming to UN3291 and
BS 7320 standards) carefully at the point of use. The containers should be placed
safely out of reach of children and as near as practicable to sites of use.85
8.10
Containers in public areas must not be placed on the floor and should be located in
a safe position. In wards and clinics sharps boxes should be mounted on the wall
8.11
Whoever uses the sharp must dispose of it themselves.
8.12
Staff should not remove the needle from the syringe before disposal into the sharps
bin.
8.13
Staff should not overfill sharps containers beyond the mark indicating they are full.
81
The Code at paragraph 10.e and Annex 2 e.
Points 8.13 to 8.14 taken from Safety Notice 2001(19) – Safe use and dispoal of sharps, Medical Devices
Agency.
83 Safety Notice 2001(20) – Blood sampling from small infants, Medical Devices Agency.
84 Points 8.6 to 8.14from both ‘The epic Project’, NICE Guideline and “Essential steps to Safe Clean Care.”
Guidelines together cover primary and secondary healthcare providers. See also RCN ibid.
85 The second sentence of 8.9 is taken from Guidance for Health Care Workers: Protection against infection
with Blood-borne viruses Department of Health 1998.
82
22
8.14
Consider the use of needlestick-prevention devices where there are clear
indications that they will provide safe systems of working for healthcare
practitioners.
8.15
There should be enough portable sharps bins for staff at all times to allow the used
needle to be disposed of safely at the point of use.86
8.16
Trusts should include specific time within training programmes at induction for all
staff to cover (see section 3);
8.16.1
The risks associated with blood and body-fluid exposure;
8.16.2
The correct use and disposal of sharps;
8.16.3
The use of medical devices incorporating sharps protection
mechanisms.
8.17
Refresher training should be made available on a regular basis.
8.18
Testing for HIV, hepatitis B and C should take place after any sharps injury.87 (Blood
from the donor should be tested for these and syphilis, blood from recipient is stored
and tested if previous exposure to these agents likely or immunity needs to be
established)
8.19
All exposure incidents should be reported promptly, following local reporting
arrangements (usually to the trust’s occupational health service).88
8.20
Dispose of sharps bins immediately when they are full.89
8.21
Do not handle syringes without gloves.
8.22
All cases of occupational exposure to blood or body fluid from patients infected with
HIV, HCV or HBV, and all incidents where PEP for HIV has started (whatever the
HIV status of the source), should be reported to the Health Protection Agency
national surveillance scheme.90
Points 8.15 – 8.17 The Management of Health, Safety and Welfare Issues for NHS Staff 2005. Chapter 19
– Needlestick management.
87 The Management of Health, Safety and Welfare Issues for NHS Staff 2005. Chapter 18 – Blood-borne
viruses. See also section 27 Blood-borne Viruses below.
88 The Management of Health, Safety and Welfare Issues for NHS Staff 2005. Chapter 19 – Needlestick
management.
89 Points 8.20 and 8.21 taken from Examples of good and bad practice in avoiding shaprs injuries http://www.hpa.org.uk/infections/topics_az/bbv/good_bad.htm
90 Taken from The management of health, safety and welfare issues for NHS staff 2005 – NHS Employers
86
23
9
Short-term indwelling urethral catheters in acute care91
9.1
NHS bodies should have in place policies based on best practice guidance for the
care of patients whose treatment involves the use of invasive devices; the policies
should be easily accessible by all relevant healthcare workers, compliance with
policy should be audited and information should be included in IC training
programmes for all relevant staff groups92.
9.2
Assessing the need.
9.3
9.4
9.5
9.2.1
Only use indwelling urethral catheters after considering alternative
methods of management.
9.2.2
Review regularly the patient’s clinical need for continuing urinary
catheterisation and remove the catheter as soon as possible.
9.2.3
Document catheter insertion and care.
Selection of catheter type.
9.3.1
Choice of catheter material will depend on clinical experience, patient
assessment and anticipated duration of catheterisation.
9.3.2
Select the smallest gauge catheter that will allow free urinary outflow.
A catheter with a 10ml balloon should be used. Urological patients
may require larger gauge sizes and balloons.
Aseptic catheter insertion.
9.4.1
Catheterisation is an aseptic procedure. Ensure that healthcare
personnel are trained and competent to carry out urethral
catheterisation.
9.4.2
Clean the urethral meatus prior to the insertion of the catheter.
9.4.3
Use an appropriate lubricant from a single use container to minimise
urethral trauma and infection.
Catheter maintenance.
9.5.1
9.6
91
92
Connect indwelling urethral catheters to a sterile closed urinary
drainage system.
Ensure that the connection between the catheter and the urinary drainage system is
not broken except for good clinical reasons, e.g. changing the bag in line with the
manufacturer’s recommendations.
Points 9.2-9.14 from ‘The Epic Project’. See also Saving Lives, High Impact Intervention 5
The Code at Appendix 3
24
9.7
Decontaminate hands and wear a new pair of clean, non-sterile gloves before
manipulating a patient’s catheter and decontaminate hands after removing gloves.
(See section 6).
9.8
Obtain urine samples from a sampling port using an aseptic technique.
9.9
Position urinary drainage bags below the level of the bladder on a stand that
prevents contact with the floor. Where such drainage cannot be maintained, e.g.
during moving and handling, clamp the urinary drainage bag tube and remove the
clamp as soon as dependent drainage can be resumed.
9.10
Empty the urinary drainage bag frequently enough to maintain urine flow and
prevent reflux. Use a separate and clean container for each patient and avoid
contact between the urinary drainage tap and container.
9.11
Do not add antiseptic or antimicrobial solutions into urinary drainage bags.
9.12
Do not change catheters unnecessarily or as part of routine practice.
9.13
Routine personal hygiene is all that is needed to maintain meatal hygiene.
9.14
Bladder irrigation, instillation and washout do not prevent catheter –associated
infection.
25
10
Long-term urethral catheters in primary and community care93
10.1
NHS bodies should have in place policies based on best practice guidance for the
care of patients whose treatment involves the use of invasive devices; the policies
should be easily accessible by all relevant healthcare workers, compliance with
policy should be audited and information should be included in IC training
programmes for all relevant staff groups94.
10.2
Education
10.3
10.4
10.2.1
Patients and carers should be educated about and trained in
techniques of hand decontamination, insertion of intermittent
catheters where applicable, and catheter management before
discharge from hospital with an emphasis on the techniques for
reducing risk of infection.95
10.2.2
Community and primary healthcare personnel must be trained in
catheter insertion, including suprapubic catheter replacement and
catheter maintenance.
10.2.3
Urinary catheter insertion, manipulation, washing out, urine sampling
and removal will be undertaken by trained and competent staff using
strictly aseptic techniques.96
10.2.4
Follow-up training and ongoing support of patients and carers should
be available for the duration of long-term catheterisation.
Assessing need.
10.3.1
Indwelling urinary catheters should be used only after alternative
methods of management have been considered.
10.3.2
The patient’s clinical need for catheterisation should be reviewed
regularly and the urinary catheter removed as soon as possible.
10.3.3
Catheter insertion, changes and care should be documented.
Drainage options.
10.4.1
Following assessment, the best approach to catheterisation that
takes account of clinical need, anticipated duration of catheterisation,
patient preference and risk of infection should be selected.
10.4.2
Intermittent catheterisation should be used in preference to an
indwelling catheter if it is clinically appropriate and a practical option
for the patient.
93
Un-annotated wording from the NICE Guideline
The Code at Appendix 3
95 Point 10.2.1 combined from ‘Winning Ways’ and the NICE Guideline
96 ‘Winning Ways’
94
26
10.5
10.6
97
10.4.3
For urethral and suprapubic catheters, the choice of catheter material
and gauge will depend on an assessment of the patient’s individual
characteristics and predisposition to blockage.
10.4.4
When long term indwelling use is unavoidable, a catheter of low
allergenicity will be used.97
10.4.5
In general, the catheter balloon should be inflated with 10ml of sterile
water in adults and 3-5ml in children
10.4.6
In patients for whom it is appropriate, a catheter valve may be used
as an alternative to a drainage bag.
Insertion.
10.5.1
All catheterisations carried out by healthcare personnel should be
aseptic procedures. After training, healthcare personnel should be
assessed for their competence to carry out these types of
procedures.
10.5.2
Intermittent self-catheterisation is a clean procedure. A lubricant for
single-patient use is required for non-lubricated catheters.
10.5.3
For urethral catheterisation, the meatus should be cleaned before
insertion of the catheter, in accordance with local guidelines/policy.
10.5.4
An appropriate lubricant from a single use container should be used
during catheter insertion to minimise urethral trauma and infection.
Maintenance.
10.6.1
Indwelling catheters should be connected to a sterile closed urinary
drainage system or catheter valve.
10.6.2
Healthcare personnel should ensure that the connection between the
catheter and the urinary drainage system is not broken except for
good clinical reasons, (for example changing the bag in line with the
manufacturer’s recommendations).
10.6.3
Healthcare personnel must decontaminate their hands and wear a
new pair of clean, non-sterile gloves before manipulating a patient’s
catheter, and must decontaminate their hands after removing gloves.
(See section 6).
10.6.4
Carers and patients managing their own catheters must wash their
hands before and after manipulation of the catheter.
10.6.5
Urine samples must be obtained from a sampling port using an
aseptic technique.
Point 10.3.4 an addition from ‘Winning Ways’
27
10.6.6
Urinary drainage bags should be positioned below the level of the
bladder, and should not be in contact with the floor.
10.6.7
A link system should be used to facilitate overnight drainage, to keep
the original system intact.
10.6.8
The urinary drainage bag should be emptied frequently enough to
maintain urine flow and prevent reflux, and should be changed when
clinically indicated.
10.6.9
The meatus should be washed daily with soap and water.
10.6.10
Each patient should have an individual care regimen designed to
minimise the problems of blockage should be documented in each
newly catheterised patient.
10.6.11
Bladder instillations or washouts must not be used to prevent
catheter-associated infection.
10.6.12
Catheters should be changed only when clinically necessary, or
according to the manufacturer’s current recommendations.
10.6.13
Antibiotic prophylaxis when changing catheters should only be used
for patients with a history of catheter-associated urinary tract
infection following catheter change, or for patients who have a heart
valve lesion, septal defect, patent ductus or prosthetic valve. or
proven urinary infection
10.6.14
Reusable intermittent catheters should be cleaned with water and
stored dry in accordance with the manufacturer’s instructions.
28
11
Insertion and maintenance of central venous catheters in acute care98
11.1
NHS bodies should have in place policies based on best practice guidance for the
care of patients whose treatment involves the use of invasive devices; the policies
should be easily accessible by all relevant healthcare workers, compliance with
policy should be audited and information should be included in IC training
programmes for all relevant staff groups99.
11.2
Central venous line insertion, manipulation and removal will be undertaken by
trained and competent staff using strictly aseptic techniques.
11.3
Selection of catheter type.
11.4
11.5
11.3.1
Use a single-lumen catheter unless multiple ports are essential for
the management of the patient.
11.3.2
If total parenteral nutrition is being administered, use one central
venous catheter or lumen exclusively for that purpose.
11.3.3
Use a tunnelled catheter or an implantable vascular access device
for patients in whom long-term (>30 days) vascular access is
anticipated.
11.3.4
Consider the use of an antimicrobial impregnated central venous
catheter for adult patients who require short-term (>10 days) central
venous catheterisation and who are at high risk for CR-BSI. This is
now commonly recommended as standard
Selection of insertion site.
11.4.1
In selecting an appropriate insertion site, assess the risks for
infection against the risks of mechanical complications.
11.4.2
Unless medically contraindicated, use the subclavian site in
preference to the jugular or femoral sites for non-tunnelled catheter
placement100.
11.4.3
Consider the use of peripherally inserted catheters as an alternative
to subclavian or jugular vein catheterisation.
Optimum aseptic technique during catheter insertion.
11.5.1
11.6
Use optimum aseptic technique, including a sterile gown, gloves, and
a large sterile drape, for the insertion of central venous catheters.
Cutaneous antisepsis.
Un-annotated wording from ‘The Epic Project’. See also: Saving Lives: High Impact Intervention 2
The Code at Appendix 3
100 In practice this is difficult in critical care. Most units use the jugular in preference because of the risk of
pneumothorax
98
99
29
11.7
11.8
11.6.1
Clean the skin site with an alcoholic chlorhexidine gluconate solution
prior to CVC insertion. Use an alcoholic povidone-iodine solution for
patients with a history of chlorhexidine sensitivity.
Allow the
antiseptic to dry before inserting the catheter. IV care bundles are
now being introduced as part of DH High Impact Interventions –
these use 2% chlorhexidine not the standard 0.5%
11.6.2
Do not apply organic solvents, e.g. acetone, ether, to the skin before
catheter insertion.
11.6.3
Do not routinely apply microbial ointment to the catheter placement
site prior to insertion.
Catheter care.
11.7.1
Before accessing the system, disinfect the external surfaces of the
catheter hub and connection ports with an aqueous solution of
chlorhexidine gluconate or povidone-iodine, unless contraindicated
by the manufacturer’s recommendations.
11.7.2
A dedicated occlusive transparent dressing will be used to allow
continuous inspection of the exit site and will be changed at no later
than seven days.101
11.7.3
Do not apply antimicrobial ointment to CVC insertion sites as part of
routine catheter site care.
11.7.4
Routinely flush indwelling central venous catheters with an
anticoagulant unless advised otherwise by the manufacturer.
Replacement strategies.
11.8.1
Do not routinely replace non-tunnelled CVC as a method to prevent
catheter-related infections.
11.8.2
Use guide wire assisted catheter exchange to replace a
malfunctioning catheter, or to exchange an existing catheter if there
is no evidence of infection at the catheter site or proven CR-BSI.
11.8.3
If CR-infection is suspected, but there is no evidence of infection at
the catheter site, remove the existing catheter and insert a new
catheter over a guide wire; if tests reveal CR-infection, the newly
inserted catheter should be removed and, if still required, a new
catheter inserted at a different site102.
11.8.4
Do not use guide wire assisted catheter exchange for patients with
CR-infection. If continued vascular access is required, remove the
‘The Epic Project’ suggests that a gauze dressing is also appropriate, however, the guideline in ‘Winning
Ways’ is taken here as the more recent guideline.
102
In practice In practice this is usually avoided as the risk of catheter infection after guide wire exchange is
high
101
30
implicated catheter, and replace it with another catheter at a different
insertion site.
11.9
11.8.5
Replace all tubing when the vascular device is replaced.
11.8.6
Replace intravenous tubing and stopcocks no more frequently than
at 72-hour intervals, unless clinically indicated.
11.8.7
Replace intravenous tubing used to administer blood, blood products,
or lipid emulsions at the end of the infusion or within 24 hours of
initiating the infusion.
11.8.8
The date of insertion and date of removal of the device will be
documented in the clinical records as a matter of routine.103 Also the
doctor inserting must be indicated
Antibiotic prophylaxis
11.9.1
103
Do not administer systematic antimicrobials routinely before insertion
or during use of a central venous catheter to prevent catheter
colonisation or bloodstream infection.
Addition from ‘Winning Ways’
31
12
Care of patients with central venous catheters in community care104
12.1
NHS bodies should have in place policies based on best practice guidance for the
care of patients whose treatment involves the use of invasive devices; the policies
should be easily accessible by all relevant healthcare workers, compliance with
policy should be audited and information should be included in IC training
programmes for all relevant staff groups105.
12.2
Central venous line insertion, manipulation, and removal will be undertaken by
trained and competent staff using strictly aseptic techniques.106
12.3
Education.
12.4
12.5
12.3.1
Before discharge from hospital, patients and their carers should be
taught any techniques they may need to use to prevent infection and
safely manage a central venous catheter.
12.3.2
Community healthcare personnel caring for a patient with a central
venous catheter should be trained, and assessed as competent, in
using and consistently adhering to the infection prevention practices
described in this guideline.
12.3.3
Follow-up training and support should be available to patients with
central venous catheters and their carers.
General asepsis.
12.4.1
An aseptic technique must be used for catheter site care and for
accessing the system.
12.4.2
Before accessing or dressing central venous catheters, hands must
be decontaminated either by washing with an anti microbial liquid
soap and water, or by using an alcohol handrub.
12.4.3
Hands that are visibly soiled or contaminated with dirt or organic
material must be washed with soap and water before using an
alcohol handrub.
12.4.4
Following hand antisepsis, clean gloves and a no-touch technique or
sterile gloves should be used when changing the insertion site
dressing.
Catheter care site.
12.5.1
Preferably, a sterile, transparent, semi-permeable polyurethane
dressing should be used to cover the catheter site.
104
Un-annotated wording from NICE Guideline (applies in the Community setting)
The Code at Appendix 3
106 ‘Winning Ways’
105
32
12.6
107
12.5.2
If a patient has profuse perspiration, or if the insertion site is bleeding
or oozing, a sterile gauze dressing is preferable to a transparent,
semi-permeable dressing.
12.5.3
Gauze dressings should be changed when they become damp,
loosened or soiled, and the need for a gauze dressing should be
assessed daily.
A gauze dressing should be replaced by a
transparent dressing as soon as possible.
12.5.4
Transparent dressings should be changed every 7 days, or sooner if
they are no longer intact or moisture collects under the dressing.
12.5.5
Dressings used on tunnelled or implanted central venous catheter
sites should be replaced every 7 days until the insertion site has
healed, unless there is an indication to change them sooner.
12.5.6
An alcoholic chlorhexidine gluconate solution should be used to
clean the catheter site during dressing changes, and allowed to air
dry. An aquaeous solution of chlorhexidine gluconate should be
used if the manufacturer’s recommendations prohibit the use of
alchohol with the product.
12.5.7
Individual sachets of antiseptic solution or individual packages of
antiseptic-impregnated swabs or wipes should be used to disinfect
the dressing site.
12.5.8
Healthcare personnel should ensure that catheter-site care is
compatible with catheter materials (tubing, hubs, injection ports, luer
connectors and extensions) and carefully check compatibility with the
manufacturer’s recommendations.
General principles for catheter management.
12.6.1
The injection port or catheter hub should be decontaminated using
either alcohol or an alcoholic solution of chlorhexidine gluconate
before and after it has been used to access the system.
12.6.2
In-line filters should not be used routinely for infection prevention.
12.6.3
Antibiotic lock solutions should not be used routinely to prevent
catheter-related bloodstream infections (CRBSI).
12.6.4
Systematic antimicrobial prophylaxis should not be used routinely to
prevent catheter colonisation of CRBSI, either before insertion or
during the use of a central venous catheter.
12.6.5
Generally, a single lumen catheter should be used unless patient
care dictates otherwise107. A single lumen catheter should be used
preferably to administer parenteral nutrition. If a multilumen catheter
is used, one port must be exclusively dedicated for total parenteral
Saving Lives: High Impact Intervention 2.
33
nutrition, and all lumens must be handled with the same meticulous
attention to aseptic technique.
108
109
12.6.6
The catheter site should be observed daily108
12.6.7
Preferably, a sterile 0.9 percent sodium chloride injection should be
used to flush and lock catheter lumens.
12.6.8
When recommended by the manufacturer, implanted ports or openended catheter lumens should be flushed and locked with heparin
sodium flush solutions.
12.6.9
Systematic anticoagulants should not be used routinely to prevent
CRBSI.
12.6.10
If needleless devices are used, the manufacturer’s recommendations
for changing the needleless components should be followed.
12.6.11
When needleless devices are used, healthcare personnel should
ensure that all components of the system are compatible and
secured, to minimise leaks and breaks in the system.
12.6.12
When needleless devices are used, the risk of contamination should
be minimised by decontaminating the access port with either alcohol
or an alcoholic solution of chlorhexidine gluconate before and after
using it to access the system.
12.6.13
In general, administration sets in continuous use need not be
replaced more frequently than at 72-hour intervals unless they
become disconnected or a catheter-related infection is suspected or
documented.
12.6.14
Administration sets for blood and blood components should be
changed every 12 hours, or according to the manufacturer’s
recommendations.
12.6.15
Administration sets used for total parenteral nutrition infusions should
generally be changed every 24 hours. If the solution contains only
glucose and amino acids, administration sets in continuous use do
not need to be replaced more frequently than every 72 hours.
12.6.16
The date of insertion and date of removal of the device will be
documented in the clinical record as a matter of routine.109
Saving Lives: High Impact Intervention 2.
‘Winning Ways’
34
13
110
111
Peripheral intravenous cannulae110
13.1
NHS bodies should have in place policies based on best practice guidance for the
care of patients whose treatment involves the use of invasive devices; the policies
should be easily accessible by all relevant healthcare workers, compliance with
policy should be audited and information should be included in IC training
programmes for all relevant staff groups111.
13.2
Intravenous cannula insertion will be carried out by trained and competent staff
using strictly aseptic techniques.
13.3
The number of lines, lumens and stopcocks will be kept to the absolute minimum
consistent with clinical need.
13.4
Peripheral intravenous cannulae insertion sites will be regularly inspected for signs
of infection and the cannula removed if infection is suspected.
13.5
Peripheral intravenous cannulae will be kept in place for the minimum time
necessary and changed every 72 hours irrespective of the presence of infection.
13.6
Administration sets will be changed immediately following a blood transfusion,
intravenous feed or at 24 hours (whichever is sooner). For other clear fluids,
change will occur at 72 hours.
13.7
The date of insertion and date of removal of the device will be documented in the
clinical record as a matter of routine.
Points 13.2-13.7 ‘Winning Ways’
The Code at Appendix 3
35
14
112
Respiratory support112
14.1
Ventilator tubing will only be changed when visibly soiled or malfunctioning.
14.2
Gloves will be worn for handling respiratory secretions or contaminated objects.
14.3
Gloves and appropriate personal protection will be used when aspirating respiratory
secretions.
14.4
Hands will be decontaminated after glove removal. (See section 6).
14.5
The date of insertion and the date of removal of the device will be documented in
the clinical records as a matter of routine.
Points 14.1-14.5 ‘Winning Ways’. See also: Saving Lives: High Impact Intervention 4
36
15
Care during enteral feeding (primary care) 113
15.1
15.2
15.3
113
Education.
15.1.1
Patients and carers should be educated about and trained in the
techniques of hand decontamination, enteral feeding and the
management of the administration system before being discharged
from hospital.
15.1.2
Community staff should be trained in enteral feeding and
management of the administration system.
15.1.3
Follow-up training and on-going support of patients and carers
should be available for the duration of home enteral tube feeding.
Preparation and storage of feeds.
15.2.1
Wherever possible pre-packaged, ready-to-use feeds should be used
in preference to feeds requiring decanting, reconstitution or dilution.
15.2.2
The system selected should require minimal handling to assemble,
and be compatible with the patient’s enteral feeding tube.
15.2.3
Effective hand decontamination must be carried out before starting
feed preparation.
15.2.4
When decanting, reconstituting or diluting feeds, a clean working
area should be prepared and equipment dedicated for enteral feed
use only should be used.
15.2.5
Feeds should be mixed using cooled boiled water or freshly opened
sterile water and a no-touch technique.
15.2.6
Feeds should be stored according to the manufacturer’s instructions
and, where applicable, food hygiene legislation.
15.2.7
Where ready-to-use feeds are not available, feeds may be prepared
in advance, stored in a refrigerator, and used within 24 hours.
Administration of feeds.
15.3.1
Minimal handling and an aseptic no-touch technique should be used
to connect the administration system to the enteral feeding tube.
15.3.2
Ready-to-use feeds may be given for a whole administration session,
up to a maximum of 24 hours. Reconstituted feeds should be
administered over a maximum 4-hour period.
15.3.3
Administration sets and feed containers are for single use and must
be discarded after each feeding session.
Points 15.1 to 15.15 in the NICE Guideline
37
15.3.4
The stoma should be washed daily with water and dried thoroughly.
15.3.5
To prevent blockage, the enteral feeding tube should be flushed with
fresh tap water before and after feeding or administering
medications.
Enteral feeding tubes for patients who are
immunosuppressed should be flushed with either cooled freshly
boiled water or sterile water from a freshly opened container.
38
16
114
Intravenous feeding lines (patenteral nutrition)114
16.1
Intravenous feeding lines will only be used when there is no suitable alternative, and
even then kept in place for as short a time as possible.
16.2
Insertion, manipulation, and removal of intravenous feeding lines will be undertaken
by trained and competent staff using strictly aseptic techniques.
16.3
A dedicated line or lumen of a multi-channel line will be used. No other infusion or
injection will go via this route. Three-way taps will not be used.
16.4
Any additives to intravenous fluid containers will be introduced aseptically in a unit
or safety cabinet designed for the purpose, by trained staff using strictly aseptic
techniques.
16.5
Intravenous feeding cannulae insertion sites will be regularly inspected for signs of
infection and the cannula removed if infection is suspected. Feed must be stopped if
patient develops fever or positive blood cultures
16.6
The date of insertion and the date of removal of the device will be documented in
the clinical record as a matter of routine.
Points 16.1 - 16.6 ‘Winning Ways’
39
17
Decontamination of instruments and other devices115 116
17.1
As part of its duty to provide and maintain a clean and appropriate environment, an
NHS body must ensure that there are effective arrangements for the appropriate
decontamination of instruments and other equipment117. A Trust must implement
robust Trust-wide policies for decontamination to avoid patient contamination by
inadequately decontaminate re-usable instruments118.
17.2
Lead Managers for decontamination of equipment used for treatment must be
designated119. The decontamination lead should have responsibility for ensuring that
a decontamination programme is implemented in relation to the organisation and
that it takes proper account of relevant national guidelines120.
17.3
The Decontamination Programme should demonstrate that decontamination of
reusable devices takes place in appropriate dedicated facilities, appropriate
procedures are used for the acquisition and maintenance of decontamination
equipment, staff are trained in decontamination processes and hold appropriate
competencies for their role and there is a monitoring system in place to ensure that
decontamination processes are fit for purpose and meet the required standard121.
17.4
The core clinical care protocol for closure of wards, departments and premises to
new admissions should include provision on the need for environmental
decontamination prior to re-opening122.
17.5
The core clinical care protocol for control of MRSA should address decontamination
of colonised patients; the core clinical care protocol for control of Clostridium difficile
should address environmental decontamination123.
17.6
An NHS body must have systems to protect patients and staff which minimise the
risk of transmission of infection from medical devices and other equipment which
comes into contact with patients or their body fluids124
17.7
Reusable medical devices should be decontaminated in accordance with
manufacturer’s instructions and current guidelines; systems should allow reusable
medical devices to be tracked through decontamination processes to ensure the
processes have been carried out effectively; systems should be implemented to
enable the identification of patients on whom the medical devices have been
used125.
Points 17.2 – 17.8 ‘Winning Ways’ Action Area Two. See also RCN ibid
See also 26:Variant Creutzfeldt – Jakob Disease
117 The Code at paragraph 4 (f) and Appendix 2f. See also Core Standard C4c) Healthcare Commission
requiring all reusable medical devices to be properly decontaminated prior to use and that the risks
associated with decontamination facilities are well managed.
118 Saving Lives: Challenge 9
119 The Code at paragraph 4(b)
120 The Code at Annex 1
121 The Code at Annex 1
122 The Code at Annex 2, paragraph h.
123 The Code at Annex 2, paragraph l.
124 The Code at Appendix 2, paragraph f
125 The Code at Appendix 2 paragraph f. Note that currently individual instruments cannot be marked and
only tracking of trays or packs of instruments is possible
115
116
40
17.8
Policies should be in place for handling instruments designed for single use only126.
Devices designated for single use must not be reprocessed.
17.9
Reusable devices will be decontaminated in a sterile services department with
requisite facilities and expertise.
17.10 Endoscopes will be decontaminated according to national guidelines.
17.11 If devices have to be decontaminated locally, an automated process will be used.
Manual cleaning of devices will be restricted to those items deemed incompatible
with these processes.
17.12 Staff involved in decontamination will be properly trained and wear personal
protective clothing e.g. gloves, masks and aprons.
17.13 Staff will ensure that there is an audit trail for each recycled item.
17.14 Guidance on the prevention of transmission of CJD through medical procedures will
be followed.
17.15 Clinical staff will ensure that equipment is clean, maintained and fit for purpose. A
piece of equipment used for more than one patient will be decontaminated
according to current guidelines following each and every use.127
126
127
The Code at Appendix 2, paragraph g
Point 17.9 ‘Winning Ways’ Action Area Three
41
18
Decontamination of Endoscopes128
18.1
Decontamination should begin as soon as possible after endoscopes and their
accessories have been used.
18.2
Thorough manual cleaning with a suitable detergent and in accordance with the
endoscope manufacturer’s instructions is an essential first stage.
18.3
Thorough rinsing completes manual cleaning.
18.4
After manual cleaning the instrument must either be disinfected of sterilized.
18.5
Where practical single-use devices should be used.
18.6
Reusable accessories should be autoclavable129.
18.7
Reusable accessories should be traceable in accordance with HSC 200/032.
18.8
All automated endoscope reprocessors should be cleaned and disinfected in
accordance with the manufacturer's instructions before use.
18.9
High level disinfection not sterilization endoscopes must be stored sealed in the
container or packaging in which they were first sterilized.
18.10 On completion of disinfection, the endoscope should be purged with compressed air
to facilitate drying. Alternatively, 70% alcohol may be used to dry internal surfaces
and channels.
18.11 Lensed instruments should not be placed in alcohol for periods in excess of 5
minutes.
18.12 Flexible endoscopes should be stored suspended vertically in ventilated storage
cabinets to allow circulation of air. They should not be in contact with other
endoscopes or flat surfaces.
18.13 Before storage, the rubber seals of the suction and air/water valves should be
lubricated sparingly with silicone oil or in accordance with the manufacture's
instructions.
18.14 Prior to the next use of an endoscope or accessory which has been sterilized by
autoclaving, the user must check that seals are intact, the packaging is undamaged
and that the chemical indicators are showing the correct colour change consistent
with exposure to sterilising agent.
18.15 Chemical indicators should not be relied upon to demonstrate sterility of eh package
contents.
128
129
Taken from Decontamination of Endoscopes, Medical Devices Agency, Device Bulletin 2002(05)
Endoscopes are not autoclavable
42
19
Control and Prevention of MRSA in Healthcare Facilities130
19.1
Grades of evidence and recommendations.
Each recommendation, as graded by the US Centres for Disease Control and
Prevention (CDC), is categorised on the basis of existing scientific date, theoretical
rationale, applicability and economic impact. These grades were chosen in
preference to those published by the Scottish Intercollegiate Guidelines Network or
the National Institute for Clinical Excellence as they include scientific evidence and
are not exclusively clinical. The CDC/Hospital Infection Control Practices Advisory
Committee (HICPAC) system for categorising recommendations is as follows;
19.2
19.1.1
Category 1a. Strongly recommended for implementation and
strongly supported by well-designed experimental, clinical or
epidemiological studies.
19.1.2
Category 1b. Strongly recommended for implementation and
strongly supported by certain experimental, clinical or
epidemiological studies and a strong theoretical rationale.
19.1.3
Category 1c. Required for implementation, as mandated by federal
or state regulation or standard. The UK equivalent is to operate
within European Union or UK Health & Safety Legislation.
19.1.4
Category 2. Suggested for implementation and supported by
suggestive clinical or epidemiological studies or a theoretical
rationale.
19.1.5
No recommendation. Unresolved issue. Practices for which
insufficient evidence exists or for which there is no consensus
regarding efficacy.
Surveillance.
19.2.1
Surveillance must be undertaken routinely as part of the hospital’s
infection control programme and must be a recognised element of
the clinical governance process. There should be clear arrangements
identifying those responsible for acting on the results in individual
hospital directorates (Category 1b).
19.2.2
For benchmarking purposes, surveillance data should be collected
and reported in a consistent way, to agreed case definitions and
using agreed speciality activity denominators, with stratification
according to case mix (Category 1b).
19.2.3
Surveillance data should be fed back to the hospital staff routinely,
readily intelligible to most hospital staff, considered regularly at
hospital senior management committees and used in local infection
control training. MRSA surveillance should include:
‘Guidelines for the control and prevention of meticillin-resistant Staphylococcus arueus (MRSA) in
healthcare facilities’ Journal of Hospital Infection (2006)
130
43
19.2.4
19.2.5
19.3
19.2.3.1
Any mandatory requirements (Category c),
19.2.3.2
Results of microbiological investigations for clinical purposes
(Category 1b),
19.2.3.3
Results of microbiological investigations undertaken for
screening purposes (Category 1b).
The dataset should include
19.2.4.1
Patient, laboratory, unit/ward and hospital identifiers;
19.2.4.2
Patient demographics (address, age, sex)
19.2.4.3
Date of admission,
19.2.4.4
Date of onset of infection (if appropriate),
19.2.4.5
Site of the primary infection, if appropriate (if bacteraemia,
source of the bacteraemia),
19.2.4.6
Date specimen taken,
19.2.4.7
Site of specimen (blood culture, wound, etc),
19.2.4.8
19.2.4.9
Where the MRSA was acquired (hospital, community,
speciality, etc)
Whether part of an outbreak and
19.2.4.10
Antimicrobial susceptibilities.
Other desirable items include the primary diagnosis, an assessment
of severity of underlying illnesses, prior antimicrobial therapy and
possible risk factors for infection (Category 2).
Antibiotic Stewardship
19.3.1
Avoidance of inappropriate or excessive antibiotic therapy and
prophylaxis in all healthcare settings (Category 1a).
19.3.2
Ensuring that antibiotics are given at the correct dosage and for an
appropriate duration (Category 1b).
19.3.3
Limiting the use of glycopeptide antibiotics to situations where their
use has been shown to be appropriate. If possible, prolonged course
of glycopeptide therapy should be avoided (Category 1a).
19.3.4
Reducing the use of broad-spectrum antibiotics, particularly thirdgeneration cephalosporins and fluroquinolones, to what is clinically
appropriate (Category 1b).
19.3.5
Instituting antibiotic stewardship programmes in healthcare facilities,
key components of which include the identification of key personnel
44
who are responsible for this, surveillance of antibiotic resistance and
antibiotic consumption, and prescriber education (Category 1c).
19.4
131
132
Screening.
19.4.1
The core clinical care policy on MRSA should make provision for
screening, including screening of all elective admissions by March
2009 and emergency admissions at presentation as soon as is
practicable131
19.4.2
Active screening of patients for MRSA carriage should be performed
and the results should be linked to a targeted approach to the use of
isolation and cohorting facilities (Category 2)132.
19.4.3
Certain high-risk patients should be screened routinely, and certain
high-risk units should be screened at least intermittently in all
hospitals. The fine detail regarding which patients are screened
should be determined locally by the infection control team and must
be discussed with the appropriate clinical teams and endorsed by the
relevant hospital management structure. They will be influenced by
the local prevalence of MRSA in the hospital and unit concerned, the
reason for admission of the patient, the risk status of the unit to which
they are admitted, and the likelihood that the patient is carrying
MRSA. Patients at high risk of carriage of MRSA include those who
are;
19.4.3.1
Known to have been infected or colonised with MRSA in the
past (Category 1b),
19.4.3.2
Frequent re-admissions to any healthcare facility (Category
1b),
19.4.3.3
Recent inpatients at hospitals abroad or hospitals in the UK
which are known or likely to have a high prevalence of MRSA
(Category 1b),
19.4.3.4
Residents of residential care facilities where there is a known
or likely high prevalence of MRSA carriage (Category 1b).
19.4.4
Other risk groups may be defined by local experience, based on
screening initiatives or outbreak epidemiology. Published examples
have included injecting drugs, patients infected with human
immunodeficiency virus, and members of professional contact sport
teams (Category 1b).
19.4.5
Units caring for patients at high risk for suffering serious MRSA
infections among colonised patients include;
19.4.5.1
Intensive care,
19.4.5.2
Neonatal intensive care,
The Code at Annex 2(l)
Universal rapid screening for MRSA. See CMO letter 16.11.06, Department of Health
45
19.4.5.3
Burns,
19.4.5.4
Transplantation,
19.4.5.5
Cardiothoracic,
19.4.5.6
Orthopaedic,
19.4.5.7
Trauma,
19.4.5.8
Vascular surgery,
19.4.5.9
Renal,
19.4.5.10
Regional, National and International referral centres,
19.4.5.11
Other specialist units as determined by the infection control
team and as agreed with the senior clinical staff of the units
and relevant hospital management structure.
19.4.6
Patients on elective surgical units (e.g. orthopaedic, vascular),
usually with short inpatient stays, are at lower risk of MRSA
acquisition than patients on trauma and emergency units, or mixed
units. Due account of these differences should be taken when local
screening policies are being established. (Category 2).
19.4.7
All patients who are at high risk of carriage for MRSA should be
screened at the time of admission unless they are being admitted
directly to isolation facilities and it is not planned to attempt to clear
them of MRSA carriage (Category 2). Patients likely to have surgery
and found to be MRSA positive should be started on topical
suppression. The course is five days and ideally should be
completed on the day of sugery. Suppression followed by a delay
before surgery will result in recolonization of some patients.
19.4.8
Regular (e.g. weekly or monthly, according to local prevalence)
screening of all patients on high-risk units should be performed
routinely (Category 2). Topical suppression given to colonized
patients will reduce the likelihood of spread of MRSA to other
patients, especially if single room isolation is inadequate.
19.4.9
In addition, screening all patients (regardless of their risk-group
status) should be considered on admission to high-risk units
(Category 2). The decision about whether or not to perform routine
admission screening should be made explicitly by the infection
control team in consultation with the senior clinical staff of the units,
and should be agreed with the relevant hospital management
structure. Such ‘blanket’ screening may be used intermittently, and
may be worthwhile if the local prevalence of MRSA carriage in such
patients is higher than usual for the UK, if there are sufficient local
isolation/cohorting resources to manage carriers effectively, and if
local policies for clearance of carriage and/or use of surgical
prophylaxis with glycopeptides are in place.
46
19.4.10
19.5
The following sites should be sampled for patients (Category 1b)
19.4.10.1
Anterior nares,
19.4.10.2
Skin lesions and wounds and sites of catheters,
19.4.10.3
Catheter urine,
19.4.10.4
Groin/perineum,
19.4.10.5
Tracheotomy and other skin breaks in all patients,
19.4.10.6
Sputum from patients with a productive cough.
19.4.11
The umbilicus should be sampled in all neonates. One should also
consider sampling the throat.
19.4.12
The decision whether to perform screening of patients on admission
to the wards or regular screening of inpatients on the wards should
be decided by the local infection control team in consultation with the
senior clinical staff of the units, and as agreed with the relevant
hospital management structure (Category 2). In principle hospitals
with significant problems with MRSA transmissions or a high
prevalence of MRSA carriage or infection should consider performing
more widespread and regular screening than units with low
prevalence. However, this approach has resource implications and
should first be used in areas where the clinical impact of high MRSA
prevalence is highest (i.e. in the ‘high-risk’ clinical areas). The aim is
to identify all positive patients within the hospital to allow targeting of
isolation and cohorting facilities in order to minimise the risk of
onward transmission to other patients and to allow administration of
topical suppression
19.4.13
When possible, patients awaiting elective admission who satisfy local
requirements for screening should be screened before admission by
their general practitioners or in pre-admission clinics (Category 2).
Patients who are at high continuing risk of acquiring MRSA between
the time of preadmission screening and that of admission (e.g. they
reside in a residential care facility which is known to have a high
prevalence of MRSA) must be rescreened on admission, and should
be isolated or cohorted according to policies in place on the admitting
unit until both sets of screening results are known.
Actions to be taken if screening results are positive.
19.5.1
In general, detection of patients colonised or infected with MRSA on
a ward should be an indication for increased screening (Category 2).
19.5.2
Little evidence exists to guide the details of an appropriate response,
but this should be influenced by the risk group of the affected unit, by
the number of newly detected MRSA-positive patients, by the
adequacy of nurse numbers to staff the ward, and by the availability
47
of isolation and cohorting facilities. There is always a delay between
MRSA acquisition by a patient and its presence being detectable by
screening samples, so it is recommended that at least three screens
at weekly intervals should be performed before a patient can be
considered to be at low risk of having acquired MRSA if they have
been nursed in proximity to unknown and unisolated MRSA positive
patients or by the same staff (Category 2).
19.5.3
The screening for MRSA in each unit within a hospital should be
subject of regular audit, with the results reviewed by the hospital’s
infection control committee. The results should also be made
available to management.
19.5.4
Screening of staff is not recommended routinely but if new MRSA
carriers are found among the patients on a ward, staff should be
asked about skin lesions. Staff with such lesions should be referred
for screening and for consideration of dermatological treatment by
the relevant occupational health department (Category 1b).
19.5.5
Staff with persistent carriage at sites other than the nose should be
considered for referral for appropriate specialist management (e.g.
ear, nose and throat; dermatology) who should arrange follow-up
screening according to local protocols (Category 1b)
19.5.6
Staff screening is indicated if transmission continues on a unit
despite active control measures, if epidemiological aspects of an
outbreak are unusual, or if they suggest persistent MRSA carriage by
staff (Category 2).
19.5.7
Care is needed to distinguish between the transient carriage (i.e.
nasal carriage which is lost within a day or so of removal from
contact with MRSA-positive patients and carries little risk of onward
transmission) and prolonged carriage (especially associated with skin
lesions) (Category 1b). This is usually best achieved by screening
staff as they come on duty at the beginning of their shift and not as
they leave at the end of their shift.
19.5.8
Nurses, doctors, physiotherapists, other allied health professionals
and non-clinical support staff (e.g. porters) should be considered for
screening, and the implications for onward spread by staff working on
other wards should also be considered (Category 2).
19.5.9
The special difficulties and risks posed by agency and locum staff
should be considered (Category 1b).
19.5.10
Appropriate sampling sites for staff screening include anterior nares,
throat and any areas of abnormal or broken skin (Category 1b) As a
guide to the use of eradication measures, one should consider
screening the hairline and groin/perineum of staff members found to
be MRSA positive.
19.5.11
It is recommended that a minimum of three screens at weekly
intervals, while not receiving antimicrobial therapy, should be
performed before a previously positive staff member can be
48
considered to be clear of MRSA (Category 2), and due note should
be taken of the individual’s risk of transmission to patients when
agreeing their continuation or return to work. In principle, only staff
members with colonised or infected hand lesions should be off work
while receiving courses of clearance therapy.
19.5.12
No recommendation is made about performance of ‘discharge
screening’.
19.5.13
Performance of active screening for MRSA in each unit within a
hospital must be the subject of regular audit, with the results
reviewed and minuted by the hospital’s infection control committee
and made available to the appropriate hospital management
structure (Category 1b).
19.5.14
Units with highly prevalent endemic MRSA should consider focusing
screening, control measures and other resources on high-risk units at
first, with the intention of rolling them out to lower-risk areas after the
position has improved (Category 2). Screening should not be seen as
an end in itself, but rather it should be linked to specific, locally
determined packages of control measures.
19.5.15
Geographically adjacent healthcare facilities, and those exchanging
large numbers of patients because of clinical links, should liaise to
agree common and efficient control measures (Category 2). Such
links should capitalise on any developing networking relationships
among clinical and laboratory units, such as those encouraged
through the Pathology Modernisation initiative.
19.5.16
Results of screening cultures should be made available promptly to
the clinical and infection control teams of other healthcare facilities to
whom a patient is to be, or has recently been transferred (Category
1b) Refusal to accept transfer of a patient is not justifiable on the
basis of the risk posed to other patients by an individual’s carriage of
or infection with MRSA. All units should have procedures in place
adequate facilities for containment of MRSA.
19.5.17
Trusts should develop local protocols for informing patients, carers,
relatives and staff members of the MRSA status with due regard for
confidentiality (Category 2).
49
20
Action when patients infected or colonized with MRSA are detected133
20.1
All patients undergoing implant, cardiothoracic or neurosurgery should be screened
pre-operatively134
20.2
The course of action taken when a patient colonized or infected with MRSA is
detected depends on a variety of factors including;
20.2.1
whether the ward is non-acute,
20.2.2
whether the ward is acute,
20.2.3
whether the ward is intensive care or other high-risk unit,
20.2.4
the facilities available for patient isolation,
20.2.5
the experience of MRSA in the hospital:
20.2.6
20.2.5.1
first identification of MRSA in the hospital or unit,
20.2.5.2
frequent re-admissions and transfers but little spread,
20.2.5.3
evidence of spread,
20.2.5.4
MRSA endemic locally.
Ward design:
20.2.6.1
20.2.6.2
133
134
Nightingale’, i.e., open-plan with no bays’
wards with bays and/or cubicles.
20.2.7
Whether affected patients are likely to be heavy shedders of MRSA,
e.g., those with burns or infected eczema.
20.2.8
The virulence and potential transmissibility of the organism. Often
this will not be immediately apparent but may be known if the patient
was MRSA positive previously and the strain was typed.
20.3
It is not possible to be prescriptive for all circumstances as decisions need to be
based on the local situation. The hospital’s infection control policy should identify
which clinical areas and included in each clinical risk category (see below).
Depending on local clinical practice and ward case-mix, it may be more practical for
some hospitals to merge clinical risk categories.
20.4
Patients colonized or infected with MRSA should be informed and clearly identified
for infection control purposes. This can be done by tagging their medical records, in
a manner agreed locally to preserve patient confidentiality, so that they are
recognised immediately on admission to hospital. Hospitals may keep a list of
known affected patients with the admissions or A&E department or have them
Un-annotated wording from ‘The Revised Guideline’
Saving Lives: High Impact Intervention 3
50
identified on the hospital computer so they are admitted directly to an isolation
room. Patients may also be given cards indicating that they have been infected or
colonized with MRSA in the past. This has the benefit of informing staff if the
patient is admitted to a different hospital or healthcare centre for treatment.
20.5
Basic infection control measures;
20.5.1
‘Alert’ Organism Surveillance, as a minimal surveillance method,
20.5.2
Correctly performed hand washing and disinfection (see section 6),
20.5.3
Wearing of gloves and disposable aprons for contact with body
fluids, lesions and contaminated materials (see section 7),
20.5.4
Appropriate isolation of patients with, or suspected of having, a
communicable infection (see section 38),
20.5.5
Rational use of antibiotics and an antibiotic policy,
20.5.6
High standards of aseptic techniques,
20.5.7
High standards of ward cleaning,
20.5.8
Careful handling of used linen and its transport in sealed bags of the
appropriate colour,
20.5.9
Avoiding overcrowding of patients,
20.5.10
Reviewing the need for and minimizing intra- and inter-ward transfers
of patients,
20.5.11
Maintaining adequate and appropriately skilled nursing and other
staff levels,
20.5.12
Regular monitoring of compliance with infection control policies
through effective audits,
20.6
An endemic situation occurs when there is the continuing presence of MRSA, with
or without infection, in a given hospital or specific group of patients in the hospital
despite standard control procedures. The infection control team should continue to
assess its occurrence and whether most cases are new acquisitions within the
hospital or admissions and transfers of already affected patients. The general
principles above should be reviewed and reinforced, with emphasis on monitoring
compliance with infection control policies, particularly antibiotics used for
prophylaxis and empiric therapy, and reducing movement of patients between
wards.
20.7
Minimal–risk areas:
20.7.1
long-stay care of the elderly,
20.7.2
psychiatry,
51
20.7.3
20.8
20.9
psycho geriatric.
Action on identification of a case.
20.8.1
Basic control methods as detailed above, but isolation is not
necessary.
20.8.2
Cover lesions from which MRSA has been isolated with an
impermeable dressing.
20.8.3
A decision may be made on clinical grounds (e.g. patient unlikely to
be re-admitted to a higher risk area) not to treat colonization in
patients in low-risk clinical areas of the hospital, where the situation
is similar to that in community residential homes.
20.8.4
Exceptions to this approach may be necessary where there is regular
transfer from such units to higher dependency areas. Then, the
policy for that area should be adopted.
20.8.5
The transfer of patients to long-stay units should not be affected by
MRSA status.
Low-risk areas;
20.9.1
Most medical wards,
20.9.2
General wards,
20.9.3
Acute-care of the elderly,
20.9.4
Non – neonatal paediatric.
20.10 Admission screening should include patients who are;
20.10.1
Known to be previously infected or colonized with MRSA,
20.10.2
Frequent re-admissions,
20.10.3
Transferred from MRSA-affected hospitals or nursing homes,
20.10.4
Transferred from hospitals abroad.
20.10.5
These patients should, if possible, be admitted to an isolation room
or ward until deemed to be free of MRSA.
20.11 Action to be taken on identification of a single case;
20.11.1
Basic control measures should be in place,
20.11.2
Isolate the index case,
52
20.11.3
Carry out a full MRSA screen of the index patient,
20.11.4
Eradicate carriage.
20.11.5
Screening of other patients is not usually necessary, but consider it if
clinical infections are detected.
20.12 Moderate-risk areas;
20.12.1
General surgical,
20.12.2
Urological,
20.12.3
Neonatal,
20.12.4
Gynaecology/obstetric,
20.12.5
Dermatology.
Local factors may, however, dictate changes to this categorisation.
20.13 The action should be as detailed above, with the addition of the following measures:
20.13.1
Screen the nose, perineum, skin lesions and manipulated sites of all
patients in the ward if there are two or more cases with circumstantial
evidence of transmission.
20.13.2
Isolate carriers if possible.
20.13.3
Use an antiseptic detergent for washing affected patients.
20.13.4
Screen staff if there is evidence of further spread; exclude colonized
staff from work.
20.14 High-risk areas;
20.14.1
Intensive care,
20.14.2
SCBU’s,
20.14.3
Burns,
20.14.4
Transplantation,
20.14.5
Cardiothoracic,
20.14.6
Orthopaedic,
20.14.7
Trauma,
20.14.8
Vascular,
53
20.14.9
Regional, national or international referral centres.
20.15 The action should be as detailed above, with the addition of the following measures:
20.15.1
Admission screening: regional, national or international referral
centres should consider screening all patients on admission to the
unit. All high risk units should screen patients transferred from an
MRSA-affected ward.
20.15.2
Discharge screening: patients in affected high-risk areas who are
transferred to other institutions should be screened at the receiving
or discharging institution, by arrangement. This may also be useful
for surveillance purposes, as it monitors incidence in the discharging
unit.
20.15.3
Screen the nose, perineum, skin lesions and manipulated sites of all
other patients in the unit after a single case.
20.15.4
Screen all staff if additional cases of MRSA occur with circumstantial
evidence of spread.
20.16 Action in an acute hospital without endemic problems.
20.16.1
If this is a first encounter with MRSA or a new encounter after
previous successful control, every reasonable effort should be made
to detect colonized or infected patients on admission and to prevent
spread of the organism. Action following the identification of early
cases in any area of the hospital should be as described above.
20.17 Patient sampling.
20.17.1
Swabs should be moistened in saline or peptone water and rubbed
firmly over the area with 10-20 strokes, and sent immediately to the
laboratory or, if this is not possible, placed in transport medium.
20.18 Suggested sampling sites;
20.18.1
Admission screening, ward screening and screening of staff with
positive nasal swabs: nose, perineum/groin, lesions and manipulated
sites (e.g. catheter urine, indwelling intra-vascular catheters,
tracheotomies, sputum).
20.18.2
Further samples may be considered if clinically or epidemiologically
indicated, for instance the throat (especially in denture wearers or if
nasal screening swabs remain persistently positive), faeces, urine,
vaginal and axillary swabs. Consider hair and fingers and contact or
sweep – plates from patient’s bedding if assessing extent of
dispersal.
20.18.3
Initial staff screening: nose and lesions.
20.18.4
The umbilicus should be sampled in infants.
54
20.19 Patient isolation.
20.19.1
Standard source isolation procedures should be instituted for
affected patients in high to low risk clinical areas in a fresh encounter
or an endemic situation. The patient’s medical and psychological
welfare should not be compromised by unnecessarily restrictive
infection control practices.
20.20 Type of isolation.
20.20.1
An isolation ward with hand wash basins and preferably with toilet
facilities in the individual rooms is very desirable as this has been
shown to be effective in controlling spread.
20.20.2
An extraction fan system removing air to the outside environment is
advisable for nursing staphylococcal dispersers. The individual
rooms should have a good communication system and a television
set. Good visibility of patients from outside the room is important.
20.20.3
Side-rooms should be used when there is no isolation unit, but are
less likely to be effective.
20.20.4
Cohort nursing by gathering all MRSA patients in one ward or in a
defined area of a ward and using designated staff whose own
movements are restricted is preferable to side-rooms being occupied
by MRSA patients on many different wards. Movement of these
patients to other areas of the ward or to the rest of the hospital
should be minimised. (This is usually ineffective as staff other than
nurses are shared unless a designated isolation ward is used)
20.20.5
The implications of MRSA colonization, infection and treatment
should be explained to the patient and close relatives prior to transfer
to a side-room, isolation unit or designated area.
20.21 Isolation procedures.
20.21.1
Disposable aprons or gowns should be worn by all staff handling the
patient or having contact with their immediate environment. This also
applies to visitors who assist with the patient’s bodily care. Visitors
who only have social contact with the patient, such as shaking
hands, do not need to wear protective clothing, but do need to wash
hands after leaving the room.
20.21.2
Gloves do not obviate the need for hand-washing and should be
worn when there is handling of the patient or their immediate
environment, contact with their secretions, and handling of
contaminated dressings or linen.
20.21.3
Masks are rarely necessary other than perhaps for procedures that
may generate staphylococcal aerosols, such as sputum suction,
chest physiotherapy or procedures on patients with exfolative skin
conditions. (No recommendation).
55
20.21.4
The door should be kept closed to minimise spread to adjacent
areas. If this is likely to compromise patient care, for instance in the
elderly confused patient, a risk assessment should be made as to
whether the door may be kept open. Such patients often benefit from
being nursed together in a cohort with other MRSA patients. The
side-room door must be kept shut during procedures that may
generate staphylococcal aerosols, such as chest physiotherapy,
wound dressing or bed-making.
20.21.5
Visitors to the cubicle or ward and staff from other wards and
departments, e.g. physiotherapists, radiographers, other medical
teams, students, should only enter after permission and instructions
from the nurse in charge.
20.21.6
A card or information sheet may be useful, particularly for side-rooms
in larger wards.
20.22 Cleaning and disinfection.
20.22.1
Antiseptic detergents (e.g. triclosan, povidone – iodine,
chlorhexidine) or alcohol (70%) should be available for staff hand
disinfection before and after contact with the patient or their
immediate environment. (See section 6).
20.22.2
Instruments
or
equipment
(e.g.,
writing
materials,
sphygmomanometers, stethoscopes, lifting slings, physiotherapy
exercise machines) should be designated for MRSA patients. If not
possible, such items should be suitably disinfected before use on
another patient.
20.22.3
The side-room in which an MRSA patient has been cared for should
be cleaned after the patient’s discharge according to the local
disinfection policy, with special attention to horizontal surfaces and
dust-collecting areas.
Hot water and detergent are usually
satisfactory. Decisions whether a disinfectant is needed should be
made by the infection control team. Pillows and mattress covers
should be checked for damage. Therapy beds need special
cleaning.
20.22.4
Additional general measures which may reduce spread include
installing an alcoholic antiseptic dispenser at the ward entrance and
requesting all staff entering and leaving the ward to use an antiseptic
hand rub. (No recommendation)
20.22.5
There should be planned periodic thorough cleaning of the whole
ward, including bedding and curtains.
20.22.6
Handle clinical waste carefully and dispose according to hospital
policy.
20.22.7
Handle linen carefully and enclose in appropriate bag as decided by
the Infection Control Team. Bedding and adjacent curtains should be
sent to the laundry after the patient’s discharge.
56
20.23 Ward closure.
20.23.1
20.23.2
Such a step should only be taken after a risk assessment has been
carried out by the outbreak control group, with full consideration of all
the facts by relevant parties. An isolation ward would reduce the
necessity for closing the ward. Factors which should be considered
include:
20.23.1.1
MRSA strain e.g., is it known to be virulent and/or
transmissible,
20.23.1.2
Number of cases,
20.23.1.3
Clinical activity and availability of alternative facilities locally,
20.23.1.4
Staffing levels, skill mix, dependence on agency staff,
20.23.1.5
Whether risk of transmission outweighs benefit of admission.
A thorough clean of the ward should be carried out after it has been
closed and patients transferred elsewhere.
20.24 Monthly and quarterly reporting of MRSA bacteraemia is mandatory135.
20.24.1
The Data that is required to be reported monthly by microbiology
laboratories to the Health Protection Agency by the 15th of the
Following month are:
20.24.1.1
20.24.2
Total number of MRSA positive blood cultures. (The data will
not be validated at this stage.)
The data that is required to be reported quarterly by microbiology
laboratories to the Health Protection agency are:
20.24.2.1
Total number of MRSA positive blood culture episodes.
Repeat reports in the same individual within 14 days of the
first report are considered to be part of the original episode
and should not be reported. Duplicate reports that are more
than 14 days apart from the first report of that episode should
be reported, as these are considered to be a separate
episode.
20.24.2.2
Total number of Staphylococcus aureus positive blood culture
episodes. Repeat reports in the same individual within 14
days of the first report are considered to be part of the original
episode and should not be reported. Duplicate reports that are
more than 14 days apart from the first report of that episode
135
Mandatory Surveillance of Methicillin Resistant Staphylococcus Aureus (MRSA) Bacteraemias. 9 th June
2005. Department of Health
57
should be reported, as these are considered to be a separate
episode.
20.24.3
20.24.2.3
The total number of positive blood culture sets.
20.24.2.4
The total number of blood cultures (sets taken, not individual
bottles).
All data reported on a quarterly basis must be validated. This data
will be used to inform the monthly tracking progress towards the
Trust MRSA target.
58
21
Treatment of MRSA infected or colonised patients136
21.1
Treatment of colonization with combinations of systemic agents following failure with
topical agents must be considered carefully: some combinations may have severe
side-effects. A risk assessment should be made as to whether the benefits
outweigh the risks. It is important to discuss this with the affected person. In
addition, resistance may emerge rendering these agents ineffective in the treatment
of subsequent MRSA infection and other conditions.
21.2
When mupirocin is used, susceptibility testing to identify low-level and high-level
resistance is essential. Prolonged (more than seven days) or repeated courses
(more than two courses in a single hospital admission) of mupirocin must be
avoided because of the risk of the development of resistance. Furthermore,
prolonged or repeated courses may be unsuccessful.
21.3
The following procedures are suggested, but the final decision should be made by
the infection control team depending on local circumstances. Treatments should be
reviewed weekly.
21.4
Nasal carriers.
21.5
136
21.4.1
Apply a small amount of 2% mupirocin in a paraffin base with a
cotton swab thoroughly to the inner surface of each nostril threetimes daily for five days.
21.4.2
Sample the nose two days after completing the course of the
treatment.
21.4.3
If the nasal swab is still positive check for throat colonization and
repeat the course of treatment.
21.4.4
If the strain is mupirocin-resistant or not eradicated after two courses
of treatment, an alternative agent should be considered. For
example if the strain is neomycin sensitive, apply naseptin cream
(0.5% neomycin plus 0.1% chlorhexidine) to the nose four-times daily
for seven days. Other products have been used with varying
success, e.g., 1% chlorhexidine cream, bacitracin or povidone-iodine
ointment. Although these products are less effective than mupirocin,
they may reduce the numbers of organisms present.
21.4.5
Antibiotics which may be required for systemic use (for example
fusidic acid, gentamicin and vancomycin) should not be used
topically.
21.4.6
Use antiseptic detergents for washing the patient.
Skin carriers.
Un-annotated wording from ‘The Revised Guideline’
59
21.6
21.5.1
Patients carrying MRSA in any site should bathe daily for five days
with an antiseptic detergent such as 4% chlorhexidine, 2% triclosan
or 7.5% povidone - iodine. The skin should be moistened and the
anti-septic-detergent applied thoroughly to all areas before rinsing in
the bath or shower. Special attention should be paid to known
possible carriage sites including axilla, groin, perineum and buttock
area. The antiseptic detergent should also be used for all other
washing procedures and for bed bathing.
21.5.2
If the strain is not eradicated the course may be repeated and may
be continued if agreed by the Infection Control Team.
21.5.3
The hair should be washed twice weekly with one of the antiseptic
detergents. An antiseptic shampoo, such as povidone-iodine or
centrimide, may be less drying and preferred by the patient.
Ordinary shampoo can be used afterwards if desired.
21.5.4
After satisfactory completion of a course of treatment, clean clothing,
bedding, towels and a flannel should be provided.
21.5.5
If skin irritation is reported with any of the antiseptic detergents, the
infection control team should be informed immediately.
An
alternative agent may be suggested. Antiseptics should be used with
care in patients with eczema, dermatitis or the more delicate aging
skin. A dermatologist should be consulted for advice on such
patients. It may be advisable to use an antiseptic bath additive with
emollients (No recommendation).
21.5.6
Hexachlorophane powder (e.g. 0.33% SterZac powder) can be
applied to axillae and groins, particularly if these sites are also
colonized, but should not be applied to open lesions. Caution is also
required in the use of hexachlorophene in neonates.
21.5.7
All patients and staff in the ward, irrespective of whether they are
known to be colonized, may be advised to use antiseptic detergents
for bathing and washing in certain circumstances, for example during
an outbreak in a high-risk unit or surgical wards (No
recommendation).
Throat carriers.
21.6.1
These are difficult to treat and their role in infection is uncertain.
Systemic treatment is usually required. This should be considered
only in exceptional circumstances, for example evidence of
transmission from a throat carrier, or when it is contributing to a
continuing outbreak. This must be clearly explained to the patient or
member of staff.
21.6.2
If treatment is required, a course of rifampicin with fusidic acid or
ciproflaxcin should be given for a period of five days, according to the
susceptibility of the strain. Trimethoprim may also be effective with
other agents, e.g. rifampicin (if shown to be active against the MRSA
in the laboratory)
60
21.7
21.8
21.6.3
Courses should usually not be repeated since side effects are
common and increase with the length of the treatment. The risk of
emergence of resistance is also increased.
21.6.4
The value of local treatment such as antiseptic gargles or sprays is
uncertain, but it may reduce staphylococcal load (no
recommendation).
Infected or colonized skin lesions.
21.7.1
Mupirocin (0.5%) in polyethylene glycol may be applied to small
lesions but not to large raw areas such as burns, or to indwelling
plastic devices.
21.7.2
Treatment should not extend beyond seven to 10 days and a repeat
course should preferably be avoided since resistance may emerge.
21.7.3
Dressings containing chlorhexidine or povidone-iodine may be
applied to infected or colonized wounds. These are unlikely to
reduce numbers of organisms and thus dissemination (No
recommendation).
21.7.4
Systemic treatment with rifampicin and fusidic acid or ciprofloxacin
should be considered only in exceptional circumstances in an
attempt to eliminate carriage or if there is significant local skin
infection (No recommendation).
Staff carriers.
21.8.1
Staff should be examined for infected lesions and, if present, should
be removed from duty if working in a high or moderate risk area. If
continuing to work in a low or minimal risk area the lesion should be
covered with an impermeable dressing. Occupational Health have
primary responsibility for the treatment of staff. Refer for assessment
by an ear nose and throat specialist if a throat carrier, or by a
dermatologist if there is a skin condition.
21.8.2
Nasal carriers should be treated with mupirocin and antiseptic
detergents as recommended for patients. In most ward areas staff
who are only nasal carriers can continue working whilst on mupirocin
treatment if the strain is susceptible or has low-level resistance. In
high-risk wards they should be excluded from work for 48 hours from
the start of the mupirocin treatment.
21.8.3
Failure to eradicate MRSA after two courses of treatment should be
reviewed by the ICT. Possibilities for further management include
changing agents, continuing skin treatment indefinitely, a course of
systemic antibiotics or transfer to another area of work.
21.8.4
Lesions should be treated with topical mupirocin or alternative agents
as recommended for patients.
61
21.8.5
21.9
Local managers should confirm that exclusion of staff for infection
control purposes is not deemed sick leave (No recommendation).
Follow up of treated carriers.
21.9.1
At least three negative swabs from previously positive sites should
be examined, preferably at weekly intervals, before accepting that
MRSA has been cleared.
21.9.2
Re-emergence of resistant strains is common and can occur over
period of up to a year or more, particularly where antibiotics have
been prescribed. Therefore, previously positive patients should be
considered to be MRSA carriers and re-sampled on subsequent readmissions, irrespective of previous evidence of clearance. Patients
notes should be appropriately labelled to enable rapid recognition on
subsequent admissions.
21.10 Systematic treatment of carriers.
21.10.1
Vancomycin or teicoplanin, possibly combined with rifampicin, are
the agents of choice for severe infections. For continuing treatment
or for less severe infections other agents may be considered if the
organisms are susceptible, for example combinations of rifampicin
and fusidic acid.
Other possible agents are ciprofloxacin,
trimethoprim, clarithromycin and erythromycin.
21.10.2
Transfer and discharge of colonized or infected patients
21.11 Within the hospital.
21.11.1
Transfer of MRSA affected patients to other wards should be
minimised to reduce the risk of spread, but this should not
compromise other aspects of care, such as rehabilitation. Before
transfer of a patient cleared of infection or colonisation from the
isolation ward to another ward, they should:
21.11.1.1
Bathe and wash their hair with an antiseptic detergent
21.11.1.2
Have clean clothing
21.11.1.3
Be transferred to a bed with clean linen. The patient’s original
bed linen should be left behind on the ward.
21.11.2
Transport of the patient should be carefully supervised:
21.11.3
Lesions should be occluded whenever possible with an impermeable
dressing.
21.11.4
Attendants who may be in contact with the patient should wear
disposable plastic aprons on leaving the isolation ward or side-room
with the patient. This is unnecessary if contact is unlikely. Aprons
should be removed when contact with the patient has finished and
disposed of as clinical waste.
62
21.11.5
Gloves should only be worn if staff transporting the patient have skin
abrasions, or if specifically instructed to do so by the nurse in charge
or by the infection control team.
21.11.6
The trolley or chair should be cleaned with 70% alcohol or another
appropriate disinfectant (e.g. a chlorine-releasing agent containing
1000ppm available chlorine) after use by the patient and before
being used for another patient. All linen should be dealt with
according to hospital policy.
21.11.7
Staff should wash hands thoroughly with antiseptic (e.g.
chlorhexidine detergent) and dry them thoroughly after dealing with
the patient and cleaning the trolley or chair.
21.12 Visits to out-patients and specialist departments.
21.12.1
Visits by MRSA patients to other departments should be kept to a
minimum. If this is necessary, either for investigation or treatment,
prior arrangements should be made with senior staff of the receiving
department, so that control of infection measures for that department
can be implemented. These should include;
21.12.1.1
Dealing with these patients at the end of the working session if
at all possible,
21.12.1.2
The patient should spend the minimum time in the
department, being sent for when the department is ready and
not left in a waiting area with other patients,
21.12.1.3
Staff coming into close contact with the patient should wear
disposable gloves and aprons. The importance of hand
washing should be emphasised. Staff should avoid direct
contact with other patients whilst dealing with an MRSA
patient,
21.12.1.4
Equipment and the number of staff attending should be kept to
a minimum,
21.12.1.5
Surfaces with which the patient has had direct contact should
be wiped clean with 70% alcohol, a chlorine-releasing agent
containing 1000ppm available chlorine or a phenolic
disinfectant (1-2%),
21.12.1.6
Linen should be treated according to the hospital policy,
21.12.1.7
Staff should was hands thoroughly with antiseptic (e.g.
chlorhexidine detergent) and dry them thoroughly after dealing
with the patient,
21.12.1.8
Transport measures should be indicated in Section 33 below.
21.13 Surgical operations.
63
21.13.1
Every effort should be made to eliminate MRSA before surgery. If
not possible, the following should be performed;
21.13.1.1
Bathe the patient in an antiseptic detergent,
21.13.1.2
Cover the affected lesion with an impermeable dressing,
21.13.1.3
Clean the area adjacent to the lesion with 70% alcohol,
21.13.1.4
Apply mupirocin to the nose before the operation if the patient
is a nasal carrier,
21.13.1.5
Vancomycin or teicoplanin should be given prophylactically to
cover surgical procedures in colonized or infected patients,
following discussion with a consultant medical microbiologist
or infectious disease physician. In addition, prophylaxis with
vancomycin or teicoplanin should be considered for patients
undergoing surgery, particularly if high risk such as implant
surgery, who may have been exposed to risk of acquisition of
the strain during an outbreak on their ward,
21.13.1.6
Patients should be allowed to recover after surgery in the
operating theatre or an area not occupied by other patients to
avoid possible contamination of the usual recovery area,
21.13.1.7
Theatre surfaces in close contact or near the patient, such as
the operating table or instrument trolley, should be disinfected
before being used for the next patient.
21.14 Burns units.
21.14.1
Patients with large burns are often heavily colonized with antibioticresistant organisms, including MRSA. When colonized with MRSA,
widespread dispersal may occur and prevention of spread is difficult.
Although MRSA can cause severe infections in colonized patients,
many units have endemic colonizing strains and have given up
attempts at eradication. Patients with MRSA-colonized burns from
abroad or in a general hospital may require admission to a
specialized burns unit and risks must be balanced between the
hazard to other patients and the patient’s need for specialist
treatment. Isolation of these patients is desirable.
21.14.2
In order to prevent the spread of infection, every effort should be
made to ensure that the burns unit is self contained (i.e. has its own
facilities such as operating theatre, intensive care and isolation
beds), that its staff do not work on other wards and that the basic
principles of infection control are adhered to.
21.15 Ambulance transportation.
64
21.15.1
The ambulance service should be notified in advance by the
responsible clinician or by their delegated ward staff, if considered
necessary by the infection control team.
21.15.2
There is no evidence that ambulance staff or their families are put at
risk by transporting patients with MRSA.
21.15.3
To minimise MRSA transfer to other patients who may be at risk of
MRSA infection, ambulance staff should use an alcohol hand rub
after contact with a patient with MRSA in addition to good basic
infection control practice.
21.15.4
Most carriers may be transported with others in the same ambulance
without any special precautions, other than changing the bedding
used by a carrier. However, if transport of a potentially heavy
disperser is necessary (e.g. patient with a discharging lesion which
cannot be enclosed by an impermeable dressing, or widespread
colonized skin lesions), advice should be obtained from a member of
the infection control team. It may then be necessary to transport this
patient alone and for ambulance staff handling the patient to use an
alchoholic handrub and wipe down surfaces in contact with the
patient with 70% alcohol afterwards. High-risk patients should not be
transported in the same ambulance as a known MRSA patient.
21.15.5
If further measures are required in special circumstances, the
infection control team should inform the ambulance service.
21.15.6
No extra cleaning of the ambulance is usually required after
transporting an MRSA positive patient.
21.16 Transfer to another hospital.
21.16.1
MRSA infection or colonization should not be a barrier to good
clinical care. Consequently, inter-hospital transfers for good clinical
reasons should not be prevented. However, unnecessary movement
should be avoided.
21.16.2
Identification of infected or colonized patients is the responsibility of
the transferring hospital. Before transfer, the clinician responsible for
the patient or a member of the infection control team at the
transferring hospital should inform the infection control team at the
receiving hospital.
21.17 Discharge of patients.
21.17.1
MRSA patients should be discharged promptly from hospital when
their clinical condition allows.
21.17.2
The General Practitioner and other healthcare agencies involved in
the patient’s care should be informed.
21.17.3
MRSA carriers will not normally require special treatment after
discharge from hospital. If a treatment course still needs to be
65
completed in particular circumstances the infection control team
should advise about this.
21.17.4
If the patient is discharged to a nursing or convalescent home, the
medical and nursing staff should be informed in advance. Carriage
of MRSA is not a contraindication to the transfer of a patient to a
nursing or convalescent home.
21.17.5
Patients should be informed that there is no risk to healthy relatives
or others outside the hospital, unless they are hospital workers with
patient contact, when they may pose a risk to other patients. In this
case the infection control doctor of the hospital discharging the
patient should be informed.
21.17.6
There is no indication for routine screening before hospital discharge
to the community.
21.18 Deceased patients.
21.18.1
The infection control precautions for handling deceased patients are
the same as those used in life. Any lesions should be covered with
impermeable dressings. Plastic body bags are not necessary. There
is negligible risk to relatives, mortuary staff or undertakers, as long as
basic infection control precautions are followed.
66
22
Temporary, locum or agency staff
22.1
Temporary staff including doctors and nurses are often required in hospitals at
relatively short notice. The clinical needs of patients should take precedence over
potential difficulties with MRSA control measures, in particular the risk that
temporary staff who move frequently from hospital to hospital may be MRSA
carriers137.
22.2
Temporary staff who have not cared for patients with MRSA should be employed
whenever possible, or, if time allows, pre-employment screening should be
considered if they have looked after positive patients.
22.3
Temporary staff should be deployed to care for non-MRSA patients and permanent
staff should be designated to care for MRSA positive patients wherever possible.
22.4
If the use of temporary staff on MRSA affected wards cannot be avoided,
preference should be given to staff who can work for several days rather than one
session.
22.5
Following a period of employment, temporary staff may request to be screened for
MRSA carriage, but routine screening post-employment is at the discretion of the
temporary member of staff, the occupational health department and the infection
control team.
22.6
Agency staff are obliged to be familiar with and comply with relevant legislation
affecting their work, including the Control of Substance Hazardous to Health
Regulations.138
22.7
Employers should be satisfied that all staff working for the NHS who do blood
exposure-prone procedures, have had the necessary tests and immunisations to
enable them to undertake their duties with the minimum risk to themselves and
others. These include locum and agency staff.139
Un-annotated wording from ‘The Revised Guidelines’.
Note also that the Code at paragraph 11 imposes on NHS Bodies a duty to ensure, so far as is reasonably
practicable, that healthcare workers are free of and protected from exposure to communicable infections
during the course of their work, and that staff are suitably educated in the prevention and control of HCAI
138 Care Standards Act 2000. Training and Occupational Health provisions apply to all staff including
temporary and locums.
139 The management of health, safety and welfare issues for NHS Staff, 2005. Chapter 18 – Blood-borne
infections. See also 24 Blood-Borne viruses below.
137
67
23
Sample processing140
23.1
The main factors affecting specimen processing are laboratory resources and
whether a highly sensitive test or rapid results are required.
23.2
Sensitivity of detection.
23.3
23.4
23.2.1
Where sensitivity is required, for instance during screening of all
patients on a ward, enrich the sample in Oxoid Nutrient Broth No. 2
plus extra sodium chloride or in salt Robertson’s cooked meat. As
some strains may be more sensitive to salt, an alternative strategy
may be to use a lower salt concentration and add an antibiotic such
as aztreonam or nalidixic acid to inhibit Gram – negative organisms.
23.2.2
If several sites are being screened per patient, the full set of swabs
may be placed in one bottle of enrichment broth. If this yields MRSA,
repeat specimens from individual sites should be placed in individual
broths.
23.2.3
Methicillin should not be added to the enrichment media as it is
unstable and may be inhibitory to small numbers of organisms.
Sensitivity is improved by incubating broths at 30ºC.
23.2.4
Enrichment broths may then be subcultured onto nutrient or blood
agar plates containing 4mg/L methicillin and incubated overnight at
30ºC. This should provide evidence of methicillin resistance the
following day. Molecular screening is more sensitive than culture
Speed of detection.
23.3.1
Where speed is of the essence, for instance to determine the MRSA
status of a patient awaiting surgery, it may be necessary to inoculate
the swab on blood or nutrient agar in addition to enrichment cultures.
23.3.2
Plates containing 4mg/L methicillin may be used, provided it is
recognized that small numbers of MRSA may fail to grow.
23.3.3
Different strains of MRSA vary in their susceptibility to other
antibiotics; an ‘extended’ antibiogram may assist in the more
immediate identification of particular strains.
Typing of isolates.
23.4.1
140
Typing can be performed by the PHLS’s Staphylococcal Reference
Section in the Laboratory of Hospital Infection at Colindale, London,
which can also assist with the identification of epidemic strains and
provide information on the potential for invasiveness. The selection
of patient isolates for typing is easier where there is a single cluster
of MRSA colonized or infected patients on a particular ward or
isolates with differing characteristics. Where there are several wards
Un-annotated wording from ‘The Revised Guidelines’
68
or units involved, or in continuing or complex MRSA outbreaks, a
proportion of the isolates should be sent which test the hypotheses in
time and place. Other temporally-related isolates should be stored
for later typing if necessary. The Staphylococcal Reference Unit can
advise on representative typing of isolates in continuing outbreaks, to
follow the evolution of the outbreak strain as well as identify and reintroductions, transfers or new strains.
69
24
Microbiological support141
24.1
NHS Bodies must ensure that if services are provided by a microbiology laboratory
in connection with the arrangement it makes for infection prevention and control, the
laboratory has in place appropriate protocols and that it operates according to the
standards from time to time required for accreditation by Clinical Pathology
Accreditation (UK) Ltd142.
24.2
NHS Body protocols should include a microbiology laboratory policy for investigation
of HCAI and surveillance and standard operating procedures for the examination of
specimens143.
24.3
Timely and effective specialist microbiological support should be provided for the
infection control service.
24.4
If a Trust does not have Clinical Pathology Accreditation the following will need to
be provided;
24.4.1
Arrangements for access to, and provision for, specialist
microbiology support, including the interpretation of results.
24.4.2
Written procedures relating to the collection, handling and disposal of
specimens.
24.4.3
Written procedure for the reporting of results on each test.
24.4.4
The Infection Control Team should have appropriate access to
laboratory results via an effective computer system.
24.4.5
Advice on infection control is available on a 24 hour basis. (Out of
hours cover is most sensibly provided by the consultant
microbiologist on call for the Trust rather than by a dedicated
infection control nurse on call).
24.5
Funding for outbreaks of infection should be agreed in advance.
Some
organisations have found it beneficial to identify within the infection control policy
exactly how funding for outbreaks will be financed e.g. within directorates, as this
can promote effective infection control practices.
24.6
If a Service Level Agreement (SLA) exists for infection control services, written
evidence will be required as to how an outbreak will be funded and by which
organisation. This should be part of the SLA.
24.7
Appropriate arrangements should be in place for meeting all laboratory costs arising
from infection outbreaks.
141
Items 23.2 to 23.6 are un-annotated wording from CNST Guidelines 7.1.5
The Code at paragraph 9: Duty to ensure adequate laboratory support.
143 The Code at Annex 1
142
70
25
Competencies for Directors of Infection Prevention and Control144
General
The Director of Infection Prevention and Control (DIPC) will have overall responsibility for creating
a culture of effective hygiene practice i.e. to ensure that infection control is everyone’s business.
It may be an extension of the role of an individual already in post. Relevant expertise may be
brought in sessionally from an Acute Trust. He need not be on the Board.
Acute NHS Trusts
A DIPC should have a professional qualification, e.g. doctor, nurse or scientist.
A DIPC should have expertise and experience in infection control, management of the infected
patient, decontamination protocols and antibiotic usage.
Competencies:
DIPCs should demonstrate these to the Trust CEO/Board or show ability to access the expertise to
satisfy the criteria set out in Winning Ways Action Area 6.

General
o
o
o
o
o
o
o
o
o
o

Strategic thinking and decision making
Leadership
Planning and delivery
Resource management
Change management
Drive for results
Team-working and communication
Managing relationships
Corporate commitment
Holding to account
Infection Control
Practical experience in dealing with or managing all matters of Infection Control, to at least the
standard of the Diploma in Hospital Infection Control or an equivalent. This will include
development of Standard Operational Policies (SOPs) for control of infection, epidemiological
expertise pertaining to outbreak control and knowledge of infection control in the built environment
and facilities management. This will require involvement in contracts and their management.

Management of the Infected Patient
Experience in clinical management of the microbial component of infectious diseases, usually as a
member of a Clinical Team.

Decontamination
144
Un-annotated wording from Competencies for Directors of Infection Prevention and Control.]
See also paragraph 2.11 above for the requirements of The Code
71
Knowledge of current guidelines for decontamination (cleaning, disinfection and sterilization) of reusable surgical equipment. This includes the relevant Health Technical Memoranda, Device
Bulletins and International Standards Organisation standards.

Antibiotic usage
Expertise in the clinical use of antibiotics, both for treatment and prophylactic purposes.
A DIPC should interact with:










the control of infection team and committee
decontamination lead
use of medicines committee
health and safety
clinical governance
risk management and controls assurance structures
clinical boards
occupational health service.
link to New Procedures Committee if established
domestic services
Non-Acute NHS Trusts (including Primary Care Trusts , Mental Health
and Ambulance Trusts)
A DIPC may be the individual nominated at Board level to have executive responsibility for
infection control. That individual may be a senior clinician, for example Director of Public Health or
Lead Nurse, or an Infection Control Doctor or Nurse with an agreed Service Level Agreement with
the Trust.
Competencies

The general competencies noted above will be applicable. It is appreciated however that some
specific requirements will need to be imported as required to fulfil the overall needs, and
ensure that the competencies are fully met.
Suitable sources for such expertise will include experts in an adjacent acute trust.
Ambulance Trusts should have already identified a senior professional with lead responsibility for
Infection Control. This may be combined with the Health and Safety remit or Clinical Governance.
All Primary Care Trusts and Mental Health NHS Trusts will need specialist microbiological and
medical/nursing infection control input. Provision for this must be included in the Service Level
Agreements with an Acute NHS Trust.
In Non-acute NHS Trusts, the prudent use of antibiotics should be the responsibility of the Director
of Infection Prevention and Control through the Prescribing Committee and Pharmacy Advisors.
The chair and line managers may be different but the Board level response should be through the
Director of Infection Prevention and Control.
The Director of Infection Prevention and Control should link the activities of the Immunisations Coordinator and Occupational Health provider with infection control and report on them at Board level.
72
Independent health care facilities providing NHS services
These organisations will also need to designate a Director of Infection Prevention and Control and
should use the above guidelines to identify an appropriate individual.
73
26
Variant Creutzfeldt – Jakob Disease (vCJD)145
26.1
An NHS body must have a core policy on the control of Transmissible Spongiform
Encephalopathies. That policy should make provision for the management of known
or high risk patients146.
26.2
When handling medical devices in procedures carried out on known/suspected CJD
patients and on patients in risk categories for CJD (including disposal/quarantining
procedures) the risks should be assessed in all cases where there may be exposure
to biological agents; when appropriate, measures should be introduced either to
prevent, or adequately control exposure147.
26.3
All cases where CJD of any type is a possible diagnosis should be reported to the
National CJD Surveillance Unit (CJDSU) so that any necessary action can be taken.
26.4
Effective and thorough cleaning of surgical instruments to remove as much organic
debris as possible before sterilisation makes the major contribution to risk reduction.
It is therefore essential that all existing cleaning and sterilisation procedures operate
to the highest standards in line with extant guidance. Instruments designated for a
single episode of use should be discarded after use and never reprocessed.
26.5
The guidance produced jointly in April 1998 by the Advisory Committee on
Dangerous Pathogens (ACDP) and the Spongiform Encephalopathy Advisory
Committee (SEAC) on safe working and the preventions of infection must be
followed to ensure optimum clinical care and management of patients with CJD of
any type.
26.6
Single-use kits should always be used for all lumbar-punctures.
26.7
Where practical options for using single-use instruments are available which do not
compromise clinical outcome, consideration should be given to using these for
surgical procedures.
26.8
Instruments and equipment used in the care of patients with confirmed CJD of any
type should not be re-used and should be disposed of by incineration.
26.9
Instruments used on patients suspected of having CJD of any type should be
quarantined pending confirmation of a diagnosis (and should then be destroyed by
incineration unless a definitive alternative diagnosis is confirmed)148.
26.10 Certain categories of patient should be regarded as presenting a potential risk
(defined in the ACDP/SEAC guidance as recipients of hormones derived from
human pituitary glands, recipients of human dura mater grafts, and people with a
family history of CJD).
145
Wording taken for items 25.2 to 25.11 from HSC 1999/178: Variant Creutzfeldt-Jakob disease (vCJD):
minimising
the risk of transmission.
146 The Code at Annex 1 and Appendix 2
147 The Code at Appendix 2
148 See Annex A of HSC 1999/178 for more detailed information
74
26.11 Instruments and equipment used in procedures involving brain, spinal cord or eyes
carried out on a patient in a risk category as defined in the ACDP/SEAC guidance
should be destroyed by incineration.
26.12 Fulfil the requirements of the COSHH Regulations when any worker is exposed to
the infective agent associated with CJD of any type.149
26.13 All endoscopes should have a unique identification number to ensure that whole
pool of endoscopes does not need to be quarantined and destroyed if one
endoscope has been used of a patient with CJD.
149
See Annex B of HSC 1999/178 for more detailed information
75
27
Blood-Borne Viruses (BBVs)
27.1
NHS Trusts should have in place a core policy on the prevention and management
of occupational exposure to blood-borne viruses and post-exposure prophylaxis.
The policy should include provision for immunisation against Hepatitis B, the
wearing of gloves and other protective clothing, the safe handling and disposal of
sharps, including the provision of medical devices incorporating sharps protection
and measures to reduce risks during surgical procedures. Management should
include designation of 1 or more doctors to whom staff can be referred, provision of
clear information to healthcare staff about reporting potential occupational exposure,
arrangements for post-exposure prophylaxis against hepatitis B and HIV and follow
up and follow up of hepatitis C exposures150.
27.2
Health Authorities, Health Boards and NHS Trusts should draw up their own
detailed local guidelines on prevention of spread of BBVs in the health care
setting.151
27.3
Blood-borne viruses (HIV, hepatitis B and C) can be transmitted in the healthcare
setting from patient to healthcare worker, patient to patient, or healthcare worker to
patient. In general, the risks of transmission arise from exposure to blood and in
certain exceptions other bloody fluids or body tissues from an infected person.152
27.4
The following list details the body fluids that should be handled with the same
precautions as blood;
27.4.1
Cerebrospinal fluid,
27.4.2
Peritoneal fluid,
27.4.3
Pleural fluid,
27.4.4
Pericardial fluid,
27.4.5
Synovial fluid,
27.4.6
Amniotic fluid,
27.4.7
Semen,
27.4.8
Vaginal secretions,
27.4.9
Breast milk,
27.4.10
Any other body fluid containing visible blood, including saliva in
association with dentistry,
27.4.11
Unfixed organs or tissues.
150
The Code at paragraph 10 and Annex2.
Guidance for clinical health care workers: protection against infection with blood-borne viruses. London:
DH 1998
152 Points 27.12– 4 and 27.45 to 50 The management of health, safety and welfare issues for NHS staff.
2005 edition. Chapter 18, blood-borne viruses.
151
76
27.5
27.6
Assessment of risk153
27.5.1
Under the COSHH regulations, employers are required to carry out a
risk assessment of the work to be done and current procedures in
order to be able to prevent or control exposure to substances
hazardous to health.
27.5.2
Each team or group of Health Care Workers (HCWs) working
together on a task should discuss the hazards involved in their
current methods of working and ways of reducing these hazards.
This process should include a consideration of the risks to others
involved by such activities as the disposal of sharps, bodies, tissues,
body fluids, and contaminated disposable items and the maintenance
of equipment.
27.5.3
The team should be encouraged to devise safe, and reasonably
practicable procedures and routines for performing each task; ensure
they are followed after appropriate training and keep them under
active review.
27.5.4
The appropriate level of precautions to be taken for any procedure
should be determined according to the extent of possible exposure to
blood and not because of knowledge or speculation about the
infectious status of the patient. All blood, tissues and the body fluids
at 27.4 above should be regarded as potentially infectious. This
approach is sometimes referred to as "Universal Precautions".
General measures to reduce the risk of occupational exposure154
27.6.1
The following measures will help to minimise the risk of exposure to
BBVs and are appropriate for all healthcare settings;155
27.6.1.1
wash hands before and after contact with each patient, and
before putting on and after removing gloves,
27.6.1.2
change gloves between patients,
27.6.1.3
cover existing wounds, skin lesions and all breaks in exposed
skin with waterproof dressings. Wear gloves if hands are
extensively affected,
27.6.1.4
wear gloves where contact with blood can be anticipated,
27.6.1.5
avoid sharps usage where possible, and where sharps usage
is essential, exercise particular care in handling and disposal,
153
Taken from Guidance for clinical health care workers: protection against infection with blood-borne
viruses
154 Points 27.6 to 27.13.1un-annotated wording from Guidance for clinical health care workers: protection
against infection with blood-borne viruses.
155 See also sections 6 and 7 above on hand hygiene and personal protective equipment
77
27.7
27.6.1.6
avoid wearing open footwear in situations where blood may be
spilt, or where sharp instruments or needles are handled,
27.6.1.7
27.6.1.8
clear up spillage of blood promptly and disinfect surfaces,
wear gloves when cleaning equipment prior to sterilisation or
disinfection, when handling chemical disinfectant and when
cleaning up spillages,
27.6.1.9
follow safe procedures for disposal of contaminated waste.156
27.6.1.10
HCWs, with chronic skin disease such as eczema, should
avoid those invasive procedures which involve sharp
instruments or needles when their skin lesions are active, or if
there are extensive breaks in the skin surface.
27.6.1.11
A non-intact skin surface provides a potential route for bloodborne virus transmission, and blood-skin contact is common
through glove puncture that may go unnoticed.157
27.6.2
HCWs should be encouraged to follow good practice methods.
HCWs and their employers should keep themselves informed of safe
methods of working.
27.6.3
Any cost effectiveness assessment of newer working practices
should include a consideration of the costs of occupational health
follow-up of HCWs after needlestick injuries, the possible morbidity of
HCWs in these circumstances and associated costs, and any legal
claims against Health Authorities, Health Boards, NHS Trusts or
independent practitioners for compensation for occupationally
acquired BBV infections.
Safe handling and disposal of sharps
The guidance at section 8 above should be followed to minimise the risk of infection.
27.8
Gloves and venepuncture158
27.8.1
Gloves cannot prevent percutaneous injury but may reduce the risk
of acquiring a BBV infection. Although punctured gloves allow blood
to contaminate the hand, the wiping effect can reduce the volume of
blood to which the worker's hand is exposed and in turn the volume
inoculated in the event of percutaneous injury.
27.8.2
Some HCWs with long experience of performing venepuncture
without gloves may prefer not to wear them to avoid a perceived
reduction of manual dexterity and possible consequent increased risk
of percutaneous injury.
27.8.3
The following is advised;
156
See 33: Disposal of Clinical Waste below.
Points 26.6.1.10 and 26.6.1.11 from HIV Infected Health Care Workers: Guidance on Management and
Patient Notification.
158 See also section 7 above: Personal Protective Equipment above
157
78
27.9
27.8.3.1
gloves should be available to all HCWs who wish to wear
them for venepuncture,
27.8.3.2
inexperienced venepuncturists including medical students,
should become accustomed to the wearing of gloves from the
beginning of their training, and should not take blood from
patients known to be infected with BBVs until trained and
considered competent,
27.8.3.3
all venepuncturists, including those who are experienced,
should wear gloves if there are cuts or abrasions on the hands
and it is not practical for them to be covered by waterproof
dressings alone, or if the patient is so restless that the risk of
injury to the HCW is increased.
27.8.4 Single
use
medical
gloves
(ie
surgical
gloves
and
examination/procedure gloves) should conform to the
requirements of the relevant European Standard. If latex
gloves cannot be worn because of the possibility of an allergic
reaction, gloves produced from synthetic materials to the
above standard should be used.
Measures to reduce the risks during surgical procedures
In order to minimise the risk of injury, the tasks of each member of the surgical team
should be outlined. Specific hazards, and measures to reduce the risks from these
should be identified for each team member and should be reviewed periodically.
27.10 Reducing the risk of percutaneous exposure: methods, procedures and equipment
The following measures may reduce the risk of percutaneous exposure and should
be considered where practicable;
27.10.1
have no more than one person working in an open wound/body
cavity at any time (unless essential to the safe and successful
outcome of an operation),
27.10.2
use a "hands-free" technique where the same sharp instrument is not
touched by more than one person at the same time, avoid hand to
hand passing of sharp instruments during an operation,
27.10.3
assure safer passage of necessary sharp needles and instruments
via a "neutral zone", announce when a sharp instrument or needle is
placed there. The "neutral zone" may be a tray, kidney basin or an
identified area in the operative field,
27.10.4
ensure that scalpels and sharp needles are not left exposed in the
operative field, but always removed promptly by the scrub nurse
having been deposited in the neutral zone by the operator or
assistant,
27.10.5
use instruments rather than fingers for retraction, and for holding
tissues while suturing,
79
27.10.6
use instruments to handle needles and to remove scalpel blades,
27.10.7
direct sharp needles and instruments away from own non-dominant,
or assistant's hand,
27.10.8
remove sharp suture needles before tying suture; tie suture with
instruments rather than fingers.
27.11 Alternative equipment and procedures should be considered where practicable;
27.11.1
eliminate any unnecessary use of sharp instruments and needles,
e.g. by appropriate substitution of electrocautery, blunt-tipped
needles (see 3.16) and stapling devices,
27.11.2
opt for alternative less invasive surgical procedures where
practicable and effective,
27.11.3
avoid scalpel injuries associated with assembly/disassembly, by
using scalpels which are either disposable, have retractable blades
or which incorporate a blade release device,
27.11.4
avoid the use of sharp clips for surgical drapes; blunt clips are
available as are disposable drapes incorporating self-adhesive
operating film,
27.11.5
consider double gloving with a larger pair of gloves innermost for
optimum comfort.
27.12 Reducing the risk of blood-skin contact
The following measures may reduce the risk of blood-skin contact and should be
considered;
27.12.1
if a glove puncture is suspected or recognised, rescrub if possible
and reglove as soon as safety permits,
27.12.2
change gloves regularly if performing, or assisting with a prolonged
surgical procedure even if no glove puncture is suspected or
recognised,
27.12.3
the need for protection of body, eyes and face,
27.12.4
choose waterproof gowns, or wear a surgical gown with waterproof
cuffs and sleeves and a plastic apron underneath if blood contact
and therefore "strikethrough" is considered a risk - such as
procedures anticipated to involve high blood loss,
27.12.5
if legs or feet may be contaminated (as in obstetric and some other
procedures performed in the lithotomy position), ensure that
impermeable gown/apron covers legs and wear impermeable
footwear. Wellington or calf length overboots are preferable to shoes
or clogs. Surgical drapes with "catch-basins" are available to reduce
the risk of leg and foot contamination,
80
27.12.6
wear protective headwear and surgical mask. Male HCWs should
consider wearing hoods rather than caps to protect freshly shaven
cheeks and necks, Also to cover beards
27.12.7
ensure that all blood is cleansed from a patient's skin at the end of an
operation before patient leaves theatre,
27.12.8
remove protective clothing including footwear on leaving the
contaminated area. All contaminated reusable protective clothing,
including footwear, should be subjected to cleaning and disinfection
or sterilisation, with appropriate precautions for those undertaking it.
Footwear should be adequately decontaminated after use.
27.13 Measures to reduce eye and other facial exposure
27.13.1
Protect mucous membrane of eyes with protective eyewear. This
should prevent splash injuries (including lateral splashes) without
loss of visual acuity and without discomfort. Face shields may be
considered appropriate for procedures which involve a risk of splatter
of blood including aerosols or other potentially infectious material.
Various forms of combined eye and face protection are available.
Guidance on the choice of eye wear is given in BS7028: Guide for
Selection, Use and Maintenance of Eye Protection for Industrial and
other uses. BS EN 166: 1988 lays down requirements for eye
protectors.
27.13.2
Eye wash should be available in case of accidental exposure.
Contact lenses should be removed prior to eyewashing.
27.14 Exposure Prone Procedures
27.14.1
Exposure prone procedures (EPPs) are those where there is a risk
that injury to the worker may result in the exposure of the patient's
open tissues to the blood of the worker. These include procedures
where the worker's gloved hands may be in contact with sharp
instruments, needle tips and sharp tissues (spicules of bone or teeth)
inside a patient's open body cavity, wound or confined anatomical
space where the hands or fingertips may not be completely visible at
all times. See Annex A for examples of UKAP advice on EEPs159
27.14.2
Procedures where the hands and fingertips of the worker are visible
and outsider the patient’s body at all times, and internal examinations
or procedures that do not involve possible injury to the worker’s
gloved hands from sharp instruments and / or tissues, are considered
not to be EPP provided routine infection control procedures are
adhered to at all times. Examples of such procedures include;
159
Exposure Prone Procedures are those where there is a risk that injury to the worker may result in the
exposure of the patient's open tissues to the blood of the worker. These include procedures where the
worker's gloved hands may be in contact with sharp instruments, needle tips and sharp tissues (spicules of
bone or teeth) inside a patient's open body cavity, wound or confined anatomical space where the hands or
fingertips may not be completely visible at all times. (HIV Infected Health Care Workers: Guidance on
Management and Patient Notification, Department of Heath 2005)
81
27.14.2.1
Taking blood (venepuncture)
27.14.2.2
Setting up and maintaining intravenous lines or central lines
(provided any skin tunnelling procedure used for the latter is
performed in a non-exposure prone way
27.14.2.3
Minor surface suturing
27.14.2.4
The incision of external abscesses
27.14.2.5
Routine vaginal or rectal examinations
27.14.2.6
27.14.2.7
Simple endoscopic procedures
.
27.15 HBeAG positive HCWs160
27.15.1
EPPs must not be performed by HCWs who are HIV positive or
hepatitis B e antigen positive (HBeAG positive). Including surgeons
27.15.2
When undertaking a vaginal delivery, HBeAG positive HCWs must
not perform procedures involving the use of sharp instruments such
as infiltrating local anaesthetic, or suturing of a repair or episiotomy.
27.15.3
HBeAG positive HCWs must not perform an instrumental delivery
requiring forceps or suction as these may need an episiotomy or
subsequent repair.
27.15.4
HBeAG positive HCW's must not work in a renal dialysis unit.
27.16 HBsAG positive HCWs who are not HBeAG positive
27.16.1
Hepatitis B surface antigen positive (HBsAG positive) HCWs who are
not HBeAG positive need not be barred from any area of work. In
accordance with existing guidance they should receive expert
advices on avoiding transmission of infection to others. Should a
HBsAG positive HCW who is not HBeAG positive be associated with
the transmission of infection to a patient, the restrictions at 27.15
would be applicable.
27.16.2
Notwithstanding paragraph 27.16.1, all HCWs who are HBsAG
positive must not carry out EPPs until their e-antigen status has been
established. Testing fro e-antigen markers should be carried out in
one laboratory, each using a different assay type.
27.16.3
Any e-antigen positive HCW who is successfully treated with alpha
interferon and whose e-antigen negative status is sustained for 12
months after cessation of treatment may be able resume EPPs. The
advice of the UK Advisory Panel should be sougth as to whether a
return to duties involving EPPs would be appropriate.
Points 27.15 to 27.16 taken from Protecting Healthcare Workers and Patients from Hepatitis B –
Recommendations of the advisory group on hepatitis – 1993.
160
82
27.17 Blood samples taken from HCWs who perform EPPs, for the purpose of testing for
the current hepatitis B infection of response to vaccine should be taken directly by
the occupational health service or be a person commissioned to do so by the
occupational health service. These blood samples should not be used for testing for
the presence of any other blood borne virus and HCWs should be assured of this.
27.18 In the circumstance of investigation of possible transmission of blood borne virus
infection from a HCW to a patient, blood samples should be taken obtained directly
by a member of the Incident Investigation Team or a person commissioned to do so
on their behalf.161
27.19 Hepatitis B immunisation162
27.19.1
All HCWs, including students and trainees, who have direct contact
with patient's blood or other potentially infectious body fluids or
tissues should be immunised against HBV.
27.19.2
It is recognised that those whose work involves EPPs or renal
haemodialysis, including medical, dental, nursing and midwifery
students, are at risk of transmitting hepatitis B to their patients.
Unless they are known to be naturally immune to HBV, they should
be immunised and their response to immunisation should then be
checked.
27.19.3
The response to vaccine should be checked 2-4 months after
completion of the primary course. An anti-HBs level of 100 miu/ml is
considered to reflect an adequate response to the vaccine and to
confer protective immunity. In the absence of natural immunity levels
of anti-HBs between 10 and 100 miu/ml indicate a response to the
vaccine but one that may not necessarily confer long-lasting
immunity and which may require boosting. The specificity of levels of
anti-HBs below 10 miu/ml cannot be assured and such levels cannot
be considered as evidence of a response to the vaccine. If there is a
delay in checking the response, a booster dose should be given
before anti-HBs titres are measured as levels of antibody gradually
fall after immunisation.
27.19.4
About 10% of people do not respond to a primary course of vaccine.
Lack of response is commoner in those over the age of 40 and those
who are immunocompromised. Some people fail to respond to
vaccine because they are carriers of the hepatitis B virus (see
paragraph 27.20.1).
27.19.5
In non-responders who are not carriers of the virus, booster doses
may improve the response. Newer vaccines are also being
developed with the aim of improving response rates. A single booster
dose is recommended in poor responders (anti HBs 10-100 miu/ml
measured 2-4 months after the primary course) and a repeat course
in nonresponders (anti-HBs<10miu/ml measured 2-4 months after
the primary course).
161
Points 27.16.2 to 28.18 taken from 1996 addendum to HSG(93)43
Points 27.19.2 to 27.20.7 taken from Protecting Healthcare Workers and Patients from Hepatitis B –
Recommendations of the advisory group on hepatitis – 1993.
162
83
27.19.6
Recommendations about subsequent booster doses in those who
have responded to the primary course of vaccine are contained in
“Immunisation against Infectious Desease”163 which also contains
advice about adverse effects of and contraindications to vaccine.
27.19.7
In line with existing guidance, it is also desirable that hepatitis B
vaccine should be given to all staff who are at risk of acquiring
hepatitis B occupationally because they are at risk of injury from
blood-stained sharp instruments, contamination of surface lesions by
blood or bloodstained body fluids or of being deliberately injured or
bitten by patients
27.20 Follow-up of immunisation in staff carrying out EPPs
163
27.20.1
Those whose work involves EPPs and who fail to respond to a full
course of vaccine should be referred for specialist advice and
counselling. Consent should be sought for further testing to find out
who are vaccine non-responders and who are hepatitis B carriers.
27.20.2
Staff who are found to be HBeAg positive are regarded as being at
risk of transmitting hepatitis B to their patients in the course of EPPs.
They should receive advice regarding the duties they may continue
to perform. They should not carry out EPPs unless laboratory tests
indicate that they are no longer at risk of transmitting infection in the
health care setting. Local advisers may wish to seek the help of the
Advisory Panel in making this assessment. Spontaneous loss of
HBeAg with development on anti-HBe occurs in about 5-15% of
those infected as adults each year10 and a further 1-2% lose HBsAg.
Those infected as adults may respond well to treatment with
interferons and the carrier state may be reversed in up to 40% of
those treated.
27.20.3
Advice regarding the duties that HBeAg positive health care workers
may continue to perform may be sought initially from a physician,
medical microbiologist or clinical virologist with experience of
hepatitis B but arrangements should be made to seek advice from a
specialist occupational physician as soon as possible. Occupational
health services which do not employ a specialist occupational
physician should refer individuals to a specialist occupational health
physician in another unit. The Association of National Health Service
Occupational Physicians has produced a list of senior specialists who
can be contacted by those working in occupational medicine in the
field. The close involvement of occupational health departments in
developing local procedures for managing HBV-infected health care
workers is strongly recommended.
27.20.4
In order to minimise the scope for ambiguity and conflict of interest it
is recommended that all matters arising from and relating to the
employment of HBeAg positive health care workers are co-ordinated
through a consultant in occupational health medicine. Further it is
recommended that all Health Authorities and NHS Trusts need to
HMSO 1992
84
take steps to identify such a consultant who should also be available
for consultation by general medical and dental practitioners and their
employees and should liaise with local private sector hospitals and
offer such a service to them if the private hospital wishes.
27.20.5
Every effort should be made to persuade staff of the benefits of
immunisation and to explain the importance of testing to see whether
they have responded to the vaccine and to avoid putting patients at
risk. The restrictions imposed upon HBeAg positive staff should also
apply to those who refuse immunisation or subsequent monitoring
unless they are already known to be naturally immune or their status
as e-antigen negative carriers has been unequivocally established.
27.20.6
Physicians who are aware that infected health care workers under
their care have not followed advice to modify their practice must
inform the General Medical Council, General Dental Council or the
UK Central Council for Nursing, Midwifery and Health Visiting. In the
case of health care workers not covered by one of these statutory
bodies the health care worker’s employing authority should be
informed.
27.20.7
Staff in post who are vaccine non-responders and who have no
markers of previous hepatitis B infection are at risk of acquiring
infection. They may continue without restriction of practice provided
that inoculation incidents are reported, treated and followed up in
accordance with standard guidelines. Employing authorities have a
duty to educate staff to report inoculation incidents promptly.
27.21 Since the guidance at paragraph 27.20 was issued some concerns have been
raised about the reliability of some of the currently available commercial enzyme
immunoassay kits for HBeAg and anti- HBe. Further work on evaluation of these
commercial kits has been commissioned. Until more is known about the
performance of individual kits, caution must be exercised in the interpretation of the
results of HBeAg/anti-HBe status based on the results of a single test kit. The
following procedure is recommended when evaluating the HBeAg/anti- HBe status
of known carriers of hepatitis B surface antigen:27.21.1
Sera (volume at least 2 ml) should be sent for testing for HBeAg/antiHBe in at least two laboratories and tested by a different assay by
each laboratory. Laboratories should use the test kits with which
they are most familiar.
27.21.2
Alternatively sera may be sent to the Virus Reference Division,
Central Public Health Laboratory which will arrange for confirmation
of its e-marker results in another expert laboratory as appropriate.
27.21.3
It is important that the determination of e-markers is undertaken in
laboratories known to be experienced in this work.
27.21.4
The results of e-marker tests should be verified by the same testing
of a second serum sample from the health care worker to exclude the
possibility of mis-identification of specimens.
85
27.21.5
Where uncertainty about e-marker status remains, specialist
virological advice should be sought.
27.22 Annex B to this addendum suggests a protocol and provides a flow diagram for the
investigation of health care workers who have anti-HBs levels <10 miu/ml after three
doses of hepatitis B vaccine. Annex C to this addendum suggests a protocol and
provides a flow diagram for testing of health care workers who have not yet been
immunised.
27.23 Security of establishing immunity/infectivity
It is important that those performing tests of hepatitis B carriage (HBsAg), response
to vaccine (anti-HBs levels) or infectivity (HBeAg/anti-HBe) should take steps to
ensure that samples tested are from the health care worker in question. Where
feasible, samples should be taken by the occupational health doctor or nurse.
Where this is not feasible, samples should be taken by a person acting on behalf of
occupational health. Local arrangements will need to be made to take account of
local circumstances.
27.24 Investigation of possible cases of transmission of bloodborne viruses from health
care workers to patients
A prosecution in 1994 involved a health care worker who substituted blood from a
non-infectious source in order to avoid detection as an e-antigen positive carrier of
hepatitis B (Comm Dis Rep 1996;6:R119-R125). In the light of this case, all blood
samples taken as part of an investigation of possible transmission of bloodborne
virus infection should be taken directly by a member of the incident investigation
team. If this is not possible, the incident investigation team should arrange for a
person to take the sample, acting on their behalf. In such a case it will be for the
incident investigation team to initiate the arrangement, rather than the health care
worker.
27.25 Decontamination and waste disposal
Many occupational exposures to BBVs result from failure to adhere to basic rules
concerning decontamination, waste disposal etc. The following general guidance
should be drawn to the attention of all staff who come into contact with blood
contaminated material.
27.25.1
It is recommended that a member of senior management is
designated as clinical waste control officer whose function it will be to
oversee the operation of the clinical waste policy. This is particularly
important in order to protect third parties, such as ancillary staff, and
anyone else present in the health care setting, such as patients and
their visitors, from preventable exposure.
27.25.2
The Infection Control Team should collaborate with relevant staff
over the implementation and monitoring of routine procedures such
as disinfection or sterilisation of instruments and equipment,
production of sterile supplies and safe collection and disposal of
clinical waste.
27.26 Equipment and materials
86
27.26.1
Single use equipment should be used where appropriate, particularly
where decontamination cannot be carried out effectively. Any
reusable equipment which is to be reused and which has been
employed for a procedure involving potential contact with a patient's
blood must be sterilised or disinfected before it is reused. Such
equipment includes items which may not necessarily be in direct
contact with the patient e.g. manual self inflating resuscitation bags
and dental handpieces.
27.26.2
Reusable equipment must be of a type that is readily decontaminated
without distortion or damage to its function. The manufacturer's
instructions must be consulted to ensure compatibility of materials
with the methods of decontamination employed.
27.26.3
When selecting suction and aspiration equipment, apparatus which
will discharge directly into a waste outlet is to be preferred in order to
reduce the potential for accidental spillage. High speed aspirators
used for dentistry should exhaust externally in order to avoid the
spread of potentially infectious material within the surgery.
27.27 Decontamination of equipment
27.27.1
Thorough physical cleaning of instruments in warm water with
detergent to remove blood and debris is essential prior to disinfection
or sterilisation, for either procedure to be effective. Neither cold nor
hot water should be used for this purpose; the former may harden
fats and the latter may cause proteinaceous material to adhere.
27.27.2
Advice on sterilisation and disinfection is given in Annex B.
27.28 Disposal of clinical waste
27.28.1
All waste which is contaminated with blood, tissues and other
potentially infectious body fluids (see Table 1, page 9) should be
treated as "clinical waste"164 in accordance with the Health and
Safety Commission's Health Services Advisory Committee's
document, Safe disposal of clinical waste165.
27.28.2
Attention is drawn to the duties of the employer under the HSWA
which extends to employees working in the home environment. The
employer must ensure that adequate arrangements are made for
safe disposal of clinical waste in the community as well as in the
hospital setting.
27.29 Contaminated linen
164
Clinical waste, as defined in the HSAC document, is considered to be `waste arising from medical,
nursing, dental, veterinary, pharmaceutical or similar practice; investigation, treatment, care, teaching or
research which by nature of its toxic infectious or dangerous content may prove a hazard or give offence
unless previously rendered safe and inoffensive. Such waste includes human or animal tissue or excretions,
drugs and medical products, swabs and dressing, instruments or similar substances and materials'.
165 See Safe Disposal of Clinical Waste, DoH 2006
87
27.29.1
As with all other contaminated items, clothing and linen stained with
blood or other potentially infected body fluids which is to be reused
should be handled with care and placed in suitable bags for safe
storage and transportation for laundering. Colour coded according to
Waste Regulations
27.29.2
The recommended temperatures for thermally disinfecting linen are
contained in the Department of Health's guidance Hospital laundry
arrangements for used and infected linen. In the community setting
or elsewhere without access to specialist services, contaminated
clothing or linen should be:
27.29.2.1
washed with detergent using the hot wash cycle of a domestic
washing machine to a temperature of at least 80°C; or
27.29.2.2
dry cleaned at elevated temperatures, or dry cleaned cold followed
by steam pressing; or
27.29.2.3
incinerated.
27.29.3
Overloading of washing machines should be avoided. If washing by
hand is unavoidable, household rubber gloves must be worn.
27.30 Labelling, transport and reception of specimens
166
27.30.1
Any person responsible for handling specimens or other potentially
hazardous material has duties under the HSWA and the COSHH
Regulations to conduct the work safely.
27.30.2
Other regulations which apply are: The Carriage of Dangerous
Goods (Classification, Packaging and Labelling) and Use of
Transportable Pressure Receptacles Regulations 1996166.
27.30.3
Specimens from patients with known or suspected BBV infection
should be conspicuously labelled or marked "danger of infection".
Accompanying paperwork should be similarly labelled. For reasons
of patient confidentiality the diagnosis, if known, should not be
specified.
27.30.4
Specimens for transportation by hand or by local transport should be
despatched in individual sealable transparent plastic bags. A suitable
means of containing request forms, e.g. a separate pocket on the
bag, should be provided. The request form should give sufficient
information to the laboratory staff receiving it to assess what special
precautions may be required in the laboratory. Such information is
confidential and is only available to those who "need to know". It
should not be available to porters and others transporting specimens.
27.30.5
More detailed information on collection, labelling, despatch and
transport of specimens is available in the guidance used by the
Advisory Committee on Dangerous Pathogens (ACDP), Protection
Carriage of Dangerous etc. Regs. 1996
88
against blood-borne infections in the workplace (see Annex A)167.
27.31 Postage of specimens within the UK168
27.31.1
Clinical material which may contain BBVs may be sent by post
provided that the conditions of the Post Office are met. It is
recommended that screw-capped plastic containers are used in order
to minimise the possibility of leakage or breakage. The Post Office
guide should be consulted for the latest instructions for posting
pathological material.
27.32 Body handling and disposal
27.32.1
When there is any risk of contact with blood and body fluids in
handling bodies for any purpose, gloves should be worn and other
protective clothing as necessary.
27.32.2
Drainage tube sites and open wounds should be covered by
waterproof dressings. Those despatching a body for storage, post
mortem examination or embalming should ensure there are no
sharps remaining in it.
27.32.3
Wherever a person who is known or suspected to be infected with a
BBV dies, it is the duty of those with knowledge of the case to ensure
that those who need to handle the body, including funeral personnel,
mortuary and post-mortem room staff are aware that there is a
potential risk of infection. Making those who may be at risk aware of
a known or suspected hazard is a statutory duty under the HSWA.
Although the diagnosis should be kept confidential, the discreet use
of "danger of infection" or similar labelling is appropriate, always
making clear what type of precautions are needed.
27.32.4
Any body which is externally contaminated with blood, or known or
suspected to be infected with a BBV should be placed in a
disposable plastic body bag as soon as possible. Absorbent material
may be needed when there is leakage, e.g. from surgical incisions or
wounds.
27.32.5
Mortuary staff should ensure that good liaison is maintained between
themselves and those who submit bodies for post-mortem
examination or storage and those who collect bodies for disposal.
27.33 Post-mortem examination
27.33.1
Those undertaking post-mortem examination should adopt similar
precautions to those recommended in this document for invasive
procedures on living patients.
167
There are specific regulations for handling of specimens from suspected viral haemorrhagic fever issued
by ACDP.
168 See also The Code at Appendix 2: Biological samples, cultures and other materials should be transported
in a manner that ensures that they do not leak in transit.
89
27.33.2
Further guidance is provided by the Health and Safety Commission
Health Services Advisory Committee in Safe working and the
prevention of infection in the mortuary and post-mortem room, and by
the ACDP in Protection against blood-borne infections in the
workplace (see Annex A).
27.34 Management of Blood Exposure Incidents
27.34.1
All HCWs in hospital and elsewhere (eg general medical and dental
practice) should be informed and educated about the possible risks
from occupational exposure and should be aware of the importance
of seeking urgent advice following any needlestick injury or other
possible exposure. Training should ensure that all staff know how
and to whom to report, and that confidentiality is guaranteed.
27.34.2
HCWs or any other person in the health care setting exposed to HBV
or HIV infected blood or body fluids should be offered appropriate
post-exposure prophylaxis. HCWs particularly at risk of exposure to
HIV should be encouraged to consider in advance, whether in the
event of an occupational exposure to HIV, they would wish to take
prophylaxis.
27.34.3
Every employer should draw up a policy on the management of
exposures. Each Health Authority, Health Board or NHS Trust should
designate one or more doctors to whom health care staff may be
referred immediately for advice if they have been exposed to
potentially infected blood. Local policies should also specify who will
be responsible for provision of post-exposure prophylaxis and follow
up. Doctors in OH Services should be considered for this role.
Sources of expert advice may also include consultants in virology,
microbiology, infectious diseases, HIV disease, hepatology, genitourinary medicine and public health medicine.
27.34.4
The OH Service should advise managers and staff on the
management of injuries sustained at work, e.g. needlestick injuries,
and in cases where entitlement to NHS or industrial injuries benefits
is under consideration.
27.34.5
General medical and dental practitioners should also ensure that
provisions are in place for themselves and their staff, including
access to urgent occupational health advice.
27.34.6
Information, counselling and psychological support should be made
available to any employee who reports an exposure and potential risk
of a BBV infection. This may include encouragement to provide a
baseline sample for storage and follow up samples for testing as
appropriate for HIV, HBV or HCV infection, and advice about
treatment. While testing earlier might be appropriate in some cases,
testing at 6 months after the exposure will usually exclude the
possibility of transmission of these infections. Pre-test discussion
should reflect the importance of any test procedure and the
implications of the results. Discussion after the tests should provide
the necessary support.
90
27.34.7
The designated doctor(s) must maintain awareness of the latest
developments in post-exposure prophylaxis including the use of
hepatitis B immunoglobulin and hepatitis B vaccine and the use of
anti-retroviral drugs following occupational exposure to HIV infection.
27.35 Post-exposure procedures
27.35.1
Action after a HCW has been exposed to blood or other potentially
infectious body fluids should take account of the interests of both the
worker and the source patient. The circumstances which led to the
exposure should be identified and all possible steps taken to prevent
recurrence.
27.35.2
Immediately following any exposure, the site of exposure, i.e. wound
or non-intact skin, should be washed liberally with soap and water
but without scrubbing. Exposed mucous membranes including
conjunctivae should be irrigated copiously with water, after first
removing contact lenses if present. If there has been a puncture
wound, free bleeding should be encouraged gently but the wound
should not be sucked.
27.35.3
HCWs who sustain an occupational exposure should report the
exposure promptly and seek urgent advice on further management
and treatment.
27.35.4
Provision should be made for an appropriate person to be available
outside normal working hours to advise and treat health care workers
who sustain significant occupational exposures. This person must be
provided with a written version of the Health Authority, Health Board
or NHS Trust's policy on the management of exposures.
27.36 Testing and counselling
27.36.1
The designated doctor will need, where possible, to obtain
information from or about the source patient concerning possible
indicators of BBV infection, including risk factors and results of
previous tests for HIV and hepatitis, medical history suggestive of
such infection; and details of past and current antiviral therapy in
patients known to be HIV infected. The source patient should be
asked to consent to testing for BBV infections including HIV, HBV
and HCV. This will entail pre-test discussion and obtaining fully
informed consent. If the source patient is approached in a sensitive
manner, it is understood that consent to testing is rarely withheld.
Syphilis should also be tested.
27.36.2
A situation may arise exceptionally where it is necessary to balance
the health interests of the exposed health care worker and others
against those of the source patient in deciding whether or not a blood
sample which has already been obtained from the patient for other
purposes should be tested for evidence of infection. In such cases
the doctor should have regard to the guidance in Serious
Communicable Diseases issued by the General Medical Council. A
doctor must be able to justify a particular course of action taken in
exceptional circumstances.
91
27.37 Post exposure prophylaxis – HBV
27.38 If the HCW may have been exposed to HBV infected blood post-exposure
prophylaxis should be considered. Guidance from the Public Health Laboratory
Services (PHLS) Hepatitis Sub-committee is given in, Exposure to hepatitis B virus;
guidance on post exposure prophylaxis (Communicable Disease Report, Vol 2,
Review No 9, August 1992). A summary is given in the table below.
Significant Exposure
HBV status of
person exposed
≤ 1 dose HB
vaccine preexposure
≥ 2 doses HB
vaccine (antiHBs not known)
Known
responder to
HBV vaccine
(andti HBs ≥ 10
miU/ml)
Known
responder to
HB
vaccine(antiHBs < 10
miU/ml 2-4
months-post
vaccination)
HBsAg
source
positive
Unknown source
HBsAg
source
Accelerated
course of HB
vaccine169
HBIG x 1
One dose of HB
vaccine
followed by
second dose
one month later
Consider
booster dose of
HB vaccine
Accelerated
course of HB
vaccine109
HBIG x 1
Consider
booster dose of
HB vaccine
Non-significant Exposure
negative
Continued risk
No further risk
Initiate course
of HB vaccine
Initiate course
of HB vaccine
No HBV
prophylaxis
Reassure
One dose of HB
vaccine
Finish course of
HB vaccine
Finish course of
HB vaccine
No HBV
prophylaxis
Reassure
Consider
booster dose of
HB vaccine
Consider
booster dose of
HB vaccine
Consider
booster dose of
HB vaccine
No HBV
prophylaxis
Reassure
HBIG Consider
booster dose of
HB vaccine x 1
No HBIG
Consider
booster dose of
HB vaccine
No HBIG
Consider
booster dose of
HB vaccine
No prophylaxis
Reassure
27.39 Post exposure prophylaxis – HVC
27.39.1
At present there is no post exposure prophylaxis available for HCV
27.40 Post exposure – HIV
27.40.1
If the source patient is known to be infected with HIV or is considered
to be at risk but has not been tested, the UK Health Departments'
advice in Guidelines on post-exposure prophylaxis for health care
workers occupationally exposed to HIV (see Annex A) should be
followed. These guidelines developed by the Expert Advisory Group
on AIDS (EAGA) offer advice on: assessment of the risk to a health
169
An accelerated course of vaccine consists of doses spaced at 0, 1 and 2 months. A booster dose may be
given at 12 months
to those at continuing risk of exposure to HBV
92
care worker of acquiring HIV infection after occupational exposure;
when post-exposure prophylaxis (PEP) should be recommended; the
choice of anti-retroviral drugs; how to ensure that all health care
workers have immediate, 24 hour access on advice to PEP, to drugs
and to appropriate support; and the setting up of local PEP policies
and protocols. Decisions about prescribing PEP should follow a risk
assessment of the incident, based on the circumstances of the
exposure and the source patient.
27.41 Work practices during follow up
27.41.1
Pending serological follow up after occupational exposure to HIV, a
HCW need not avoid performing EPPs. This is because the risk of
the HCW having become occupationally infected, combined with the
even smaller risk of that infection then being transmitted to a patient
during an EPP is of such small order as not to merit such a
restriction. Advice should be given about safer sex and avoiding
blood donation during the follow up period. However in the event of
the HCW seroconverting and having established HIV infection,
performing EPPs must cease in accordance with EAGA's
recommendations in AIDS/HIV infected health care workers:
guidance on the management of infected health care workers.
27.41.2
Adherence to the recommendations on immunisation (see
paragraphs 27.19.1) should minimise the risk of health care workers
being occupationally infected with HBV. However, should infection
occur the Health Departments' guidance in Protecting Health Care
Workers and Patients from hepatitis B should be followed.
27.42 Reporting of incidents
27.42.1
Any blood exposure must be reported promptly to the person
designated to record such accidents. A full record must be prepared
and preserved and the HCW referred to the doctor previously
designated by the Health Authority, Health Board, or NHS Trust (see
paragraph 27.34.3).
27.42.2
Under the RIDDOR Regulations, employers may be required to
report to the HSE significant occupational exposure to BBVs. The
most likely requirement, if any, may be the need to report a
dangerous occurrence, namely "any accident or incident which
resulted or could have resulted in the release or escape of a
biological agent likely to cause severe human infection or illness".
Cases of BBV infection resulting from exposure in the health care
setting will also normally be a reportable disease within the meaning
of RIDDOR. More detailed guidance on requirements of RIDDOR
can be obtained from the HSE.
27.42.3
Occupational health physicians and clinicians involved in the care of
HCWs are encouraged to report (in complete confidence) incidents
involving occupational exposure to BBVs, and their outcome, to
CDSC or SCIEH. Such reporting is voluntary but is necessary in
order to provide the most up-to-date information on risks of HIV
93
transmission and on the side effects and benefits of prophylaxis
where relevant.
27.43 Management of HCWs infected with BBVs
27.43.1
Those who have acquired BBV infections should be referred to an
appropriate specialist for assessment and any further clinical
management.
27.43.2
Recommendations from the Expert Advisory Group on AIDS and
from the Advisory Group on hepatitis on the management of HCWs
infected with blood-borne viruses are given in other guidelines.
These are kept under continuing review and updated in the light of
emerging epidemiological evidence. Those providing occupational
health advice should be aware of the latest recommendations. In
some workers infected with blood-borne viruses a modification of
working practices will be necessary to avoid performing EPPs where
injury to the HCW could result in the worker's blood contaminating a
patient's open tissues.
27.43.3
If doubts exist about the need for modification of working practices,
or a change in work area, the UK Advisory Panel for Health Care
Workers Infected with BBVs (UKAP) can be asked to advise.
Contact should be made through the UKAP's DH, secretariat on an
anonymous basis. Where changes are necessary, employers should
make every effort to make available suitable alternative work or
retraining opportunities or both, in accordance with good general
principles of occupational health practice.
27.44 Compensation for occupationally infected HCWs
27.44.1
The NHS Injury Benefits Scheme provides temporary or permanent
benefits for all NHS employees who lose remuneration because of an
injury or disease attributable to their NHS employment. The scheme
is also available to medical and dental practitioners providing general
medical and dental services in the NHS.
27.44.2
Industrial Injuries Disablement Benefit can be paid where an
employed person contracts viral hepatitis, known as prescribed
disease B8, which includes hepatitis B and C. As part of the
qualification the claimant must have worked in an environment where
they have had contact with human blood or blood products, or a
source of viral hepatitis. HIV is not a prescribed disease under the
Social Security Acts. However, HCWs who have acquired HIV
because of exposure to HIV infected material in the workplace may
be able to claim compensation under the Industrial Injuries Scheme
where there has been an accident arising out of and in the course of
employment, e.g. a needlestick injury.
27.44.3
The occupational health service, as well as advising managers and
staff on the management of injuries sustained at work, should also
provide advice in cases where entitlement to benefits for
occupationally acquired infection is under consideration. Details of
the NHS scheme can be obtained from the NHS Pensions Agency,
94
Injury Benefits Manager, 200-220 Broadway, Fleetwood, Lancs SY7
8LG. Leaflets and advice on the Industrial Injuries Disablement
Scheme can be obtained from local Benefits Agency Offices.
27.45 Testing.
27.45.1
Hepatitis B.
27.45.1.1
Healthcare workers who will perform exposure-prone procedures
should be tested for hepatitis B infection at the pre-appointment
check and at the time of immunisation. Relying on anti-HB’s
response to vaccine to indicate non-infectivity may not be secure,
since some infectious carriers of the virus could be missed.
27.45.2
Hepatitis C
27.45.2.1
Testing is recommended for healthcare workers intending to begin
professional training for a career that relies upon the performance of
exposure-prone procedures.
27.45.3
HIV, hepatitis B and C. Testing should take place after:
27.45.3.1
a healthcare worker to patient blood-exposure incident,
27.45.3.2
a patient to healthcare worker incident,
27.45.3.3
a sharps injury,170
27.45.3.4
exposure to body fluids.
27.46 Draft guidance published by the Department of Health ‘Health Clearance for serious
communicable diseases: new healthcare workers’, recommends that preappointment health checks for new workers should include:
27.46.1
Checks for TB disease/immunity,
27.46.2
Offer of hepatitis B immunisation, with post-immunisation testing of
response,
27.46.3
A reminder to them of their professional responsibilities in relation to
serious communicable diseases,
27.46.4
An offer of testing for hepatitis C and HIV.
27.47 All new healthcare workers who will perform exposure-prone procedures need to
have both standard and additional health clearance for serious communicable
diseases, before appointment or starting training. It is recommended that this
includes medical students as well as qualified clinicians, although not usually
nursing students.
170
See 7 Safe Use and Disposal of Sharps.
95
27.48 Employers should be satisfied that all staff working for the NHS who do exposureprone procedures, have had the necessary tests and immunisations to enable them
to undertake their duties with the minimum risk to themselves and others. These
include:
27.48.1
Healthcare workers returning from research experience, voluntary
service with medical charities, sabbaticals, exchanges or periods of
unemployment,
27.48.2
Medical students returning from electives in countries where there is
a high prevalence of blood-borne viruses,
27.48.3
Locum and agency staff,171
27.48.4
Overseas healthcare workers applying for employment or a training
place in the NHS, including those applying under international
recruitment arrangements.
27.49 There is a range of measures that can be taken to avoid exposure to blood-borne
viruses. These can include wearing non-powdered latex gloves and other protective
clothing172 and the safe handling and disposal of sharps173. If followed correctly, they
should protect both the healthcare worker and the patient.
27.50 All high-risk exposure incidents should be reported to the surveillance scheme as
well as the trust’s occupational health department, and they should be reviewed to
consider how to prevent recurrence.
27.51 Heath workers or any person in healthcare exposed to infected blood or body fluids
should be offered appropriate post-exposure prophylaxis policies and procedures.
All healthcare workers should be aware of local post-exposure prophylaxis polices
and procedures, in particular the need for prompt action following a known or
potential exposure to HIV.
27.52 Healthcare workers who are hepatitis C virus RNA positive, should not be allowed to
perform EPPs.174
27.53 Healthcare workers who have been treated successfully with antiviral therapy may
resume EPPs or start professional training for a career that relies upon the
performance of EPPs. Healthcare workers who remain hepatitis C virus RNA
negative 6 months after cessation of treatment should be allowed to return to
performing EPPs at that time. As a further check, they should be shown still to be
hepatitis C virus RNA negative 6 months later.175
27.54 Staff should be provided with information and training about measures to reduce the
risk of occupational exposure to hepatitis C infection (e.g. safe handling and
disposal of sharps and measures to reduce risks during surgical procedures).176
See also 19 – Temporary, locum or agency staff.
See also 6 – Personal Protective Equipment
173 See also 7 – Safe Use and Disposal of Sharps
174 Health Service Circular. “Hepatitis C Infected Health Care Workers” 14 th August 2002.
175 ibid.
176 ibid.
171
172
96
27.55 Hepatitis B infected healthcare workers who are e-antigen negative and who have a
viral load which exceeds 10³ genome equivalents per ml should be prevented from
performing EPPs in the future. Healthcare workers whose viral load does not
exceed 10³ genome equivalents per ml need not have their working practices
restricted but they should receive appropriate occupational advice.177
27.56 Hepatitis B infected healthcare workers who are e-antigen negative and who do not
have a viral load which exceeds 10³ genome equivalents per ml at 12 monthly
intervals can continue to perform EPPs.178
27.57 NHS Trusts should ensure that there are arrangements in place to manage blood
exposure incidents for both healthcare workers and patients. Health Authorities,
NHS Trusts or Primary Care Trusts should designate medical staff to assess
incidents and to consider the need for hepatitis B immunoprophylaxis, where
indicated.179
27.58 In the event of a healthcare worker or patient sustaining an injury where there is the
possibility of HIV transmission (e.g a sharps injury with an instrument that has been
in contact with blood or other body fluids), guidance on HIV post-exposure
prophylaxis from EAGA should be followed. This guidance can be found at
http://www.dh.gov.uk/prod_consum_dh/idcplg?IdcService=GET_FILE&dID=18719&
Rendition=Web 180
177
Hepatitis B Infected Health Care Workers. Guidance on Implementation of Health Service Circular
2000/020.
178 ibid.
179 ibid.
180 See also: HIV Infected Health Care Workers: Guidance on Management and Patient Notification.
97
28
Blood-Borne Viruses in Renal and Transplantation Units181
28.1
Clinical governance and audit
28.1.1
28.2
Immunisation of patients against hepatitis B (HBV)
28.2.1
28.3
Staff in clinical contact with patients should be immunised against
HBV. Non-responders should be given a further course of vaccine
and poor responders an additional dose. Non-responders and poor
responders to hepatitis B vaccine who are HBsAg negative need not
be restricted from employment in renal units, but non-responders (i.e.
those with anti-HBs levels of less than 10 mIU/ml) should be tested
annually for HBsAg. Lack of measurable antibody does not
necessarily indicate lack of immunity
Immunisation of carers against HBV
28.4.1
28.5
Immunisation against HBV is recommended for patients on dialysis
or in transplantation programmes. Patients with chronic renal failure
should be immunised as soon as it is anticipated that they may
require dialysis or transplantation. Vaccine and, if appropriate,
hepatitis B immunoglobulin should be given to susceptible patients
who have been exposed to HBV.
Immunisation of staff against HBV
28.3.1
28.4
Regular clinical audit of the recommendations in these guidelines 182
should form an integral part of good practice and of a renal unit’s
contribution to local clinical governance initiatives.
Carers should be tested for hepatitis B surface antigen (HBsAg) and
those who are negative should be offered immunisation against HBV.
Non-responders and poor responders should be allowed to continue
to help their relative or friend with dialysis. A carer who is infected
with HBV should be advised of the risk of transmission and of the
precautions necessary to prevent it.
Post-exposure prophylaxis
28.5.1
Post-exposure prophylaxis with hepatitis B vaccine and/or hepatitis B
immunoglobulin (HBIG) as appropriate should be considered for
patients, staff and carers exposed to HBV infected blood or
bloodstained body fluids. After performing a risk assessment, staff
and carers who have previously responded to vaccine, and patients
with anti-HBs levels above 10 mIU/ml should be offered a booster
dose of vaccine. Those who have failed to respond to immunisation
(i.e. have never had anti-HBs levels of 10 mIU/ml or above) should
181
Wording adapted from Good Practice Guidelines for Renal Dialysis / Transplantation Units, Prevention
and Control of Blood-borne Virus Infection – Department of Health 2002. The text here is taken mainly from
the executive summary. More detailed guidance is contained in the main body of the document. See also
Safe Practice in Renal Medicine, DoH 2006
182 I.e. - Good Practice Guidelines for Renal Dialysis / Transplantation Units, Prevention and Control of
Blood-borne Virus Infection – Department of Health 2002
98
be given HBIG. Patients whose anti-HBs levels have fallen to below
10 mIU/ml should be given HBIG and a dose of vaccine. For
maximum effectiveness, HBIG should be given within 48 hours of
exposure to HBV infected blood; if an anti-HBs level is not known or
cannot be determined within that time frame, HBIG should be given.
Where immunisation has not taken place, HBIG should be given and
an accelerated course of hepatitis B vaccine commenced.
28.6
28.7
Booster doses of vaccine
28.6.1
The duration of protection afforded following immunisation with
recombinant hepatitis B vaccines remains unclear. There is
increasing evidence in immunocompetent individuals of persisting
immunological memory for 10-15 years or more in successfully
immunised individuals, even after anti-HBs levels have fallen or are
undetectable. However, the limits of this immunological memory are
unknown.
28.6.2
Booster doses of vaccine are recommended for immunised
individuals following direct exposure to HBsAg positive blood, unless
they have received a booster within the preceding 12 months.
28.6.3
The role of immunological memory in patients with chronic renal
failure on renal dialysis does not appear to have been studied and
protection may persist only as long as anti-HBs levels remain above
10 mIU/ml. Anti-HBs levels should therefore be monitored annually
and a booster dose of vaccine given if antibody levels fall below 10
mIU/ml.
28.6.4
Booster doses of vaccine should also be considered for patients
intending to visit countries with a high endemicity of hepatitis B,
particularly if they are to receive haemodialysis, and have not
received a booster in the last 12 months.
Testing patients for BBV infections
28.7.1
Testing should be carried out to allow early detection of BBV
infection in a unit and rapid intervention to prevent its spread. The
patient’s informed consent to testing should be obtained. Those who
withhold consent should be managed in accordance with the local
practice for patients infected with BBVs. Infected patients should not
be denied dialysis.
28.7.2
Patients admitted or re-admitted to a unit should be tested for
HBsAg, and HCV and HIV antibody, unless they have been tested in
the month before admission. Additionally, patients who are HCV
antibody negative and are immunosuppressed, have undergone a
renal transplant, or are being admitted from a unit where there has
been a recent HCV transmission, should be tested for HCV RNA.
Dialysis units should ensure that they have arrangements for
obtaining test results rapidly, before dialysis is carried out in the main
unit. A segregation facility should be used if it is necessary to dialyse
a patient before test results are available.
99
28.8
28.9
28.7.3
Re-admitted patients who have been dialysed outside the UK should
be tested and found negative for HBsAg, HCV antibody and HCV
RNA before being dialysed in the main unit. A risk assessment of
potential BBV exposure overseas should also be carried out, and
where exposure is considered likely, enhanced surveillance for one
or more BBVs should be instituted. This should involve testing for
HBsAg 2-weekly for 3 months and/or for HCV RNA 2-weekly for 3
months. A risk assessment for the likelihood of HIV infection should
be conducted.
28.7.4
Patients who are being treated in dialysis units should be tested for
HBsAg ideally monthly but at least every 3 months. All patients
should be tested for HCV antibody every 3 months. HIV antibody
testing should be based on a risk assessment.
28.7.5
When a previously unidentified case of HBV infection is found, units
should carry out an HBsAg test on all patients who have shared a
dialysis machine or a dialysis session with the infected patient since
that patient’s last negative test. Those patients who have not
demonstrated an anti-HBs titre ≥ 100 mIU/ml in the preceding 12
months should be re-tested weekly for 3 months, and be given a
booster dose of vaccine. Hepatitis B immunoglobulin (HBIG) should
be considered for non-responders to hepatitis B vaccine (anti-HBs <
10 mIU/ml). If a case of HCV or HIV infection is found, a polymerase
chain reaction (PCR) test should be carried out on those patients
who may have been exposed to the infection during dialysis sessions
(i.e. have shared a dialysis machine or dialysis session with the
infected patient) and repeated at 2-weekly intervals for 3 months.
Virological advice should be obtained about the need for further
tests.
Routine precautions against BBV infection
28.8.1
Renal units should regularly conduct a rigorous local risk assessment
and review of their infection control policies and practices to establish
the extent of the additional precautionary measures necessary.
28.8.2
Staff should observe barrier precautions against exposure to blood
and adhere strictly to infection control practices to prevent crossinfection between dialysis patients.
28.8.3
The staffing levels and environmental conditions in dialysis units
should be sufficient to permit safe working practices.
28.8.4
Units should review the safety aspects of the environment at regular
intervals and whenever a virus transmission has been recognised.
Avoidance of risk
28.9.1
Clinicians should consider home treatment for suitable patients as a
means of reducing patient exposure to BBV hazards in the dialysis
unit.
28.10 Action to be taken when BBV transmission occurs in a unit
100
28.10.1
When there is evidence that HBV, HCV or HIV transmission has
occurred in a unit, the local infection control team should be notified,
infected patients should be dialysed in a segregated area and
enhanced virological surveillance should be undertaken. Prophylactic
immunisation against HBV should be given where appropriate. An
outbreak control team should be set up.
28.11 Relatives and friends who assist patients with dialysis treatment
28.11.1
Relatives and friends who assist patients with dialysis in a renal unit
should be instructed in the precautions for preventing BBV crossinfection. When appropriate, units should supply these carers with
protective clothing and equipment. Units should also ask them to
report any incident in which they are exposed to blood or if they
develop any symptoms of hepatitis.
28.12 Management of BBV infected patients
28.12.1
Patients infected with HBV should ideally be dialysed in separate
isolation facilities. Where these are not currently available, patients
should be segregated in a separate area from other patients during
dialysis. Patients infected with HCV should also be segregated from
uninfected patients during dialysis. Segregation of HIV infected
patients should be considered based on a local risk assessment.
Because of the risk of cross infection, patients with different BBV
infections should not be dialysed in a single segregated area at the
same time. Staff caring for infected patients should adhere rigorously
to infection control precautions.
28.12.2
Units will need to consider how to achieve the necessary degree of
segregation required for each BBV taking account of the layout of
their units and the number of infected patients to be treated. Full
advantage should be taken of all isolation and separate treatment
facilities (isolation rooms, bays, side wards or moveable partitions)
and by suitable rostering of infected patients for treatment.
28.13 Nursing patients in segregated area
28.13.1
Whenever possible, staff should nurse only infected or uninfected
patients during a shift. If this is not practicable, more experienced
staff should be assigned the task of caring for a mixed group of
patients. Designated staff should nurse affected patients when there
has been an outbreak of BBV infection in a unit.
28.14 Use of dedicated dialysis machines
28.14.1
Separate machines should be used for patients infected with HBV.
Dedicated machines are not required for patients with HCV or HIV
provided that cleaning and disinfection processes are properly
carried out between patients according to the manufacturers’
instructions.
28.15 Transplantation units
101
28.15.1
Rigorous application of procedures to prevent the risk of blood
contamination and transmission of infection is essential and local risk
assessments should be carried out on transplantation units. Some of
the segregated areas in transplantation units should have facilities for
dialysis.
28.16 Equipment and prevention of BBV transmission
28.16.1
The blood tubing set supplied for use with dialysis machines is
intended for single-use and should be disposed of in an approved
manner after a single session on one patient. The filter on the venous
pressure monitoring line of the tubing set should be replaced if there
is evidence of contact with blood. The rupture of a filter is unlikely but
if it occurs, machine components which might have been
contaminated with blood should be replaced or decontaminated in
accordance with the manufacturer’s instructions. If replacement or
decontamination cannot be done locally, the machine should be
taken out of service and the manufacturer’s help obtained.
28.16.2
The dialysis fluid circuit of the dialysis machine should be
decontaminated between patients according to the method
recommended by the manufacturer. External surfaces of machines
should also be disinfected after the machine has been used by a
BBV infected patient. Surfaces of all machines should be disinfected
daily.
28.16.3
If a dialyser is supplied for “single-use only”, or equivalent, it should
be destroyed by incineration or other methods approved for disposal
of clinical waste, after a single dialysis session on one patient.
Dialysers should not be re-used unless specified by the dialyser
manufacturer.
28.17 Occupational health
28.17.1
There should be a designated occupational health department with
medical cover with responsibility for renal unit staff.
28.17.2
Staff with extensive epithelial deficiency such as eczema should not
work on renal units when their skin lesions are active or if there are
extensive breaks in the skin surface.
28.18 Testing of staff and staff fitness for work in dialysis units
28.18.1
Staff who have clinical contact with patients should demonstrate that
they are immune to, or not infected with, HBV, or that if HBsAg
positive, they are not HBeAg positive or HBeAg negative with a viral
load (HBV DNA) exceeding 103 genome equivalents per ml.
28.18.2
Staff who have not demonstrated immunity to HBV should be tested
annually for HBsAg.
102
28.18.3
Staff who know themselves to be infected with, or who may have
been exposed to, HCV or HIV should seek occupational health
advice.
28.19 Confidentiality for BBV infected staff
28.19.1
Staff found to be infected with BBVs are entitled to confidentiality:
information about their status should only be given to those who
need to know, and only with the infected staff member’s consent.
Staff should be made aware of arrangements for talking to an
occupational health physician or other person in confidence if they
are concerned that they might have a BBV infection.
28.20 Staff training and supervision
28.20.1
Staff in renal units should be made aware of the BBV hazards and
should be given adequate training in safe working practices. New
and inexperienced staff should be supervised until they are
considered competent to practise safely on their own.
28.21 Blood exposure incidents
28.21.1
Renal units should have a comprehensive policy for the management
of blood exposure incidents and their reporting to the occupational
health or other designated department. Reports of such incidents
should be monitored by the designated department for indications
that procedures or equipment need to be modified.
103
29
Management of Outbreaks of Gastro-Enteritis183
29.1
An annual winter flurry of outbreaks is a regular feature on the infection control
calendar, therefore an annual November memorandum from the infection control
team may help raise awareness at the right time of year.
29.2
Since food-borne outbreaks have occurred in hospitals, kitchen hygiene practices
should be reviewed regularly and monitored. It should be borne in mind that
outbreaks have been associated with pre-symptomatic, symptomatic and post
symptomatic food handlers and that viral shedding can also occur from
asymptomatic, infected individuals.
29.3
If the characteristics of the outbreak suggest a point source, epidemiological
investigations should be undertaken to identify or exclude a food or water source.
29.4
Recommended control measures for Small Round Structured Viruses (SRSV’s)
within affected clinical areas, using the categories described below;
Category I: Strongly recommended and strongly supported by welldesigned experimental epidemiological studies.
Category II: Strongly recommended and viewed as effective by
experts in the field and by the working group, based on strong
rationale and suggestive evidence, even though definitive studies
may not have been done.
No Category: an unresolved issue as there is insufficient evidence
or consensus regarding efficacy.
29.4.1
Cohort nurse or isolate symptomatic individuals (Category II),
29.4.2
Wear gloves and apron for contact with an affected patient or
environment (Category II),
29.4.3
Wash hands with soap and water after contact with an affected
patient or environment, after removing gloves and apron (Category I),
29.4.4
Remove exposed food such as fruit (No Category),
29.4.5
Consider use of antiemetics for patients with vomiting (No Category),
29.4.6
Exclude affected staff from the ward immediately and until 48 hour
symptom free (Category II), In some cases a longer period of
exclusion may be needed at discretion of the infection control team
29.4.7
Close the ward to prevent the introduction of new susceptible
patients. Avoid transfer to unaffected wards or departments (unless
medically urgent and after consultation with infection control staff).
183
Management of hospital outbreaks of gastro-enteritis. 2000 The Hospital Information Society. The Code
also requires NHS bodies to have core policies on disinfection, closure of wards and specific alert organisms
including Clostridium Difficile and Diarrhoeal infections
104
The priority is to stop the spread of the virus to other areas (Category
II),
29.4.8
Exclude non-essential personnel from the ward (Category II),
29.4.9
Caution visitors and emphasise hand hygiene (Category II),
29.4.10
Clean and disinfect vomit and faeces spillages promptly (Category
II),
29.4.11
Increase the frequency of routine ward, bathroom and toilet cleaning
(Category II),
29.4.12
Use freshly prepared 0.1% (1000 ppm) hypochlorite to disinfect hard
surfaces after cleaning (Category II), Detergent alone is ineffective
29.4.13
The ward should not be re-opened until 722 hours after the last new
case and 72 hours after uncontained vomiting and diarrhoea
(Category II),
29.4.14
Thoroughly clean the ward and change the bed curtains before reopening (Category II), using chlorine releasing agent
29.4.15
Clean carpets and soft furnishings with hot water and detergent, or
steam clean. Vacuum cleaning is not recommended (No Category).
29.5
Gloves and apron should be used whenever contact with an affected patient or the
contaminated environment is anticipated. There is currently no evidence to justify
the use of masks for patients or staff and these are not recommended.
29.6
Affected staff should be excluded from duty for 48 hours after their last symptoms
and should be excluded again if they subsequently relapse.
29.7
Non-essential staff should be excluded from affected clinical areas and wards
should be closed to admissions to prevent the introduction of further susceptible
individuals. Such staff are common vectors for spread
29.8
Avoid patient movements to unaffected areas (unless medically urgent and after
consultation with infection control staff) and other institutions. (Category II).
29.9
Staff working in affected areas must not then work in unaffected areas within 48
hours (includes agency and bank staff). (Category II).
29.10 Essential medical and paramedical staff (such as physiotherapists) should,
wherever possible, be dedicated to the affected ward(s) during an outbreak and not
work in the other areas. Where this is not possible, affected wards should be visited
after unaffected wards and staff should be reminded of the very sudden onset of
vomiting typical of SRSV infection and the need to leave an unaffected area rapidly,
if nausea arises while at work.
29.11 Agency and banking nursing staff who are normally working on unaffected wards
should not be used to cover single shifts on affected wards on an ad-hoc basis. If
staff shortages require the use of outside staff, they should be booked to work for a
105
block of several days or more to anticipate staffing requirements, even though this
may result in early direct costs.
29.12 Wards should inform the infection control team immediately whenever there is a
cluster (two or more cases) of unexplained vomiting or diarrhoea among patients or
staff. This will allow the rapid institution of control measures after assessment by the
team. Other areas of the hospital should be warned of the problem early so that
staff are vigilant and can give notice of spread to new areas.
29.13 The Occupational Health team should also be informed of any outbreaks and may
help to collect information about symptomatic staff.
29.14 Managers should be updated at least daily during an outbreak to allow appropriate
operational and manpower planning. An outbreak meeting is held usually daily.
29.15 The consultant in communicable disease control should be informed where (a) more
than one ward is affected or (b) the staffing of the hospital is compromised or (c) the
operational capacity of the hospital is affected.
29.16 All outbreaks should be reported to the Communicable Disease Surveillance
Centre, Central Public Health Laboratory, Colindale, as a matter of course.
29.17 Education and information should be provided for staff, patients and visitors during
an outbreak as handouts and as ward door posters. These should provide a brief
explanation of the nature of the illness, routes of transmission and basic infection
control precautions.
29.18 Guidance on cleaning up vomit and faeces:
29.18.1
Wear disposable gloves and aprons,
29.18.2
Use paper towels to soak up excess liquid. Transfer these and any
solid matter directly into a clinical waste bag,
29.18.3
Clean the soiled area with detergent and hot water, using a
disposable cloth,
29.18.4
Disinfect the contaminated area with freshly made 1000 ppm (0.1%)
hypochlorite solution. Note that hypochlorite is corrosive and may
bleach furnishings and fabrics.Important to change cloths and mops
between contaminated and noncontaminated areas.
29.18.5
Dispose of gloves, apron and cloths into the clinical waste bag,
29.18.6
Wash hands thoroughly using soap and water and dry them.
29.19 Contaminated linen and bed curtains should be placed carefully into laundry bags
appropriate to guidelines for infected linen (soluble alginate bags with a colour
coded outer bag) without generating further aerosols. Contaminated pillows should
also be laundered as infected linen unless they are covered with an impermeable
cover, in which case they should be disinfected with 0.1% hypochlorite solution.
29.20 Contaminated carpets should be cleaned with detergent and hot water, then
disinfected with hypochlorite (if bleach-resistant) or steam cleaned.
106
29.21 Contaminated hard surfaces should be washed with detergent and hot water, using
a disposable cloth, then disinfected with 0.1% hypochlorite solution. Cloths should
be disposed of as clinical waste. Non-disposable mop heads should be laundered
on a hot wash.
29.22 Horizontal surfaces, furniture and soft furnishings in the vicinity of the soiled area
should be cleaned with detergent and hot water, using a disposable cloth.
29.23 Fixtures and fittings in tiled areas should be cleaned with detergent and hot water
using a disposable cloth, and then disinfected with 0.1% hypochlorite solution.
29.24 Cleaning up vomit in food preparation areas;
29.24.1
Using the above principles, carefully remove all vomit and clean the
area,
29.24.2
Disinfect the food preparation area (including vertical surfaces) with a
freshly prepared hypochlorite-based cleaner that releases 1000 ppm
of available chlorine,
29.24.3
Destroy any exposed food, food that may have been contaminated
and food that has been handled by an infected person,
29.24.4
Any incident of vomiting should be reported to the infection control
team and appropriate managers.
107
30
Multi-Resistant Acinetobacter (MRAB) Outbreaks184
30.1
NHS Bodies should have a core policy on Acinetobacter which includes provision
for surveillance of identified patients at risk and high risk environments and
procedures for managing infected patients to prevent spread of infection185.
30.2
Where a single patient is found to be positive, then ideally s/he should be isolated in
a side-room and infection control and antimicrobial prescribing reviewed.
30.3
Risk assessment of the case should be performed and numbers and results of
clinical specimens from other patients on the ward/unit reviewed to inform whether
screening of other patients is indicated.
30.4
Risk factors for colonisation or infection should be reviewed, including intensive care
or burns unit admissions, prolonged length of hospital stay, surgical and other
wounds, broad spectrum antibiotic treatment including carbapenem usage, urinary
and vascular catheters, ventilation and parental nutrition.
30.5
Where there is more than one patient in isolate, conduct an investigation, agree
case definitions and record time, place and person details of all infected and
colonised patients.
30.6
Perform regular outbreak meetings with all relevant Healthcare workers to feedback
key information, review the success of interventions and make new plans as
appropriate.
30.7
Review all infection control procedures and re-enforce or correct these, including
hand hygiene, correct use of gloves and device usage.
30.8
Instruments or equipment (e.g. writing materials. Sphygmomanometers,
stethoscopes, lifting slings, resuscitator bags) should be designed for affected
patients. If possible, single-patient use items are to be preferred, if not, such items
should be suitably decontaminated before use on another patient. Special attention
should be paid to ventilator circuits, suction catheters and humidifiers.
30.9
A cluster of MRAB cases should trigger an audit and review of these measures.
30.10 The area in which the patient was cared for should be cleaned after the patient’s
discharge according to the local disinfection policy, with special attention to
horizontal surfaces and dust collecting areas, bedclothes, curtain rails, beds, tables,
ventilators, sinks, doorknobs, telephones and computer keyboards.
30.11 All unused disposable items should be discarded (stocks of these should thus be
kept to the minimum needed for care of the patient).
30.12 A decision on whether disinfectant is needed should be made by the Infection
Control Team: chlorine-based agents (e.g. NaDCC at 1,000 ppm) with a compatible
184
185
Interim Working Party Guidance on the Control of multi-resistant Acinetobacter outbreaks
The Code at Annex 2, paragraph l.
108
anionic detergent if required can be recommended. In case of corrosion problems,
70% alcohol can be used.
30.13 Pillows, mattress covers and mattresses should be checked for damage and
similarly disinfected. Therapy beds need specialist cleaning (e.g. high quality
thermal washing/disinfection). Special mattresses must be cleaned according to
manufacturers’ instructions after patient use.
Where cases are continuing, consider closing ward and performing thorough
decontamination of the environment and all the equipment. Eradication from the
environment can be difficult and requires repeated cleaning
109
31
Control of Tuberculosis186
31.1
NHS Bodies should have in place a core policy on specific alert organisms and in
the case of Acute Trusts these should include control of tuberculosis and multi-drug
resistant tuberculosis. Such policies should include provision for isolation of infected
patients, transfer of infected or colonised patients within NHS bodies or to other
health facilities and treatment compliance187.
31.2
Treatment should be undertaken in the patient’s home whenever possible but some
patients will need admission because of the severity of illness etc.
31.3
Adults with non-pulmonary tuberculosis can be nursed on a general ward although
aerosol generating procedures such as abscess or wound irrigation may necessitate
patient isolation. Patients with suspected pulmonary tuberculosis should initially be
admitted to a single room vented to the air outside until their sputum status is known
and risk assessments are made.
31.4
Patients whose bronchial washings are smear positive should be managed as noninfectious unless;
31.4.1
The sputum is also smear positive or becomes so after a
bronchoschpy,
31.4.2
They are on a ward with immuno-compromised patients, or
31.4.3
They are known or suspected of having MDR-TB.
31.5
Patients whose induced sputum is smear positive should be managed as infectious.
31.6
Children with tuberculosis and their visitors should be segregated from the rest of
the ward until the visitors have been screened to exclude them as a source of
infection.
31.7
Only those, including young children, who have already been in close contact with
the patient before diagnosis, should be allowed to visit while the patient is
considered infectious.
31.8
Marked crockery and separate washing up facilities are unnecessary and no special
precautions are needed for bed linen, books etc. Fumigation rooms are
unnecessary.
31.9
Because of the more serious consequences of infection, those who attended
confirmed or suspected infectious MDR-TB patients should use dust/mist-fume
masks meeting the 1992 Personal Protective Equipment (EC Directive) Regulations.
31.10 Staff in casual contact with a case of smear positive tuberculosis should be
reassured and reminded of the possible symptoms of tuberculosis to report. Staff
who have undertaken mouth to mouth resuscitations without appropriate protection,
prolonged care of a high dependency patient or repeated chest physiotherapy on a
patient should be managed as close contacts.
186
187
Control and prevention of tuberculosis in the United Kingdom: Code of Practice 2000
The Code at paragraph 10 and Annex 2 paragraph l.
110
31.11 If an individual on an open ward is diagnosed as having infectious tuberculosis,
decisions about appropriate action should take into account the degree of infectivity,
the duration before the infectious incident was isolated, the proximity of contact and
whether other patients were unusually susceptible to infection.
111
32
Pandemic Influenza: Infection Control188
32.1
NHS Bodies should have in place a core policy on specific alert organisms and in
the case of Acute Trusts these should include respiratory viruses. Such policies
should include provision for an alert system for suspect cases, isolation criteria,
infection control measures and terminal disinfection and discharge189.
32.2
NHS Bodies should have in place a core policy on major outbreaks of
communicable infection. The degree of detail should reflect local circumstances but
should cover initial assessment, communication, management and organisation,
investigation and control. Contact details of those likely to be involved in outbreak
management should be reviewed annually. Provision to report such outbreaks as
SUIs and formal arrangements should be in place to fund the cost of dealing with
outbreaks190.
32.3
Dispose of used tissues in nearest waste bin,
32.4
Wash hands after coughing, sneezing, using tissues, or contact with respiratory
secretions and contaminated objects191,
32.5
Keep hands away from the mucous membranes of the eyes and nose,
32.6
Certain patients (e.g. the elderly, children) may need assistance with containment of
respiratory secretions; those who are immobile will need a receptacle (e.g. a plastic
bag) readily at hand for immediate disposal of tissues and a supply of hand wipes
and tissues.
32.7
Where possible, in common waiting areas or during transport, coughing/sneezing
patients should wear surgical masks to assist in the containment of respiratory
secretions and to reduce environmental contamination192.
32.8
NHS Trusts should ensure that they can implement the proposals set out in the
Pandemic Influenza Contingency Plan published by the Health Protection Agency.
188
Points 31.3 to 31.8 taken from Guidance for Pandemic Influenza: Infection Control in Hospitals and
Primary Care Settings. Department of Health
189 The Code at paragraph 10 and Annex 2, paragraph l.
190 The Code at paragraph 10 and Annex 2, paragraph c.
191 See also section 5: Hand hygiene
192 See also section 7: Personal Protective Equipment
112
33
Standard (Universal) infection control precautions/Aseptic technique
33.1
NHS bodies have a duty to have in place a core policy on standard (universal)
infection control precautions193.
33.2
The policy should be based on evidence based guidelines including hand hygiene
and the use of personal protective equipment194. It should be easily accessible to all
groups of staff, patients and the public; compliance should be audited and
information on policy should be included in the induction programme for all staff
groups195
33.3
Aseptic technique should be included as part of induction for all staff196
33.4
NHS bodies have a duty to have in place a core policy on aseptic technique197.
33.5
Clinical procedures should be carried out in a manner that maintains and promotes
the principles of asepsis. Education, training and assessment in the aseptic
technique should be provided to all persons undertaking such procedures; the
technique should be standard across the organisation; audit should be undertaken
to monitor compliance with aseptic technique198.
193
The Code at paragraph 10 (Note that this requirement is only mandatory for acute Trusts and those
defined at Appendix 1 to the Code)
194 The Code at paragraph 10 and Annex 2, paragraph a. See also sections 6 and 7 above (see note 170
above)
195 The Code at Annex 2
196 See section 3.1 above
197 The Code at paragraph 10
198 The Code at Annex 2, paragraph b.
113
34
199
200
Patient movement
34.1
An NHS body should be able to demonstrate evidence of joint planning between the
ICT and the bed managers for planning patient admissions, transfers, discharges,
and movements between departments and other health facilities199.
34.2
An NHS body should have in place a policy addressing, where relevant, admission,
transfer, discharge and movement of patients between departments, and within and
between healthcare facilities200.
The Code at Annex 1 (patient movements)
The Code at paragraph 2f
114
35
201
Anti-microbial prescribing201
35.1
Local prescribing should be harmonised with that in the British National Formulary,
wherever possible; Choice of agent will depend on local antibiotic sensitivity
patterns
35.2
All local guidelines should include information on drug, regimen and duration;
Guidelines must cover both therapeutic and prophylactic prescribing and aim to
reduce excessive antibiotic use and hence C difficile
35.3
Procedures should be in place to ensure prudent prescribing.
The Code at Annex 2
115
36
Occupational Health202
36.1
36.2
An NHS body must ensure that it has in place policies and procedures in relation to
the prevention and control of HCAI such that203:
36.1.1
all staff can access Occupational Health (OH) Services;
36.1.2
there are OH policies in place for the prevention and management of
communicable infections in healthcare workers;
36.1.3
OH services should include health screening for communicable
diseases;
36.1.4
Management of exposure to HCAIs, includes provision
emergency out of hours treatments and relevant immunisations.
for
In cases of BBVs arrangements should include identifying and managing hepatitis
B, HIV, hepatitis C infected healthcare workers and restricting their practice as
necessary in line with DoH guidance. Provision should also be made to enable
liaising as appropriate with the UK advisory panel for health care workers infected
with BBVs. There are restrictions on staff with evidence of infectivity for hepatitis B
or C in performing exposure prone procedures (EPPs).
202
These duties arise in addition to duties imposed under the Health and Safety at Work Act 1974 and
associate legislation, in particular the Control of Substances Hazardous to Health Regulations 2002 and
2004 (see above at section 2).
203 The Code at paragraph 11
116
37
204
205
Disposal of Clinical Waste
37.1
The risks from healthcare waste should be properly controlled involving an
assessment of risk, development of policies, having arrangements in place to
manage risks, monitoring the way arrangements work and awareness of legislative
change204.
37.2
Precautions for handling healthcare waste should include: training and information,
personal hygiene, segregation of wastes, use of appropriate personal protective
equipment, immunisation, appropriate procedures for handling waste, appropriate
packaging and labelling, suitable transport on and off-site, clear procedures for
dealing with accidents, incidents and spillages, appropriate treatment and disposal
of such waste205.
37.3
Systems should be in place to ensure that the risks to patients from exposure to
infections caused by healthcare waste present in the environment are properly
managed and that duties under environmental law are discharged. The most
important are duty of care in management of waste, duty to control polluting
emissions to the air, duty to control discharges to sewers, obligations of waste
managers206.
The Code at Appendix 2.
The Code at Appendix 2.
206
The Code at Appendix 2. Note that There are new Waste Regulations governing the labelling and
packaging of all waste to which all healthcare premises must adhere.
117
38
Isolation of Patients/Patient movement/Ward Closure207
38.1
An NHS body providing in-patient care has a duty to ensure that it is able to provide
or secure the provision of adequate isolation facilities for patients sufficient to
prevent or minimise the spread of HCAI208.
38.2
An NHS body must have in place a core policy on the appropriate isolation of
patients which should address potential sources of infection, the use of protective
measures and equipment and the management of outbreaks209.
.
38.3
The isolation policy should be evidence based and reflect local risk assessment;
indications for isolation should be included in the policy as should procedures for the
infection control management of patients in isolation; information on isolation should
be easily accessible to all groups of staff, patients and the public210
38.4
There should be policies in place about the allocation of patients to isolation
facilities based on local risk assessment. The risk assessment should include
considering the need for special ventilated isolation facilities211.
38.5
Isolation provisions should be included in the core clinical care policies on MRSA,
Clostridium difficile and the specific alert organism policies (mandatory for acute
trusts) on Glycopeptide resistant enterococci, control of tuberculosis, respiratory
viruses, diarrhoeal infections and viral haemorrhagic fevers212.
38.6
An NHS body must ensure that it provides sufficient and suitable information on
each patient’s infection status whenever it arranges for a patient to be moved from
the care of one organisation to another so that any risks to the patient and others
from infection may be minimised.
38.7
An NHS body should be able to demonstrate evidence of joint planning between the
ICT and the bed managers for planning patient admissions, transfers, discharges,
and movements between departments and other health facilities 213.
38.8
NHS bodies should have in place systems for the provision of advice by the ICT to
the CEO and Medical Director on the closure of wards and departments to new
admissions; with clear criteria in relation to closures, management arrangements for
redirecting admissions (drawn up with ICT input) and the need for environmental
decontamination prior to re-opening214.
207
See the Code at paragraph 2f and 8
The Code at paragraph 6
209 The Code at paragraph 10 and Appendix 2, paragraph k.
210 The Code at Annex 2, paragraph d.
211 The Code at Annex 1
212 The Code at Annex 2, paragraph l.
213 The Code at paragraph 11
214 The Code at Annex 2h
208
118
39
Dissemination of Information
39.1
An NHS body must ensure that it makes suitable and sufficient information available
to patients and the public about the organisation’s general systems and
arrangements for preventing and controlling HCAI215.
39.2
An NHS body must ensure that it makes suitable and sufficient information available
to each patient concerning any particular considerations regarding the risks and
nature of any HCAI that are relevant to their care and any preventative measure
relating to HCAI that a patient ought to take after discharge216.
.
39.3
An NHS body has a duty to provide information when a patient moves from the care
of one health body to another and must ensure that it provides suitable and
sufficient information on each patient’s infection status whenever it arranges for a
patient to be moved from the care of one organisation to another so that any risks to
the patient and others from infection may be minimised217
39.4
Areas relevant to the provision of such information include general principles
pertaining to the prevention and control of HCAI; the role and responsibilities of
individuals in the prevention and control of HCAI when visiting patients; encouraging
vigilance in patients; compliance by visitors with hand-washing and visiting
restrictions; reporting breaches of hygiene; explanations of incidents/outbreaks;
feedback on patient pathways; provision of information across organisational
boundaries such as pre-admission screening and post-operative wound
surveillance218.
39.5
There should be a local protocol for the dissemination of information about HCAIs
between healthcare organisations to facilitate surveillance and optimal management
of infections in the wider community219.
39.6
Trust data relating to the risks of infection should be analysed to identify patterns
and trends. The Trust Board and senior management should receive data with
sufficient frequency to enable them to identify the key areas of risk arising from
HCAI and to comply with their general duties in provision and implementation of an
assurance framework220.
215
The Code at paragraph 6. Note also a duty under the COSHH Regulations to carry out a suitable and
sufficient assessment of the risk of infection acquisition. The Healthcare Commissions’ Core Standard C16
imposes a general duty to inform patients. That does not create a private right as between Trust and patient.
A Trust owes a legal duty to its patient to provide such information as would be provided by a responsible
body of practitioners in order to obtain proper consent to treatment. Where the patient asks for information
that should be provided.
216 The Code at paragraph 5
217 The Code at paragraph 7
218 The Code at Annex 1
219 The Code at Annex 2, paragraph j.
220 Healthcare Associated Infection. What more can the NHS do? Healthcare Commission July 2007
119
40
Risk Management and Integrated Governance
40.1
An NHS Trust should ensure that it has undertaken suitable and sufficient
assessments of the risk of infection to patients; it has identified those risks and
taken steps to control them; it has recorded its findings; implemented the steps
identified and put in place appropriate methods to assess if further steps are
needed221.
40.2
Trusts should undertake systematic risk assessment and risk management222.
Infection control should be managed as part of an integrated corporate risk
management system223.
.
40.3
40.4
Risk assessment should be proactive, better undertaken at local level. It should also
be reactive and be based on learning from patient safety incidents. The Healthcare
Commission expects Trusts to use the model described by the National Patient
Safety Agency224.
There should be an appropriate system of surveillance and reporting in place, both
for the national reporting requirements and locally. This should form part of the
learning system used by Trusts.
221
The Code at paragraph 3. Note also a duty under the COSHH Regulations to carry out a suitable and
sufficient assessment of the risk of infection acquisition.
222 Core Standard C7c, Healthcare Commission
223 HCAI. What more can the NHS do? Paragraph 9.1.1
224 Seven Steps to Patient Safety. HPA (See mandate at paragraph 9.1.2 of HCAI. What more can the NHS
do?)
120
Annex A
Examples of UKAP advice on exposure prone procedures225
1
The UKAP has been making recommendations about the working practices of
health care workers (HCW’s ) infected with HIV since the end of 1991 and HCW’s
infected with other blood-borne viruses (BBV’s) since September 1993. Advice for
occupational physicians arises from individual queries, cases or general issues
which have been referred to the UKAP since its inception.
2
Exposure prone procedure criteria
3
2.1
Judgements are made by occupational physicians, or in conjunction
with the UKAP where doubt or difficulty exists, about whether any
procedure is or is not exposure prone against the following criteria;
2.2
EPPs are those where there is a risk that injury to the worker may
result in exposure of the patient’s open tissues to the blood of the
worker. These procedures include those where the worker’s gloved
hands may be in contact with sharp instruments, needle tips or sharp
tissues (spicules of bones or teeth) inside a patient’s open body
cavity, wound or confined anatomical space where the hands or
fingertips may not be completely visible at all times.
2.3
Occupational physicians and others who need to make decisions
about the working practices of infected healthcare workers may find
the following examples of UKAP advice helpful. In some cases this
advice may help to clarify matters, and in others it may suggest the
need to seek further specific advice about the individual case under
consideration
Cautionary note
3.1
225
Individual working practices may vary between hospitals and
between healthcare workers. Advice for one healthcare worker may
not always be applicable to another. This list must therefore be
interpreted with caution, as it provides examples only and is not
exhaustive.
4.
The following advice has been given by UKAP in relation to specialities and
procedures. Please note that these are only examples and do not obviate the need
for a full risk assessment at local level, including the procedures likely to be
undertaken by a HCW whose practice is restricted in a particular post; the way in
which they would be performed by that individual; and the context in which they
would operate e.g. colleagues available to take over if an exposure prone procedure
becomes necessary.
5.
Accident and Emergency (A&E)
HIV Infected Health Care Workers: Guidance on Management and Patient Notification.
121
5.1
A&E staff who are restricted from performing EPPs should not
provide pre-hospital trauma care.
5.2
These staff should not physically examine or otherwise handle acute
trauma patients with open tissues because of the unpredictable risk
of injury from sharp tissues such as fractured bones. Cover from
colleagues who are allowed to perform EPPs would be needed at all
times to avoid this eventuality.
5.3
Other EPPs which may arise in an A&E setting would include;
5.3.1 Rectal examination in presence of suspected pelvic fracture,
5.3.2 Deep suturing to arrest haemorrhage,
5.3.3 Internal cardiac massage.
(See also Anaesthetics, Biting, Paramedics and Resuscitation)
5.4
Anaesthetics
5.4.1
Procedures performed purely percutaneously are not
exposure prone, not have endotracheal intubation nor the use
of a laryngeal mask being considered so.
5.4.2
The only procedures currently preformed by anaesthetics
which would constitute EPPs are;
5.4.2.1 The placement of portacaths (very rarely done)
which involves investigating a small pouch
under the skin and may sometimes require
manoeuvres which are not under direct vision,
5.4.2.2 The insertion of chest drains in accident and
emergency trauma cases such as patients with
multiple rib fractures.
5.4.3
The insertion of a chest drain may or may not be considered
to be exposure prone depending on how it is performed.
Procedures where, following a small initial incision, the chest
drain with its internal trochar is passed directly through the
chest wall (as may happen e.g. with a pneumothorax or
pleural affusion) and where the lung is well clear of the chest
wall, would not be exposure prone. However, where a larger
incision is made, and a finger is inserted into the chest cavity,
as may be necessary e.g. with a flail chest, and where the
health care worker could be injured by the broken ribs, the
procedure should be considered exposure prone.
5.4.4
Modern techniques for skin tunnelling involve wire guided
techniques and putting steel or plastic trochars from the entry
site to the exit site where they are retrieved in full version.
Therefore skin tunnelling is no longer considered to be
exposure prone (see also Arterial cutdown).
5.5 Arterial Cutdown
5.5.2
Although the use of more percutaneous techniques has made
arterial or venous cutdown to obtain access to blood vessels
122
an unusual procedure, it may still be used in rare cases.
However, as the operator’s hands are always visible, it should
no longer be considered exposure prone.
5.6 Biting
5.6.2
Staff working in areas posing a significant risk of biting should
not be treated as performing EPPs. In October 2003, UKAP
considered a review of the available literature on the risk of
onward transmission from health care workers infected with
blood-borne viruses to patients. The review showed that the
published literature on this subject is very scarce. In follow-up
studies of incidents involving infected health care workers
working with patients known to be ‘regular and predictable’
biters, there were no documented cases of transmission from
the health care worker to the biter. However, where biters
were infected, there were documented cases of
seroconversion in their victims and the risk of infection was
increased in the presence of;
5.6.2.1 Blood in the oral cavity – risk proportionate to
the volume of blood,
5.6.2.2 Broken skin due to the bite,
5.6.2.3 Bite associated with previous injury i.e. nonintact skin,
5.6.2.4 Biter deficient in anti-HIV salivary elements
(IgA deficient).
5.6.3
Based on the available information, it can only be tentatively
concluded that even though there is a theoretical risk of
transmission of a blood borne virus from an infected health
care worker to a biting patient, the risk remains negligible.
The lack of information may suggest that this has not been
perceived to be a problem to date, rather than that there is an
absence of risk.
5.6.4
The evidence is dynamic and the area will be kept under
review and updated in the light of any new evidence that
subsequently emerges suggesting that there is a risk.
However, it is important for biting incidents to be reported and
risk assessments conducted in accorded with NHS
procedures. Biting poses a much greater risk to health care
workers than to patients. Therefore employers should take
measures to prevent injury to staff, and health care workers
bitten by patients should seek advice and treatment, in the
same way as after a needlestick injury.
5.7 Bone Marrow Transplants
5.7.2
Not exposure prone.
5.8 Cardiology
123
5.8.2
Percutaneous procedures including angiography/cardiac
catheterisation are not exposure prone. Implantation of
permanent pacemakers (for which a skin tunnelling technique
is used to site the pacemaker device subcutaneously) may or
may not be exposure prone. This will depend on whether the
operator’s fingers are or are not concealed from view in the
patient’s tissues in the presence of sharp instruments during
the procedure (see also Arteral cutdown).
5.9 Chiropodists
5.9.2
See Podiatrists.
5.10 Dentistry and orthodontics (including hygienists)
5.10.2 The majority of procedures in dentistry are exposure prone,
with the exception of;
5.10.2.1
Examination using a mouth mirror only,
5.10.2.2
Taking extra-oral radiographs,
5.10.2.3
Visual and digital examination of the
head and neck,
5.10.2.4
Visual and digital examination of the
endentulous mouth,
5.10.2.5
The construction and fitting of full
dentures.
5.10.3 However, taking impressions from dentate or partially dentate
patients would be considered exposure prone, as would the
fitting of partial dentures and fixed or removable orthodontic
appliances, where clasps and other pieces of metal could
result in injury to the dentist.
5.10.4 In general dental practice, procedures which are considered
to be exposure prone usually fall into category 1 or 2.
Hospital-based dental surgery will include category 3
procedures.
5.11 Ear, Nose and Throat Surgery (Otolanyngology)
5.11.2 ENT surgical procedures generally should be regarded as
exposure prone with the exception of simple ear or nasal
procedures, and procedures performed using endoscopes
(flexible and rigid) provided fingertips are always visible. Nonexposure prone ear procedures include sptpedectomy /
stapedoctomy, insertion of ventilation tubes and insertion of a
titanium screw for a bone anchored hearing aid.
5.12 Endoscopy
5.12.2 Simple
endoscopic
procedures
(e.g.
gastroscopy,
bronchoscopy) have not been considered exposure prone. In
general there is a risk that surgical endoscopic procedures
(e.g. cystoscoppy, laparoscopy – see below) may escalate
124
due to complications which may not have been foreseen and
may necessitate an open EPP. The need for cover from a
colleague who is allowed to perform EPPs should be
considered as a contingency (see also Biting).
5.13 General Practice
5.13.2 See Accident and Emergency, Biting, Minor Surgery,
Midwifery/Obstetrics, Resuscitation.
5.14 Gynaecology (see also Laparoscopy)
5.14.2 Open surgical procedures are exposure prone. Many minor
gynaecological procedures are not considered exposure
prone, examples include dilation and curettage (D & C),
suction termination of pregnancy, colposcopy, surgical
insertion of depot contraceptive implants/devices, fitting
intrauterine contraceptive devices (coils), and vaginal egg
collection provided fingers remain visible at all times when
sharp instruments are in use.
5.14.3 Performing cone biopsies with a scalpel (and with the
necessary suturing of the cervix) would be exposure prone.
Cone biopsies performed with a loop or laser would not in
themselves be classified as exposure prone, but if local
anaesthetic was administered to the cervix other than under
direct vision, i.e. with fingers concealed in the vagina, then
the latter would be an exposure prone procedure (category
1).
5.15 Haemodialysis/Haemofiltration
5.15.2 See Renal Medicine
5.16 Intensive care
5.16.2 Intensive care does not generally involve EPPs on the part of
medical or nursing staff.
5.17 Laparoscopy
5.17.2 Mostly non-exposure prone because fingers are never
concealed in the patient’s tissues. Exceptions are, exposure
prone if main trochar inserted using an open procedure, as for
example in a patient who has had previous abdominal
surgery. Also exposure prone if rectus sheath closed at port
sites using J-needle, and fingers rather than needle holders
and forceps are used.
5.17.3 In general there is a risk that a therapeutic, rather than a
diagnostic, laparoscopy may escalate due to complications
which may not have been foreseen necessitating an open
exposure prone procedure. Cover from colleagues who are
125
allowed to perform EPPs would be needed at all times to
cover for this eventuality.
5.18 Midwifery/Obstetrics
5.18.2 Simple vaginal delivery, amniotomy using a plastic device,
attachment of fetal scalp electrodes, infiltration of local
anaesthetic prior to an episiotomy and the use of scissors to
make an episiotomy cut are not exposure prone.
5.18.3 The only EPPs routinely undertaken by midwives are repairs
following episitomies and perineal tears: category 1 in the
case of first degree lacerations; category 2 in the case of
second, third and fourth degree lacerations. Repairs of third
and fourth degree tears are normally undertaken by medical
staff who may include general practitioners assisting at births
in a community setting.
5.19 Minor Surgery
5.19.2 In the context of general practice, minor surgical procedures
such as excision of sebaceous cysts, skin lesions,
cauterization of skin warts, aspiration of bursae, cortisone
injections into joints and vasectomies do not usually
constitute EPPs.
5.20 Needlestick/Occupational Exposure to HIV
5.20.2 Health care workers need not refrain from performing EPPs
pending follow up on occupational exposure to an HIV
infected source. The combined risks of contracting HIV
infection from the source patient, and then transmitting this to
another patient during an exposure prone procedure is so low
as to be considered negligible. However in the event of the
worker being diagnosed HIV positive, such procedures must
cease in accordance with this guidance.
5.21 Nursing
5.21.2 General nursing procedures do not include EPPs. The duties
of operating theatre nurses should be considered individually.
Theatre scrub nurses do not generally undertake EPPs.
However, it is possible that nurses acting as first assistant
may perform EPPs (see also Accident and Emergency, Renal
Medicine/Nursing, and Resuscitation).
5.22 Obstetrics/ Midwifery
5.22.2 See Midwifery/Obstetrics. Obstetricians perform surgical
procedures, many of which will be exposure prone according
to the criteria.
5.23 Operating Department Assistant/Technician
126
5.23.2 General duties do not normally include EPPs.
5.24 Ophthalmology
5.24.2 With the exception of orbital surgery which is usually
performed by maxillo-facial surgeons (who perform many
other EPPs), routine ophthalmological surgical procedures
are not exposure prone as the operator’s fingers are not
concealed in the patient’s tissues. Exceptions may occur in
some acute trauma cases, which should be avoided by EPP
restricted surgeons.
5.25 Optometry
5.25.2 The training and practice of optometry does not requre the
performance of the EPPs.
5.26 Orthodontics
5.26.2 See Dentistry and orthodontics (including hygienists).
5.27 Orthopaedics
5.27.2 Exposure prone procedures;
5.27.2.1
Open surgical procedures,
5.27.2.2
Procedures involving the cutting of
fixation of bones, including the use of K-wire
fixation and osteotomies,
5.27.2.3
Procedures involving the distant
transfer of tissues from a second site (such as
in a thumb reconstruction),
5.27.2.4
Acute hand trauma,
5.27.2.5
Nail avulsion of the toes for in-growing
toenails and Zadek’s procedure (this advice
may not apply to other situations such as when
nail avulsions are performed by podiatrists).
5.27.3 Non-exposure prone procedures;
5.27.3.1
Manipulation of joints with the skin
intact,
5.27.3.2
Arthroscopy, provided that if there is
any possibility that an open procedure might
become necessary, the procedure is
undertaken by a colleague able to perform the
appropriate open surgical procedure,
5.27.3.3
Superficial surgery involving the soft
tissues of the hand,
5.27.3.4
Work on tendons using purely
instrumental tunnelling techniques that do not
involve fingers and sharp instruments together
in the tunnel,
127
5.27.3.5
Procedures
for
secondary
reconstruction of the hand, provided that the
operator’s fingers are in full view,
5.27.3.6
Carpal tunnel decompression provided
fingers and sharp instruments are not together
in the wound,
5.27.3.7
Closed reductions of fractures and
other percutaneous procedures.
5.28 Paediatrics
5.28.2 Neither general nor neonatal/special care paediatrics has
been considered likely to involve any EPP’s. Paediatric
surgeons do perform EPPs (see also Arterial cutdown).
5.29 Paramedics
5.29.2 In contrast to other emergency workers, a paramedic’s
primary function is to provide care to patients. Paramedics do
not normally perform EPPs. However, paramedics who would
be restricted from performing EPPs should not provide prehospital trauma care. This advice is subject to review as the
work undertaken by paramedics continues to develop (see
also Accident and Emergency, Biting and Resuscitation).
5.30 Pathology
5.30.2 In the event of an injury to an EPP restricted pathologist
performing a post mortem examination, the risk to other
workers handling the same body subsequently is so remote
that no restriction is recommended.
5.31 Podiatrists
5.31.2 Routine procedures undertaken by podiatrists who are not
trained in and do not perform surgical techniques are not
exposure prone. Procedures undertaken by podiatric
surgeons include surgery n nails, bones and soft tissue of the
foot and lower leg, and joint replacements. In a proportion of
these procedures, part of the operator’s fingers will be inside
the wound and out of view, making them EPPs (see also
Orthopaedics).
5.32 Radiology
5.32.2 All percutaneous procedures, including imagining of the
vascular tree, biliary system and renal system, drainage
procedures and biopsies as appropriate, are not EPPs (see
also Arterial cutdown).
5.33 Renal Medicine
5.33.2 The 2002 guidance stated, “obtaining vascular access at the
femoral site in a distressed patient may constitute an
128
exposure prone procedure as the risk of injury to the HCW
may be significant.” There have since been technological
advances in the way venous access is obtained, including in
renal units. In procedures performed now, the operator’s
fingers remain visible all the time during the procedure.
Therefore these procedures are not exposure prone and
neither haemofiltration nor haemodialysis constitute EPP.
5.33.3 The working practices of those staff who supervise
haemofiltration and haemodialysis circuits do not include
EPPs. (Different guidance applies for hepatitis B infected
health care workers.)
5.34 Resuscitation
5.34.2 Resuscitation performed wearing appropriate protective
equipment does not constitute an EPP. The Resuscitation
Council (UK) recommends the use of a pocket mask when
delivering cardio-pulmonary resuscitation. Pocket masks
incorporate a filter and are single use.
5.35 Surgery
5.35.2 Open surgical procedures are exposure prone. This applies
equally to major organ retrieval because there is a very small,
though remote, risk that major organs retrieved for transplant
could be contaminated by a health care worker’s blood during
what are long retrieval operations while the patient’s
circulation remains intact. It is possible for some
contaminated blood cells to remain following pretransplantation preparatory procedures and for any virus to
remain intact since organs are only chilled to 10 degrees C.
(see also Laparoscopy, Minor Surgery).
5.35.3
5.36 Volunteer health care workers (including first aid)
5.36.2 The important issue is whether or not an infected health care
worker undertakes EPPs. If this is the case, this guidance
should be applied, whether or not the health care worker is
paid for their work.
129
Annex B
PROTOCOL FOR THE INVESTIGATION OF HEALTH CARE WORKERS WHO PERFORM
EXPOSURE PRONE PROCEDURES AND WHO ARE APPARENT NONRESPONDERS TO
HEPATITIS B VACCINE
When a blood sample is taken for determining post-immunisation anti-HBs levels, occupational
health physicians or appropriate members of staff supervising the immunisation programme may
wish to obtain consent from the health care worker to proceed with tests for markers of hepatitis B
infection if necessary. If consent was not obtained at this stage, it should be obtained before further
testing is undertaken.
Post-immunisation testing
Assay anti-HBs response.
Those with anti-HBs levels at 2-4 months post vaccination of less than 10 miu/ml are considered
apparent non responders.
All apparent non responders should be tested for HBsAg as soon as possible after the anti-HBs
result becomes available. IF HBsAg POSITIVE PROCEED TO PARAGRAPH 6 BELOW.
In HBsAg negative subjects only, anti-HBc should then be determined. HBsAg negative subjects
who are also anti-HBc negative are true non responders and should be considered for booster
doses or a second course of vaccine. HBsAg negative subjects who are anti-HBc positive will have
been exposed to hepatitis B virus some time in the past and have naturally acquired immunity.
Investigation of HBsAg positive health care workers
Health care workers found to be HBsAg positive should cease to perform exposure prone
procedures until their e-antigen status is established.
All HBsAg positive health care workers should be tested further for e-markers. This should be
carried out as a matter of urgency. Sera for e-markers should be sent to at least two different
laboratories and tested by a different assay in each laboratory. Alternatively sera may be sent to
the Virus Reference Division, Central Public Health Laboratory which will arrange for confirmation
of its e-marker results in another expert laboratory as appropriate.
The results of e-marker tests should be verified by testing a second serum sample from the health
care worker to exclude the possibility of mis-identification of specimens.
A decision about the need for long term restriction of working practices should await full
confirmation of e-antigen status from both laboratories and results of tests for anti-HBcIgM, the
latter to distinguish between acute infection and carriage. Those found to be anti-HBcIgM positive
will require follow up and appropriate testing to check for resolution of their infection, which could
be expected in the majority of cases.
If doubt exists about a workers e-marker status after results from two laboratories have been
obtained, specialist virological advice should be sought.
This protocol is summarised in the flow chart below.
130
INVESTIGATION OF HEALTH CARE WORKERS WHO PERFORM EXPOSURE PRONE
PROCEDURES AND WHO SHOW NO RESPONSE TO HEPATITIS B IMMUNISATION
Assay anti -HBs
Anti-HBs
>10 miu/ml
= Immune
Anti-HBs
<10 miu/ml
= no response to vaccine
131
Test for HBsAg
HBsAg positive
= current infection with HBV
HBsAg Negative
Test for e-Markers
and anti-HBcIgM 226
Test for anti-HBc
It is currently recommended that
that tests for HBeAg and anti
HBe should be carried out in two
different laboratories each using
a different assay. Alternatively
sera may be sent to the Virus
Reference Division, Central
Public Health Laboratory.
HBeAg positive
High infectivity
Exclude from
exposure prone procedures
226
HBsAg negative
and anti HBc =
naturally acquired immunity
anti-HBc negative
= true vaccine
non-responder
HBeAg negative and anti-HBE negative
Anti-HBE positive
Assay of anti -HBc IgM will differentiate between acute hepatitis B and the chronic carrier state
134
Annex C
PROTOCOL FOR THE INVESTIGATION OF HEALTH CARE WORKERS WHO PERFORM
EXPOSURE PRONE PROCEDURES AND WHO HAVE NOT YET BEEN IMMUNISED
Occupational health physicians or appropriate members of staff supervising the immunisation
programme will need to obtain consent from the health care worker to test for markers of hepatitis
B infection.
Testing health care workers required to perform exposure prone procedures who
have not yet been immunised
Test for HBsAg.
If HBsAg negative initiate or complete immunisation. Response to vaccine should then be tested in
accordance with Annex B. IF HBsAG POSITIVE PROCEED TO PARAGRAPH 4.
Investigation of HBsAg positive health care workers
Health care workers found to be HBsAg positive should cease to perform exposure prone
procedures until their e-antigen status is established.
All HBsAg positive health care workers should be tested further for e-markers. This should be
carried out as a matter of urgency. Sera for e-markers should be sent to at least two different
laboratories and tested by a different assay in each laboratory. Alternatively sera may be sent to
the Virus Reference Division, Central Public Health Laboratory which will arrange for confirmation
of its e-marker results in another expert laboratory as appropriate.
The results of e-marker tests should be verified by testing a second serum sample from the health
care worker to exclude the possibility of mis-identification of specimens.
A decision about the need for long term restriction of working practices should await full
confirmation of e-antigen status from both laboratories and results of tests for anti-HBcIgM, the
latter to distinguish between acute infection and carriage. Those found to be anti-HBcIgM positive
will require follow up and appropriate testing to check for resolution of their infection, which could
be expected in the majority of cases.
If doubt exists about a workers e-marker status after results from two laboratories have been
obtained, specialist virological advice should be sought. This protocol is summarised in the flow
chart below.
135
INVESTIGATION OF HEALTH CARE WORKERS WHO PERFORM EXPOSURE PRONE
PROCEDURES AND WHO HAVE NOT YET RECEIVED HEPATITIS B IMMUNISATION
Obtain consent to test for anti-HBs, HBsAg and where appropriate, hepatitis B e-markers.
Test for HBsAg
HBsAg positive
= current infection
with HBV
HBsAg Negative
Immunise
Investigate
response
(See Annex A)
Test for e-markers
and anti-HBcIgM 227
It is currently recommended that
that tests for HBeAg and anti
HBe should be carried out in two
different laboratories each using
a different assay. Alternatively
sera may be sent to the Virus
Reference Division, Central
Public Health Laboratory.
HBeAg positive
High infectivity
Exclude from
exposure prone procedures
227
HBeAg and anti-HBE negative
Anti-HBE positive
Assay of anti-HBcIgM will differentiate between acute hepatitis B and the chronic carrier state
136
Bibliography
1. Protecting Health Care worker and Patients from Hepatitis B. Health service Guidelines.
DoH, 1993
2. Protecting Health Care worker and Patients from Hepatitis B: Recommendations of the
Advisory Group on Hepatitis. DoH, 1993
3. Ventilation in Healthcare Premises, HTM 2025. NHS Estates, 1994.
4. Clostridium Difficile Infection: Prevention and Management: A Report by the joint DH/PHILs
Working Group,1994
5. Hospital Infection Control, HSG (95). DoH, 1995
6. Good Practise Guide: Sterilization. HTM 2010. NHS Estates, 1995
7. Addendum to: Protecting Health Care worker and Patients from Hepatitis B. Health service
Guidelines. DoH, 1996
8. Addendum to: Protecting Health Care worker and Patients from Hepatitis B. Health service
Guidelines. NHS Executive,1996
9. Management and Control of Viral Haemorrhagic Fevers. Advisory Committee on
Dangerous Pathogens, 1996
10. Healthcare Waste Management: Segregation of Waste Streams in Clinical Areas. HTM
2065. NHS Estates, 1997
11. Washer-disinfectors. Operational management. HTM 2030.NHS Estates, 1997
12. Clean Steam for Sterilization. HTM 2031. NHS Estates,1997
13. Revised Guidelines for the Control of Methicillin-Resistant Staphylococcus Aureus Infection
in Hospitals, DoH (Category I and II recommendations) 1998 (NB see ‘71’, below)
14. Guidance for Clinical Health Care Workers: Protection against Infection with Blood-Borne
Viruses. DoH, 1998
15. Guidelines for Optimal Surveillance of Clostridium Difficile Infection in Hospitals.
Communicable Disease and Public Health, 1998
16. The Prevention and Control of Tuberculosis in the United Kingdom: UK Guidance on the
Prevention and Control of 1. HIV-related TB, 2. Drug-resistant, including multiple drugresistant TB. 1998
17. Health Service Circular. “Variant Creutzfeldt-Jakob Disease: Minimising the risk of
Transmission”. DoH,1999
18. Health service Circular. “Controls assurance in Infection Control: Decontamination of
Medical Devices”. 1999
19. Management of hospital outbreaks of gastro-enteritis due to small round structured viruses.
HPA, 2000
137
20. Hepatitis B Infected Health Care Workers. Guidance on Implementation of Health Service
Circular 2000/020. 2000
21. Control and prevention of tuberculosis in the United Kingdom: Code of Practice 2000
22. Health Service Circular. “Decontamination of medical devices” .DoH 2000
23. The Control of Legionella; Revised Approved Code of Practise. Health and Safety
Executive, 2000
24. Department of Health: The Epic Project: Developing National Evidence-Based Guidelines
for Preventing Healthcare Associated Infections. 2001
25. Getting Ahead of the Curve. A Strategy for combating infectious diseases. DoH 2002
26. The Control of Substances Hazardous to Health Regulations, 2002
27. COSHH: A brief guide to the regulations: What you need to know about the COSHH
Regulations 2002
28. Health Service Circular. “Hepatitis C Infected Health Care Workers”. August 2002
29. Hepatitis C Infected Health Care Workers: Guidance on Implementation of Health Service
Circular. DoH, 2002
30. Infection Control in the Built Environment: Design and Planning. NHS Estates, 2002
31. Decontamination of Endoscopes. Device Bulletin. MDA, 2002
32. Bench Top Sterilizers – Guidance on purchase, Operation and Maintenance. Device
Bulletin. MDA, 2002
33. Good Practise Guidelines for Renal dialysis/transplantation units: prevention and control of
blood-borne virus infection. DoH, 2002
34. Department of Health: Winning Ways – Working Together to Reduce Hospital Associated
Infection in England. Report from the Chief Medical Officer. DoH 2003
35. Health and Safety Regulation. A Short Guide. HSE 2003
36. A Guide to the Decontamination of Reusable Surgical Instruments. NHS Estates, 2003
37. National Standards- Local Delivery, a Strategy for Modernising the Provision of
Decontamination Services. NHS Estates, 2003
38. NICE Guidelines: Infection Control – Prevention of Healthcare-Associated Infection in
Primary and Community Care. NICE 2003
39. Examples of Good and bad Practise in Avoiding Sharps Injuries. HPA, 2003
40. Surveillance of Healthcare Associated Infections. DoH PL CMO, 2003
41. National Clostridium Difficile standards Group Report to the DoH. HPA,2003
138
42. Safe Working and the Prevention of Infection in the Mortuary and Post-Mortem Room.
Health and Safety Executive, 2003
43. Revised National Standards of Cleanliness for the NHS, April 2004
44. Competencies for Directors of Infection Prevention and Control. DoH May 2004
45. Audit Tools for monitoring infection control standards. ICNA 2004
46. Towards Cleaner Hospitals and lower rates of infection. A Summary of Action. DoH 2004
47. A Matron’s Charter: An Action Plan for Cleaner Hospitals. DoH, 2004
48. Standards for Better Health. DoH 2004
49. Revised Guidance on Contract Cleaning. NHS Estates, 2004
50. Patient Safety Alert 2: Alcohol Hand Rub. NPSA September 2004
51. Health Building Notes: Sterile Services Department NHS Estates, 2004
52. Updating the evidence-base for national evidence-based guidelines for preventing
healthcare-associated infections in NHS hospitals in England: a report with
recommendations. The epic project, 2004
53. Stopping Tuberculosis in England – An Action Plan from the Chief Medical Officer. DoH,
2004
54. Preventing person-to Person Spread Following Gastrointestinal Infections: Guidelines for
public Health Physicians and Environmental health Officers. HPA, 2004
55. Control of Substances Hazardous to Health Regulations 2004
56. Saving Lives. NHS Modernisation Agency. DoH, June 2005
57. Good Practice in Infection Prevention and Control. RCN, 2005
58. The management of health, safety and welfare issues for NHS staff (“the Blue Book”). 2005
59. Immunisation against infectious disease (“The Green Book”). Chapter 15: Hepatitis B. DoH,
2005
60. HIV Infected Health Care Workers: Guidance on Management and Patient Notification.
Department of Health. July 2005
61. Biological Agents: Managing the Risks in Laboratories and Health Care Premises. Health
and Safety Executive, 2005
62. Mandatory Surveillance of Methicillin Resistant Staphylococcus Aureus (MRSA)
Bacteraemias, DoH PL CMO, 2005
63. Guidelines for the Laboratory Diagnosis and Susceptibility Testing of Methicillin-Resistant
Staphylococcus Aureus (MRSA). Journal of Antimicrobial Chemotherapy, 2005
139
64. Transmissible spongiform encephalopathy agents: Safe Working and the Prevention of
Infection. Guidance from the Advisory Committee on Dangerous Pathogens and the
Spongiform Encephalopathy Advisory Committee. DoH, 2005
65. Interim Working Party Guidance on the Control of Multi-resistant Acinetobacter Outbreaks.
HPA, 2005
66. UK Health Departments’ UK Influenza Pandemic Contingency Plan. DoH,2005
67. Guidance for Pandemic Influenza: Infection Control in Hospitals and Primary Care Settings.
DoH, 2005
.
68. Essential Steps to Safe, Clean Care: Reducing health care associated infection (HCAI)
including MRSA. DoH 2006
69. Dangerous Goods Transport. Department for Transport, 2006
70. Transport of Infectious substances. A Guidance Document produced by the Department for
Transport, the Civil Aviation Authority and the Maritime and Coastguard Agency, 2006
71. Guidelines for the control and prevention of Meticillin-resistant Staphylococcus Aureus
(MRSA) in healthcare facilities. – Journal of Hospital Infection, 2006
72. Sterilization, Disinfection and Cleaning of Medical Equipment: Guidance on
Decontamination. Microbiology Advisory Committee to Department of Health, Medical
Devices Agency, 2006
73. Code of Practice for the Prevention and Control of Health Care Associated Infection,
October 2006
74. Medical Devices and Medicinal Products. MHRA, 2006
75. Guidelines for the Prophylaxis and treatment of Methicillin-Resistant Staphylococcus
Aureus (MRSA) Infections in the UK. Journal of Antimicrobial Chemotherapy, 2006
76. Safe Practice in Renal Medicine. DoH 2006
77. PL/CMO/2006/4: Screening for MRSA colonisation: a summary of best practice, 2006
78. Safe Management of Healthcare Waste. DoH 2006
79. CNST General Clinical Risk Management Standards to 2008
80. Glycopeptide Resistant Enterococci (GRE) –Questions and Answers. HPA
81. PL CMO (2007)4: Changes to the mandatory healthcare associated infection surveillance
system for Clostridium difficile associated diarrhoea. DoH April 2007.
82. Healthcare Associated Infection: What else can the NHS do? Healthcare Commission July
2007
83. PL/CMO/2007/6 – Enhanced C.Difficile infection surveillance system.
84. Clean Safe Care: Reducing infections and saving lives
140
141
142