Universal/Standard Infection Control Precautions
Universal/Standard Infection Control Precautions Reference Number: 622 Author & Title: Yvonne Pritchard Senior Infection Prevention and Control Nurse Responsible Director: Director of Nursing Review Date: 19 December 2017 Ratified by: Helen Blanchard Director of Nursing and Midwifery Director of Infection Prevention and Control Date Ratified: 19 December 2014 Version: 2.0 Related Policies and Guidelines Antibiotic Resistant Micro-organisms Policy Aseptic Non Touch Technique Policy Blood Borne Virus Policy Clostridium difficile Policy Hand Decontamination Policy Isolation Policy Influenza A, Control and treatment of Linen Policy Diarrhoea and /or Vomiting Policy, Management of Waste policy, Management and disposal of Sharps Policy Meningitis Policy MRSA Policy Scabies Policy Skin Management, Protective Gloves and Latex Sensitivity Policy Tuberculosis Policy Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.: 622 Status: Final Page 1 of 26 Index: 1. Policy Summary _______________________________________________ 4 2. Policy Statements _____________________________________________ 4 3. Definition of Terms Used _______________________________________ 4 4. Duties and Responsibilities _____________________________________ 5 4.1. Chief Executive___________________________________________________ 5 4.2. Director of Infection Prevention Control (DIPC) ________________________ 5 4.3. Infection Prevention and Control Team _______________________________ 5 4.4. Consultants, Managers/Matrons and Senior Sisters ____________________ 5 4.5. All staff _________________________________________________________ 6 5. Universal Standard Infection Control Precautions ___________________ 7 5.1. Risk assessment _________________________________________________ 7 5.2. Hand decontamination_____________________________________________ 7 5.3. Personal protective equipment ______________________________________ 8 5.4. Gloves __________________________________________________________ 9 5.5. Disposable aprons and gowns _____________________________________ 10 5.6. Blood/body fluid spillage__________________________________________ 13 5.7. Waste disposal __________________________________________________ 14 5.8. Segregation of waste _____________________________________________ 14 5.9. Sharps _________________________________________________________ 15 5.10. Inoculation (Sharps) injury ____________________________________ 15 5.11. Preventing inoculation injury __________________________________ 15 5.12. Linen disposal ______________________________________________ 16 5.13. Pathology specimens_________________________________________ 16 5.14. Decontamination of equipment _________________________________ 17 5.15. Last offices _________________________________________________ 17 5 Monitoring Compliance ________________________________________ 18 6 Review _____________________________________________________ 19 7 Training_____________________________________________________ 19 8 References __________________________________________________ 20 Appendix 1: Risk assessment Guide for Selection of Protective Equipment based on risk of Exposure to Blood or Body Fluid ______________________ 21 Appendix 2: Moments for Hand Hygiene ____________________________ 22 Appendix 3: Guidance for the Selection of Masks ______________________ 23 Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.: 622 Status: Final Page 2 of 26 Document Control Information ______________________________________ 24 Ratification Assurance Statement _____________________________________ 24 Consultation Schedule _______________________________________________ 25 Equality Impact: (A) Assessment Screening ____________________________ 26 Amendment History Issue Status 1.0 Approved Date April 2011 Reason for Change Re-ratification 2.0 Dec 2014 Review and Update Approved Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Authorised Operational Governance Committee Helen Blanchard – Director of Nursing Ref.: 622 Status: Final Page 3 of 26 1. Policy Summary Universal/standard precautions are the practices that must be adopted by all healthcare workers (HCWs) when potentially coming into contact with any patient’s blood, tissue or body fluid. They are based on a set of principles designed to minimise exposure to and transmission of a wide variety of micro-organisms. Since every patient is a potential infection risk it is essential that universal/standard precautions are used for all patients all of the time. The purpose of this policy is to provide guidance for staff within the Royal United Hospitals Bath NHS Foundation Trust about the requirements and processes for implementing universal/standard Infection Control Precautions. There are a number of key elements to universal/standard control precautions, all of which when appropriately implemented are designed to reduce the risk of transmission of micro-organisms. The application of transmission based precautions when patients are managed with known infections will support the prevention of the spread of healthcare associated infections. This policy applies to all individuals in the employ of the Royal United Hospitals Bath NHS Foundation Trust. 2. Policy Statements Universal/standard precautions are fundamental in reducing the spread of infection. The precautions are effective in reducing the risk of transmission of infection to patients, staff and visitors. Staff must follow the guidance within this policy to ensure that patient safety is maintained at all times and that members of staff are also not put at risk of acquiring an infection whilst working within the Trust. 3. Definition of Terms Used Universal/standard precautions underpin all infection prevention and control practice. The precautions must be used for all patients whether they are known to have an infection or not. Universal/standard precautions are a collection of essential practices that when used together will reduce the risk of patients, visitors and staff from developing transmissible infections. Personal protective equipment (PPE) is the equipment that must be worn by HCWs to protect patients and staff against the risk of infection. Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.: 622 Status: Final Page 4 of 26 4. Duties and Responsibilities All staff have a responsibility for ensuring that the principles outlined within this document are universally applied. The key organisational responsibilities are identified as: 4.1. 4.2. 4.3. 4.4. Chief Executive To ensure that infection prevention and control is a core part of clinical governance and patient safety programmes Promote compliance with infection prevention and control policies in order to reduce health care associated infections Awareness of legal responsibilities to identify, assess and control risk of infection Appoint Director of Infection Prevention and Control Director of Infection Prevention Control (DIPC) Oversee infection prevention and control policies and their implementation Responsible for infection prevention and control team Report directly to the Chief Executive and Trust Board Challenge inappropriate hygiene and infection prevention and control practice Assess impact of plans / policies on infection control Member of clinical governance and patient safety structures Infection Prevention and Control Team Review and update this policy Provide additional advice regarding the application of this policy within clinical areas. Include universal/standard precautions in all induction and update training for clinical staff Promote good practice and challenge poor practice Consultants, Managers/Matrons and Senior Sisters Must establish a cleanliness culture across their units and promote compliance with infection control guidelines Ensure that staff attend infection prevention and control training as per the training matrix Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.: 622 Status: Final Page 5 of 26 4.5. All staff The employee has a responsibility to carry out risk assessments and use the appropriate equipment provided Employees are responsible for ensuring that any breach of this policy is immediately reported to their manager All clinical staff must attend the mandatory Infection Prevention and Control update at two yearly intervals Clinical staff have a responsibility towards the safer working practices of their colleagues or co-workers such as students or trainees under their supervision Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.: 622 Status: Final Page 6 of 26 5. Universal Standard Infection Control Precautions 5.1. Risk assessment Implementation of universal/standard precautions is dependent on an initial risk assessment of the patient, the task being undertaken and the situation. All body fluids may pose a risk of transmission of micro-organisms. Staff must select the appropriate protective equipment. The Risk assessment guide for selection of protective equipment based on risk of exposure to blood or body fluid: Appendix 1 will support staff in assessing the risk of contamination to the healthcare workers clothing and skin by the patient’s blood, body fluids, secretions and excretions. Additional precautions Where a patient is known to have a specific infection or colonisation then reference to specific Infection Control Policy is recommended for additional precautions: Antibiotic resistant micro-organisms Blood borne viruses Carbapenemase producing Enterbacteriaceae (CPE) Chicken pox or shingles Clostridium difficile Meningitis Meticillin resistant Staphylococcus aureus (MRSA) Influenza Scabies Transmissible Spongiform Encephalopathy Agents Including CJD and vCJD Tuberculosis Viral diarrhoea and vomiting 5.2. Hand decontamination Regular hand hygiene must be highlighted as one of the most critical interventions to prevent cross infection in healthcare facilities (Damani 2012). All employees must receive training in the appropriate hand hygiene techniques on induction into the Trust. Ongoing assessment and training of the techniques are undertaken as part of the Trust’s mandatory infection control updates for employees working in clinical settings at two yearly intervals. The RUH embraces the ‘Five Moments for Hand Hygiene’ Appendix 2 ( WHO 2009), aiming to link specific hand hygiene actions to specific infectious outcomes in patients, by giving clear advice on how to integrate hand hygiene into the complex task of care Appendix 2. Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.: 622 Status: Final Page 7 of 26 Bacteria and viruses cannot penetrate intact skin. It is vital to maintain skin in a good condition and prevent cracking, chapping and drying of the skin. Moisturiser is available in all clinical areas to maintain skin moisture. Staff must inform their line manager if their hands become sore or cracked. Hand decontamination using liquid soap and water The following activities are examples of when hands must be washed using detergent and water: Whenever hands are visibly dirty After removal of gloves Following any handling of blood or body fluids After any microbial contamination (e.g. wound examination, wound dressing, sputum aspiration etc) Before performing an aseptic procedure Before preparing, handling or eating food After visiting the toilet After patient toileting After handling laundry After dealing with patients symptomatic with diarrhoea and vomiting This is not an exhaustive list. Hand decontamination using alcohol based gel or solution The following activities are examples of when alcohol based gel or solution can be used on socially clean hands: Prior to and following examination of a patient Prior to handling patient equipment On entering and leaving the clinical environment Between social patient contact e.g. ward rounds Before entering and leaving an isolation room or area Before and after transfer of patients from / bed/ chair/ trolley This is not an exhaustive list. Refer to Hand Decontamination Policy. 5.3. Personal protective equipment Personal Protective Equipment (PPE) is additional to normal clothing and uniforms and is used to protect both the patient and health care worker from the risk of cross infection. PPE should be available for all staff and may include aprons and fluid repellent gowns/suits, gloves (sterile and non-sterile latex free), masks and eye protection (goggles and face visors). The use and selection of PPE is based on the assessed risk of the clinical intervention to be undertaken i.e. identify the likelihood and level of risk associated with contamination by blood and/or body fluids. Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.: 622 Status: Final Page 8 of 26 Under Health and Safety legislation the Trust has a responsibility to ensure that staff have access to appropriate PPE and staff have a responsibility to use PPE in appropriate situations (Health & Safety Executive 1999). 5.4. Gloves The use of gloves can reduce the risk of acquiring infection through direct skin contact between HCW and patients. Gloves should not be worn unnecessarily or as a substitute for hand decontamination as prolonged and indiscriminate use may cause adverse reactions and skin sensitivity (WHO 2009). Gloves are a single use item Gloves can reduce the likelihood of contact dermatitis in staff exposed to chemical agents Gloves must be worn when direct contact with contact with blood, body fluids, non-intact skin or mucus-membranes is anticipated Gloves must be changed between patients and different procedures on the same patient Gloves must not be worn when using computer keyboards, answering the phone, writing in patient’s care records or serving meals Gloves must be disposed of in an orange clinical waste bin Hands must be decontaminated with soap and water immediately on removal of gloves Indications for wearing gloves: Venepuncture Wound inspection Cannula insertion Aseptic Non Touch Technique Emptying urinary catheter bags/stoma bags Cleaning soiled equipment Cleaning the clinical environment IV drug administration Invasive procedures Contact with body fluids Surgical procedures – use sterile gloves This is not an exhaustive list. Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.: 622 Status: Final Page 9 of 26 Sterile gloves Sterile gloves reduce the likelihood of transmission of microorganisms from the health care worker’s hands to the patient during sterile and invasive procedures (Damani 2012). Training on the correct procedure for donning and removing sterile gloves must be provided for staff to prevent the contamination of the outer surface of the glove and the hands. Gloves and latex allergy The standard gloves in use within the Trust are latex free however some staff may develop sensitivity to other components within the gloves. If a healthcare worker has a latex allergy or sensitivity to specific chemicals in gloves, they must report this to their line manager and seek advice from the Occupational Health Department. Where a patient is known to be allergic to latex staff must ensure that latex free gloves are used. Refer to Skin Management, Protective Gloves and Latex Sensitivity Policy Storage of gloves Gloves can be damaged if they are stored in adverse conditions. To ensure that integrity is not affected they must be stored away from direct sunlight, excessive heat, humidity and moisture. Gloves can also be affected by x-ray machines, high intensity fluorescent lights and ultraviolet lights. If a box has been opened and stored in a room with an infected patient the gloves will be exposed to contamination with microorganisms so it is vital that unused gloves are disposed of once the patient has been discharged. 5.5. Disposable aprons and gowns Disposable plastic aprons or gowns must be worn to reduce the level of contamination of uniforms/clothing where direct patient care is given and there is potential for the dispersal of pathogens. The type of apron or gown to be worn depends on an assessment of risk of contact with body fluids. Such activities may include: Assisting patients with toileting Bathing Changing soiled linen Procedures causing splashing of body fluids or blood This is not an exhaustive list. Aprons: Must be worn where there is a risk of blood or body fluid contamination of the uniform/clothing Must be changed between patients and different procedures on the same patient The apron must be disposed in an orange clinical waste bin. as clinical waste Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.: 622 Status: Final Page 10 of 26 May be worn for decontamination activities, including cleaning and disinfection Non-sterile impermeable water repellent gowns are worn: where there is a likelihood of splashing with large amounts of blood or body fluids where there is a likelihood of prolonged contact with patients who have multiresistant microorganisms, e.g. Carbapenemase producing Enterobacteriaceae (CPE) when providing care for a patient with possible viral haemorrhagic fever Like aprons gowns must be removed and replaced after each episode of care or task and disposed of as clinical waste. Sterile water-impervious gowns protect patients from infection where they are undergoing surgical or aseptic procedures such as insertion of central venous catheters. Disposable coveralls Disposable coveralls may be used if there is a risk of contamination from chemicals or when providing care for a patient with possible/confirmed viral haemorrhagic fever. Careful attention must be paid when donning and doffing coveralls as there is a risk that the clothing beneath the suit may become contaminated. Staff must consult local procedural documents and have received local training on wearing the suits before using them. Eye protection Mucous membranes of the eyes and mouth must be protected when there is a risk of splashes, droplets or aerosols of blood or body fluids. Eye protection may be achieved through the use of goggles, visors or face shields. They must be comfortable to wear, fit correctly and allow for clear vision. Where possible single use eye protection should be used and this must be disposed of as clinical waste. If reusable equipment is used it must be decontaminated appropriately and stored in a clean environment. Eye protection must be worn for one episode of care only. Eye protection must be available in all areas especially those where splashes are more likely, e.g. Emergency Department, Endoscopy, Theatres, Central Delivery Suite, Critical Care Unit. Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.: 622 Status: Final Page 11 of 26 Masks and respirators Masks are worn to protect the wearer from potential exposure to micro-organisms via splashes of blood or body fluid. The use of a mask must be based on an assessment of risk of body fluid exposure. Staff may select a face mask or respirator depending on the level of protection required. Refer to Guidance for the selection of masks: Appendix 3 Masks are rarely worn in general ward environments. Surgical face masks protect the wearer from expelling droplets (>0.5 microns) into the environment. If the mask is fluid resistant, the wearer will be protected from splashes. Respirators are made to specific standards EN 149 2001, FFP2, FFP3. Respirators are worn to protect the healthcare worker from airborne particles (<0.5microns) such as viruses. Staff must receive training in the correct application of these masks to ensure their efficacy. Guidance for the selection of masks Selection of the appropriate mask is required to ensure protection is adequate. Where a mask is required it should be applied prior to entering the isolation room Masks must be worn correctly and be close fitting Masks must be handled as little as possible Masks must be changed between operations or patients Masks must be changed if wet Discard masks immediately after removal into an orange clinical waste bin Hands must be washed on removal of mask Guidance for the selection of masks: Appendix 3. Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.: 622 Status: Final Page 12 of 26 5.6. Blood/body fluid spillage Protective clothing, e.g. gloves and apron, must be worn when dealing with blood/body fluid spillage. The area must be made safe to prevent further contamination and protect staff and patients. Blood/body fluid spillage can be divided into groups: Soiling of equipment or where it is not practicable to use a hypochlorite powder e.g. splashes and drips Spillage on the floor or a large surface area Methods to clean up blood spills Splashes and drips Use PPE: gloves and apron Wipe the area immediately with a paper towel soaked sodium hypochlorite solution e.g. Actichlor Plus® 10,000 ppm (10 x 1.7g tablet in one litre of cold water) Discard gloves and paper towel as clinical waste using an orange waste bag Wash hands with soap and water and dry hands immediately Larger spills Use PPE: gloves and apron Sprinkle the spill with NaDCC (a solid form of hypochlorite) granules e.g. Titian Sanitizer™ until the fluid is absorbed. Leave the spill for a contact period of about 3-5 minutes to allow for disinfection. Either scoop up the granules and any paper towels used and discard into an orange clinical waste bag Wipe the area immediately with a paper towel soaked sodium hypochlorite solution e.g. Actichlor Plus® 10,000 ppm (10 x 1.7g tablet in one litre of cold water) Discard gloves and paper towel as clinical waste using an orange waste bag Wash hands with soap and water and dry hands immediately Body fluids, eg vomit, urine, faeces Use PPE, wear gloves and apron Clear away spillage with paper roll Wash area with detergent and water using paper roll Dispose of used paper roll in an orange clinical waste bin Dispose of PPE in an orange clinical waste bin Decontaminate hands using soap and water Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.: 622 Status: Final Page 13 of 26 5.7. 5.8. Waste disposal Waste bins/bags must be of the appropriate UN-approved type, colour, size Adequate supplies of waste bags/bins must be available to ensure that waste segregation is able to take place correctly Waste bag holders are fire-proof, leak-proof, foot pedal operated, secure, well-maintained and clean Signs and notices must be displayed to ensure that staff can quickly refer to correct information about segregation of waste and the correct container to use Waste bins and other containers must be kept clean Segregation of waste All waste is to be segregated at the point of use. The most common waste categories are: Orange bag: potentially infectious clinical waste Tiger striped bags: disposal of offensive non-infected waste Yellow bag: Diagnostic specimens from permitted areas only Sharps bins: yellow lidded sharps bins take standard clinical sharps including sharps contaminated with medicines; purple lidded bins take sharps contaminated with cytotoxic/cytostatic substances Yellow burn bins: Recognisable anatomical waste, drugs for incineration must go in separate burn bin (refer to waste policy) Black bags, General non-recyclable and non-hazardous waste Clear plastic bags: Waste for recycling i.e. paper, cans, plastic bottles and containers, separated and put into tied, clear plastic bags & flattened cardboard, loosely loaded Hazardous Waste (e.g. solvents and chemicals, aerosols, gas cartridges, chemicals, oils, batteries, inkjet and toner cartridges, tyres, fluorescent tubes and compact fluorescent lights (CFLs), mercury, sodium lamps, waste electrical and electronic equipment (WEEE) Orange clinical waste bags and ‘tiger striped’ bags must be closed using the ‘swan necked’ method and tied with a coded zip tie. Only staff that have been trained and are aware of the correct procedure should be involved in the handling of clinical waste. Sharps bins must be kept separate from other clinical waste and MUST NOT be put into clinical waste bags. Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.: 622 Status: Final Page 14 of 26 In order for waste to be traced back to the point of generation: Sharps bins must have the front label fully completed and signed Burn boxes must be have the RUH Department name, date and signature of the person who closed the box written on the box Refer to Management and Disposal of Waste policy. 5.9. Sharps Sharps can be defined as any object in the healthcare setting that could puncture the skin and permit the entry of bacteria or viruses into the body. Sharps include needles, scalpels, suture needles, lancets, scissors, surgical instruments stitch cutters, glass ampoules, intravenous cannulae, vacuum blood collecting systems, fragments of bone and patient’s teeth. This is not an exhaustive list. Where possible the sharps provided by the Trust will have a safety mechanism built into their design. The safety mechanism must be used to prevent the risk of inoculation injuries. 5.10. Inoculation (Sharps) injury An inoculation injury occurs where a needle or other sharp contaminated with blood or other high risk body fluid penetrates percutaneously (through the skin). Such injuries also include cuts, pinches, scratches, bites which break the skin and splashes of body fluids to the eyes. Accidents with needles are the most common, so injuries from sharps are often called needle stick injuries. 5.11. Preventing inoculation injury The emphasis on preventing contaminated inoculation injury must focus on ensuring safe handling practices are in place. Staff must: Attend the appropriate Infection Prevention and Control training, Use appropriate PPE, Always discard used sharps into a sharps container at the point of use, Ensure that needles are not re-sheathed, Use a clean plastic tray to carry sharps; never carry loose sharps in your hands, Ensure that sharps containers are not filled above the mark indicating they are full, Use temporary closure mechanisms when sharps boxes are not in use, Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.: 622 Status: Final Page 15 of 26 Locate sharps containers in safe positions, e.g. secured to a wall and away from children’s reach, Report all incidents (including near misses) involving contaminated sharps at the time of occurrence, or as soon as possible afterwards, to the line manager/Supervisor/Team Leader on duty and Occupational Health. Refer to Sharps Policy. 5.12. Linen disposal Used linen is a potential source of infection as it is likely to be contaminated with potentially pathogenic organisms. Gloves and aprons must be worn when dealing with soiled, wet or blood stained linen Linen should be bagged by the bedside, never carried through a clinical area by hand Linen bags must be half full only. They must not be overfilled Linen from infected patients or blood stained must be placed in an inner red alginate bag, and then placed into an outer white plastic bag When removing soiled linen avoid the production of aerosols If patient’s clothing is being laundered at home, place soiled laundry in a water soluble clothing bag, inside an outer plastic bag. Inform visitors that laundry is awaiting collection in the patient’s locker Refer to Linen Policy. 5.13. Pathology specimens All specimens should be handled with care. PPE must be used when handling specimens. All specimens must be safely contained in a leak proof container which is additionally placed in a sealed polythene bag Ensure the outside of the container and bag remain free from contamination with blood or body fluids Bio-hazard specimens from known or clinically suspected infected patients If there is a risk of spillage of contents then the specimen should be placed inside a second polythene bag i.e. ‘double bagging’. The following bio-hazard specimens must not be sent via the vacuum tube system; Classic or variant Creutzfeldt-Jakob disease (CJD) Diphtheria Hepatitis B or C Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.: 622 Status: Final Page 16 of 26 HIV Paratyphoid Rabies virus Tuberculosis Typhoid If Viral Haemorrhagic fever is suspected, the microbiologist must be contacted before any specimens are taken or sent 5.14. Decontamination of equipment Reusable equipment can be a potential source of infection if not appropriately decontaminated after each use. Cleaning is an essential stage in the decontamination process and must always precede disinfection and /or sterilization. Selection of the appropriate decontamination method will ensure that the equipment is clean and fit for purpose. Check manufacturer’s instructions for use of suitable cleaning agents. The user of the device is responsible for ensuring that it is visibly clean and free from contamination with blood/body fluids following each procedure and prior to reuse or prior to sending for repair (internally/externally). The user must sign and date the appropriate labels to confirm that cleaning has taken place. During decontamination, the user must check clinical equipment for signs of damage and send for repair or disposal if appropriate. A completed label must accompany each piece of equipment sent for repair. Suitable personal protective equipment must be worn during decontamination procedures to protect the healthcare worker from exposure to microorganisms or infectious agents, where the risk of splash is anticipated. Refer to Decontamination Policy for detailed guidance of suitable methods of decontamination 5.15. Last offices When carrying out the last offices the following should be implemented. Wear PPE; gloves and apron Remove all drains, catheters and intravenous lines except where a post mortem is required Contain leakage from wounds and line sited by ensuring they are covered with a waterproof dressing After carrying out last offices a body bag must be used in the following circumstances: Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.: 622 Status: Final Page 17 of 26 When a body is leaking body fluids or there is gross external contamination with blood Staff must ensure that mortuary staff are aware of the reason for using a body bag When a patient has or is strongly suspected of having one of the following biohazard conditions: Anthrax Classic or variant Creutzfeldt-Jakob disease (CJD) Diphtheria Hepatitis B, C HIV Meningococcal septicaemia / meningitis if death occurs before 48 hours of appropriate antibiotic therapy being completed Rabies virus Invasive β-haemolytic Streptococcus Group A disease if death occurs before 48 hours of appropriate antibiotic therapy being completed Tuberculosis Typhoid/ Paratyphoid Viral Haemorrhagic fever Any soiled patient’s clothing must be placed in a water soluble clothing bag which must be secured and placed inside a property bag. Any itemised list of contents must be attached. If in doubt contact the Infection Prevention and Control Team - Bleep 7991 5 Monitoring Compliance Infection Prevention and Control Team will audit components of the policy as part of the annual audit programme with the support of the Audit department. Audits of compliance with the policy will be undertaken by Ward managers/Senior Sisters using the ‘Saving lives High Impact Interventions’ audit tools Results of audits are reported weekly via the HCAI report and at the Infection Prevention and Control Committee which meets every two months. Where short falls are identified, Ward managers and Matrons will ensure that improvement programmes are agreed and put in place to improve compliance. Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.: 622 Status: Final Page 18 of 26 6 Review This policy will be subject to a planned review every three years as part of the Trust’s Policy Review Process. It is recognised however that there may be updates required in the interim arising from amendments or release of new regulations, Codes of Practice or statutory provisions or guidance from the Department of Health or professional bodies. These updates will be made as soon as practicable to reflect and inform the Trust’s revised policy and practise. 7 Training Managers are responsible for ensuring all their staff receive the type of initial and refresher training that is commensurate with their role(s). Staff must refer to the Mandatory Training Profiles, available on the intranet, to identify what training in relation to Infection Prevention and Control is relevant for their role and the required frequency of update. Further information is available on the statutory and mandatory training web pages about each subject and the available training opportunities. The Mandatory Training Policy identifies how training non-attendance will be followed up and managed and is available on the intranet. Training statistics for mandatory training subjects are collated by the Learning & Development team, and are reported to the Strategic Workforce Committee. Staff must keep a record of all training in their portfolio. All staff and managers can access their mandatory training compliance records via the Trust’s mandatory reporting tool (STAR) available on the intranet. Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.: 622 Status: Final Page 19 of 26 8 References Damani, N (2012) Manual of Infection Prevention and Control Third edition. Oxford University Press, Oxford. Department of Health. Saving Lives: reducing infection, delivering clean and safe care. London: Department of Health. 2007 Department of Health. The Health and Social Care Act 2008 – Code of Practice on the prevention and control of infections and related guidance. London: Department of Health. 2010. Fraise, A and Bradley, Christine (eds) (2009) Alliffe’s Control of Healthcare – associated Infection. London, Hodder Arnold Health & Safety Executive, Control of Substance Hazardous to Health (COSHH) 1999 National Audit Office. Reducing Healthcare Associated Infections in Hospitals in England. London. The Stationary Office. 2009 Loveday H.P. et al (2014) epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospital in England. Journal of Hospital Infection 86S1 S1-S70 Protective clothing – Principles and Guidance. Infection Control Nurses Association 2002 WHO Guidelines on Hand Hygiene in Health Care (2009). World Health Organisation Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.: 622 Status: Final Page 20 of 26 Appendix 1: Risk assessment Guide for Selection of Protective Equipment based on risk of Exposure to Blood or Body Fluid Assess actual and potential risk of blood or body fluid exposure in task being undertaken No blood/body fluid contact 1. Gloves not required 2. Apron if clothing may be exposed i.e. moving patient or bed making 3. Eye protection and mask not required 4. Wash hands before and after contact 5. Dispose of linen in white linen bag at bedside 6. Decontaminate equipment between patients 7. Dispose of waste appropriately Potential exposure to blood/body fluid. High risk of splash 1. Wear gloves 2. Wear apron as above and if splash to clothing likely 3. Wear mask/eye protection if appropriate 4. Dispose of soiled linen as infected i.e. red alginate bag then red plastic bag at bedside 5. Dispose of soiled waste in orange clinical waste bags 6. Decontaminate equipment with appropriate method 7. Wash hands after contact and removal of gloves Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Potential exposure to blood/body fluid. Low risk of splash patient confirmed as infectious e.g. Chicken pox, MRSA, Clostridium difficile, TB 1. Wear gloves 2. Wear apron 3. Wash hands before and after patient contact and on removal of gloves 4. Wear mask if appropriate 5. Wear eye protection if appropriate 6. Dispose of soiled linen as infected at bedside 7. Dispose of soiled waste in orange clinical waste bags 8. Decontaminate equipment appropriately Ref.: 622 Status: Final Page 21 of 26 Appendix 2: Moments for Hand Hygiene The RUH embraces the ‘Five Moments for Hand Hygiene’ ( WHO 2009), aiming to link specific hand hygiene actions to specific infectious outcomes in patients, by giving clear advice on how to integrate hand hygiene into the complex task of care. 1. Before patient contact When? Clean your hands before touching a patient when approaching him/her. Why? To protect the patient against harmful germs carried on your hands 2. Before a clean/aseptic procedure When? Clean your hands immediately before a clean/aseptic procedure. Why? To protect the patient from harmful germs, including the patient’s own from entering his/her body. 3. After body fluid exposure risk When? Clean your hands immediately after exposure risk to body fluids and after glove removal. Why? To protect yourself and the healthcare environment from harmful patient germs. 4. After patient contact When? Clean your hands after touching a patient and his/her immediate surroundings when leaving the patient’s side. Why? To protect yourself and the healthcare environment from harmful patient germs. 5. After contact with the patient’s surroundings When? Clean your hands after touching any object or furniture in the patient’s immediate surroundings when leaving – even if the patient has not been touched Why? To protect yourself and the healthcare environment from harmful patient germs. Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.: 622 Status: Final Page 22 of 26 Appendix 3: Guidance for the Selection of Masks Type of mask Standard Surgical mask Protection provided Basic protection No fluid repellence Surgical mask with fluid shield Direct fluid repellence No eye protection Surgical mask with fluid shield and integral visor Fluid repellence Eye protection High level protection PFR mask conforming to EN149 (Sometimes called ‘Duck bill’) or FFP3 valved respirator mask Indication for use Immuno-suppressed patient Circulating theatre staff Patients with Group A Streptococcus when changing dressings or undertaking aerosol generating procedures Patients with bacterial meningitis, Diphtheria, RSV or bronchiolitis Non-immune staff caring for patients with mumps, measles, chickenpox or rubella. Surgical scrub team During procedures that are likely to generate splashes of blood or body fluids Surgical scrub team Emergency Department High standard Filters 0.2 - .5 microns Lasts up to 8 hours Suitable for high risk procedures Staff require training to ensure ‘fit’ is correct Tuberculosis – for aerosol generating procedures (see TB policy) Multi drug resistant Tuberculosis Influenza SARS Viral haemorrhagic fevers Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.: 622 Status: Final Page 23 of 26 Document Control Information Ratification Assurance Statement Dear Helen Blanchard Please review the following information to support the ratification of the below named document. Name of document: Universal/Standard Infection Control Precautions Name of author: Yvonne Pritchard Job Title: Senior Infection Prevention and Control Nurse I, the above named author confirm that: The Policy presented for ratification meets all legislative, best practice and other guidance issued and known to me at the time of development of the Policy; I am not aware of any omissions to the Policy, and I will bring to the attention of the Executive Director any information which may affect the validity of the Policy presented as soon as this becomes known; The Policy meets the requirements as outlined in the document entitled Trust-wide Policy for the Development and Management of Policies (v4.0); The Policy meets the requirements of the NHSLA Risk Management Standards to achieve as a minimum level 2 compliance, where applicable; I have undertaken appropriate and thorough consultation on this Policy and I have documented the names of those individuals who responded as part of the consultation within the document. I have also fed back to responders to the consultation on the changes made to the Policy following consultation; I will send the Policy and signed ratification checklist to the Policy Coordinator for publication at my earliest opportunity following ratification; I will keep this Policy under review and ensure that it is reviewed prior to the review date. Signature of Author: Name of Person Ratifying this policy: Helen Blanchard Job Title: Director of Nursing and Midwifery Signature: Date: 17 December 2014 Date: 19 December 2014 To the person approving this policy: Please ensure this page has been completed correctly, then print, sign and post this page only to: The Policy Coordinator, John Apley Building. The whole policy must be sent electronically to: ruh-tr.policies@nhs.net Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.: 622 Status: Final Page 24 of 26 Consultation Schedule Name and Title of Individual Dr E Abrishami, Consultant Microbiologist and Infection Control Doctor Helen Blanchard, Director of Nursing and Midwifery/DIPC Bupe Banda, Occupational Health Nurse Bronia Charity, Stores Manager Julia Bloomfield, Infection Prevention and Control Nurse Dana Di.Iulio, Infection Prevention and Control Nurse Katie White, Infection Prevention and Control Nurse Lucy Butcher, Infection Prevention and Control Nurse Judy Bull, Sterile Services Manager Gareth Veal, Estates Compliance Manager Tim Evans, Portering Manager Mark Grover, Respiratory Nurse Specialist Jo Miller, Head of Nursing Medicine Sharon Bonson, Head of Nursing Surgery Vicky Tinsley, Head of Nursing and Midwifery Women and Children’s Date Consulted 10.11.2014 Amanda Speed, Biomedical Scientist, Haematology Department, Pathology Laboratory 11.12.2014 Christine Williams, Biomedical Scientist, Haematology Department, Pathology Laboratory 16.12.2014 01.12.2014 10.11.2014 10.11.2014 10.11.2014 10.11.2014 10.11.2014 10.11.2014 10.11.2014 10.11.2014 10.11.2014 10.11.2014 10.11.2014 10.11.2014 10.11.2014 The following people have submitted responses to the consultation process: Name and Title of Individual Julia Bloomfield, Infection Prevention and Control Nurse Mark Grover, Respiratory Nurse Specialist Christine Williams, Biomedical Scientist, Haematology Department, Pathology Laboratory Christine Williams, Biomedical Scientist, Haematology Department, Pathology Laboratory Date Responded 14.11.2014 Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.: 622 Status: Final Page 25 of 26 08.12.2014 16.12.2014 16.12.2014 Equality Impact: (A) Assessment Screening To be completed when submitted to the appropriate Executive Director for consideration and approval. Person responsible for the assessment: Name: Job Title: Yvonne Pritchard Senior Infection Prevention and Control Nurse Does the document/guidance affect one group less or more favourably than another on the basis of: Yes/No Race Yes No Ethnic origins (including gypsies and travellers) Yes No Nationality Yes No Gender (including gender reassignment) Yes No Culture Yes No Religion or belief Yes No Sexual orientation Yes No Age Yes No Yes No Is there any evidence that some groups are affected differently? Yes No If you have identified potential discrimination, are there any valid exceptions, legal and/or justifiable? Yes No N/A Is the impact of the document/guidance likely to be negative? Yes No N/A If so, can the impact be avoided? Yes No N/A What alternative is there to achieving the document/guidance without the impact? Yes No N/A Can we reduce the impact by taking different action? Yes No N/A Disability (learning disabilities, physical disability, sensory impairment and mental health problems) Comments If you answered NO to all the above questions, the assessment is now complete, and no further action is required. If you answered YES to any of the above please complete the Equality Impact: (B) Full Analysis Document name: Universal Standard Infection Control Precautions Issue date: 23 December 2014 Author: Yvonne Pritchard Ref.:622 Status: Final Page 26 of 26
© Copyright 2024