General Practice SAMPLE. Preventing Infection. Workbook and Guidance for General Practice 2nd Edition. Name. Job Title 1

Transcription

1 General Practice Name Preventing Infection Workbook and Guidance for General Practice 2nd Edition Job Title 1

2 General Practice Section 1 Section 2 - Standard precautions Key topics Section 3 - Specific infections Section 4 - Section 5 Contents 3 Page 1. Introduction 4 2. Infection prevention and control 5 3. Standard precautions Hand hygiene Personal protective equipment Sharps management Blood and body fluid spillages Waste management Laundry Decontamination of equipment Isolation Environmental cleanliness Aseptic technique Specimen collection Viral gastroenteritis/norovirus Clostridium difficile MRSA PVL - Staphylococcus aureus MRGNB CPE 69 Commentary 73 Key references 74 Certificate of completion 75 Tick when completed Contents

3 Preventing Infection Workbook and Guidance 1. Introduction 1. Introduction As a community NHS Infection Prevention and Control (IPC) team based in North Yorkshire, our aim is to support the diversity of health and social care providers in promoting best practice in infection prevention and control. Now in its 2nd edition, this Workbook for General Practice complements a range of educational infection prevention and control resources which can be viewed at: This Workbook and Guidance is intended to be the foundation for best practice for infection prevention and control. By applying the principles within the Workbook you will demonstrate commitment to high quality care and patient safety. The Francis Report 2013 states It is unacceptable for a patient to be injured by contracting certain types of infection as a result of the failure to apply methods of hygiene and infection control accepted by a specified standardsetting body, preferably NICE. The Workbook and Guidance is aimed at all staff working in a General Practice, this includes not only front-line clinical staff, but all staff groups including receptionists and cleaning staff. The Workbook has been designed to be undertaken in stages. This will allow you to complete the Test your knowledge questions before moving on to the next section. On completion, your manager will check that you have achieved 100% competency in your infection prevention and control knowledge and then sign the Certificate of completion. You should keep the Workbook as evidence of learning and as an on-going reference guide to provide you with easily accessible advice for day-to-day care of patients. The Workbook is evidence-based and includes latest national guidance. Completion of this Workbook also helps your General Practice demonstrate compliance with the Health and Social Care Act 2008 and Care Quality Commission requirements in relation to infection prevention and control training. Dr Richard Hobson Director of Infection Prevention and Control/ Consultant Microbiologist Harrogate and District NHS Foundation Trust 4

4 General Practice 2. Infection prevention and control The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance (Department of Health, January 2015), states that, Good infection prevention (including cleanliness) is essential to ensure that people who use health and social care services receive safe and effective care. Infection prevention and control is a key priority for the Department of Health, reinforced with the standards set out in the Health and Social Care Act 2008 and the Care Quality Commission (CQC) requirements. Infection prevention and control spans the five key questions the CQC will be asking about your service: How safe? How effective? How caring? How responsive? How well-led? An infection occurs when micro-organisms enter the body and cause damage. These micro-organisms can come from a variety of sources and often take advantage of a route into the body provided by a wound or an invasive medical device, e.g., catheter. Some infections can reach the bloodstream. When this occurs it is known as a bacteraemia, which can cause serious or life threatening infection and can result in death. Infection prevention and control means doing everything possible to prevent infection from both developing and spreading to others. Understanding how infections occur and how different micro-organisms (germs), such as bacteria, viruses and fungi, spread is essential to preventing infections. Healthcare associated infections The term healthcare associated infection (HCAI) refers to infections associated with the delivery of healthcare in any setting, e.g., hospitals, GP surgeries, care homes, in a 5 2. Infection prevention and control

5 General Practice Antimicrobials It is important to ensure appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of antimicrobial resistance. General Practice prescribing accounts for 80% of NHS antibiotic use and this antibiotic use must be both necessary and appropriate. Antibiotics should not be prescribed for viral infections. The Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use (NICE Guidance NG15, August 2015) recommends that GPs and nurse prescribers should support the implementation of local antimicrobial guidelines and recognise their importance for antimicrobial stewardship. Vaccines Vaccines can prevent transmission of disease from person-toperson by both patients and staff. Staff should be aware of their immune status in accordance with the guidance Immunisation Against Infectious Disease (The Green Book) Chapter 12. Correct storage of vaccines is essential to maintain their efficacy. If vaccines are not stored correctly they may lose their effectiveness. Over time vaccines naturally biodegrade and storage out of temperature may hasten the loss of potency. This may result in the vaccine failing to create the desired immune response, thereby providing poor protection. Practices should ensure vaccines are stored in line with the guidance in The Green Book or local Vaccine Cold Chain Policy. FACT Every year there are over 300,000 cases of healthcare associated infection (HCAI) in England and it is thought that up to 30% of HCAIs are preventable. In 2007, there were 9,000 deaths due to HCAI in both hospital and primary care settings in England. This costs the NHS 1 billion a year and 56 million of this is estimated to be incurred after patients are discharged from hospital Infection prevention and control

6 General Practice Chain of infection showing how MRSA can be spread Case study: Mr Brown aged 92, has a leg ulcer which is colonised with MRSA. A practice nurse dresses the wound and does not wash her hands after removing her apron and gloves. She then attends to 85 year old Mrs Smith who has a small wound on her ankle. She transmits MRSA to her when cleaning the wound and applying a new dressing. Three days later Mrs Smith is very unwell and is admitted to hospital with MRSA bacteraemia (a life threatening bloodstream infection). Example of how to break the chain of MRSA infection Patients with non-intact skin, e.g., wounds Skin wound, e.g., ankle wound Portal of entry How to break the link Hand hygiene MRSA Organism Means of transmission Via hands How to break the link Hand hygiene 9 Reservoir Leg ulcer wound People at risk Portal of exit Wound exudate 2. Infection prevention and control

7 General Practice 4. Hand hygiene Evidence and national guidance identifies that effective hand hygiene results in significant reduction in the carriage of potential pathogens (harmful micro-organisms) on the hands. Effective hand hygiene decreases the incidence of healthcare associated infection (HCAI) leading to a reduction in patient morbidity (disease) and mortality (death). Hand hygiene is the single most important way to prevent the spread of infection. Hands may look visibly clean, but microorganisms are always present, some harmful, some not. Removal of transient micro-organisms is the most important factor in preventing them from being transferred to others. Hands may become contaminated by direct contact with a patient, handling equipment and contact with the general environment. Hand hygiene refers to the process of hand decontamination where there is physical removal of dirt, blood, body fluids and the removal or destruction of micro-organisms from the hands. There are two categories of micro-organisms present on the skin of the hands Transient Transient bacteria are found on the surface of the skin. They are called transient as they do not routinely live on the hands. They are transferred to hands after contact with patients or the environment and are easily removed by routine handwashing with liquid soap and warm water. Resident Resident bacteria are found on the hands in the deep layers and crevices and live on the skin of all people. They play an important role in protecting the skin from harmful bacteria and are not easily removed by routine handwashing with liquid soap and warm water Hand hygiene (Standard precaution)

8 White Yellow Blue Red Green Clinical tasks, e.g., wound dressing. 19 General Practice Cleaning of treatment and minor operation rooms. Cleaning of general areas, e.g., consulting rooms. Cleaning of sanitary areas. Cleaning of kitchen areas. Eye protection Safety glasses or a visor should be worn when there is a risk of splashing of blood and/or body fluids to the eyes to prevent infection. Reusable eye protection should be decontaminated after each use (see section 10, page 35). Masks A splash resistant surgical mask should be worn when there is a risk of splashing of blood and/or body fluids to the nose or mouth. Masks may be required to be worn on other occasions, e.g., in the event of pandemic flu. Order for putting on PPE Pull apron over head and fasten at back of waist. Secure mask ties at back of head and neck. Fit flexible band to nose bridge. Place eye protection over eyes. Extend gloves to cover wrists. Order for removing PPE Grasp the outside of the glove with opposite gloved hand, peel off. Hold the removed glove in the gloved hand. Slide the fingers of the ungloved hand under the remaining glove at the wrist and peel off. Unfasten or break apron ties. Pull apron away from neck and shoulders lifting over head, touching inside of the apron only. Fold or roll into a bundle. Handle eye protection only by the headband or the sides. Unfasten the mask ties first the bottom, then the top. Remove by handling ties only. Clean your hands before putting on and after removing PPE. 5. Personal protective equipment (Standard precaution)

9 General Practice In the event of a needlestick/sharps injury 1. Encourage bleeding of the wound by squeezing under running water (do not suck the wound). 2. Wash the wound with liquid soap and warm water and dry. 3. Cover the wound with a waterproof dressing. 4. Report the injury to your manager immediately. 5. Immediately contact your GP or Occupational Health department. Out of normal office hours, attend the nearest Accident and Emergency (A&E) department. 6. If you have had a needlestick/sharps injury from an item which has been used on a patient (source), the GP in charge of their care may take a blood sample from the patient to test for hepatitis B, C and HIV (following counselling and agreement of the patient). 7. At the GP practice/occupational Health/A&E department: a blood sample will be taken from you to check your hepatitis B vaccination/antibody levels and you will be offered immunoglobulin if they are low. The blood sample will be stored until results are available from the patient s blood sample. If the source of the sharps injury is unknown, you will also have blood samples taken at 6, 12 and 24 weeks for hepatitis C and HIV if the patient (source) is known or suspected to be HIV positive, you will be offered Post Exposure HIV Prophylaxis (PEP) treatment. This should ideally commence within 1 hour of the injury, but can be given up to 2 weeks following the injury Sharps management (Standard precaution)

10 25 General Practice 7. Blood and body fluid spillages Blood and body fluids may contain a large number of microorganisms, which should be made safe immediately following any spillage of blood or body fluids. Dealing with a spillage may expose the member of staff to infection, therefore, appropriate personal protective equipment should be worn and standard precautions followed. Blood/blood stained body fluid spillages Disinfect spillages promptly and clean the affected area (see table below). All blood/blood stained body fluid spillage waste should be disposed of as infectious waste. Best practice is to use a chlorine-based blood spillage kit, which should be used following the manufacturer s guidance. Alternatively, use chlorine-based granules as below. * See note on page 27 regarding use on soft furnishings and carpets. Action for blood/blood stained body fluid spillages 10,000 parts per million (ppm) available chlorine granules Use Sodium Dichloroisocyanurate (NaDCC), e.g., Haz-Tab or Actichlor granules, as per manufacturer s instructions. 1. Wear a disposable apron and gloves (PPE). 2. Ventilate the area, e.g., open windows and doors, as fumes will be released from the chlorine. 3. Sprinkle granules directly onto the spillage. Leave for the required contact time which is specified on the container. 4. Clear away the granules and dispose of as infectious waste. 5. With a disposable cloth, wash the area using detergent and warm water, then dry with paper towels. 6. Dispose of cloth and paper towels as infectious waste. 7. Remove PPE and dispose of as infectious waste. 8. Wash hands thoroughly to prevent the risk of transmission of infection. 7. Blood and body fluid spillages (Standard precaution)

11 General Practice Colour stream Orange Purple Yellow and black Black Description Infectious waste, which contains infectious materials from known or suspected infectious source, e.g., contaminated PPE, contaminated dressings, very small pieces of body tissue. Waste from blood and/or body fluid spillages. Infectious waste may be treated to render it safe prior to disposal, or alternatively it can be incinerated. Cytotoxic and cytostatic waste, e.g., hormone or oxytocin-based agents. Cytotoxic and cytostatic waste must be incinerated in a permitted or licensed facility. Offensive/hygiene waste, e.g., feminine hygiene waste, nappies from healthy children, uncontaminated PPE, uncontaminated dressings. Offensive/hygiene waste may be land filled in a permitted or licensed facility. Domestic waste, which does not contain infectious materials, sharps or medicinal products, e.g., newspapers, paper towels from hand washing, uncontaminated couch roll, packaging from instruments. Domestic waste may be land filled in a permitted or licensed site. Clear or opaque receptacles can also be used for domestic waste. Recycling options should be considered where available Waste management (Standard precaution)

12 Preventing Infection Workbook and Guidance 9. Laundry (Standard precaution) To further reduce any micro-organisms, where possible, uniforms or clothing should be tumble dried and/or ironed. Always wash hands after placing uniforms or clothing in the washing machine. Note Fabric hand towels should not be used in General Practice by staff or patients as they can harbour micro-organisms which can be transferred from one person to another. Remember Changing of curtains and screens should documented. Pillows should be encased in a cleanable plastic case. It s a fact In the second half of the 19th century, commercial laundries began using steam-powered mangles or ironers. In 1920, the first commercially launderable permanentpress fabrics were introduced. In 1937 the first automatic electric washing machine was invented. Test your knowledge Please tick the correct answer True False 1. It is best practice to use disposable paper products in General Practice. 2. Curtains and fabric screen should be changed 3 monthly. 3. Uniforms should be washed at 30 o C. 34

13 10. Decontamination of equipment (Standard precaution) Preventing Infection Workbook and Guidance Chlorine-based disinfectants at 1,000 parts per million (ppm) should be used for the disinfection of equipment that has been in contact with an infected patient, non-intact skin, body fluids (not blood) or mucous membranes, e.g., areas of the body producing mucus, such as inside of the nose, mouth or vagina. Note: some chlorine-based disinfectants, e.g., Chlor-Clean, Actichlor Plus, Tristel, contain both detergent and chlorine, this reduces the need to clean equipment before disinfection. Chlorine-based disinfectants 10,000 ppm available chlorine When to use 10,000 ppm What to use On equipment that is contaminated with blood or blood stained body fluids. Use Sodium Dichloroisocyanurate (NaDCC), e.g., Haz-Tab, Actichlor, tablets as per manufacturer s instructions. A diluter bottle should be used to ensure the correct dilution is achieved. Chlorine-based disinfectants 1,000 ppm available chlorine When to use 1,000 ppm What to use On equipment that comes into contact with a known or suspected infected patient, nonintact skin, body fluids (not blood) or mucous membranes. Use Sodium Dichloroisocyanurate (NaDCC), e.g., Haz-Tab, Actichlor, Chlor-Clean, Actichlor Plus, tablets as per manufacturer s instructions. A diluter bottle should be used to ensure the correct dilution is achieved. 36

14 General Practice 11. Isolation Dedicated isolation treatment rooms are not required in General Practices, but General Practices are expected to implement reasonable precautions when a patient is suspected or known to have a transmissible infection, Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance. The implementation of standard precautions will reduce the risk of the transmission of infection in General Practice. However, patients with specific infections who may be a risk to others, e.g., a child with chickenpox or a patient with influenza during an outbreak of Pandemic Influenza, should be segregated so that the risk of infection to other patients in waiting or communal areas is minimised. Where possible, arrangements should be made to see these patients in their own home or in a separate area of the practice away from other patients. Preparation Refer to your local policy on Isolation. The designated room or area should be free from clutter and where possible, equipment not required for the consultation should be removed from the room. A risk assessment should be undertaken for the personal protective equipment (PPE) required, e.g., disposable apron and gloves. The routine wearing of masks is usually not required, however for certain infections, e.g., Pandemic Influenza, Ebola, or new emerging infections, national guidance should be followed. PPE should be worn and removed correctly (see page 19) Isolation (Key topic)

15 Preventing Infection Workbook and Guidance 13. Aseptic technique (Key topic) Wear a disposable apron and sterile gloves. Ensure all fluids, equipment and materials used are sterile. Check sterile packs are within the expiry date and there is no evidence of damage or moisture penetration. Ensure contaminated or non-sterile items are not placed in the sterile field. Do not reuse single use items. Aseptic technique competency Only staff trained and competent in an aseptic technique should undertake this procedure. An Aseptic technique competency assessment record and Aseptic technique procedure audit tool for both urinary catheterisation and wound dressing are available at It is good practice to undertake peer audits to monitor competency and a record of training and audit should be available. Procedure for dressing a wound using an aseptic technique Explain the procedure to the patient. Be Bare Below the Elbows. Decontaminate hands with liquid soap and warm water and dry with paper towels or use an alcohol handrub and allow to dry. Decontaminate the dressing trolley with detergent and warm water or detergent wipes. Assemble dressing packs and equipment, check all items are in date and packaging is intact. Position patient comfortably and decontaminate hands. Put on a disposable apron. 44

16 Preventing Infection Workbook and Guidance 14. Specimen collection (Key topic) Specimen Indication Wound swab Sputum Urine Faeces Swelling, redness, heat, a yellow or green discharge, increased discharge of fluid, wound deterioration, fever. Productive cough (green or yellow) or presence of blood in sputum. Pain on passing urine, increase in frequency, fever, new urinary incontinence, new or worsening confusion, flank or lower abdominal pain. Diarrhoea, increase in frequency, presence of blood, abdominal pain. Specimens delivered by patients Wherever possible, reception staff should avoid handling specimens due to the risk of infection. Specimens should be in an appropriate container. If there is leakage or an inappropriate container is used, the specimen should be rejected as it may not be processed by the laboratory due to the risk of infection. In exceptional circumstances, if a specimen is not in an appropriate container and where transfer to the correct container is necessary, PPE should be worn. Specimens should be labelled correctly and all details completed on the form and placed in the appropriate specimen bag. 48 Container Sterile cotton swab in transport medium. Charcoal medium increases survival of bacteria during transportation. Store at room temperature. Plain universal container. Store at room temperature. Universal container with boric acid (red top) which prevents bacteria from multiplying in the container. Refrigerate. Stool specimen container (at least 1 / 4 full). Store at room temperature.

17 Preventing Infection Workbook and Guidance 15. Viral gastroenteritis/norovirus Viral gastroenteritis is spread by: contaminated hands of patients and staff contaminated surfaces and equipment contaminated food (food can be contaminated when being prepared by an infected person with viral gastroenteritis). Cleaning an episode of diarrhoea or vomiting at the General Practice 1. Wear appropriate personal protective equipment (PPE), e.g., disposable apron and gloves. 2. Ventilate the area if possible by opening windows and doors. 3. Clean up vomit or diarrhoea promptly with paper towels. 4. Use a spillage kit or clean area with detergent and warm water or detergent wipes followed by a chlorine-based disinfectant at 1,000 parts per million (see page 26). 5. Dispose of waste and PPE as infectious waste. 6. Wash hands with liquid soap and warm water. Advice for patients with viral gastroenteritis Drink plenty of fluids to prevent dehydration. Wash hands thoroughly after each episode of diarrhoea and vomiting with liquid soap and warm water. If possible, infected patients should try to avoid preparing and handling food for other people until free from symptoms for 48 hours. Stay at home, do not visit friends, relatives, hospitals or care homes, until free from symptoms for 48 hours. Disinfect toilets and surrounding area at home with a household bleach as per manufacturer s instructions. 52

18 Preventing Infection Workbook and Guidance 16. Clostridium difficile Clostridium difficile infection (CDI) treatment advice for prescribers (should be given in accordance with local and national guidance) When to treat When antibiotics are required Non-severe CDI: treat in primary care. First episode: Metronidazole 400 mg* Mild CDI: not associated with a raised WCC, typically TDS for days (70% of patients associated with <3 stools of type 5-7 on the Bristol Stool respond to metronidazole in 5 days; 92% in 7 days). Form Scale per day. Moderate CDI: associated with a raised WCC (<15 x 10 9 /L), If not responding contact local Consultant Microbiologist. typically associated with 3-5 stools per day. If second episode: oral vancomycin 125 mg* QDS for days or seek Consultant Microbiologist advice Review progress daily. Severe CDI: specialist treatment only. Admit as an emergency. Severe CDI: associated with WCC >15 x 10 9 /L or an acute 56 Please note vancomycin caps 125 mg QDS cannot be administered via PEG. *The choice of antibiotic treatment may differ, please refer to your local Antimicrobials Guidelines. rising serum creatinine (i.e., 50% above baseline) or evidence of severe colitis. Life-threatening CDI: includes hypotension, partial or complete ileus of toxic megacolon, or CT evidence of severe disease. Clostridium difficile Prescribing notes and general advice How to respond to positive laboratory results Initiate treatment as indicated (and isolate the patient if in a nursing/care home). Stop concomitant (non-c. difficile) antibiotics if safe to do so and any laxatives. Review and stop any concomitant PPI use if possible. Do not use antimotility drugs, e.g., loperamide. Prudent antibiotic prescribing reduces the risk of C. difficile infection and/or relapsing infection. Broad-spectrum agents, in particular, should not be prescribed unless there is a clear clinical need. For patients with a recent history, i.e., within one year, of C. difficile, advice should be sought from a Consultant Microbiologist on appropriate antibiotic choice for recurring CDI. Faecal transplanation is undertaken in some hospitals. Further advice can be obtained from your local Consultant Microbiologist.

19 Preventing Infection Workbook and Guidance 17. MRSA MRSA screening In accordance with Department of Health guidance, MRSA screening is routinely undertaken by hospitals. If a MRSA positive result is diagnosed after a patient has been discharged from hospital, the General Practice may be contacted by the local Infection Prevention and Control (IPC) or Public Health England (PHE) team to discuss the need for decolonisation treatment. If MRSA screening is to be undertaken at the General Practice, swabs should be taken in accordance with local policy. The sites to be swabbed usually include nose and any vulnerable sites, e.g., wound, and if a urinary catheter is in-situ a catheter specimen of urine should also be taken. How to take a nasal swab for MRSA screening Wash hands and apply non-sterile gloves. Place a few drops of either sterile water or sterile normal saline onto the swab taking care not to contaminate the swab. Place the tip of the swab inside the nostril at the angle shown. It is not necessary to insert the swab too far into the nostril. Gently rotate the swab ensuring it is touching the inside of the nostril. Repeat the process using the same swab for the other nostril. Place the swab into the container. Dispose of gloves and wash hands. Complete patient details on the container and specimen form. Request MRSA screening under clinical details on the form. 60

20 Preventing Infection Workbook and Guidance 18. PVL Staphylococcus aureus Use a clean designated towel which should be kept separate, to avoid use by other people. The towel should be washed frequently on a hot wash cycle, e.g., 60 o C. Regularly vacuum and dust with a damp cloth all rooms including personal items. A household detergent is adequate for cleaning. Clean the wash basin, taps and bath after use with household detergent and a disposable cloth. Cover nose and mouth with a tissue when coughing or sneezing, because PVL-SA can live in the nose. Immediately dispose of the tissue and then wash hands with liquid soap and warm water. If you are a carer in a nursery, hospital, care home or work in the food industry, e.g., chef, waitress, you should not return to work until the lesion has healed. Do not visit a gym or take part in contact sports until all lesions are healed. It s a fact The toxin was first described by Panton and Valentine in A PCR test for PVL virulence genes and simultaneous discrimination of MRSA from MSSA has recently been developed. The unit at Colindale can provide a result within the working day. Test your knowledge Please tick the correct answer 1. PVL-SA can cause recurrent boils or skin 66 True False abscesses. 2. PVL-SA can be spread by using shared towels and shared razors.

21 Preventing Infection Workbook and Guidance 20. CPE Note Patients found to be positive for CPE either colonised or infected, should have been given advice about CPE and a CPE card. The card should be shown to healthcare providers involved in their care. For further details visit Remember Using standard precautions will minimise the spread of CPE and should be rigorously implemented, but no additional infection control precautions are required. Seek advice from your local Community Infection Prevention and Control or Public Health England team if required. It s a fact Identification of CPE in England by the Public Health England National Reference Laboratory has risen from fewer that 5 patients reported in 2006 to over 600 in The resistant CPE bacteria produce an enzyme (carbapenemase) that breaks down the antibiotic and makes it ineffective. Test your knowledge Please tick the correct answer 1. There are very few antibiotics for the 72 True False treatment of CPE infections. 2. It is not necessary to undertake hand hygiene when dealing with a CPE patient.

22 Preventing Infection Workbook and Guidance Key references Key references British Medical Association (May 2012) CQC Registration What you need to know, Appendix B Policies and Protocols Guidance for GP Available at [Accessed 07/07/15] Care Quality Commission Homepage [online] Available at [Accessed 14/07/15] Department of Health (July 2015) The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance Department of Health (June 2015) Toolkit for managing carbapenemase-producing Enterobacteriaceae in non-acute and community settings Department of Health (2013) Health Technical Memorandum 07-01: Safe management of healthcare waste Department of Health (January 2009) Clostridium difficile infection: How to deal with the problem Harrogate and District NHS Foundation Trust (May 2015) Community Infection Prevention and Control Guidance for Health and Social Care Health Protection Agency (November 2011) Guidelines for the management of Norovirus outbreaks in acute and community health and social care settings Health Protection Agency (November 2008) Guidance on the diagnosis and management of PVLassociated Staphylococcus aureus infection (PVL-SA) in England 2nd Edition Healthcare Commission (October 2007) Investigation into outbreaks of Clostridium difficile at Maidstone and Tunbridge Wells NHS Trust Loveday HP, et al, epic3: National Evidence-Based Guidelines for Preventing Healthcare- Associated Infections in NHS Hospitals in England Journal of Hospital Infection 86S1 (2014) S1 S70 Medicines and Healthcare Products Regulatory Agency (April 2015) Managing Medical Devices Guidance for healthcare and social services organisations Available at publications/managing-medical-devices. [Accessed 22/07/15] Mid Staffordshire NHS Foundation Trust (2013) The Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry volume 2: Analysis of evidence and lessons learned (part 2), Chaired by Robert Francis QC 2013 National Institute for Health and Care Excellence (August 2015) Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use Available at guidance/ng15/resources. [Accessed 19/08/15] National Institute for Health and Clinical Excellence (2012) Infection: prevention and control of healthcare-associated infections in primary and community care Clinical Guideline 139 National Patient Safety Agency (August 2010) The national specifications for cleanliness in the NHS: Guidance on setting and measuring performance outcomes in primary care medical and dental premises Public Health England (2013) Immunisation Against Infectious Disease (The Green Book) Available at [Accessed 06/07/15] Royal College of Nursing (April 2014) The Management of waste from health, social and personal care RCN guidance Royal College of Nursing (January 2012) Essential practice for infection prevention and control Royal College of Nursing (2012) Tools of the trade: RCN guidance for health care staff on glove use and the prevention of contact dermatitis Royal Marsden (March 2015) The Royal Marsden Hospital Manual of Clinical Nursing Procedure 9th Edition [online] Available at [Accessed 14/07/15] 74

23 Preventing Infection Workbook and Guidance Written and produced by Community Infection Prevention and Control Harrogate and District NHS Foundation Trust Tel: August 2015 Harrogate and District NHS Foundation Trust, Community Infection Prevention and Control