INFECTION PREVENTION AND CONTROL GUIDELINES FOR GENERAL PRACTICES

Transcription

1 INFECTION PREVENTION AND CONTROL GUIDELINES FOR GENERAL PRACTICES Date Issued: November 2010 Review Date: November

2 NHS Stoke on Trent Infection Prevention and Control Team

3 INFECTION PREVENTION AND CONTROL GUIDELINES FOR GENERAL PRACTICES CONTENTS PAGE 1. INTRODUCTION The Health and Social Care Act 2008 and Code of Practice Roles and responsibilities LOCAL SOURCES OF ADVICE WHY INFECTION PREVENTION AND CONTROL IS IMPORTANT THE CHAIN OF INFECTION STANDARD INFECTION PREVENTION AND CONTROL PRECAUTIONS What are standard infection prevention and control precautions? Hand hygiene Personal protective equipment (PPE) TRANSMISSION BASED (DISEASE SPECIFIC ) PRECAUTIONS Service user placement/isolation facilities Meticillin Resistant Staphylococcus Aureus (MRSA) Clostridium difficile Extended spectrum beta lactamase producers (ESBLs,) 33 Glycopeptide resistant enterococci (GRE) and other resistant micro organisms 6.5 Influenza Creutzveldt-Jakob Disease Other infections OUTBREAKS General Suspected food poisoning Closure of premises Further advice Viral outbreaks of diarrhoea and vomiting SURVEILLANCE AND DATA COLLECTION Infection records Root Cause Analyisis for MRSA and Clostridium difficile Notifiable diseases PREVENTION OF OCCUPATIONAL EXPOSURE TO INFECTIONS Blood borne viruses and sharps Post exposure prophylaxis Other immunisations Protection against tuberculosis ASEPTIC TECHNIQUE What is an aseptic technique? Principles of asepsis Procedure 51 NHS Stoke on Trent Infection Prevention and Control Team

4 CONTENTS PAGE 11. WOUND CARE Aseptic dressing technique Clean dressing technique 12. INVASIVE DEVICES VENEPUNCTURE MINOR SURGERY Definition Facilities for minor surgery Infection prevention and control practices STORAGE AND HANDLING OF VACCINES Vaccine refrigerators Vaccines Administration of vaccines Disposal of vaccines Training Further information SPECIMEN COLLECTION AND TRANSPORT Specimen collection Handling specimens Transport of specimens Disposal of specimens Further information CLEANING THE ENVIRONMENT General Floors and other hard surfaces Curtains, blinds and soft furnishings Cleaning equipment and materials Colour coding Cleaning schedules Management of body fluid spillage Deep cleaning Key points when cleaning DECONTAMINATION OF CARE EQUIPMENT (MEDICAL DEVICES) Good practice Purchase of equipment Methods of decontamination Single use items Decontamination of items sent for inspection/repair WASTE DISPOSAL Legislation Waste categories Storage of clinical waste Disposal of sharps 78 NHS Stoke on Trent Infection Prevention and Control Team

5 20 PEST CONTROL ADMISSION, DISCHARGE AND TRANSFER OF SERVICE USERS ANTIMICROBIAL PRESCRIBING UNIFORMS AND WORK WEAR OCCUPATIONAL HEALTH Occupational health advice Immunisations Exclusion from work Inoculation/needle stick injuries Skin and soft tissue infections NEW BUILD, REFURBISHMENT AND SERVICE DEVELOPMENT INFECTION PREVENTION AND CONTROL TRAINING BIBLIOGRAPHY 83 APPENDICES Appendix 1 Definitions from the Health and Social Care Act Appendix 2 Checklist for Health and Social Care Act Appendix 3 Policy template 117 Appendix 4 Statements for job descriptions 119 Appendix 5 Infection Control Audit Tools 121 Appendix 6 Role profile and objectives for an Infection Control Link Person 139 Appendix 7 Standard precautions information leaflet 143 Appendix 8 5 Moments for hand hygiene 145 Appendix 9 Six stage hand washing technique 147 Appendix 10 MRSA information leaflet for care workers 149 Appendix 11 MRSA leaflet for service users and visitors 151 Appendix 12 MRSA screening leaflet 153 Appendix 13 Clostridium difficile information leaflet 155 Appendix 14 Medicines which can produce diarrhoea 157 Appendix 15 Bristol stool Chart 159 Appendix 16 E. Coli Appendix 17 Pulmonary TB 163 Appendix 18 Chickenpox and Shingles 165 Appendix 19 Scabies 167 Appendix 20 Norovirus - Diarrhoea and vomiting leaflet 169 Appendix 21 Flowchart- Action to take following a sharps/inoculation injury 171 Appendix 22 Checklist to assess risk following a sharps/inoculation injury 173 Appendix 23 Sharps poster 175 Appendix 24 Action to take following sharps find 177 Appendix 25 Aseptic technique poster 179 Appendix 26 Antimicrobial guidelines Appendix 27 National Patient Safety Agency Colour Coding 183 Appendix 28 Example of a cleaning schedule 185 NHS Stoke on Trent Infection Prevention and Control Team

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7 1. INTRODUCTION Infection prevention and control is an essential element of high quality care. Having effective infection prevention and control measures in place contributes to the safety of the environment for service users, care workers and others. These guidelines provide information that will support general practices to put in place all the reasonable infection prevention and control measures that are required to protect service users and care workers from infection and enable general practitioners to meet the requirements of the Health and Social Care Act The Health and Social Care Act 2008 can be accessed at: To be consistent with the Health and Social Care Act 2008 these guidelines use the same terms and definitions. Service user is used to describe patients, residents and clients. Registered providers are all organisations that provide health and social care and include both NHS and independent healthcare providers. Care Worker is used to refer to any employee whose normal duties involve providing direct care to service users. More definitions used in the Health and Social Care Act 2008 and these guidelines can be found in Appendix The Health and Social Care Act 2008 and Code of Practice The Health and Social Care Act 2008, Code of Practice for health and adult social care on the prevention and control of infections and related guidance (Department of Health 2009) requires all organisations which provide health and adult social care to have policies, procedures and protocols in place which minimise the risk of infection. This Act came into force in April 2009 for NHS care providers. Independent health and adult social care will be brought into registration under the Health and Social Care Act 2008 from October The Code is currently being revised to cover health care providers in primary care. Primary care providers will, as part of the registration requirements, be required to comply with the Health and Social Care Act 2008 and Code of Practice from April The Code of Practice is used by the Care Quality Commission (CQC) to assess compliance with the registration requirements on cleanliness and infection prevention and control. The Code and related guidance sets out how the Care Quality Commission will assess compliance with the registration requirement Cleanliness and infection prevention and control and describes how providers of care may meet the registration requirements related to the prevention and control of infections. There are 10 criteria that providers of adult health and social care are required to meet. Table 1 Compliance Criteria for the Health and Social Care Act 2008 Compliance What the registered provider will need to demonstrate criteria 1 Systems to manage and monitor the prevention and control of infection. These systems use risk assessments and consider how susceptible service users are and any risks that their environment and other users may pose to them. 2 Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections. NHS Stoke on Trent Infection Prevention and Control Team

8 Compliance What the registered provider will need to demonstrate criteria 3 Provide suitable accurate information on infections to service users and their visitors. 4 Provide suitable accurate information on infections to any person concerned with providing further support or nursing/medical care in a timely fashion. 5 Ensure that people who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to others. 6 Ensure that all staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection. 7 Provide or secure adequate isolation facilities. 8 Secure adequate access to laboratory support as appropriate. 9 Have and adhere to policies, designed for the individual s care and provider organisations, that will help prevent and control infections. 10 Ensure so far as is reasonably practical, that care workers are protected from exposure to infections that can be caught at work and that all staff are suitably educated in the prevention and control of infection associated with the provision of health and social care. A check list to help care providers assess their progress against these requirements can be found in Appendix 2. All providers of care must comply with other relevant legislation, such as the Health and Safety at Work Act 1974 and the Control of Substances Hazardous to Health Regulations (2002). The Infection Prevention and Control Team of NHS Stoke on Trent have developed these local guidelines to support general practices meet the requirements of the Code. By following these guidelines general practices will ensure that they are taking all reasonable steps to protect service users, care workers and others from acquiring infection. In developing these guidelines the Infection Prevention and Control Team of NHS Stoke on Trent would like to acknowledge the guidelines produced by the South West Health Protection Agency in 2007 and those produced by NHS Highlands in Tools to support and help organisations to effectively manage and prevent infection have been published and should be used. The tools include Saving Lives for acute health care settings and Essential Steps to Clean, Safe Care for non acute settings. Both of these were published by the Department of Health in 2006 and 2007 and are available from the Department of Health website Managers and care workers in all sectors of health and social care, whether statutory or voluntary, must be aware of their local infection prevention and control arrangements and whom they can contact for advice, guidance or in the event of an incident. It may be that they employ their own infection prevention and control specialist or team, or may have a contract or informal arrangements with the local Primary Care Trust (PCT), hospital team or Health Protection Unit. NHS Stoke on Trent Infection Prevention and Control Team

9 Many infection prevention and control problems and outbreaks can be resolved quickly if action is taken at the earliest opportunity and advice is received from the appropriate specialists. Ensuring that the principles of infection prevention and control are incorporated into all service and building developments will result in the provision of the best possible environment for the prevention and control of infection. Accessible policies will inform care workers and managers, of infection prevention and control precautions and the actions that need to be taken in the event of an incident such as a needle-stick or inoculation injury. This will also be underpinned by infection prevention and control training. Infection knows no boundaries and draws no distinction between service users, care workers, professional groups or institutions. By ensuring that everyone practices a good standard of infection prevention and control at all times they will all play their part in reducing infection. Health care providers and their managers have a responsibility to ensure all the elements of an infection prevention and control programme with appropriate infrastructures are in place in their own organisation. This is a requirement of The Health and Social Care Act The programme should include: The infection prevention and control measures needed in the service; The policies, procedures and guidance that are needed and how they will be kept up to date and how compliance is monitored; The initial and ongoing training that care workers will receive. The infrastructure should: Be a record of the names and contact details of sources of expert infection prevention and control advice; Include guidance for care workers about the circumstances in which contact should be made. New guidance, legislation and regulations that have implications for control of infection are published and updated frequently and will need to be referred to in conjunction with these guidelines. All care workers must have access to a written infection prevention and control policy (see Appendix 3 for Policy template) and receive training in infection prevention and control. The infection prevention and control responsibilities for all care workers should be included in their job descriptions (Appendix 4) and in personal development plans. Registered providers will need to report an annual statement/report which provides a review of: Any outbreaks/incidents of infection and the action taken following these; Audits undertaken; Risk assessments undertaken for prevention and control of infection; Training received by care workers; Review and update of policies, procedures and guidance. In all care settings which deliver healthcare there should be a programme of audit of infection prevention and control practices. (Examples of Audit tools can be found in Appendix 5). In case of difficulty or problem not covered by these guidelines please contact those listed under Local Sources of Advice in Section 2 or refer to NHS Stoke on Trent Policies at NHS Stoke on Trent Infection Prevention and Control Team

10 1.2 Roles and responsibilities The Registered Provider The owner/s of the practice are responsible under health and safety legislation for maintaining an environment which is safe for service users, care workers and others alike. Suitable arrangements and procedures for prevention and control of infection will form part of the health and safety requirements The Practice Manager The practice manager should have access to advice on infection prevention and control from a suitably qualified and competent individual and is responsible for ensuring that there are effective measures in place for the prevention and control of infection which include: The provision of up to date policies, procedures and guidelines which are approved by local infection control specialists. These should be readily available, understood by all members of staff and used within the practice. Infection prevention and control training for all staff that is appropriate to their role both at induction and on a regular basis and training records kept. Monitoring the implementation and effectiveness of infection prevention control policies and procedures at least annually by using standardised audit/quality improvement tools approved by the local infection prevention and control specialists Designating an Infection Prevention and Control Lead for the practice The Director of Infection Prevention and Control (DIPC) The DIPC in an organisation providing health care has overall responsibility for infection prevention and control and is accountable to the registered provider of care. This role is usually in NHS providers of health care The Infection Prevention and Control Lead for the organisation. (IPC lead) The role of the IPC lead in primary care will depend on the organisational structures and the complexity of the care provided and their role is similar to the DIPC in health care. Both the DIPC and the IPC lead are responsible for producing an annual report/statement on infection prevention and control which should include: information on incidents and outbreaks of infection; risk assessments; training and education of staff; infection prevention and control audits; and the actions that have been taken to rectify any problems The Care Quality Commission (CQC) The CQC aims to ensure that better care is provided for everyone, whether in hospital, care homes, people s own homes, or elsewhere. It regulates health and adult social care services, whether provided by the NHS, local authorities, private companies or voluntary organisations. It also protects the rights of people detained under the Mental Health Act. Their work brings together independent regulation of health, mental health and adult social care. Before 1 April 2009 this work was carried out by the Healthcare Commission, the Mental Health Act Commission and the Commission for Social Care Inspection. These organisations no longer exist. NHS Stoke on Trent Infection Prevention and Control Team

11 1.2.6 The Health Protection Units (HPU). The Health Protection Teams/Units (HPUs) are part of the Health Protection Agency. The HPUs are responsible for the control of infectious disease and environmental hazards within a county. The HPUs are comprised of Consultants in Communicable Disease Control (CCDC) and Health Protection Nurses (HPNs)/Infection Prevention and Control Nurses (IPCNs) and other supporting staff. Outbreaks and incidents of infection in the community will be monitored and investigated by the HPU and they will initiate and co-ordinate any necessary action to limit further spread Consultants in Communicable Disease Control (CCDC) and/or Consultants in Health Protection (CHP) The CCDC and the CHPs are employed by the Health Protection Agency. CCDCs are responsible for the control of communicable disease within their locality. They may advise the local community and infection prevention and control teams on communicable disease control including the management of outbreaks. They are appointed as the Proper Officer of the Local Authority, which has statutory duties and powers relating to communicable disease control Health Protection Nurses (HPN) The HPNs are employed by local HPUs and are able to provide specialist advice on infection prevention and control in the community when outbreaks and other incidents occur. The local HPU is to be informed of any suspected outbreak of infection in the community and will provide and lead the investigation and management of the outbreak The Community Infection Prevention and Control Nurse (CIPCN) The CIPCN is usually employed by the primary care trust (PCT) and provides advice, education, training, policy development and audit functions to the care providers in the PCT. The level of support given to general practices by the CIPCN will be dependent on local service level agreements Hospital Infection Prevention and Control Teams provide an infection prevention and control service for the hospitals. The hospital infection prevention and control teams are comprised of an Infection Prevention and Control Doctor, who is usually a consultant microbiologist, and Infection Prevention and Control Nurses The General Practitioner (GP) The GP is responsible for the diagnosis and treatment of all those registered under their care. The GP has an ethical responsibility to consider the implications of a diagnosis of an infectious disease for the health of the public. Liaison with the CCDC/local HPU is important in infectious disease control; the GP is responsible for notifying the CCDC/local HPU of certain infectious diseases (see section 8.3 Notifiable Diseases). The GP has a responsibility to prescribe appropriate antibiotics and be mindful of the link between antibiotic prescribing and Clostridium difficile infection, for following the local antimicrobial prescribing policy and being aware of advice from the local Medicines Management Team, which includes the PCT pharmacy advisors Environmental Health Officers (EHOs) work for local authorities. They advise on food safety and kitchen design, pest control and waste disposal. They are responsible for the control of pollution and other nuisances. Their duties include the NHS Stoke on Trent Infection Prevention and Control Team

12 inspection of food premises to enforce the requirements of the Food Safety Act They investigate complaints about food and collaborate with the HPU in the investigation of outbreaks, particularly of food or water-borne illness. They will coordinate the collection of samples and delivery to the laboratory during an outbreak to speed the outbreak investigation Infection Prevention and Control Link Person is an employee working in a health care setting and who has received some additional training in infection prevention and control and is appointed by their manager to act as a link between the Infection Prevention and Control Nurse or Health Protection Nurse and the workplace. A role profile is available in Appendix Practice Staff/Care workers Infection prevention and control is the responsibility of everyone working within the practice although the management of this will be shared by the management team and the designated IPC lead. All staff/care workers have a responsibility to ensure that they: Are aware of the location, how to access and be able to demonstrate an understanding of the practice policies on the prevention and control of infection. Follow the infection prevention and control policies of the practice and to work in such a way that the infection risk to service users, themselves and others is minimised. Receive infection prevention and control training appropriate to their role. Report any recurrent skin, soft tissue and other infections that may be transmittable to service users to their line manager and occupational health advisor Informal carers look after their partners, spouses, relatives, friends, and neighbours on an informal basis. They often have no formal training in care, but practice staff should be able to provide information about any care procedures they will undertake. NHS Stoke on Trent Infection Prevention and Control Team

13 2. LOCAL SOURCES OF ADVICE NHS Stoke on Trent Head of Infection Prevention and Control and Infection Prevention and Control Specialist Nurses NHS Stoke on Trent London House 4 th Floor Hide Street Stoke-on-Trent ST4 1NF Tel: Mobile : Mobile : Health Protection Unit Health Protection Unit West Midlands North Crooked Bridge Road Stafford ST16 3NE Tel: Consultant in Communicable Tel: Disease Control Health Protection Nurses Tel: Consultant Microbiologist University Hospital of North Staffordshire Pathology Laboratory Tel: (General Office) NHS Stoke on Trent Infection Prevention and Control Team

14 3. WHY INFECTION PREVENTION AND CONTROL IS IMPORTANT Many infections have the potential to spread in the health care environment and both service users and care workers are at risk. In general practice activities are undertaken which may increase the risk of infection. Infections acquired in primary care may have serious consequences for service users, they may worsen underlying medical conditions and in some instances may be life threatening. Service users receiving care may have an increased susceptibility to infection due to a number of risk factors: Age; Immune status; Poor nutrition; Underlying medical conditions such as cancer, diabetes, heart problems; Antibiotic and other medications; Incontinence; Surgical procedures; Indwelling medical devices such as urinary catheters or gastric feeding tubes ; Breaks in the skin. In recent years infection prevention and control has also become more of a challenge across all health care settings due to complexity of care and the increasing numbers of organisms that have become resistant to treatment with antibiotics. Resistant organisms that have increased include: meticillin resistant Staphylococcus aureus (MRSA) Extended Spectrum Beta Lactamase producers (ESBLs). Glycopeptide resistant enterococci (GRE). There has also been an increase in the numbers of cases of Clostridium difficile infection and the emergence of relatively new organisms such as E. coli As well as the challenge posed by the emergence of resistant micro organisms many general practices have extended their activities to include interventions that may carry an increased risk of infection to service users e.g. carrying out minor surgical procedures. It is essential that appropriate infection prevention and control measures are in place to provide a safe environment that minimises the risk of infection to all. NHS Stoke on Trent Infection Prevention and Control Team

15 4. THE CHAIN OF INFECTION In order for infection to occur several things have to happen. This is often referred to as the Chain of Infection. The six links in the chain are: The source of the micro organism Link 1 The main types of micro organism causing human infection include bacteria (e.g. salmonella), viruses (e.g. hepatitis A, B or C), fungi or yeasts (e.g. candida). Infected individuals may act as a source of infection for others because the micro organisms that are found on the skin and in body fluids could be passed on to others. Reservoirs for micro organisms Link 2. These are places where micro organisms may live and survive. Reservoirs can include people, animals, the environment, food or water. Contaminated food may act as a reservoir, for example if it is contaminated with salmonella or campylobacter. If the meat is not thoroughly cooked, those eating it may become infected. Other examples of reservoirs for micro organisms include articles such as towels, flannels, wash bowls, bed pans, contaminated equipment etc. The way micro organisms leave the body Link 3 Sometimes termed portal of exit, this can occur in a number of ways. For example, Clostridium difficile leaves the body in the faeces and, if diarrhoea is present, high numbers of C difficile micro organisms and spores are excreted and can contaminate the environment and equipment. The method of spread of micro organisms from person-to-person Link 4 Micro organisms are spread in several ways. These include direct or indirect contact (including ingestion, sexual contact, mother to foetus, injection or inoculation) and some infections are airborne and are inhaled, e.g. influenza and pulmonary tuberculosis. Unwashed hands are the most common way to spread infection. Micro organisms may be present in any body fluids (excretions and secretions). If hands come into contact with body fluids they may become contaminated and carry micro organisms from one person to another if hands are not washed. In addition the micro organisms can be spread from person-to-person via a contaminated environment (e.g. dust) or equipment. Some infections may be spread via the air, such as the cold and influenza viruses. The infection may be spread in droplets or aerosols produced by coughs and sneezes. Some childhood illnesses are also spread in this way. Micro organisms enter into the body. - Link 5 This is sometimes referred to as the portal of entry. In order for micro organisms to cause an infection they must gain entry into the body. Different micro organisms have different ways of entering our bodies. For example, salmonella needs to be ingested (eaten), others may cause infection if they are inhaled e.g. influenza. Others, such as hepatitis B, enter the bloodstream via broken skin, injection or sexual intercourse. A susceptible person (person at risk of infection) - Link 6 Once micro organisms have gained entry to the body they will only cause infection if the person is susceptible to infection. In many cases the body s defence NHS Stoke on Trent Infection Prevention and Control Team

16 mechanisms will prevent infection occurring. People may develop infections if the body s natural defences are breached and the micro organisms are in sufficient numbers to cause illness. Immunity to some infections can be developed after being infected (e.g. chickenpox) or after immunisation (e.g. hepatitis B and influenza). Certain people are more susceptible or at greater risk of infection for a variety of reasons. People who are very young or the very old are more at risk because their immune system may not be developed or may be less efficient. In addition, some medications, such as steroids and cytotoxic agents can damage the immune system and increase the infection risk as can underlying diseases such as diabetes, blood disorders, cancer and HIV. The Chain of Infection Link 1 Source Link 6 Person at risk Link 2 Reservoir Link 5 Way into the body Link 4 Method of spread Link 3 Way out of the body Breaking the chain of infection Breaking the chain of infection by targeting one or more links can prevent the spread of infection. This usually involves: Eradicating the source of infection through appropriate antimicrobial therapy; Preventing the method of spread through infection prevention and control measures; such as hand and personal hygiene; use of Personal Protective Equipment ; environmental cleaning; decontamination of equipment; disposal of waste. Protecting the individual at risk by immunisation; Preventing micro organisms from entering the body by: wearing protective clothing; using an aseptic technique when handling invasive devices or dressing wounds; covering wounds and insertion sites with sterile dressings etc. It will not be possible to identify all service users who have an infection. Some diseases are infectious before any signs develop. Some infections may not show any signs or NHS Stoke on Trent Infection Prevention and Control Team

17 symptoms, such as hepatitis B or HIV. Some people may carry a micro organism without developing the infection themselves, e.g. salmonella or MRSA. For this reason it is important for everyone to follow standard precautions at all times to help protect service users, care workers and others from infection. 5. STANDARD INFECTION PREVENTION AND CONTROL PRECAUTIONS 5.1 What are standard infection prevention and control precautions? The aim of standard infection prevention and control precautions is to break The Chain of Infection and they are the core measures that should be used at all times, in all care settings, by all care workers. They are based upon the assumption that every individual could be carrying potentially harmful micro organisms and that there is the potential for transmission of infection. The underlying principle of standard infection prevention and control precautions is that: All body fluids must be treated as potentially infectious therefore standard infection prevention and control precautions must be followed at all times In all situations the care worker must assess the risk of the task that they are doing, and assess both the risks to and from the service user to themselves and others. The two key elements of standard precautions are hand hygiene and the use of personal protective equipment. A staff information leaflet for standard precautions can be found in Appendix Hand hygiene Good hand hygiene is the most important way to prevent the spread of infection. An intact skin provides an efficient waterproof barrier; therefore everyone should look after their skin and cover any breaks in the skin with a waterproof plaster. If skin becomes contaminated with body fluids these should be washed off as soon as possible What are your hands carrying? Micro organisms found on hands may be categorised as either resident or transient. Resident micro organisms are: Deep seated; Difficult to remove; Part of the body s natural defence mechanism; Associated with infection following surgery or invasive procedures, especially those involving implants and invasive devices. Transient micro-organisms are: Superficial; Transferred easily to and from the hands; A significant cause of cross infection; Easily removed with good hand hygiene When should you decontaminate hands? The point of care as the crucial moment for hand hygiene The point of care refers to the service user s immediate environment in which the care worker has contact with the service user or when treatment is taking place. This NHS Stoke on Trent Infection Prevention and Control Team

18 may be the treatment room, consulting room, or the service user s home. This time represents the point when the risk of transfer of micro organisms is greatest. To assist care workers The World Health Organisation (WHO) has identified five moments for hand hygiene : 1. Clean your hands before touching a service user. 2. Clean your hands after touching a service user and the immediate surroundings. 3. Clean your hands immediately before an aseptic technique. 4. Clean your hands immediately after an exposure risk to body fluids (and after glove removal). 5. Clean your hands after touching any object or furniture in the service user s immediate surrounding when leaving even if the service user has not been touched. (National Patient Safety Agency 2008) A poster demonstrating five moments of hand hygiene can be found in Appendix Hand hygiene facilities Hand wash facilities that include as a minimum a hand wash basin, supplied with hot and cold water, liquid soap and disposable paper towels should be available and easily accessible at all hand wash basins that are used by care workers for hand washing. A lack of appropriate facilities should be brought to the attention of the manager and the Infection Prevention and Control Lead for the practice. Hand wash basins used by care workers for clinical procedures should be designated as such and have mixer taps that are wrist, sensor, elbow or foot operated. These hand wash basins should not be used for any other purpose. In situations where paper towels and liquid soap are not available e.g. in the service user s own home there should be a portable system in place for care workers to use e.g. a toolbox equipped with paper towels, liquid soap, aprons and gloves or a hand hygiene kit. Hand hygiene kits are available from some companies Hand hygiene products The products chosen must be acceptable to the users, and not have a detrimental effect upon the skin of care workers. Liquid soap In most care settings, hand washing with liquid soap (preferably one that contains an emollient) and water is all that is required. There is no need to use antibacterial soaps. Liquid soap dispensers should be provided. These should be wall mounted, kept clean and maintained regularly. The dispenser should have single use cartridges that are discarded when empty to reduce the risk of accidental contamination and cross infection. Soap dispensers must not be refilled or topped up. Paper towels Soft user-friendly paper towels should be provided for drying hands. These should be provided in wall mounted holders that are easy to use and clean. Cloth towels must not be used. NHS Stoke on Trent Infection Prevention and Control Team

19 Alcohol hand rubs Alcohol hand rubs should be available for use at the point of care. They are available in wall mounted, portable and small personal dispensers. The most appropriate way of delivering the alcohol hand rub should be chosen and will depend on the needs of both service users and care workers. Alcohol hand rubs are useful in many situations especially when delivering domiciliary care and are recommended for use to compliment hand washing with soap and water as and when appropriate. Alcohol hand rubs provide a quick and effective method of disinfecting clean hands when hand washing facilities are limited. They should be applied using the illustrated six stage technique (Appendix 9) until the hands are dry. After using on a maximum of five consecutive occasions hands should be washed with soap and water to prevent a build up of residue on the hands. They are not suitable for use on hands that are soiled or during outbreaks of diarrhoeal illness (Clostridium difficile and norovirus) when washing with soap and water is necessary. Alcohol hand rubs used following hand washing with soap and water can be used to achieve hand disinfection prior to carrying out aseptic procedures including minor surgery. Hand wipes Impregnated hand wipes are not as effective as hand washing or the use of alcohol hand rub and should not be used as a substitute Hand Hygiene procedures Hand hygiene procedures can be considered as: Routine hand hygiene Hand disinfection Surgical hand hygiene Routine hand hygiene Ensure that the wrists and forearms are exposed by removing any items of clothing that may hinder thorough hand hygiene. Effective hand washing involves four stages: Preparation requires wetting hands under warm running water before applying liquid soap. The solution must come into contact with all surfaces of the hands. Washing using soap and water and applying the recommended six stage technique (Appendix 9). Rinsing under warm clean running water. Drying with good quality disposable paper towels. Hands should be washed by systematically rubbing all parts of the hands and wrists being particularly careful to include the areas of the hand which are most frequently missed i.e. the finger tips, finger webs and thumbs. 1. Turn on the taps using elbows if possible. 2. Wet hands before applying liquid soap. Wash hands thoroughly with liquid soap and running water, following the recommended six-stage technique (Appendix 9). The solution must come into contact with all surfaces of the hand. 3. Rinse hands under running water, holding the hands down. NHS Stoke on Trent Infection Prevention and Control Team

20 4. Turn off the taps using the elbows. If elbow operated taps are not available, use a paper towel to turn off the tap. 5. Dry hands thoroughly using a good quality paper towel (cotton hand towels may harbour bacteria and should not be used). Correct hand drying is essential to aid the removal of transient micro organisms and to protect the integrity of the skin. Hands not dried properly may become dry and cracked leading to an increased risk of harbouring micro organisms. Dispose of towels in a foot-operated bin (never lift the bin lid by hand to avoid re-contamination of hands). 6. Nail brushes should not be used for routine hand washing. Nail brushes can damage the skin leading to an increased risk of harbouring micro organisms or dispersing skin scales. If a nail brush is necessary it must be single-use and disposed of immediately after use. Hand disinfection This process should be carried out after contact with a service user with a known or suspected infection or before contact with particularly susceptible service users. It involves the application of an alcohol hand rub after the procedure for routine hand hygiene described above. Surgical hand hygiene This process results in the destruction of transient micro organisms and a reduction in the numbers of resident micro organisms and should be carried out: Before invasive and aseptic procedures e.g. minor surgery, insertion of intra uterine contraceptive devices. Surgical hand hygiene can be achieved in two ways: Wash hands using soap and water using the 6 stage technique and then apply two applications of 5ml alcohol hand rub/gel. Each application should be applied using the 6 stage technique and allowed to dry. Wash hands using the 6 stage technique with an antiseptic hand scrub solution. Lather well and wash all surfaces of the hands and wrists for 2 minutes, before rinsing and drying with paper towels Hand and skin care An intact skin is a natural barrier to infection consequently all care workers need to be aware of the potentially damaging effects of frequent hand washing and the use of alcohol hand rubs. Care workers should protect and maintain their skin integrity and minimise the risk of skin irritation by observing the following:- Always wet hands before applying soap. Rinse hands thoroughly after washing to remove all traces of soap. Use good quality paper towels to dry hands thoroughly, including the area between the fingers. Regularly use aqueous based hand creams to keep the skin moist and supple. Do not wear gloves for any longer than is necessary for the task. Always wash hands thoroughly after removing gloves. Always wear gloves when handling blood, body fluids, secretions and excretions, or chemicals. NHS Stoke on Trent Infection Prevention and Control Team

21 Any care worker who develops a skin irritation or allergy that may be due to the use of hand hygiene products should report this to the care home manager, their occupational health advisor and their GP Bare below the elbow A Bare below the elbow initiative has been recommended and endorsed by the Department of Health and has been widely adopted across the NHS. This requires all care workers that have direct contact with service users, their equipment and environment: To have short sleeves; Not to wear wrist watches, jewellery on the hands or arms other than a plain band; To keep nails short and clean; Not to wear artificial nails, nail polish or nail jewellery. Jewellery and wrist watches may become contaminated with and harbour micro organisms, consequently care workers providing care should ensure that prior to commencing a shift all wrist and hand jewellery apart from a plain band is removed Respiratory hygiene/ Cough etiquette Hand hygiene is an important part of respiratory hygiene and cough etiquette. The following measures will assist good practice When coughing, sneezing, wiping or blowing the nose, cover the nose and mouth with disposable single use tissues. Dispose of used tissues immediately into the appropriate waste stream. Wash hands after coughing, sneezing wiping or blowing the nose, or after contact with respiratory secretions Involving service users. Service users must be educated on the importance of hand hygiene to reduce the risk of cross infection to themselves and others and should ensure that care workers responsible for delivering care have decontaminated their hands prior to any contact. Service should be provided with information and advice on the correct six stage hand hygiene technique (see poster in Appendix 9). 5.3 Personal protective equipment The use of personal protective equipment (PPE) is essential for health and safety, and offers protection both to service users and care workers. PPE is worn in addition to normal work clothes, whether these are the care workers own or a uniform. Inevitably, the clothes that the care worker wears will become contaminated with micro organisms in the course of the day. However, if PPE is utilised when appropriate then there is little evidence that contamination of clothing plays a major role in the transmission of infection. PPE includes: Gloves Aprons Face, mouth/eye protection, e.g. masks/goggles/visors. Water repellent gowns In considering what protective clothing might be necessary in any situation it is necessary to carry out a risk assessment. This means asking whether the task that is about to be performed gives rise to any possibility of contact or contamination with NHS Stoke on Trent Infection Prevention and Control Team

22 blood or other body fluids. If the answer is yes, then appropriate protective clothing is necessary Risk assessment for protective clothing (Gloves, aprons and eye/face protection). Table 2 Low Risk Moderate Risk High Risk No risk of contact with blood and body fluids Risk that clothing or skin will be contaminated with blood and body fluid Risk that eyes, clothing or skin will get splashed with blood and body fluids PPE not required Apron and gloves Eye and face protection, water repellent gowns and gloves Gloves The need for gloves and the selection of appropriate ones must be based on a careful risk assessment (refer to Table.3). This will involve consideration of the actual task to be carried out, and the potential risks to both the service user and care worker. Gloves should only be worn if there is a possibility that hands will have contact with: Blood Body fluids Secretions Excretions Mucous Hazardous substances An intact skin provides a natural barrier to infection. During any service user contact considered to be social where there is no contact with the above, gloves are not required and hand hygiene using the six stage technique is sufficient. The following flow chart and table can be used to carry out a risk assessment to decide on the most appropriate glove for the task. NHS Stoke on Trent Infection Prevention and Control Team

23 Table 3 Are gloves really necessary? Gloves are NOT required for procedures where there is minimal risk of cross infection between service user and care worker. E.g. basic care procedures where there is no contact with blood and body fluids, taking recordings (BP, temperature and pulse) Gloves ARE required for procedures where there is a risk of cross infection between service users and care workers and further risk assessment should be undertaken Is there a risk of exposure to blood and body fluids? Do not wear gloves No Non sterile vinyl Yes Is a sterile field required? Yes No Sterile examination glove should be used for aseptic procedures: Dressing surgical wounds Inserting urinary catheters Manipulating Sterile surgical gloves should be used for surgical procedures. Minor surgery Insertion of intra uterine contraceptive devices. Non sterile nitrile or a synthetic glove with equivalent properties should be used for: Venepuncture Taking Smears Contact with blood and body fluids Handling specimens Cleaning P.E.G sites Dressing chronic wounds e.g. leg ulcers and pressure sores NHS Stoke on Trent Infection Prevention and Control Team

24 Table 4 Selection of appropriate gloves Procedure to be performed Invasive procedures which involve breaking the skin involving contact with blood or body fluids, e.g. surgery, for which high levels of protection for the service user and care worker are required. Non-invasive procedures involving exposure to blood or body fluids, or exposure to excreta, such as urine, faeces, vomit, and where there is little likelihood of exposure to hazardous or corrosive substances. General cleaning procedures Handling chemicals or other hazardous substances. Food handling Suitable gloves Sterile, non-powdered examination or surgeons glove. For those who are sensitised to natural rubber latex (service users and care workers), synthetic materials must be available e.g. vinyl, nitrile or neoprene. Non-sterile, non-powdered well fitting examination gloves For those who are sensitised to natural rubber latex, synthetic materials must be available e.g. vinyl, nitrile or neoprene. Polythene gloves must not be used for clinical care. Flock-lined household, nitrile or vinyl gloves If contact with blood or body fluid is likely, wear a glove that is comparable with (2) as outlined above. A glove that offers the necessary protective qualities, e.g. latex for high resistance to water-based chemicals and nitrile for resistance to solvents and oil based chemicals. Polythene if necessary Key points for glove use Gloves must not be re-used or washed. Liquids may penetrate through microscopic holes in the glove, and the glove may also be damaged if it comes into contact with oils or silicone based lotions, disinfectants or alcohol gel. Wear gloves only when necessary. Unnecessary or overuse of gloves may result in adverse reactions in some susceptible individuals. Gloves must not be used as a substitute for hand washing/hand hygiene. There is a growing incidence of latex allergy, and latex glove use is the single biggest risk factor. Alternatives to latex must therefore be provided. Never use gloves that contain powder, as this increases the risk of allergy. Gloves should be changed after contact with each service user and at the end of each procedure. Bear in mind that it may be necessary to change gloves between tasks on the same service user to prevent cross-contamination. Gloves worn for a specific task must be removed before touching uncontaminated areas, or for example, writing in notes. Hands must be washed after gloves have been removed. NHS Stoke on Trent Infection Prevention and Control Team

25 Removing gloves The wrist end of the glove should be held and the glove pulled down gently over the hand, turning it inside out whilst doing so. Dispose of the gloves immediately into a pedal operated disposal bin and dispose of in correct waste stream. (See section 19 Waste). Wash hands immediately after removing gloves Aprons Plastic disposable aprons should be worn whenever there is a possibility that clothing or uniforms may be contaminated with blood or body fluids or when caring for service users with certain infections. A separate apron should be worn for each occasion of care given to each individual service user. Never reuse or wash single-use disposable aprons. To prevent cross infection change aprons between caring for different service users and between different tasks for the same service user. Aprons and gloves should be stored in a clean area to avoid contamination. Removal of aprons Remove the apron promptly after use by turning the outer contaminated side inward and rolling into a ball. Dispose of immediately into a pedal operated bin and wash hands. Colour coding It is a good idea to use different coloured aprons for different types of tasks. For example, use white ones when required for clinical procedures, and another colour can be worn for non clinical procedures e.g. cleaning activities. For more information on colour coding refer to section This is especially important when the same care worker is undertaking different types of tasks Face mouth and or eye protection It is unlikely that face, mouth and or eye protection will be required routinely in the general practice setting. One possible exception to this is the use of masks during a flu pandemic. Face and eye protection e.g. visors should be worn if there is a risk that blood or body fluids may splash into the eyes. Visors should be washed with general purpose detergent and warm water after use Water repellent gowns It is unlikely that water repellent gowns will be required in general practice and should only be worn if there is a risk of splashing of blood and body fluids e.g. during home deliveries. 6. ISOLATION OF SERVICE USERS WITH AN INFECTION (TRANSMISSION BASED PRECAUTIONS/ISOLATION PRECAUTIONS) In some situations it may be necessary to use additional infection prevention and control precautions known as transmission based precautions. Guidelines related to these circumstances are outlined in this section. Appropriate advice can be obtained from the Health Protection Unit or the Community Infection Prevention and Control Nurses. NHS Stoke on Trent Infection Prevention and Control Team

26 6.1 Service user placement/isolation facilities This is about ensuring that individual service users with specific infections are segregated appropriately so that the risk of infection to other service users is minimised e.g. in waiting or communal areas. This is not usually an issue in general practice as the risk of infection is minimised by the implementation of standard precautions, however there may be situations where a service user may be a risk to others e.g. a child with chickenpox or a service user with influenza during a pandemic influenza outbreak. In these circumstances arrangements should be made to see the service user in their own home or in a separate area of the practice away from other service users. Further advice can be obtained from the Community Infection Prevention and Control Nurse (CIPCN). 6.2 MRSA What is MRSA? MRSA is an abbreviation for Meticillin Resistant Staphylococcus aureus. MRSA is a strain of Staphylococcus aureus which is resistant to Meticillin or Flucloxacillin. Staphylococcus aureus is a bacterium which can be carried on the skin; this is referred to as colonisation. Approximately 30% of the population is thought to be colonised with S.aureus. In these individuals the common sites of carriage are the nose, axilla (armpit), perineum, groin, skin folds or the umbilicus. It is normally harmless and these individuals are said to be colonised. If the micro organism gains access to tissues it may cause infections ranging from boils and abscesses to bronchopneumonia and septicaemia. MRSA causes the same range of infections as non-resistant strains of Staphylococcus aureus, but they may be more difficult to treat What is colonisation? Colonisation with MRSA occurs when the micro organism is present e.g. in the nose, skin folds, the axillae (armpits), groin or perineum, without any signs of infection. The bacterium may also colonise around indwelling devices, such as urinary catheters and Percutaneous Endoscopic Gastrostomy (P.E.G) tubes. Chronic wounds such as pressure sores, and leg ulcers may also be colonised without causing any invasive infection. The wound may continue to heal while colonised with MRSA. Healthy people are unaffected by colonisation with MRSA and may be unaware of its presence, however should a person develop an infection it may be that the colonising strain is responsible for the problem What is infection? Infection occurs when the micro organism (MRSA) enters the body and causes a host (person) response, such as pain, pyrexia, inflammation, or tissue damage. MRSA has the potential to cause a range of infections including minor skin infections, surgical site infections and bacteraemia. The severity of the infection will vary depending on a number of risk factors including the individual s general health and the area of the body infected The impact of MRSA in the community Service users who are colonised with MRSA will not be aware of its presence; a proportion however may develop an infection which requires treatment. NHS Stoke on Trent Infection Prevention and Control Team

27 MRSA may be no more dangerous or virulent than Meticillin sensitive Staphylococcus aureus (MSSA), but it is more difficult to treat and continues to evolve into new potentially dangerous strains MRSA in Hospitals In UK hospitals, approximately 40-50% of all S. aureus strains from clinical specimens are MRSA positive. MRSA is therefore endemic in the hospital setting and may be a risk to vulnerable or debilitated older service users particularly those in the acute stages of illness, following surgery and those with indwelling medical devices such as vascular or urinary catheters and enteral feeding tubes How is MRSA Spread? MRSA can be spread in two ways:- Endogenous (Spread from one part of the body to another in the same person) A service user colonised with MRSA may transfer the bacteria from one part of the body to another through touch. Exogenous (Spread from person to person) This may occur via the following routes:- Directly, during healthcare treatment. Indirectly via communal shared equipment or the environment. Service users with MRSA may contaminate objects and the environment through aerosols or skin scales which may transfer to other service users either directly or via care workers hands and shared equipment. Service users may also acquire antibiotic resistant strains as a result of antibiotic exposure Who is at risk? Service users with the following are at greatest risk of infection- Intravenous devices; Surgical wounds; Chronic wounds e.g. pressure sores, leg ulcers; Repeated hospital admissions; Immunocompromised; Complex medical conditions; Multiple courses of antibiotics; Indwelling medical devices e.g. lines, catheters, and enteral feeding tubes How should service users with MRSA be cared for? Carriage of MRSA should not prevent discharge from hospital to a service user s own home, or to a care home. If simple hygiene measures are followed, service users colonised or infected with MRSA are not a hazard to relatives, care workers or other service users. The practice of Standard Infection Prevention and Control Precautions in the care of all service users will prevent most cases of transmission of MRSA. Good hand washing/hygiene is the most important method of preventing the spread of infection. Sores or wounds should be covered with an appropriate dressing which is regularly changed. (An appropriate dressing is one that is impermeable such as a hydrocolloid, or a vapour permeable film or membrane). NHS Stoke on Trent Infection Prevention and Control Team

28 6.2.9 Is MRSA a risk to care workers and others? MRSA does not usually pose a risk to care workers unless they have risk factors for infection, for example they may be immunocompromised or have skin conditions such as dermatitis or eczema. Care workers should report any dermatological problems to their Occupational Health Advisor and their GP. The family and friends of affected service users should be encouraged to undertake thorough hand hygiene; they do not need to take any special precautions and should not be discouraged from normal social contact or from contributing to care packages Additional precautions in residential care settings Service user s may share a room as long as neither they nor the person they share with has open sores or wounds, a urinary catheter or other invasive devices. Service users may receive visitors and go out of the home to visit their family and friends and for other social activities. Service user s may join others in communal areas such as sitting or dining rooms provided any wounds are covered with an appropriate dressing. Complete procedures for other service users before attending to service users with MRSA. Perform dressings and clinical procedures on a service user with MRSA in the service users room/treatment room with the door closed. Seek advice from the CIPCN if the service user has a postoperative wound, productive cough, urinary catheter, PEG or other invasive device Admission to hospital and outpatient appointments. If admitted to hospital, the receiving ward/department must be informed of the service user s MRSA history, even if not currently positive. Inform the hospital staff if the service user is to attend the hospital as an outpatient or day case. If an ambulance is required the service should be informed but there is no requirement for ambulance personnel to take any precautions other than standard precautions MRSA Screening The Department of Health recommends screening all service users that are admitted to hospital. It is estimated that 7% of all those who are admitted to hospital have the bacterium on their skin or in their nose, even though they feel quite well and have no signs of infection. MRSA screening involves testing all service users who are admitted to hospital or attending the day case department, so that those who do carry the bacterium can be identified. The MRSA bacterium is more likely to cause an infection in people who are unwell, which is why it is so important to identify the carriers before they develop an infection or before MRSA is spread to others. By identifying those service users who are carrying MRSA when they are admitted to hospital, they can be offered the best and most appropriate care and treatment in a timely manner. Care worker screening should never be undertaken except on the advice of the Health Protection Team. NHS Stoke on Trent Infection Prevention and Control Team

29 Treatment and decolonisation Skin decolonisation is the process by which the MRSA organisms that are multiplying on the skin are removed or the number of organisms is reduced. Topical regime for skin decolonisation of MRSA Antiseptic body wash The treatment should be applied daily for five days. Wet skin before application. Antiseptic wash should be applied neat as a liquid soap/shampoo. Using approximately 30mls of solution, apply to the skin using a disposable cloth. Wash vigorously from head to toe paying particular attention to known carriage sites such as the axillae (armpits), groin, and buttock areas. The solution should remain on the skin for at least one minute before being thoroughly rinsed (preferably in a shower if possible). Hair should be washed twice within the 5 day course of treatment if the service user s condition allows. (N.B. Hibiscrub can change the colour of hair dyes). Dry thoroughly using clean towels. Towels should be laundered daily and cloths discarded after use during the course of treatment. Clean clothing, bedding and towels should be used after each body and hair wash during the course of treatment. If any treatment causes irritation, stop immediately and contact the CIPCN. Mupirocin sensitive MRSA Apply Mupirocin (Bactroban) Nasal using a cotton wool bud to both nostrils 3 times per day for five days. Mupicocin resistant MRSA Apply Naseptin (Chlorhexidine 0.1%) cream to both nostrils four times a day for ten days in combination with antiseptic wash for five days. MRSA information leaflets are found in Appendices Clostridium difficile What is Clostridium difficile? Clostridium difficile is an anaerobic bacterium (i.e. does not grow in the presence of oxygen). It is found in the large intestine and is carried asymptomatically in about 5% of healthy adults. It is also common in babies - up to two thirds of infants have it in their intestines, but it rarely causes problems. It is estimated that as many as 20% (one in five) of service users over the age of 65 carries C. difficile. Individuals can be colonised with C difficile, that is carrying the organism without any signs or symptoms of infection. C difficile colonisation is usually controlled by healthy or good bacteria in the intestine which have a protective effect. Individuals may develop illness as a result of C difficile infection and this is referred to as CDI What are the signs and symptoms of CDI? C. difficile is the major cause of antibiotic associated diarrhoea and colitis. Symptoms include:- Type 5-7 stool (Bristol Stool Scale Appendix 15) or stool which takes on the shape of its container, for which no other explanation can be given; NHS Stoke on Trent Infection Prevention and Control Team

30 Fever or low grade pyrexia; Nausea and /or loss of appetite; Abdominal pain and tenderness; Raised white cell count or raised levels of C- reactive protein; Acute rising Creatinine levels; The presence of Clostridium difficile toxins A & B in the stool sample; Pseudomembranous colitis is seen on endoscopy. C difficile infection can result in severe colitis leading to bleeding and ulceration of the intestine, megacolon and at worst perforation of the bowel What causes CDI? CDI is nearly always linked to and triggered by the use of antibiotics. The effect of antibiotics, however, may not immediately be apparent and CDI can occur up to six weeks after treatment. Other factors that increase the risk are gastric surgery/interventions, tube feeding and medications that inhibit gastric acid production and gastric motility e. g.ppis (proton pump inhibitors) Who is at greatest risk of CDI? Acutely ill service users in hospital who are receiving or who have had multiple courses of antibiotics. Any service user treated with broad spectrum antibiotics, most commonly elderly service users with serious underlying disease How is CDI diagnosed? Clostridium difficile infection should always be considered as a diagnosis in its own right, not a side effect of other treatments. The following should be used to confirm or refute the diagnosis. An episode of diarrhoea, type 5 7 on the Bristol Stool Scale (Appendix 15), or stool which takes on the shape of its container, and which cannot be attributed to any other cause. Other causes should include dietary considerations, any medications which may alter bowel habit, (see Appendix 14), and any chronic bowel disease. If no other cause can be found a stool sample should be submitted to the laboratory. Please do not send samples of formed stool to the lab as they will not be processed. If the first sample is negative but symptoms persist and the service user appears unwell send a second sample 24 hours later. The following basic principles shown in the table below apply when CDI is suspected. These principles comply with specific duties of the Health and Social Care Act NHS Stoke on Trent Infection Prevention and Control Team

31 Table 5 S I G H T Suspect that a case may be infective where no alternative cause for diarrhoea can be identified Isolate the service user while determining the cause of the diarrhoea. Gloves and aprons must be used for all contacts with the service user and their environment. Hand washing with soap and water will be carried out before and after each contact with the service user and their environment. Test the stool for toxin How is Clostridium difficile spread? A service user who has C. difficile associated diarrhoea may excrete large numbers of micro organisms and spores in their liquid faeces. These can contaminate the environment, surfaces and equipment used by and in the immediate vicinity of the service user. Spores can survive in the environment for long periods and are a potential source of hand to mouth (faecal oral) infection in other service users particularly those receiving antibiotics What can be done to prevent the spread of Clostridium difficile? Preventing spread relies upon six important components; Prudent antibiotic prescribing; Isolation of symptomatic service users; Thorough hand hygiene with soap and water; Appropriate use of personal protective equipment (PPE); The use of service user specific equipment, and thorough cleaning of equipment and the environment; Where possible reduce the use of broad spectrum antibiotics. In health care environments such as care homes and hospitals the service user with C difficile associated diarrhoea should be cared for in a single room or cohort ward. Thorough hand hygiene is essential. After caring for a service user with C. difficile associated diarrhoea, hands must be washed with soap and water using the recommended six stage technique (Appendix 9), alcohol alone is not sufficient. Alcohol hand rub can be used to compliment hand washing. Always use the recommended six stage technique immediately before each and every episode of direct service user contact or care. (NICE 2003). Always use gloves and aprons for direct care with the affected service user and for other tasks carried out in the affected service user s immediate environment. This is especially important when dealing with faeces or items that may be contaminated with faeces Does CDI require treatment? A laboratory result documenting the presence of C. difficile toxin should prompt a service user re-assessment; however service users who do not have symptoms of CDI will not require treatment. NHS Stoke on Trent Infection Prevention and Control Team

32 Treatment should always be based on assessment of the service user not just the laboratory report. Treatment should aim to control symptoms and restore normal bowel flora. Any antibiotics that the service user is taking should be reviewed by the GP. In mild cases of infection just stopping the antibiotics may be sufficient for the person to recover. Other medication such as laxatives and other drugs that may cause diarrhoea should also be reviewed. Anti-peristaltic agents such as Loperamide should not be prescribed. If possible medication which inhibits stomach acid production such as proton pump inhibitors should be reviewed and if possible discontinued. Sometimes it is necessary to prescribe special antibiotics. The first line of treatment is Metronidazole which has high activity against anaerobic bacteria and may be used for up to fourteen days. For very sick service users or for treatment failure oral Vancomycin may be used. Ensure that fluid intake is recorded, and that it is adequate. Use a stool chart to record all bowel movements. If the service user s condition does not improve after 7 days treatment the GP should seek advice from the consultant microbiologist Do probiotics prevent C.difficile? The evidence for the use of probiotics is inconclusive, imprecise and has been linked to rare but reported adverse side effects Can the service user attend hospital for diagnostic tests? The risk of spread arises from contact with faecal material. If the diagnostic test is not urgent it would be best to delay it until the service user no longer has symptoms Will the presence of C. difficile delay discharge or transfer? The service user must be free from C. difficile diarrhoeal symptoms for at least 72 hours prior to transfer to another hospital or care home. Following transfer the service user should be monitored for a re-occurrence of diarrhoeal symptoms which may occur in 20-30% of cases. Service users can be discharged to their own home when they are clinically well Are repeat stool specimens required? Repeat stool specimens for clearance are not required. The service user is not an infection risk once the diarrhoea has ceased. Clostridium difficile toxin may be present for many weeks after recovery from symptoms. The laboratory will not undertake C. difficile toxin testing within four weeks of the first positive specimen collection date Care of a service user with C.difficile infection (CDI) All service users in a care home or hospital setting with diarrhoea should be isolated until they have had no symptoms for a minimum of 48 hours and have passed a formed stool/stool that is normal for them. Standard infection prevention and control precautions should be followed by all care workers at all times. Remember to assist service users to wash their own hands after using the toilet/commode/bedpan. NHS Stoke on Trent Infection Prevention and Control Team

33 In addition to standard infection prevention and control precautions: Care workers should wear disposable gloves and aprons when carrying out any care (i.e. not only when contact with blood and/or body fluids is anticipated). If the affected service user does not have their own en-suite toilet, use a dedicated commode (i.e. for their use only) which can remain in their room until they are well. Treat all linen as infected, and place directly into a water-soluble bag prior to removal from the room. Pay special attention to daily cleaning of the environment. Routine cleaning with warm water and detergent is important to physically remove any spores from the environment. After cleaning with warm water and detergent, wipe all hard surfaces with a chlorine based disinfectant (1000ppm). This is obtained by diluting Milton 1:10 or household bleach 1:100. Ensure that visitors wash their hands at the beginning and end of visiting It is important to ensure that you have adequate stocks of liquid soap, paper towels, disposable gloves and plastic aprons. Hand washing with soap and water is necessary when caring for service users with C difficile as alcohol gel will not inactivate the spores When can these extra precautions be stopped? It is not necessary to send further stool samples to the laboratory to check whether the service user is free from infection. Additional precautions can be stopped when the service user has been completely free from symptoms for 48 hours and a normal formed stool/normal for that service user has been passed. The additional isolation precautions can also be stopped at this time. Symptoms may recur in about one in five people, so if this happens, inform the GP and recommence all precautions. An information leaflet for Clostridium difficile can be found in Appendix Extended spectrum beta lactamase producers (ESBLs), Glycopeptide resistant enterococci (GRE) and other resistant/ multi resistant micro organisms Over recent years there has been an increase in the number of micro organisms that are becoming resistant to antibiotics. These include extended spectrum beta lactamase producers (ESBLs) and Glycopeptide resistant enterococci (GRE). Glycopeptides are a group of antibiotics which include vancomycin and tiecoplanin. Although these micro organisms have the ability to cause infection most service users identified with them will be colonised rather than infected and will not require treatment. The infection prevention and control measures are similar to those for MRSA What is an ESBL? ESBL an abbreviation for extended spectrum beta lactamase. ESBLs are not organisms in their own right, but are the name given to a number of bacteria that release enzymes which make the bacteria resistant to antibiotics. The types of bacteria commonly associated with ESBL production are organisms which normally inhabit the bowel such as Escherichia coli or klebsiella. The bacteria are then referred to as an ESBL producers. ESBLs are resistant to nearly all antibiotics and treatment options are very limited. NHS Stoke on Trent Infection Prevention and Control Team

34 6.4.2 Glycopeptide-resistant enterococci (GRE) GRE are bacteria that are commonly found in the faeces of humans and animals. Two main types may cause disease in humans: Enterococcus faecalis and Enterococcus faecium. In recent years some species of enterococci have become resistant to certain antibiotics, especially glycopeptides. In the past these organisms were known as Vancomycin-resistant enterococci (VRE) but today they are known as Glycopeptide-resistant or GRE. These organisms tend to cause colonisation rather than infection, though some, more vulnerable people may develop more serious infection such as urinary tract infection and bacteraemia (blood infections). Infection is often linked with the presence of invasive devices such as catheters and intravenous (IV) lines. Antibiotics are available to treat these infections. GRE can live harmlessly in the gut of healthy and sick people. Its presence doesn t necessarily need treatment with antibiotics. People who are more at risk of acquiring and becoming infected with GRE include service users needing intensive care, those with immunosuppression (oncology, haematology and transplant patients), those undergoing abdominal or cardiovascular surgery or renal dialysis and those with invasive devices such as IV lines and urinary catheters How are ESBLs, GREs and other resistant micro organisms spread? They may be passed from person to person by direct contact with a person who has an infection or carries the bacteria in their gut or on their skin. They may also be transmitted by contact with equipment and environmental surfaces that have been contaminated with the bacteria. As many of these resistant organisms live in the gut, service users who are incontinent may be a greater risk to others How can spread be prevented? In residential settings and hospitals, service users with resistant micro organisms should have their own room. The simplest but most effective measure in preventing the spread of infection is thorough hand hygiene. In addition to standard precautions aprons and gloves should be worn for contact with the service user and their immediate environment. Wear gloves and aprons for handling body fluids, excreta, stomas, linen, waste etc. Discard on leaving the service user and wash hands. Hands must be washed after giving any care or after handling linen and waste. Alcohol hand rubs should be used following hand washing with soap and water. Dispose of urine or faeces promptly and with care. Use of a washer/disinfector for cleaning bedpans and commode pans. Use an aseptic technique when dealing with invasive devices (e.g. Hickman lines), catheters etc. Maintain high standards of environmental cleanliness. Clean equipment after each and every episode of use. Designate equipment for the colonised/infected service user. No special precautions are needed with crockery and cutlery. If the service user is admitted to hospital or another residential setting, inform the care worker about the resistant micro organism so they can take appropriate precautions. NHS Stoke on Trent Infection Prevention and Control Team

35 6.4.5 Who is at risk of acquiring resistant micro organisms? Frail service users in hospital or care homes particularly those with long term indwelling devices such as a urinary catheter are most at risk. The device may become colonised with bacteria creating a potential reservoir for infection. The following factors further increase the risk:- Old age; Multiple courses of antibiotics; Prolonged hospital stays or intensive care admissions; Prolonged illness or complex medical conditions e.g. renal dialysis service users; Those in long term residential care Are care workers at risk of acquiring resistant micro organisms? Care workers may pick up these micro organisms on their hands and clothing when caring for a colonised or infected service user. By following standard precautions the risk of care workers becoming colonised is minimised and these micro organisms are readily removed by hand washing and laundering. Healthy people are not at risk from these micro organisms Will the service user require treatment? Service users who are colonised with no signs of infection will not require any treatment. In care homes and in the community, the risk of serious infection from resistant micro organisms is very small and treatment is rarely needed. The GP should contact the microbiologist to carry out a risk assessment for each affected service user Does the service user require isolation? In residential care settings the service user does not need to be confined to their room. All clinical procedures should be carried out in the service user s room. It is important that urine and faeces can be managed and contained and that standard infection prevention and control precautions are followed. Any spillages should be cleaned away immediately (i.e. clean with general purpose detergent, followed by wiping over with hypochlorite solution). 6.5 Influenza What is influenza? Influenza is a viral respiratory infection that tends to occur during the winter months. The two main types of influenza causing disease in the UK are influenza type A and B, but new strains and variants of the virus emerge each year. The incubation period is 2-3 days and cases are infectious from 1 day before the onset of symptoms and for up to 5 days after the onset. Outbreaks may occur in communities and communal settings such as schools and care homes. When the number of cases exceeds that normally expected, this is defined as an epidemic. If a completely new strain of influenza virus emerges, to which the population has no previous immunity, it may result in a global outbreak, known as a pandemic, which can affect large numbers and have a high death rate. The onset of influenza is sudden with a high fever (> C), dry cough, headache, aches and pains in the joints and muscles, chills and a general feeling of tiredness. Fever usually reduces after the second day and the nose may become stuffy and a sore throat may develop. People with influenza should stay at home and rest, drink plenty of fluids and may find symptom relief with painkillers, cough mixture etc. NHS Stoke on Trent Infection Prevention and Control Team

36 Antibiotics are not required unless there is also a bacterial infection Who is at risk? Most people recover from influenza within a few days. However, influenza may be serious in newborn babies, people aged over 65 years and people of any age with existing chronic diseases. High-risk conditions include people with cardiac, respiratory, renal and liver disease and those with impaired immune systems. Bronchitis and secondary bacterial infections such as pneumonia can result in hospital admission and can be life-threatening How is influenza spread? Influenza is highly infectious and is one of the most difficult infectious diseases to control because the virus spreads rapidly and easily from person to person. This is through two routes: Direct via droplets expelled from infected people (coughing, sneezing and talking) which land on the mucous membranes of other people and enter the body. Indirect via hands touching contaminated surfaces, and then touching the nose, mouth or eyes. The infection spreads easily within households and settings such as care homes and other institutions where individuals live or work in a shared environment. The good news is that careful hand hygiene and environmental cleaning can easily deactivate the virus How can influenza be prevented? Each year a new influenza vaccine is developed which provides immunity against the strains of influenza circulating that year. Every autumn the vaccine is offered to anyone aged over 65 years, people with a high-risk condition and their carers, people residing in care homes and front-line health and social care staff. Antiviral drugs can be offered to at-risk groups when influenza is circulating in the community. Health and social care teams should report any suspected cases in their care to the GP and any clusters to the Health Protection Team How can the spread of influenza be avoided? People with influenza should:- Try to stay away from contact with others during the infectious period; Stay in their own room, if living in a care home; Use disposable tissues and wash hands after coughing and sneezing. Carers should: Wash their hands after giving care, handling used tissues or items contaminated with respiratory secretions; Keep the environment clean Pandemic flu what is it? Pandemic flu is when there is a worldwide outbreak of flu. This happens when a new flu virus that is able to spread easily from person to person emerges. Because the virus is new, the human immune system will have no pre-existing immunity, and the majority of the population will therefore be susceptible. This makes it likely that NHS Stoke on Trent Infection Prevention and Control Team

37 people who contract pandemic flu will experience more serious disease than that caused by seasonal flu. There were three worldwide flu pandemics in the last century in: 1918/1919 Spanish flu 1957/1958 Asian flu 1968/1969 Hong Kong flu. These pandemics were caused by new subtypes of flu that were probably formed by a combination of genes from both avian (bird) and human flu viruses. There is concern that the currently circulating strain of avian influenza/bird flu (H5N1) may combine with another strain, or adapt to the human body and result in a pandemic. Pandemics of the previous century spread around the globe in six to nine months, but because of the speed of international travel today, it would probably reach all continents within three months or less Swine Flu H1N1 Is a new sub type of influenza that emerged as a result of changes to the swine flu virus that had been circulating in the United States. These changes have meant that it is now able to infect humans and can spread easily from person to person. As it is a new sub type very few people have been exposed or have developed immunity to it so large numbers of the population will be susceptible and it is for this reason and extent of spread across the globe that the World Health Organisation declared a Pandemic in All front line care workers and those at greatest risk were offered swine flu vaccine What can be done to prepare? As a provider of community care, it is important that you have a plan prepared in the event of an outbreak of pandemic influenza. If a vaccine is available for the strain of flu causing the pandemic both service users who are perceived to be at a greater risk and care workers will be offered vaccine. All care workers who have direct contact with service users should be encouraged to have the vaccine. This should minimise the impact of the pandemic on the service provided by the practice. The service will have to be managed with fewer care workers, as it is expected that in a pandemic, healthy younger people will also be infected. Over the course of the pandemic up to 50% of the population may become ill, and care workers will be off work, either because they are ill themselves, or because they are caring for relatives. The plan should include how to cope with this situation. Identify which aspects of the service are essential and must carry on, and which might be stopped if necessary. How many care workers do you need to do the basics? Other very practical issues are: Health and Safety - you still have a duty to protect your employees; Training and education - for care workers who may be asked to take on alternative roles; Staff welfare - e.g. sick leave policy, protecting those most at risk such as pregnant women; Parents - what to do if schools close. Identify a person within the practice that can start writing your plan. NHS Stoke on Trent Infection Prevention and Control Team

38 A wealth of guidance has been published nationally and regionally is updated regularly and is available at: In the event of future pandemics guidance will be issued at global, national and local levels for all health care providers including those in general practice. 6.6 Creutzfeldt Jakob Disease (CJD) What is CJD? CJD is rare and fatal degenerative brain disease. It is thought to be caused by infectious proteins known as prions, which are very resistant to conventional disinfection and sterilisation processes. It has a long incubation period, up to 25 years, and causes sponge-like gaps to appear in the brain tissue. CJD cannot spread by normal contact. There are 4 types of CJD:- Variant CJD (vcjd) generally affects younger people and early symptoms include personality changes and psychological symptoms. It has been associated with exposure to the prion agent responsible for Bovine Spongiform Encephalopathy (BSE). Sporadic CJD is currently the commonest form of CJD occurring randomly in the community and affecting about 50 people per year. It usually affects people over 45 years of age. Familial CJD is responsible for about 15% of cases and is inherited. It is caused by mutation in the prion protein gene. Iatrogenic CJD is acquired during medical treatments, particularly in the 1970s, such as grafts of human dura mater and corneas, administration of human pituitary derived growth hormone and the use of contaminated instruments during surgery. The long pre-clinical phase is followed by clinical features, which vary depending upon the type of CJD. The symptoms are progressive and there may be rapid deterioration. CJD can attract a great deal of media interest, so service user confidentiality is essential. Symptoms commonly include:- Personality changes and loss of intellect and memory; Sensory and motor neurological deficits; Myclonic jerks, chorea, or dystonia; Difficulty speaking, swallowing, moving and incontinence; Coma and death Infection prevention and control precautions In the community there is no risk of the spread of CJD and no special infection prevention and control measures are required. Use standard infection prevention and control precautions, e.g. the use of protective clothing, washing of contaminated clothes and linen, care with sharps and waste. NHS Stoke on Trent Infection Prevention and Control Team

39 Provide relatives with protective clothing for handling body fluids and information about the importance of hand hygiene and infection prevention and control. Health care workers should assess all service users for the risk of CJD prior to any invasive procedure. Use single-use, disposable items. This is especially important during procedures involving the nervous system, such as lumbar puncture, and certain dental procedures. After death, place the body in a body bag labelled with a danger of infection sticker. The funeral director should not embalm the body, but may carry out cosmetic work as usual. Relatives and friends may view the body and touch it as normal. There are no restrictions on burial or cremation. Liaise with the Health Protection Unit for more information and support. The HPU will contact the CJD Incidents Panel re any previous high risk procedures. 6.7 Other infections Information on other infections that may occur in the community and cause outbreaks can be found in Appendices E Coli 0157 Pulmonary TB Chickenpox/shingles Scabies 7. OUTBREAKS 7.1 General In the community setting several individuals may become ill with the same infectious disease. If these cases are linked in time, place and person an outbreak may be suspected. The GP and other care workers in primary care have important roles to play in the early detection of such outbreaks and should contact the Health Protection Agency if an outbreak is suspected so that appropriate action can be taken at the earliest opportunity to prevent further spread General control measures Different infectious diseases are spread in different ways. By using standard infection prevention and control precautions outlined in section 5, the risk of transmission of infection from body substances (such as blood, faeces, urine etc.) is very much reduced What is an outbreak? An outbreak is defined as two or more linked cases of the same infection. These cases may be connected in time, place or person. Practice staff should be aware of the micro organisms that have the potential to cause outbreaks such as norovirus, salmonella, E. coli 0157 and influenza. Care workers should also be aware that a potential outbreak does not depend on having received positive laboratory results; the presence of similar symptoms in two or more connected cases is sufficient. Seek advice promptly rather than worrying about false alarms Action to take if an outbreak is suspected If a general practitioner suspects an outbreak they should inform the Health Protection Agency and the PCT Infection Prevention and Control Nurse. In NHS Stoke on Trent Infection Prevention and Control Team

40 community settings The Health Protection Team will advise on any infection control measures that need to be taken to manage the outbreak and prevent further spread. 7.2 Suspected food poisoning Gastro-intestinal illnesses which result in diarrhoea and or vomiting may have many causes including viruses, bacteria, toxins and chemical contaminants. Causative infective micro organisms include campylobacter, Clostridium difficile, cryptosporidium, E coli 0157, giardia, Norovirus, salmonella, shigella, etc. The symptoms vary depending upon the cause of the infection. Some cause mainly vomiting whereas others cause mainly diarrhoea. Other possible symptoms may include abdominal pain, nausea or fever and bloody diarrhoea. Infections may have an incubation period of a few hours, or several days. Some infections resolve without treatment whilst others need to be treated. Micro organisms that are most likely to cause food poisoning are: Campylobacter Salmonella E Coli 0157(Information on E coli 0157 can be found in Appendix 16) Clostridium perfringins Staphylococcus aureus How is food poisoning spread? Food poisoning can be spread in the following ways: Many raw foods such as meat, poultry and raw eggs contain harmful micro organisms or toxins. These are destroyed during cooking and it is only if the food is not going to be cooked further or eaten raw that the micro organisms and toxins will not be destroyed and may cause illness. A food handler with a gastrointestinal disease, or who does not practice good hygiene, can spread micro organisms onto the food. Humans and animals can also be sources of infection and infection can spread by contact with infected diarrhoea or vomit; or indirect contact with the contaminated environment - the micro organisms being passed to the mouth and ingested. If it is suspected that the outbreak may be a result of food poisoning the General Practitioner must inform the Health Protection Unit and the Proper Officer of the Local Authority, usually the CCDC (see section 8). The Health Protection Unit will make an initial assessment to see whether the suspected outbreak is likely to be due to a viral infection or food poisoning. Any of the following should be reported as a suspected outbreak of food poisoning: Any service user diagnosed as having salmonella, campylobacter or other food related infection. Diarrhoea and/or vomiting in two or more cases in the same environment e.g. place of work, school or care establishment. Any service user diagnosed by a doctor as having food poisoning. It is much better to be cautious, and to report early, rather than to wait until there is a major problem. NHS Stoke on Trent Infection Prevention and Control Team

41 7.3 Closure of premises In the event of an outbreak of any gastro-enteritis, food poisoning or other communicable disease in the community the Health Protection Unit will be responsible for the investigation and management of the incident. The HPU will advise on the infection prevention and control measures required. If the outbreak occurs in a residential care home the HPU will advise them to stop admissions, day care and transfers to other homes or hospitals. If the outbreak is associated with other institutions or premises e.g. schools, hotels, farms, the HPU will advise whether or not premises should be closed whilst investigations are in progress. The Health Protection Unit will declare when any outbreak is over. 7.4 Further advice Further advice about any infectious disease can be obtained from the Health Protection Unit, during normal office hours. On-call Public Health Specialists may be contacted for emergency infectious disease matters out of normal working hours (See section 2 for contact details). The Health Protection Agency website provides up to date information about a wide range of infections and diseases. Visit In addition, the local authority Environmental Health Teams may have a range of information leaflets available on food-related illnesses. 7.5 Viral outbreaks of diarrhoea and vomiting Outbreaks of vomiting and diarrhoea caused by viruses, usually norovirus, have unfortunately increased substantially in recent years. These infections can occur in all settings especially where individuals live and work in a shared environment. In hospitals they can cause a major disruption to activities. Outbreaks have been reported in: Hospitals and other care facilities Schools and nurseries Prisons Cruise ships Hotels To identify outbreaks of diarrhoea and vomiting specimens should be sent if the service user has diarrhoea that is not attributable to any known cause e.g. aperients, P.E.G feed, other medications (Appendix 14). Norovirus is highly infectious. It can be spread by the faecal oral route, via aerosols that are produced when people vomit, and by touching surfaces and objects that are contaminated with virus particles that are excreted in vomit and faeces. The incubation period is 12 to 48 hours and the disease normally resolves within 48 hours. Elderly service users may suffer more adverse effects and may develop problems with hydration and nutrition Symptoms of norovirus infection Vomiting, which may be projectile; Nausea; Diarrhoea; Headache; Fever; NHS Stoke on Trent Infection Prevention and Control Team

42 Muscle aches; Service users and care workers affected. The illness usually lasts for between 24 and 48 hours, and treatment is directed mainly at ensuring that service users do not become dehydrated Prevention of Spread Particular attention to good hygiene measures is essential and during outbreaks of norovirus it is important to wash hands with soap and water as alcohol rubs alone are ineffective. Alcohol rub can be used to complement washing with soap and water. Use of PPE Enhanced environmental cleaning with a hypochlorite (bleach) solution (see section 17). Individuals with symptoms should remain off work/school until they have been symptom free for 48 hours. In care homes and other residential settings service users should stay in their own rooms until they have been symptom free for 48 hours Hospital Admission Having a diagnosis of noroviris is not an indication for admission to hospital. There is no specific treatment for norovirus and most people will recover within hours. The only indication for admission from a care home setting is if the service user s specific needs cannot be addressed. If service users develop problems with nutrition and hydration the community matron should be contacted and they may be able to provide advice and support that will prevent unnecessary admission to hospital thereby reducing the risk of further spread. 8. SURVEILLANCE AND DATA COLLECTION 8.1 Infection Records Although there is no statutory requirement for GPs to keep infection records it is good practice to keep a record on the number of cases of service users with specific infections such as MRSA, Clostridium difficile and other multi resistant organisms. This will help the practice identify any trends within their service user population and may be included in the annual report/statement of the Infection Prevention and Control Lead for the practice. 8.2 Root cause analysis (RCA) for MRSA and Clostridium difficile infections Mandatory reporting requires that the organisation reports all MRSA bacteraemias and new cases of Clostridium difficile infection (CDI) to the Department of Health; this is undertaken by UHNS Pathology Laboratory on behalf of Combined Healthcare and the North Staffordshire PCTs. All MRSA bacteraemias are classed as Serious Untoward Incident (SUI) and are reported to the Strategic Health Authority, each case has to be investigated to determine the possible cause of the bacteraemia. Patients admitted to the UHNS who are admitted with or develop the bacteraemia within 48 hours of admission are considered to be community acquired and will be investigated by primary care staff. NHS Stoke on Trent Infection Prevention and Control Team

43 All MRSA bacteraemia and new cases of CDI must be investigated within 10 days of notification using the Root Cause Analysis (RCA) process. The person undertaking the investigation should be the clinician responsible for the service user or a senior member of the clinical team. Within a community setting this may be the general practitioner, matron, ward manager or district nursing caseload holder. The nominated member of staff undertaking the investigation must use this standard documentation pack provided by Combined Healthcare and the North Staffordshire PCTs. The documentation facilitates the summary of information and prompts the questions which may assist in identifying the possible cause of the bacteraemia or CDI. 8.3 Notifiable Diseases Doctors (usually the GP) attending service users with certain infectious diseases (see the list below), whether confirmed or suspected, are obliged to notify the Health Protection Unit using a standard form available from the Health Protection Unit. Cases of other infectious diseases, which are not statutorily notifiable, (e.g. scabies and influenza) should also be reported when an outbreak is suspected. Prompt notification and reporting of cases of infectious disease is essential for the monitoring of infection and assists with investigation and outbreak control. Under the Public Health (Control of Disease) Act 1984 and the Public Health (Infectious Disease) Regulations 1988, certain diseases are notifiable to the Proper Officer of the Local Authority, usually the CCDC at the Health Protection Unit. Statutory Notifiable Diseases (to Local Authority Proper Officers) under the Public Health (Infectious Diseases) Regulations 1988 are: Acute encephalitis Acute poliomyelitis Anthrax Cholera Diphtheria Dysentery Food poisoning Leptospirosis Malaria Measles Meningitis Meningococcal septacaemia (without meningitis) Mumps Ophthalmia neonatorum Plague Rabies Relapsing fever Rubella Scarlet fever Smallpox Tetanus Tuberculosis Typhoid fever Typhus fever Viral haemorrhagic fever Viral Hepatitis (Hepatitis A, B or C) Whooping cough NHS Stoke on Trent Infection Prevention and Control Team

44 Yellow fever Leprosy is also notifiable, but directly to the HPU It has been agreed that although the following diseases are not statutorily notifiable, nevertheless, the Consultant for Communicable Disease Control should be informed of their occurrence: AIDS Psitticosis Legionnaires Disease CJD Listeriosis 9. PREVENTION OF OCCUPATIONAL EXPOSURE All practices should have policies/procedures in place to ensure that care workers are protected from occupational exposure to micro organisms, particularly those that may be found in blood and body fluids. Service users must also be protected from any communicable diseases that care workers may have. 9.1 Blood borne viruses In NHS settings, sharps injuries are one of the most common types of injury to be reported to occupational health departments. Blood borne viruses can be transmitted when blood or body fluid from an infected person comes into contact with tissue/body fluids of another person. Of main concern are those agents that persist in the blood of a carrier who may be unaware and be without symptoms, the main agents are blood borne viruses including Hepatitis B (HBV), Hepatitis C (HCV) and Human Immunodeficiency Virus (HIV), which can be the cause of Acquired Immune Deficiency Syndrome (AIDS). Body fluids, which may pose a risk of Blood-borne Virus Infection if significant occupational exposure occurs, are: Amniotic fluid Cerebrospinal fluid Human breast milk Pericardial fluid Peritoneal fluid Pleural fluid Saliva in association with dentistry (likely to be contaminated with blood, even when not obviously so) Synovial fluid Unfixed human tissues and organs Any other body fluid if visibly bloodstained Exudate or other tissue fluid from burns and skin lesions Semen Vaginal Secretions Risk of Infection to health care workers Hepatitis B & C The Hepatitis B and C virus is transmitted by blood and body fluids from an infected person and may enter through the eyes, mouth or breaks in the skin. It is recommended that care workers who have, or are likely to have, contact with blood NHS Stoke on Trent Infection Prevention and Control Team

45 and body fluids, secretions and excretions, are immunised against the Hepatitis B virus. There is no vaccine available for protection against Hepatitis C Human Immunodeficiency Virus (HIV) HIV is less transmissible than HBV/HCV but is transmitted in the same way. Acquired Immune Deficiency Syndrome (AIDS) is an alteration in the cellular immune system of a previously healthy person, causing the person with the disease to become susceptible to infection Sharps and Inoculation Injury Inoculation injuries are the most likely route for the transmission of blood borne viruses and other infections in the health care setting. A sharps/inoculation injury is when someone s blood or body fluid gains access to another person s blood or tissue. This may be caused by:- A cut or puncture of the skin by a contaminated sharp; Splashes to the eyes, nose and mouth from blood or body fluids; Contamination of a care worker s broken skin e.g. scratches, cuts, eczema by a service user s blood or body fluid; Bites which break the skin and draw blood. Most cases of occupationally acquired HIV have arisen following injury from hollow needles, and great care must be taken when handling ALL sharps. Body fluids splashed into the eye or mouth may also transmit infection. Remember all sharps injuries are potentially preventable Sharps include items such as needles, blood glucose lancets, ampoules, sharp surgical instruments, used razor blades and disposable razors that may be contaminated with blood or other body fluids Reducing the risk of sharps/inoculation injuries Use of personal protective equipment (refer to section 5) will reduce contamination of skin and clothing with blood and body fluids. The greatest risk of a blood borne virus (BBV) being transmitted is as a result of a sharps injury, especially those resulting from injury with a hollow bore needle where blood may remain. Transmission of BBVs may also result from contamination of mucous membranes with splashes of blood/body fluids. There is no evidence that BBVs can be transmitted through intact skin Sharps containers Sharps containers must be of a type UN approved, correctly assembled and never be over-filled, i.e. above the manufacturer s fill line, or ¾ full. The container must be puncture resistant and leak proof. It must be stable and provided with a handle and an aperture which will inhibit the removal of the contents, but will ensure that it is possible to dispose of items safely. It is the responsibility of the person using the sharp to dispose of it correctly Safe use of sharps The safe handling and disposal of sharps is paramount in reducing the risk of exposure to blood borne viruses and extreme care must always be taken when using and disposing of sharps. NHS Stoke on Trent Infection Prevention and Control Team

46 Avoid using sharps, including pen injecting devices when administrating medication to service users, wherever possible (e.g. use a system such as Vacutainer for venepuncture or Unistix for finger pricking). Wear disposable gloves when handling sharps. Always request assistance when using sharps with an uncooperative service user and use safe needle devices. Assemble containers following manufacturer s instructions. Label sharps containers when assembling them. Sharps containers must comply with UN3291 and BS7320: Sharps containers must be kept off the floor, away from children, and inaccessible to unauthorised persons. Do not place them on the floor, window sills or above shoulder height. Secure containers using brackets attached to the wall or a trolley. Place sharps containers of a suitable size on a level surface in each location where sharps are used. Discard all sharps into a sharps container at the point of use. Never leave needles or any other sharps lying around. Never walk about with unguarded sharps. Do not pass an exposed sharp to another person. Clinical sharps should be single-use only. Needles must not be resheathed. The user of sharps must discard them directly into a sharps container. When carrying a sharps container, or whenever the container is left unattended, use the temporary closure to prevent spillage or tampering. Carry sharps containers by the handle or on a tray, do not hold them close to the body. Do not dispose of wrappers, cotton wool, etc in sharps boxes as this may prevent the sharps being dropped in directly, and may cause an injury if someone tries to force a sharp in. Do not attempt to retrieve items from a sharps container. Do not attempt to press down upon sharps to make more room. For more information on the disposal of sharps containers see section Assessing the risk following an inoculation injury In a healthcare setting, the risk of acquiring a blood borne virus as the result of a sharps or inoculation injury from a source known to be infected has been estimated as follows:- Hepatitis B - around 1 in 3; Hepatitis C - around 1 in 30; HIV - around 1 in 300. The degree of risk should be assessed immediately after the incident has occurred and should be determined by the injured care worker and their immediate supervisor/line manager using the Risk Assessment Check List found in Appendix 22. A Significant exposure is defined as: Percutaneous Injury breaks in the skin e.g. from needles, instruments, bone fragments or a significant bite. NHS Stoke on Trent Infection Prevention and Control Team

47 Exposure of broken skin e.g. due to eczema, cuts, abrasions or injury. Exposure of mucous membrane including the eye. Injury with an unused/clean sharp No risk of infection, (except from the micro organisms on your own skin). Record incident, but no further action. Injury with a used/dirty sharp also human bite/scratch/mucous membrane splash from a source that is known or unknown. During normal working hours seek professional advice from the Occupational Health Service, or Accident and Emergency Department at the University Hospital of North Staffordshire. This should be within one hour of the incident having taken place. Out of hours the injured care worker must attend the A and E Department. Injury from a used/dirty sharp from a person known or strongly suspected to be HIV positive. During normal working hours contact the Microbiologist on call at the UHNS. If the incident occurs out of hours the injured care worker must attend the A and E Department at the local hospital immediately. The risk of acquiring an HIV infection from a sharp or inoculation injury in a low risk population when the infection status of the source is unknown is very small Immediate action to take in the event of a sharps/inoculation injury:- Bleeding from a small wound should be promoted for a few seconds by gently squeezing the surrounding skin. Do not suck or scrub. Wash the wound with warm running water and liquid soap. Cover the wound with a waterproof dressing. If the eyes are contaminated irrigate for 2 minutes with normal saline or running water. If contact lenses are worn, irrigate both before and after removal. Contaminated mucus membrane (e.g. the nose or mouth) should be washed with plenty of water. Report the injury to the person in charge who should carry out a risk assessment using the checklist in Appendix 22. Record the incident following the usual procedure. A poster and flow chart summarising the action to take in the event of a sharps or splash injury and the action to take following a sharps find can be found in Appendices Management of needle stick/inoculation incidents and post exposure prophylaxis (PEP). Human immuno deficiency virus (HIV) The Department of Health has issued guidelines on HIV post-exposure prophylaxis (PEP) for health care workers. Although HIV PEP is recommended for health care workers following high risk incidents, the risk of transmission is very small and requires the inoculation of a significant volume of infected body fluid. The side effects of the treatment may also outweigh any potential benefit. Following incidents where the source of the injury is thought to be high risk for HIV (using the check list in Appendix 22) the injured person should attend the A and E department at the University Hospital of North Staffordshire immediately where a PEP pack is kept. The decision to administer PEP will be taken by the A and E NHS Stoke on Trent Infection Prevention and Control Team

48 consultant in consultation with the Medical Microbiologist or the Infectious Diseases Consultant. If recommended, a course of PEP should be started as soon as possible after the incident. Ideally this would be within one hour if there were a high risk of exposure to HIV. However, PEP may be commenced up to 2 weeks after the injury if circumstances change, for example if the source of the injury is subsequently found to be HIV positive. The PEP specialist should advise pregnant women, who may have been exposed to HIV, regarding the risks and benefits of HIV PEP. Hepatitis B If the source of the injury is known, or suspected to be, hepatitis B positive, occupational health or the care workers GP should check the hepatitis status of the injured care worker and if appropriate consider starting a course of hepatitis B vaccine and or giving immunoglobulin. This should be administered ideally within 48 hours of the injury, though it can be given up to 7 days after the incident if necessary. Hepatitis C Where possible an attempt should be made to assess the HCV status of the source. An initial blood sample should be taken from the injured person and sent to the laboratory to be stored. If the source is found to be positive, the injured party should also be investigated for subsequent sero-conversion and appropriate referral made. There is currently no vaccine available for hepatitis C. Following all exposure incidents a review of the event should be undertaken in order to identify if a similar injury could be avoided in future Hepatitis B immunisation Hepatitis B immunisation is recommended for all care workers who may have direct contact with a service user s blood, blood-stained body fluids or tissues. All care workers of residential and other accommodation for those with learning difficulties should also be offered immunisation as higher rates of hepatitis B carriage has been found in this group of people. When immunisation is required, the cost must be borne by the employer. There are no vaccines which protect against hepatitis C or HIV. 9.3 Other immunisations It is regarded as good public health practice for everyone to be fully immunised. Care workers should be asked to consult their occupational health advisor to ensure that they are up-to-date with all immunisations and arrange boosters if necessary. The Department of Health recommends that all those involved in delivering front line care to vulnerable groups should be immunised annually against influenza. This is the responsibility of the employer to arrange and fund. Care workers should be encouraged to be immunised, for the following reasons: They personally benefit, as they reduce their chances of becoming ill. The organisation benefits because there is reduced absenteeism, and last but not least. Service users benefit because they are doubly protected. The Occupational Health Service will advise on the immunisations that care staff will require. NHS Stoke on Trent Infection Prevention and Control Team

49 9.4 Protection against tuberculosis Care worker s history of TB and or BCG vaccination should be checked at pre employment. Please contact the Occupational Health Advisor or the TB clinic if advice on this is required. If care workers are in contact with a service user with infectious TB the care workers will be followed up in the normal way. More information on TB can be found in Appendix ASEPTIC TECHNIQUE 10.1 What is an aseptic technique? The term aseptic means without micro organisms. The aseptic technique refers to the practice used to prevent the risk of infection. There are two aims of an aseptic technique: first, to protect susceptible sites on the service user from contamination by pathogenic organisms during care and nursing interventions and secondly, to protect the care worker from being exposed to potentially infectious blood and body fluids. Aseptic technique will be used for surgical and other procedures such as undertaking wound dressings or performing an invasive procedure such as inserting a urinary catheter or when managing any invasive device. Susceptible sites include:- Normal body orifices (openings) such as urethra, vagina, mouth, eyes etc. Artificial orifices such as surgical and other wounds, tracheostomy sites, insertion sites for invasive devices such as urethral catheters or intravascular catheters etc. The principles of aseptic technique involves:- Hand hygiene; Personal protective equipment; Sterile materials, equipment and fluids for invasive procedures; Separation of sterile/clean equipment from contaminated items; Avoiding direct contact with susceptible sites; A technique to avoid introducing potentially harmful micro organisms into wounds and susceptible body sites. There are two types of aseptic technique:- Surgical technique used when undertaking procedures or handling equipment that breach the body s normal defences such as surgery, insertion of catheters, intravenous devices, tracheostomy etc. Non-touch or clean technique may be used when the risk of contamination comes from micro organisms on the skin on carer s hands e.g. dressing chronic wounds, mouth care, eye care, emptying catheter bags, endotracheal suctioning etc Principles of aseptic technique Hand hygiene The removal or reduction of micro organisms from carers hands prior to aseptic procedures is essential. NHS Stoke on Trent Infection Prevention and Control Team

50 Invasive procedures - hand disinfection using skin disinfectant such as alcohol hand rub or antiseptic solution. Clean procedures - routine hand hygiene with soap and water is usually adequate unless the service user is particularly at risk of infection Protective clothing This is worn for two purposes: Protect the service user from micro organisms on the care worker s skin and clothing; Protect the care worker from micro organisms on the service user s body. Gloves are recommended for using an aseptic technique: Sterile gloves for a surgical technique. Non-sterile gloves for a clean technique. Gloves can give the wearer a false sense of security and they may touch contaminated equipment, environment or skin sites during an aseptic procedure. If hands touch a contaminated object or part of the body during an aseptic procedure, the gloves should be removed, alcohol hand rub applied to the hands and a new pair of gloves worn. Aprons are recommended for procedures where there is a risk of splash from body fluids or to protect open wounds from contamination from micro organisms on the clothing or uniform, e.g. during wound care. Eye/face protection should be worn if there is a risk of splash from blood and body fluids to the face Equipment Sterile, single-use equipment is recommended for an aseptic technique. Ensure sterile packs are not damaged and are used before the expiry date. Keep sterile and non-sterile equipment/devices separate. If sterile equipment/devices are contaminated during an aseptic technique they should be replaced immediately. It is illegal to re-use single-use items and they must not be reused. Single use items are marked:- If the contents of single use packs e.g. dressing packs are partially used the unused contents must be discarded. Dressing trolley or surface A dressing trolley or tray may be used when carrying out aseptic procedures. The trolley/tray should be cleaned at least daily and when soiled. They should be cleaned with detergent and warm water and dried with disposable paper towels. Sterile dressing aids/packs are often used for dressing wounds etc. The polythene bag can be used to arrange the sterile items on the sterile field and then to remove the soiled dressing. The care worker places a clean hand into the bag to arrange the items on the packaging, which acts as a sterile field. The bag can be used to remove the dressing, and inverted to contain the soiled dressing. The bag can be NHS Stoke on Trent Infection Prevention and Control Team

51 attached to a trolley, or laid on a surface, to act as a disposal bag for other discarded items. Avoid carrying out aseptic procedures immediately after activities that may have raised the level of airborne micro organisms, such as bed making and cleaning. Delaying for 30 minutes or so will allow the micro organisms to settle on surfaces and help to prevent contamination of open wounds from airborne micro organisms Procedure Equipment required Clean dressing trolley; non-sterile gloves; sterile gloves; dressing pack; appropriate dressings; fluids for cleaning/irrigation; hypoallergenic tape; sterile scissors; clinical waste bag (orange). 1. Explain the procedure to the service user. 2. Wash hands using the six stage hand wash technique. 3. Clean trolley surfaces with detergent and dry with paper towels. 4. Gather equipment for the procedure and place on the bottom of the trolley. 5. Ensure the service user is comfortable and their privacy and dignity is maintained. 6. Put on a clean disposable apron and disinfect hands with alcohol gel. 7. Check sterility and expiry dates of equipment used. 8. Open the outer cover of the pack and slide contents on to the trolley. 9. Open the sterile field using only the corners of the paper, being careful not to touch the inner surface of the sterile wrapping. This will now be your sterile field. 10. Disinfect hands with alcohol. 11. Put on clean disposable gloves and remove dressing. 12. Dispose of dressings and gloves into the clinical waste bag. 13. Disinfect hands with alcohol hand rub and apply sterile gloves using appropriate sterile technique. DO NOT contaminate the sterile field by dropping the glove packet onto it. Use another clean, at surface to put it on before applying sterile gloves. 14. Carry out procedure i.e. clean wound and apply new dressing as necessary. 15. Make sure protective apron and waste materials are disposed of as clinical waste (orange bag). 16. Clean trolley if it has become contaminated during procedure. 17. Wash hands after procedure. A poster demonstrating Aseptic technique can be found in Appendix WOUND/ULCER CARE The presence of a wound or ulcer can increase the risk of the individual developing infection or becoming colonised, for example with MRSA. It is therefore important to try to prevent wounds, such as pressure ulcers, if possible, and to prevent infection in existing wounds. NHS Stoke on Trent Infection Prevention and Control Team

52 The key measures that can help to prevent wound infection/colonisation include:- Hand hygiene before handling wounds or dressings; Wearing gloves when handling wounds; Using a wound dressing that is appropriate to the wound; Changing dressings when indicated and whenever the barrier-effect has been impaired (e.g. wet); Selecting a dressing that will promote healing; These principles apply regardless of whether an aseptic technique or a clean technique is used Aseptic dressing technique Must be used for acute wounds such as surgical wounds, recent trauma, burns and scalds and for chronic wounds in service users who are at greater risk of infection, e.g. those who are immuno-compromised, have circulatory problems or diabetes. For aseptic technique sterile gloves, sterile irrigation fluids and sterile equipment and dressing are used in addition to hand hygiene Clean dressing technique May be used for chronic wounds, such as leg ulcers and pressure sores in service users with normal infection risk. Clean gloves and equipment and tap water may be used in addition to hand hygiene. However care should still be taken to avoid introducing micro organisms into the wound. For further details on wound management refer to local wound management guidelines or the PCT Tissue Viability Team. 12 INVASIVE DEVICES Invasive devices such as urinary catheters, infusion devices, tracheotomies and P.E.Gs are increasingly being used by service users in the community. These devices will increase the risk of a service user developing an infection and the practice should have procedures in place for the management of these devices. The use of the device and the reason for its use should be documented in the service user s notes/care plan. The use of all devices must be reviewed and the review documented in the service user s notes. The device should be removed as soon as it is no longer required. The service user should be monitored for signs of infection associated with the device. To reduce the risk of infection an aseptic or clean non-touch technique should be used when managing these devices. In the community service users with invasive devices will normally be cared for by the specialist teams e.g. continence, nutrition, respiratory and hospital at home and any queries regarding care and management of these devices should be discussed with the appropriate team/nurse specialist. 13. VENEPUNCTURE A safe system of work is recommended for handling blood in order to protect both the patient and the healthcare worker. Vacuum blood collection systems have been shown to reduce injuries in care workers and are recommended for use wherever possible. They consist of a plastic holder, which contains or is attached to a doubleended needle or adaptor. A vacuumed tube is pushed onto the holder and blood drawn off. An aseptic technique should always be used. NHS Stoke on Trent Infection Prevention and Control Team

53 It is impossible to know of all service users infected with a blood-borne virus; therefore standard infection control precautions are important whenever taking blood. Factors that increase the risk of skin contamination with blood include: A service user who is difficult to bleed; A service user who is receiving anti-coagulation therapy; A service user who is restless and un-cooperative; A practitioner with broken skin or a cut etc; A practitioner who is inexperienced; Infection control measures Collect equipment, including a sharps container. Use disposable tube-holders to avoid re-sheathing and prevent cross infection. Decontaminate hands prior to the procedure and wear disposable gloves. If the skin is socially clean, it is not necessary to disinfect the skin. Soap and water is adequate otherwise. If spirit swabs are used ensure the alcohol has evaporated and the skin is dry before taking the blood. Allow the skin to dry and avoid touching the disinfected area. Use a vacuum blood collection system in accordance with manufacturer s guidelines and local procedures. When the needle is fully removed apply a swab to the insertion site and apply pressure to stop the bleeding (the service user may be able to do this). Discard the needle and tube-holder directly into a sharps container. Remove gloves and decontaminate hands. Label the sample and laboratory request forms with relevant clinical details and attach a bio-hazard/danger of infection sticker if necessary. Never force blood from a traditional syringe and needle into a vacuumed tube. This can damage the sample, produce aerosols and separate the syringe from the needle. 14. MINOR SURGERY There is little written guidance for general practitioners or others such as podiatrists undertaking minor surgery and the following guidelines are the consensus of accepted good practice. A number of factors may be involved in post surgical wound infection and little is written on infection risks that occur from surgery carried out in general practice. Further information may be found at: However, the principles of asepsis apply to both primary and secondary care settings. The Primary Care Trust is involved in establishing arrangements for the provision of services for minor surgery and for monitoring their safe and effective provision. It is essential that the facilities used and the practices implemented for carrying out minor surgery are of the highest possible standards to: Minimise the risk of infection to service users by the application of infection prevention and control measures Protect care workers by the application of standard precautions. NHS Stoke on Trent Infection Prevention and Control Team

54 14.1 Definition of minor surgery Minor procedures are those that are carried out under local anaesthesia and do not involve procedures below the deep fascial plane. The operative site is usually limited in size by whether it can be anaesthetised locally. Some podiatry procedures and the debridement of leg ulcers are included in this category. Some general practices have contracts to do more complex procedures such as joint injections, joint aspirations and vasectomies. For these procedures where there is a greater risk of infection consideration should be given to the provision of mechanically ventilated operating facilities Facilities for minor surgery The room Minor surgery should take place in a designated minor surgery or treatment room (which may or may not be used for other clinical activities). The room should be of a sufficient size with a floor area of metres 2. A clinical hand wash basin with lever-operated mixer taps, wall mounted liquid soap, antiseptic hand solution, alcohol hand rub and paper towels should be available. Furniture and equipment should be kept to the minimum which will allow care workers to work unhindered and facilitate cleaning. The furniture, fixtures and fittings should be made of/or covered in material that is impervious, can be wiped clean and in a good state of repair. Ventilation For most minor surgery naturally ventilated rooms are acceptable. Where more complex procedures /or procedures where the risk of infection is increased mechanical ventilation should be considered especially if refurbishment or new build projects are planned. Advice can be sought from infection prevention and control specialists. Electric extractor fans and vents should be inspected on a monthly basis and cleaned on a 3 monthly basis to prevent the build up of dust. Ceilings Ceilings should be made from non-porous material that can be easily cleaned and which will withstand regular cleaning. They should be of solid construction i.e. not a suspended ceiling and be free from cracks and visible defects. Walls Plasterwork should be smooth, free from cracks and visible defects and made from non-porous material or painted with a product that can be easily cleaned and that will withstand regular cleaning. They should be of solid construction i.e. not tiled. Walls only need to be cleaned when visibly soiled (usually every 6 months) by using detergent and water. Blood splashes should be removed as soon as possible. Work surfaces and splash backs Work surfaces and splash backs should be made of smooth, impervious material. Work surfaces should be made of material that will withstand chemical disinfection e.g. stainless steel. They should have rolled edges and all joints should be sealed. There should be separate work surfaces for clinical and non clinical activities. Surfaces should be clear of extraneous items. NHS Stoke on Trent Infection Prevention and Control Team

55 Windows Natural ventilation - the presence of opening windows is acceptable but they must be fitted with a fly screen. Mechanical ventilation - windows must not be opened during surgery. To maintain service user privacy obscured glass is preferred. Curtains should be avoided where minor surgery is carried out. If present, they should be washed on a regular basis (usually every 6 months) or when visibly soiled. Vertical wipe clean blinds are the most appropriate choice. Doors These should be self-closing with a vision panel to facilitate observation of procedures and avoid unnecessary movement in and out of the operating room. Floors Floors should be impervious, durable, non slip with welded seams and made of material that can be easily cleaned. They should have continuous coving which extends a short height up the wall. Floors should be cleaned at least daily using detergent and water; this should take place at the end of the day or session. Blood splashes should be removed and the area cleaned as soon as possible. Fixtures and fittings must be in good condition and of a design and material that can be easily cleaned. Treatment /Examination Couches The covering should be made of wipe clean impervious fabric. Covers should be intact. The couch should be protected with disposable paper which is changed between each service user. The couch should be cleaned with general purpose detergent and hot water between each service user. Privacy screen/curtains The use of curtains should be avoided where possible. Washable or disposable curtains should be used and changed at least every 3 months or sooner if visibly soiled or contaminated with blood and body fluids. Screens that can be wiped clean should be used. Hand wash sinks/scrub-up facilities These may be within the designated room and should comply with current standards. Taps should be non-hand operated. Taps and basins should conform to HTM 64 with no plugs or overflows and the waste outlet offset from directly below the tap. Sink should be large enough to avoid splashing. Liquid soap in single use wall mounted dispensers. Alcohol hand rub and or antiseptic hand scrub solution. Single use paper towels in a wall mounted dispenser. Foot or sensor operated bins with close fitting lids. If nail brushes are used they must be single use disposable. Sterile pack storage There should be adequate space with due regard to the range of procedures carried out and the throughput of service users. NHS Stoke on Trent Infection Prevention and Control Team

56 Packs and instruments should be stored in a clean area away from possible contaminants and above floor level. The design should minimize the collection of dust including appropriate racking or shelving. Sterile packs and instruments should only be laid up as required and not in advance. Prior to use sterile packs should be checked for integrity, sterility and expiry dates. Room conditions (e.g. temperature) These should be within the standard range, i.e o C, unless clinical considerations deem otherwise. Lighting This should be adequate for the task to be undertaken in the facility. The light fittings should be of a suitable construction that allows easy cleaning and does not allow a build up of dust. The light fitting should be cleaned at the end of each day using detergent and water and at the end of any procedure where the operator has to adjust the light fitting. Lighting used for patient examination/minor surgery must be fitted with a heat filter. Fittings and illumination should be in accordance with BS EN Specimen storage/transport There should be adequate facilities and space for the collection and storage of specimens. Electrical services An uninterrupted power supply is required for minor procedures to avoid loss of lighting, and any other essential electrical equipment. A battery back-up is adequate for non-hospital facilities. Electrical sockets These should be splashproof and placed 1 metre above the floor. Central heating radiators These can quickly accumulate high levels of dust so it is important that they are of a design that can be easily cleaned. They should be cleaned at a frequency that prevents build up of dirt and debris. Radiators should be painted with paint that will withstand regular cleaning Infection Prevention and Control Practices Hand hygiene Surgical hand disinfection Prior to minor surgery and other aseptic procedures the operator should carry out surgical hand disinfection. This procedure will result in the removal and destruction of transient micro organisms and can be achieved in two ways: Wash hands using soap and water using the 6 stage technique and then apply two applications of 5ml alcohol hand rub/gel. Each application should be applied using the 6 stage technique (Appendix 9) and allowed to dry. Wash hands using the 6 stage technique with an antiseptic hand scrub solution. Lather well and wash all surfaces of the hands and wrists for 2 minutes, before rinsing and drying with paper towels. NHS Stoke on Trent Infection Prevention and Control Team

57 Reusable towels must not be used. If the hands of the operator are not visibly dirty, alcohol hand rubs or equivalent may be used between cases. However, surgical hand disinfection/scrub is indicated at the start of a list, i.e. before the first case or procedure Protective Personal Equipment (PPE) PPE is worn by those carrying out minor surgical procedures to protect themselves and the service user from infection. A new disposable plastic apron and sterile gloves are the minimum PPE required for minor procedures and must be changed between cases. After use protective clothing should be disposed of as clinical waste. However, full precautions, including a sterile gown, are required if a sterile device is being implanted, or if there are other factors predisposing to infection. Masks are not usually required except when a sterile device is being implanted or there are other issues predisposing to infection. However, visors/face protection should be worn by care workers if splashing is likely Aseptic Technique All operators whether surgically trained or not must be assessed as competent in aseptic procedures and in the knowledge and understanding of the facilities that are provided Pre operative skin preparation Operation skin sites should be disinfected prior to surgery. The aim is to remove transient bacteria and reduce the number of resident bacteria. The preparation used should be fast acting and have a prolonged antibacterial effect. Antiseptic preparations that are suitable and most frequently used are those containing chlorhexidine gluconate or povidone-iodine in either an aqueous or alcohol base. Skin reactions may occur with some products. The solution should be liberally applied to the operation site and surrounding area and then allowed to dry. Skin disinfection should be carried out immediately prior to surgery. Hair removal is not always necessary and should be avoided. If required use a depilatory cream or electric clippers rather than a razor to avoid trauma to the skin which increases the risk of post operative infection Surgical instruments. There are rigorous national and local requirements in place for the decontamination of surgical instruments which are difficult to comply with outside a specialist Central Sterile Services Unit (CSSU). For this reason local reprocessing of surgical instruments should not take place in general practice. In primary care settings all surgical instruments must be managed in either one or a combination of the following: Single use sterile instruments Single use sterile instruments supplied by or sterilised by Central Sterile Services Unit that complies with the Medical Devices Directive (MDD) 93/42 EEC and is registered with an MHRA approved notified body to provide services for a third party. If reusable instruments are supplied by a CSSU they must be handled safely after use. All sharps and tissue should be removed. The used instruments should be NHS Stoke on Trent Infection Prevention and Control Team

58 wrapped in the original packaging and stored in clearly identifiable, secure, leak proof, lidded container whilst awaiting collection. Instruments should not be washed prior to return to a CSSU. Where instruments are supplied by a CSSU the traceability system employed by the CSSU should be used for example, packs supplied by the UHNS have a two part label with identical bar codes on each part. One bar code stays with the pack and the other bar code should be placed in the service users notes. This allows total traceability of the pack which is one of the DOH requirements for decontamination Organisation and work flow In the clinical area work flows should be from clean to dirty areas, with clean and dirty procedures clearly defined. The areas should be arranged to reduce the risk of cross contamination. Ideally clean and dirty activities should be carried out in separate rooms Cleaning the environment and general equipment Cleaning must be undertaken at frequencies that prevent build up of dust, dirt and debris. The frequency may range from after each use, daily to weekly depending upon the nature and volume or work undertaken in the room. Cleaning with general purpose detergent, warm water and disposable paper or cloths will be suitable for most surfaces. Detergent wipes may be used for equipment where use of water could be hazardous. Equipment and surfaces that have been contaminated with splashes of blood or body fluids may need to be disinfected with a hypochlorite (bleach) solution after cleaning. The cleaning schedule should outline the items to be cleaned, the frequency and the method. More information on cleaning the environment and equipment can be found in Section Clinical waste Clinical waste should be placed in a foot operated waste bin. Clinical waste bags should be removed at the end of each session/day and placed in a secure designated holding area for clinical waste that complies with the latest guidelines. A separate secure area, inside or outside the operative facility, e.g. a lockable bin, should be provided. Further information can be found in Section 19 and in the Stoke on Trent Primary Care Trust Waste Policy Records must be maintained using an operations register, both for audit purposes and as a safeguard for medico-legal reasons. It should include details of the date and time of operation, Service user s name and address, names of surgeon, procedure performed, if local anaesthetic was administered, name of assistant and whether histology or other specimens were sent. 15. STORAGE AND HANDLING OF VACCINES Vaccines are substances that lose their effectiveness if they are transported or stored at the incorrect temperature. It is important that the correct temperature between 2 o C and 8 o C (the Cold Chain) is maintained during transport and storage NHS Stoke on Trent Infection Prevention and Control Team

59 A designated individual (and deputy) should be responsible for ordering and storing vaccines. Reception staff should ensure that vaccines are handed over to the responsible person as quickly as possible when delivered, and know what to do if this person or their deputy is unavailable. If there is any question regarding the maintenance of the Cold Chain or transit time (more than 48 hours), the delivery should be refused and returned to the supplier. The date and time of dispatch should be noted. To retain potency vaccines must be stored in appropriate conditions: 15.1 Vaccine refrigerators Medical refrigerators are generally of a higher specification than domestic varieties. They should be validated prior to use by checking the temperature with either a thermometer or a temperature probe. The vaccine fridges should: Be a medical fridge that is lockable; Be large enough for routine stock levels plus seasonal needs e.g. flu vaccine; Be large enough for air to circulate and maintain constant temperature; Be fitted with an electric lead that is fitted into a spur point that is fused but not switched to prevent inadvertent break in electricity supply. Have to hand guidelines on action to be taken in the event of power failure including who to contact. Be fitted with a maximum and minimum thermometer. Have the temperature monitored daily with recordings of maximum and minimum temperatures which should be between 2 o C and 8 o C. Record the details of minimum and maximum temperature, time and date of recording on a chart attached to or beside the fridge. Temperature records should be retained for one year. Have the thermometer reset after each recording. Be self defrosting or defrosted every month ensuring that the Cold Chain is maintained by use of another fridge/cool box. Be kept clean and dry. The vaccine fridge should be used to store only vaccines and drugs (no food, drink or specimens). Have certain shelves designated for specific vaccines and list them on the outside of the door to minimise the time the door is kept open. Have the stock rotated. Have items stored in accordance with manufacturer s instructions (e.g. some are sensitive to light). Not be over stocked Vaccines Must be placed in the vaccine fridge immediately after they are received. Must not be left out of the fridge. Remove them just before use or transfer to a cool box if a busy session is planned Must be returned in a cool box to the fridge as soon as possible. Note the time they were out of the fridge and use them first. Do not allow vaccine ampoules/vials to come into direct contact with ice packs in cool boxes. Have good stock control systems in place. Must not be used past the expiry date. NHS Stoke on Trent Infection Prevention and Control Team

60 15.3 Administration of vaccines Vaccines should not be prepared in advance of an immunization session as this increases the risk of administering the wrong vaccine and may affect the temperature. Reconstituted vaccine must be used according to the manufacturer s recommendations, usually within 1-4 hours. Vaccines should only be removed from the fridge for the minimum length of time before administration and any opened in error must be discarded. Oral polio vaccine (OPV) should not be allowed to remain at room temperature awaiting or following an immunisation as this may decrease the potency of the vaccine. Multi-dose vials may be used for one session only. Any remaining vaccine must be discarded at the end of the session Skin Preparation If the skin is socially clean, it is not necessary to disinfect the skin prior to injection. Soap and water is adequate otherwise. If spirit swabs are used ensure the alcohol has evaporated and the skin is dry before administering the vaccine. Some live vaccines may be inactivated by alcohol Disposal of vaccines At the end of a vaccination or immunisation session any prepared or opened vaccines must be destroyed. Place the vaccines in a sharps box, for incineration. Expired vaccines must also be disposed of in a sharps box Immunisation training National standards and a core curriculum have been developed for immunisation training courses. All care workers involved with distribution, handling, storage and administration of vaccines should have received appropriate training Further Information From the UK Guidance on Best Practice in Vaccine Administration, available from the Vaccine Administration Taskforce, Shire Hall Communications, PO Box 31580, London W11 4YZ and Stoke on Trent Primary Care Trusts Vaccine Procedure , The Safe Distribution, Storage, Handling and disposal of Vaccines Procedure. 16. SPECIMEN COLLECTION, HANDLING AND TRANSPORT Specimens are an important element in care, providing information both for diagnosis and treatment. Clinical specimens include any substance, solid or liquid, removed from the service user for the purpose of analysis. It is important that care workers are trained to handle specimens safely and have appropriate immunisation cover which is regularly updated. All staff managing specimens are responsible for ensuring that the information supplied is Legible Logical Accurate NHS Stoke on Trent Infection Prevention and Control Team

61 Includes all the necessary information Complies with the requirements of information governance. The care worker taking the specimen should provide the service user with an explanation of why the specimen is being taken Specimen collection (for microbiological investigations) Specimens for microbiological investigations must only be taken if there are signs and symptoms of clinical infection. Bear in mind, for example, that any wound will be colonised with many organisms, and if swabbed in the absence of clinical infection, the culture result may lead to unnecessary treatment with antibiotics. The signs and symptoms of infection vary depending upon the nature of the infection, but include: Wound infection - cellulitis, pain, redness, pus, fever. Chest infection - fever, cough, sputum that may contain pus or blood. Urinary infection - fever, pain on passing urine, blood or pus in urine, offensive odour, malaise. Eye infection - redness, pain on moving the eyelid, discharge. Enteric (gut) infection - diarrhoea, vomiting, abdominal pain, fever, blood or mucous in faeces. The aim when collecting a microbiology specimen is to collect an adequate amount of tissue/fluid, uncontaminated by micro organisms from any outside source, but preserving any micro organisms that may be present. When obtaining specimens for microbiological investigation it is important to:- Use the appropriate container; if unsure, check with the laboratory at your local hospital. Label the specimen container with the service user s details and date prior to collection. Wash hands before and after taking the specimen. Collect an adequate amount in order to increase the possibility of detecting the micro organism. Where pus is present a sample of pus is preferable to a swab. Moisten the bacteriology swab used for dry wounds/surfaces with sterile water or saline to allow for optimum pick-up of micro organisms. Ensure that the specimen is not contaminated during collection, either by equipment or an individual s normal flora (the normal skin bacteria). Obtain specimens prior to the commencement of antibiotic therapy. If therapy has already commenced, specify the antibiotic on the request form. Complete all details on the laboratory request form in legible hand writing and include:- Details of the service user (name, DOB and NHS number); GP name and number Details of sample sent, including the site from which the sample was taken if the sample is a wound swab; NHS Stoke on Trent Infection Prevention and Control Team

62 Nature of the signs and symptoms; Date (and time if appropriate) of specimen; Duration of illness; Tests required. Recent antibiotic therapy or travel history; Whether the case is part of a cluster or outbreak of similar cases; Biohazard/danger of Infection label; Signature of the person requesting the specimen; The service user s details must be entered on both the container and the request form, the container placed in a plastic transport bag and the accompanying request form put into a separate pouch provided Handling and storage of specimens Non-sterile gloves should be worn for handling specimen containers especially those brought in by service users. Specimens must be in appropriate, robust leak proof containers. The specimen container should be in a separate pouch to the request card. The outside of the specimen container should be clean and free from contamination. Where the sample is known or suspected to be high risk a bio hazard or "danger of infection label must be attached to both the specimen and the request form. Hands should be washed after handling specimens and there should be a hand wash basin adjacent to the specimen reception area. There should be a spillage kit in specimen reception area. Specimens must be stored away from food, drink and drugs to prevent cross contamination. Specimens awaiting collection should be stored in a clean, leak proof lidded container which is washed daily with general purpose detergent and warm water, rinsed and dried Transport Send specimens to the laboratory as soon as possible after collection in order to prevent overgrowth of non-pathogens and the death of pathogenic micro organisms. The specimen transport carrier used for carrying specimens to the GP/hospital pathology laboratories must be secure and conform to guidelines set out in the Health and Safety at Work Act (1974). Other regulations that apply are the Carriage of Dangerous Goods (Classification, Packaging and Labelling) and the use of Transportable Pressure Receptacles Regulations Disposal of Specimens All specimens are clinical waste and must be disposed of safely. Urine specimens tested in the practice should be disposed of via a sluice facility or if this is not available a toilet may be used. Specimens MUST not be disposed of via a hand wash sink Further Information More detailed information on the collection of specimens can be obtained from the laboratory handbooks on the UHNS website at NHS Stoke on Trent Infection Prevention and Control Team

63 17 CLEANING THE ENVIRONMENT 17.1 General The practice environment should be visibly clean, free from dust and debris to be acceptable to service users, care workers and visitors. Regular and efficient cleaning is necessary to maintain the appearance and function of the premises. In general, it is considered that the environment has a relatively low role in the transmission of infection however the environment is known to play an important role in cross infection during outbreaks. In treatment rooms used for clinical procedures and minor surgery accumulations of dust, dirt and liquid residues will increase infection risks and must be reduced to the minimum. This can be achieved by regular cleaning and by using good design features in buildings, fittings and fixtures. The local PCT Infection Prevention and Control Team can be contacted for advice. A good standard of cleaning will control the microbial population and prevent the transfer of potentially infectious material. It is important that the chosen method of cleaning should remove the contamination, and not merely redistribute it. An audit programme for monitoring the standard of hygiene should be in place in all health care premises Floors and other hard surfaces Hard floors should be durable, of good quality, washable and smooth-finished with welded seams. They should be intact, impervious to fluids and should not allow the pooling of liquids. Carpets are not recommended in treatment rooms or other clinical areas. If carpets are provided (in non clinical areas) there should be procedures or contracts in place for regular cleaning and for dealing with spillage. Generally, for hard surfaces wet cleaning methods are preferable to dry ones, as with dry methods there is risk of dispersal into the air of micro organisms. Moist surfaces encourage bacterial growth, and thorough drying is part of the cleaning process. Impervious flooring should be washed using a neutral general purpose detergent and a mop with a detachable head that can be laundered. Mop heads used should be changed daily and laundered. Mop buckets must be washed daily after use, and stored clean, dry and inverted. If dry dusting of floors is carried out it must be with a dust attractant mop to ensure no dispersal of dust and micro organisms. Vacuum cleaning (with filters) is suitable for carpets and other soft furnishings. Work surfaces should be smooth-finished, intact, washable, durable and impervious to fluids. Cleaning with neutral general purpose detergent and hot water remains the most effective method of removing contamination including micro organisms, and therefore damp dusting with disposable paper towels/cloths should be the norm for all hard surfaces. Do not use refillable spray cleaners as they provide a breeding ground for micro organisms Curtains, blinds and soft furnishings Curtains should be laundered or cleaned when soiled or periodically (e.g. six monthly) and an adequate supply of curtains purchased to facilitate this. Blinds/screens should be of a type that can be wiped clean. Upholstered furniture should be covered in impermeable fabrics that can be wiped clean. NHS Stoke on Trent Infection Prevention and Control Team

64 Pillows if used should be in sealed plastic covers that can be wiped clean. If the covers are damaged the items should be replaced Cleaning equipment and materials Disposable, non-shedding cloths or paper roll should be provided for cleaning purposes. Equipment and materials used for general cleaning should be kept separate from those used for the cleaning of body fluid spillage. Fresh cleaning solutions should be used and changed for each room. Do not leave cloths or mops stored in disinfectants or buckets. There has been an increase in the use of micro fibre cleaning systems in health care settings. These systems reduce the time required for cleaning and minimise the use of detergents and other cleaning products. When used guidance and advice should be sought from the suppliers/manufacturers. Cream cleaner or a hard surface cleaner is usually suitable for cleaning hand washbasins and general-purpose detergent is recommended for other environmental cleaning. Follow manufacturer s instructions. Detergent wipes can be used for those items that cannot be immersed e.g. electrical equipment. A COSHH assessment is required for any cleaning materials used. The following table shows the cleaning and disinfectant products recommended for use by the Infection Prevention and Control Team at NHS Stoke on Trent. Table 6 Recommended cleaning products and disinfectants Products Examples of Products Use Neutral general purpose detergent Hospec Fairy Routine cleaning of equipment and environmental surfaces, Detergent wipes Routine cleaning of equipment and environmental surfaces, Cream cleanser Cif Stubborn marks or stains in sanitary or kitchen areas Chlorine releasing agents:- Sodium Hypochlorite (Na CIO) Sodium dichloroisocyanurate (NaDCC) Milton /Domestos Presept /haz tabs Sanichlor For blood spillage on hard surfaces DO NOT USE ON URINE SPILLS the fumes released are harmful 17.5 Colour Coding Colour coding of cleaning equipment has been adopted in many NHS settings, and practices may wish to consider adopting this. It is especially useful when care workers work across other care providers both in the independent care sector and in the NHS. NHS Stoke on Trent Infection Prevention and Control Team

65 All cleaning items, for example, cloths (re-usable and disposable), mops, buckets, aprons and gloves, should be colour coded as outlined in the table below and Appendix 27. Table 6 NATIONAL COLOUR CODING SCHEME FOR CLEANING MATERIALS AND EQUIPMENT (NATIONAL SERVICE USER SAFETY AGENCY) BLUE RED GREEN YELLOW Day rooms, wards and general areas. Sanitary areas and body fluid spills. Kitchens and food preparation (Kitchen cleaning equipment should be stored separately). Isolation Rooms Cleaning Schedules A written cleaning schedule should be devised, based on a risk assessment, which includes the management of spillage of body fluids and regular removal of dust by damp dusting high and low horizontal surfaces. This should specify those persons responsible for cleaning (especially in the cleaner's absence), the frequency of cleaning and methods used and the expected outcomes. For suggested methods and frequencies of cleaning the environment and equipment, refer to cleaning schedule in Appendix Management of the spillage of blood and body fluids Spillage of high risk body fluids Spillages of blood and high-risk body fluids must be dealt with quickly and effectively. Disposable gloves and an apron must be worn for cleaning body fluid spillage and the contaminated debris treated as clinical waste. Chlorine-releasing agents can be a hazard especially if used in large volumes, in confined spaces or mixed with other chemicals or urine. Protective clothing must be worn and the area well ventilated. A risk assessment and COSHH assessment must be carried out for dealing with these spillages both in terms of the chemicals used and the likelihood of infection. Following a risk assessment and depending upon the products available, spillage may be dealt with by any of the following methods. Commercial companies produce spillage kits with instructions that would be useful in areas such as specimen reception. Sodium dichloroisocyanurate (NaDCC) method (not carpets and soft furnishings) using sanitising powder or granules Wearing protective clothing, cover spillage with NaDCC granules. Leave for at least two minutes. Scoop up the debris with paper towels and/or cardboard. Wash the area with detergent and water and dry thoroughly. Dispose of all materials as per clinical waste. NHS Stoke on Trent Infection Prevention and Control Team

66 Clean the bucket/bowl with fresh soapy water and dry. Discard protective clothing and wash hands. Hypochlorite (Milton or bleach) method (not carpets and soft furnishings) Wearing protective clothing, soak up excess fluid using disposable paper towels. Remove organic matter using the towels and discard as clinical waste. Clean area with detergent and water and disinfect the area with towels which have been soaked in 10,000 (Milton undiluted) parts per million of available chlorine (e.g. Milton or Haz Tabs) and leave for at least two minutes and then rinse and dry thoroughly. Clean the bucket/bowl in fresh soapy water and dry. Discard protective clothing and wash hands. Detergent and water method (for soft furnishings and carpet) Steam clean or Wearing protective clothing mop up organic matter with paper towels or disposable cloths. Clean surface thoroughly using a solution of detergent and water and paper towels or disposable cloths. Rinse the surface and dry thoroughly. Dispose of materials as clinical waste. Clean the bucket/bowl in fresh hot, soapy water and dry. Discard protective clothing and wash hands Spillage of low-risk body fluids (urine, faeces, vomit etc) Wearing protective clothing mop up organic matter with paper towels or disposable cloths. Clean surface thoroughly using a solution of detergent and water and paper towels or disposable cloths. Rinse the surface and dry thoroughly. During outbreaks of viral gastroenteritis disinfect surfaces using 1000 ppm (1 part Milton to 10 parts water or bleach 1 part bleach to 100 parts water) chlorine solution after cleaning. Dispose of materials as outlined in Section 17. Clean the bucket/bowl in fresh hot, soapy water and dry. Discard protective clothing and wash hands Deep cleaning What is deep cleaning? Deep cleaning is not routine environmental cleaning that is undertaken daily within the care environment but is additional cleaning that should be undertaken in special circumstances. In care facilities providing residential care such as hospitals and care homes this would be:- Following outbreaks and would involve cleaning - the whole environment. Post discharge, transfer or death of individual service user single room and en suite. When isolation of a service user with a known infection is no longer required single room and en suite. Following refurbishment and building work. NHS Stoke on Trent Infection Prevention and Control Team

67 Periodic cleans to thoroughly clean the environment. The frequency will depend on the type of room and its use. The last two of these categories are the ones that would apply to general practices. Each care establishment should have a written cleaning schedule for both routine and deep cleaning that ensures that all areas of the premises are cleaned to a satisfactory standard. Deep cleaning is the thorough cleaning of all surfaces, floors and soft furnishings and reusable equipment. This will include: Skirting boards, picture and dado rails; Window sills and frames; All ledges, shelving and storage cupboards. All horizontal surfaces; Soft furnishings including curtains and blinds; Curtain rails and tracks; Floors and carpets ; Light fittings and lamp shades; Equipment; Furniture and fittings; Radiators; Sinks, toilets, baths and showers plus taps, flush and door handles; Soap and towel dispensers. Deep cleaning is essential to ensure that a safe environment is maintained for service users, care workers and others by minimising the risk of cross contamination What equipment is required for deep cleaning? Care workers and housekeeping staff that are carrying out deep cleaning should wear disposable plastic aprons and household or disposable gloves. The routine use of disinfectants is not recommended. The physical removal of dirt and micro organisms by wiping or scrubbing is more important than the type of cleaning agent used. If a disinfectant is required this will be advised by the local Infection Prevention and Control Nurses. Deep cleaning should be undertaken using: Clean bucket; Clean hot water and general purpose detergent; Disposable cloths; Floor mop with disposable or washable mop head; Vacuum cleaner fitted with a HEPA filter; Steam cleaner or carpet shampooer Deep cleaning procedure Wear personal protective clothing (at least disposable gloves and apron). Water and detergent solutions, disposable cloths and mop heads used for cleaning should be changed for each episode of cleaning when moving from one NHS Stoke on Trent Infection Prevention and Control Team

68 environment to another (room to room) and when the water is visibly dirty or contaminated. Remove/dispose of unwanted items. Take down curtains and send to the laundry. Clean, all furniture and fittings The Golden Rule for cleaning is to work from the cleanest to the dirtiest areas starting at the higher levels and working down. Curtains should be laundered. Carpets should be vacuumed (vacuum cleaners should be fitted with a HEPA filter) and then steam cleaned or shampooed. Discard waste and clean waste bin. Clean all cleaning equipment and leave to dry. Wash hands. Restock room with clean supplies Key points when cleaning: Wear protective clothing, i.e. apron and gloves; Prepare a fresh cleaning solution appropriately diluted for each task; Make up only the quantity required in a clean container; Some cleaning products are incompatible; only mix if advised by manufacturer; Change the solution frequently to prevent a build-up of soil or micro organisms which would recontaminate surfaces; Dispose of cleaning solution promptly in a sluice or dirty utility area; Ensure that equipment is stored clean, dry and in the designated place; Remove protective clothing and wash hands before carrying out other duties; Do not use disinfectants routinely. 18. DECONTAMINATION OF CARE EQUIPMENT AND MEDICAL DEVICES 18.1 Good practice All equipment must be clean, fit for purpose, and in a good state of repair; All equipment must be stored in an appropriate area; If there are items of equipment that are not routinely cleaned on a daily basis, there should be a written cleaning schedule and records kept of cleaning undertaken. Most general equipment can be cleaned safely using warm water and general purpose detergent. Chemical disinfection using chlorine based disinfectants may be used following cleaning if items have been contaminated with blood and high risk body fluids. All reusable medical devices that need to be sterile at the point of use should be supplied as single use disposable items or supplied by an accredited CSSU Purchase of equipment Before purchasing any new equipment, it is important to know how it can be decontaminated. Manufacturers should be able to provide written instructions on this and equipment should only be purchased if appropriate decontamination facilities are available Methods of Decontamination NHS Stoke on Trent Infection Prevention and Control Team

69 Equipment can be categorised according the risk of infection it poses to the service user. The choice of process depends on a number of factors:- The type of equipment; The organisms involved; The time available for decontamination; The risk to service users and care workers. Table 7 summarises the decontamination processes that should be used based on risk. Items that are not in direct contact with the service user or in contact with intact skin are classed as low risk and should be cleaned. Items in contact with mucous membranes (eyes, mouth or rectum) are classed as medium risk and should be single use or cleaned and disinfected (or sterilised) between uses. Items that enter the body or have contact with broken skin, broken mucous membranes or with the vagina are classed as high risk and must be single use or cleaned and sterilised Table 7 Risk assessment for decontamination of equipment Risk Application of Item Recommended Method Low Items not in direct contact Cleaning with general with service user or in purpose detergent and contact with healthy skin. drying. Medium Items in contact with mucous membranes or contaminated with virulent or readily transmissible micro organisms (body fluids) or prior to use on immunocompromised service users. Single use items. Clean item and then disinfect or sterilise (item does not need to be sterile at the point of use). Examples Floors and ceilings, walls, surfaces, examination couches, trolleys, toilets, wash hand basins, furniture and fittings. Suction catheters, aurasccopes, thermometers, ambubags, masks, respiratory equipment High Items in contact with a break in the skin or mucous membrane or for introduction into sterile body areas. Items used in the vagina must be single use or sterilised. Sterilisation in a sterile services department or single use and use item sterile Surgical instruments, urinary catheters, dressings, needles and syringes. (Adapted from the Medical Devices Agency 2005) NHS Stoke on Trent Infection Prevention and Control Team

70 Cleaning Thorough cleaning with general purpose detergent and warm water (body temperature) will remove large numbers of micro organisms from a surface. A further reduction in numbers occurs as the surface dries. Reusable medical devices cannot be effectively disinfected or sterilised without having first been thoroughly cleaned and dried. Cleaning will not be effective if surfaces are damaged or rusty. An automated method such as a thermal washer/disinfector is the most effective cleaning method and is recommended for cleaning many reusable medical devices e.g. surgical instruments prior to sterilisation. Manual cleaning Reusable surgical instruments and medical devices that require disinfection and sterilisation should not be cleaned manually they should be sent to a CSSU for reprocessing. Manual cleaning is an acceptable method for cleaning the environment and low risk equipment e.g. If any manual cleaning is undertaken there must be a risk assessment and records of agreed procedures must be in place to ensure that a consistent method is employed by all care workers. There should be a deep sink designated for the purpose and PPE (disposable gloves, apron and eye and face protection) available. How to clean care equipment. Clean the item in an area designated for cleaning. Wear protective clothing, i.e., apron, gloves and eye and face protection. Prepare a fresh cleaning solution appropriately diluted for each task. Make up only the quantity required in a sink designated for cleaning equipment/not a hand wash sink. Some cleaning products are incompatible; only mix if advised by manufacturer. Use warm water, a general purpose detergent and disposable cloths or disposable paper towels. It is not necessary to use cleaning products that contain disinfectants and other antibacterial agents. Avoid generating splash by immersing the item where possible. If splash is unavoidable wear protective eyewear. After cleaning, rinse and inspect the equipment. If the item remains soiled, repeat the cleaning process. Change the solution frequently to prevent a build-up of soil or micro organisms which would recontaminate surfaces. Ensure the item is dried as quickly as possible either using paper roll or by inverting to air-dry. Air drying is acceptable for large surfaces, but small areas should be dried with clean disposable paper towels/cloths. Dispose of cleaning solution promptly in a sluice or dirty utility area. Remove protective clothing and wash hands before carrying out other duties Disinfection Disinfection is a process used to reduce the number of micro organisms to a level that is considered safe, but which may not necessarily destroy some viruses or bacterial spores. Disinfection is usually acceptable for devices that pose a medium risk of infection if these devices cannot be effectively sterilised. Disinfection can be achieved in a number of ways including the use of heat and chemical disinfectants. Both methods have their drawbacks and it is often safer and more convenient to use a single use disposable device instead. NHS Stoke on Trent Infection Prevention and Control Team

71 Disinfection is a process additional to cleaning. It does not kill all micro organisms, but reduces their number to a level which is not harmful to health. Disinfection is necessary when items:- are contaminated by blood or body fluids, and/or come into contact with mucous membrane. How to disinfect There are two common methods of disinfection; moist heat and chemical disinfection. Moist heat is used for example in CSSU for cleaning surgical instruments prior to sterilisation and in domestic items such as dishwashers and washing machines. Moist heat disinfection Dishwashers, washing machines and washer-disinfectors are effective methods for disinfecting equipment because they clean the item and then expose the items to hot water for the required time to achieve thermal disinfection. 65 o C for 10 mins 71 o C for 3 mins 80 o C for 1 min 90 o C for 1 sec Washer-disinfectors Thermal washer-disinfectors physically clean devices and kill micro organisms by applying hot water at disinfection temperatures. They are used for cleaning instruments, bedpans and other devices. They must have a contract for planned preventive maintenance and must be cleaned and maintained in accordance with Health Technical Memorandum (HTM 2030). Chemical disinfection Chemical disinfection is normally used for cleaning heat labile equipment such as flexible endoscopes and this must be carried out in a facility designed for that purpose. Chemical disinfectants are also used to disinfect equipment and surfaces after contamination with blood and body fluids and during outbreaks. Chlorine preparations are recommended following blood spillage, during outbreaks and when caring for service users with C difficile diarrhoea. Chlorine preparations There are two widely used chlorine releasing agents, suitable for use on equipment and environmental surfaces: NaDCC (sodium dichloroisocyanurate) e.g. Presept or Haz-tabs. NaCIO (sodium hypochlorite) e.g. Milton or bleach. NaDCC is available as tablets, granules or powders, and some also contain a compatible detergent. It is preferred to NaCIO because it is:- Easier to prepare and store; Slightly more efficacious; Less damaging to surfaces. NHS Stoke on Trent Infection Prevention and Control Team

72 Different concentrations are required in different circumstances, and it is usual to describe the required concentration in parts per million, abbreviated to ppm. See Table 8. Examples: Haz Tabs, Actichlor, Precept, Sanichlor, Milton Table 8 Dilution of NaDCC and NaCIO Parts per million NaDCC Blood spills 10,000ppm 2 x 5.0g tabs in 500mls water Environment 1,000ppm 2 x 0.5g tabs in 500mls water Catering x 0.5g tabs in 2 litres of water NaCIO Milton 1% use undiluted Milton 1% diluted 1: 10 Milton 1% diluted 1:80 Chlorine releasing agents should be diluted with cold water. Once prepared, the solution should be used within 24 hours or discarded. After disinfection the item/surface should be rinsed and then dried using a paper towel Sterilisation Sterilisation is a process used to remove and destroy all microorganisms. It is recommended that sterile equipment should be obtained pre-sterilised from a manufacturer or via a Central Sterile Supplies Unit (CSSU). In general practice when sterile or disinfected items are required single use disposable items are recommended Single use and single patient use items Items labelled as Single-use are intended by the manufacturer to be used once and discarded. The manufacturer considers that the item is not suitable for use on more than one occasion or that there is insufficient evidence to ensure that this would be safe (MHRA 2000). Single-use items may alternatively be labelled as Do not re-use or as per international standards symbol for do not re-use, which is the figure 2 with a line drawn through it. Certain devices, e.g., nebulisers, may be used a number of times by the same service user and are described as being appropriate for single patient use. These items should be cleaned after each use by the service user following the manufacturer s instructions Decontamination of health care equipment prior to repair, service or investigation Equipment that has been contaminated with blood and other body fluids, or exposed to service users with a known infectious disease, should not be sent to third parties without being correctly decontaminated first. If in doubt, contact the third party in advance. After decontamination and before dispatching the item it should be NHS Stoke on Trent Infection Prevention and Control Team

73 labelled with a declaration of its decontamination status that states the method of decontamination used, or reasons why this was not possible.(medicines and Healthcare products Regulatory Authority-MHRA, 2003). Some equipment cannot be effectively decontaminated without being dismantled by an engineer. In addition decontamination may sometimes remove evidence of a fault or hinder an investigation. In these situations the manufacturer, repair organisation or investigating body should be contacted for advice regarding packaging and transportation. A decontamination status label should be attached to the item, the certificate completed accordingly and the recipient advised on protective measures required. 19. WASTE DISPOSAL 19.1 Legislation The Environmental Protection Act 1990 applies to waste disposal. This legislation places a duty of care on all those producing waste to safely manage the handling and disposal of the waste in the correct and proper manner from its production to final disposal. The following information will help meet the duty of care. Healthcare waste must be managed in accordance with current legislation and national guidelines. All healthcare organisations should have a waste policy in place, which is owned by the senior managers and supported by training and audit. This guideline does not cover the topic in detail so it is advisable for managers to refer to the original source documents in developing local policy and discuss local policy with their waste manager or Contractor. For more information see HTM 07-01: Safe Management of Healthcare Waste which can be accessed at:- and the Environment Agency at: Recent legislative changes that include the Hazardous Waste (England and Wales) Regulations 2005 and the Lists of Waste Regulations 2005 have resulted in substantial changes in the way waste is defined. Waste that is produced as a result of healthcare activities is classified as healthcare waste in section 18 of the European Waste Catalogue (EWC) Waste Categories Clinical waste This is defined as: Any waste which consists wholly or partly of: Human or animal tissue; Blood or other body fluids; Excretions; Drugs or other pharmaceutical products; Swabs or dressings; Syringes, needles or other sharp instruments; which unless rendered safe may prove hazardous or infectious to any persons coming into contact with it. And: Any other waste arising from medical, nursing, dental, veterinary, pharmaceutical or similar practice, investigation, treatment, care, teaching or research, or the collection of blood for transfusion, being waste which may cause infection to any person coming into contact with it. NHS Stoke on Trent Infection Prevention and Control Team

74 Hazardous/non hazardous waste The new national guidelines HTM07-01 further classify waste as hazardous and non hazardous waste. Table 9 Types of hazardous and non hazardous waste Examples of hazardous waste: Infectious waste Medicines Amalgam Chemicals Batteries Examples of non hazardous waste Offensive/hygiene waste Domestic waste Food waste Packaging Recyclates (paper, glass, aluminium) Infectious waste has two categories for the purposes of transport legislation: Category A: An infectious substance which is transported in a form that, when exposure to it occurs, is capable of causing permanent disability, life threatening or fatal disease in humans or animals. Highly infectious waste includes waste arising from exotic infectious diseases and laboratory cultures; Category B: An infectious substance which does not meet the criteria for inclusion in Category A Offensive waste /non-infectious waste (dressings, incontinence pads) This is non-infectious waste arising from healthcare, which does not require specialist treatment but may cause offence to those coming into contact with it; i.e. human hygiene waste, incontinence products, sanitary waste, nappies, plaster casts etc. Where the waste products of healthcare are assessed as non-infectious; i.e. noninfectious wound dressings, incontinence pads etc, the waste should be discarded as offensive/hygiene waste in a yellow bag with black stripe. Some contractors may use orange bags for disposal of offensive waste Medicinal waste Medicinal waste has two categories: 1. Cytotoxic and cytostatic; 2. Medicines others than cytotoxic and cytostatic. Cytotoxic waste arising from care must be placed into an appropriate yellow container with purple stripe or purple lid. Community healthcare workers involved in the administration of cytotoxic drugs should use the waste disposal arrangements of their Trust. If service users self-administer the cytotoxic drugs the container should be returned to the hospital or GP surgery as agreed locally. Care workers must assess waste as it is produced to identify its infectious, chemical and medicinal properties and segregate appropriately for disposal. National guidelines produce useful flowcharts. NHS Stoke on Trent Infection Prevention and Control Team

75 Household/domestic waste Pedal-operated bins with lids are recommended. Any waste that is not covered under the clinical waste groupings is classed as household domestic waste, e.g. wastepaper, cans, bottles. This waste must be disposed of through the normal household waste stream i.e. black bin liners or dustbins collected by the Local Authority. Where possible, recycling options should be considered. Household waste and clinical waste must be kept separate at all times. Reducing waste can save money and help to improve the environment. Table 10 Segregation and disposal of clinical waste Type of waste Examples Containers Disposal Infectious waste (Category A) Anatomical waste: placenta, tissues, organs etc, and laboratory waste. Waste from highly infectious diseases, e.g. Ebola virus Yellow rigid lidded bin or bag Hazardous waste for incineration Infectious waste (Category B) Clinical sharps Clinical Sharps Cytotoxic and cytostatic waste and sharps Assess for infection risk. Infectious: dressings, swabs, bandages, pads, suction liners, stoma bags, catheter bags, plastic disposable instruments (not sharps). Non-infectious: treat as offensive / hygiene waste Not contaminated with medicinal products OR Fully discharged sharps contaminated with medicinal products (NOT cytotoxic or cytostatic medicines) Partially or undischarged sharps (NOT cytotoxic or cytostatic medicines) All contaminated waste. Soft waste: including gloves, swabs, packaging etc Sharps waste: needles, syringes, ampoules etc, Orange lidded bin or bag Orange lidded sharps container Yellow lidded, liquid-proof sharps container. Yellow bag or lidded bin with purple stripe. Yellow sharps bin with purple lid Licensed or permitted treatment facility or incineration Incineration or alternative treatment facility Hazardous Waste for incineration Hazardous waste for incineration Offensive/ hygiene waste Medicines (Not cytoxics or cytostatic) Non-infectious dressings, swabs, drains, incontinence pads, suction liners, stoma bags, catheter bags, plastic disposable instruments (not sharps). Unused drugs and other pharmaceutical products. Never discard them into the drainage system. Controlled drugs: comply with local procedures. Yellow bag with black stripe Yellow rigid lidded box for liquids or solids Deep landfill Hazardous waste incineration NHS Stoke on Trent Infection Prevention and Control Team

76 Table 11 Waste packaging and colour coding (from HTM 07-01) Waste receptacle Waste type Example of contents Healthcare waste Dressings, tubing contaminated with etc. from treatment radioactive material involving low level radioactive isotopes Indicative treatment disposal Licensed incineration facility Over stickers with the radioactive waste symbol may be used on yellow packaging Infectious waste contaminated with cytotoxic and/or cytostatic medicinal products Dressings/tubing from cytotoxic or cytostatic treatment Incineration Solid Bag Container (No Images currently available) Sharps contaminated with cytotoxic and cytostatic medicinal products Sharps used to administer cytotoxic products Incineration Infectious and other waste requiring incineration including anatomical waste, diagnostic specimens, reagent or test vials and kits containing chemicals Partially discharged sharps not contaminated with cyto-products Anatomical waste from theatre Syringe body with residue medicinal product Incineration Incineration Extra robust containers used for needle exchange programmes May be black Receptacle must be UN approved for liquids Waste receptacle Waste type Example of Indicative treatment NHS Stoke on Trent Infection Prevention and Control Team

77 Medicines in original Packaging Medicines NOT in original packaging contents Waste in original package with original closures Waste tablets not in foil pack or bottle Segregate aerosols i.e. asthma inhalers disposal Incineration Hazardous waste incineration Infectious waste, potentially infectious waste and autoclaved laboratory waste Soiled dressings Licensed/permitted treatment facility Note; wheeled waste containers may remain yellow but marked and tagged as orange stream waste. Due to cost of replacements. Offensive/hygiene waste Human hygiene waste and noninfectious disposable equipment, bedding and plaster casts Deep landfill Domestic waste General refuse Paper, cardboard, cans, household flowers, plastic wrappers, food scraps, office waste, paper towels, kitchen waste, etc. Excluding glass and sharp objects Landfill Clinical Waste (Containers may vary in size and design dependant on manufacturer) NHS Stoke on Trent Infection Prevention and Control Team

78 19.3 Storage of clinical waste Foot pedal operated or hands free bins must be available where clinical waste is generated. Bins must be lined with the appropriate coloured liner. Clinical waste bags must be removed when they are three-quarters full or at the end of the day, as appropriate. Bags should be tied securely per local arrangements using tape, clips or tying in a swan-neck before removing them from the bin. Clinical waste bags and sharps boxes must be labelled with the address of where the waste was produced. This may be using labelled tape or clips, or simply by writing the address or post code in permanent marker pen onto the bag prior to use. Bags must be held by the neck and must not be thrown. Clinical waste should be stored in a designated waste collection point or wheeled bin away from residential and food preparation areas. Ideally in a lockable fixed bin awaiting collection. Bins provided for clinical waste must be kept in a secure locked location away from public access that is well-lit, ventilated and marked with warning signs. Waste must be collected by a registered carrier at regular intervals e.g. weekly. Waste contractors are under no obligation to remove waste if it does not adhere to the duty of care, e.g. packaged and labelled correctly Disposal of sharps See section for safe use of sharps. Sharps containers must comply with UN3291 and BS7320: Lock the sharps container prior to disposal. Discard when three-quarters full or after 3 months. Lock the container using the closure mechanism. Place damaged sharps containers inside a larger container, lock and label prior to disposal. If sharps are spilled from the container use a safe technique to retrieve them, e.g. a dust pan and brush, and carefully place inside the container. Never put a sharps container inside a clinical waste bag 20. PEST CONTROL Pests can be found in any property but with appropriate precautions will not pose a risk to service users and care workers. Pests include:- Insects ants, flies, cockroaches, fleas, silverfish Rodents rats and mice Birds pigeons Feral cats and foxes Control measures include:- Fitting fly screens, bird netting and covering drains; Being alert for signs of infestation such as droppings, nests and chew marks; Storing food in pest proof containers. Inspecting storage areas regularly. Keeping storage areas clean and cleaning up any spillage promptly. NHS Stoke on Trent Infection Prevention and Control Team

79 Correct waste disposal. If pests are a problem advice should be obtained from specialist pest control companies. 21. ADMISSION AND TRANSFER AND DISCHARGE OF SERVICE USERS In order to minimise the risk of infection to other service users and care workers the infection status should be passed on to those providing further support and nursing or medical care. This is essential at the time of admission or transfer between care facilities to ensure the provision of optimum care and prevent further transmission of infection. Likewise when service users are discharged home from hospital details of infection status should be passed on to the primary care team. 22. ANTIMICROBIAL PRESCRIBING Inappropriate use of antimicrobial agents has led to a significant increase in the numbers of antibiotic resistant micro organisms. In addition to this the use of broad spectrum antibiotics has increased the risk and spread of Clostridium difficile infection. All antimicrobial prescribing should be in accordance with NHS Stoke on Trent s antimicrobial prescribing guidelines 2010, and where ever possible supported by microbiological evidence. These guidelines have been sent to all prescribers. Where the service user s condition or other factors warrant prescribing outside the guidelines advice should be taken from the Consultant Microbiologist. All antimicrobial prescribing should be reviewed and amended if appropriate when microbiology results are available. Antibiotics should only be prescribed when there is clinical evidence of bacterial infection. The reason for the prescription should be clearly documented in the service user s notes. Any long term prophylaxis should be discussed with the Consultant Microbiologist. A summary of the 2010 guidelines can be found in Appendix UNIFORMS AND WORKWEAR Not all care workers are required to wear uniforms. Uniforms are not considered to be a significant source of infection but the way care workers dress will convey certain messages to the service users they care for and the public. Both infection prevention and control and public perception should underpin the organisation s uniform and dress code. Examples of good and poor practice are shown in the following table Table 12 Examples of good and poor practice for uniform/dress code Good Practice Wear short sleeves when providing care to enable good hand hygiene. Poor practice Go shopping and other public places whilst wearing uniform NHS Stoke on Trent Infection Prevention and Control Team

80 Change into and out of uniform at work or cover uniform when travelling to and from work. Wear clear name badges so that service users know who is caring for them. Change immediately if uniforms become visibly soiled or contaminated. Tie long hair back. Wear soft soled closed toed shoes to protect feet from sharps and spills Wear clothes that are machine washable Wear false nails when giving care as these can harbour micro organisms damage service users and prevent good hand hygiene Wear hand or wrist jewellery /wristwatches Wear numerous badges Wear neck ties other than bow ties for direct care Carry pens, scissors etc outside breast pockets Uniforms do not constitute protective clothing and should always be protected from contamination by the use of disposable aprons. Care workers should have sufficient uniforms to wear a clean uniform each day. Ideally they should be made of a fabric that is able to withstand a wash temperature of 60 o C. If care workers wear their own clothes in the workplace similar hygiene measures should be followed. 24. OCCUPATIONAL HEALTH 24.1 Occupational health advice There must be arrangements in place for occupational health support and advice, together with appropriate policies for the protection of care workers from infection through immunisation, the avoidance and management of incidents and training and compliance with health and safety legislation. Such policies should apply to all agency and locum staff, and to those on short-term contracts. Each new member of staff should complete a pre-employment health questionnaire and provide information about previous immunisation against relevant infections. Service users and other care workers also need to be protected from care workers infected with a communicable disease. Occupational health policies should clearly set out the responsibilities of staff members to report episodes of illness, such as vomiting and / or diarrhoea to their manager. NHS Stoke on Trent Infection Prevention and Control Team

81 24.2 Immunisations Any vaccine-preventable disease that is transmissible from person to person poses a risk to both care workers and service users. Care workers have a duty of care towards those they provide care to through their work to take reasonable precautions to protect them from communicable diseases. Immunisation of care workers may therefore: protect the individual and their family from an occupationally-acquired infection; protect service users, including the most vulnerable who may not respond well to their own immunisation; protect other care workers and allow for the efficient running of services without disruption. The most effective method for preventing infections is the adoption of safe working practices. Immunisation should never be regarded as a substitute for good practice, although it does provide additional protection. This applies to all care workers who have regular clinical contact with service users and who are directly involved in patient care and includes doctors, dentists, midwives and nurses, paramedics and ambulance drivers, occupational therapists, physiotherapists and radiographers. Students and trainees in these disciplines and volunteers who are working with service user must also be included. Routine vaccinations All care workers should be up to date with their routine immunisations, e.g. tetanus, diphtheria, polio and MMR. The MMR vaccine is especially important in the context of the ability of care workers to transmit measles or rubella infections to vulnerable groups. While healthcare workers may need MMR vaccination for their own benefit, they should also be immune to measles and rubella in order to assist in protecting service users. Satisfactory evidence of protection would include documentation of having received two doses of MMR or having had positive antibody tests for measles and rubella. BCG BCG vaccine is recommended for care workers who may have close contact with infectious patients. It is particularly important to test and immunise care workers working in maternity and paediatric departments and who are in contact with service users who are likely to be immunocompromised, e.g. transplant, oncology and HIV units. Hepatitis B Hepatitis B vaccination is recommended for care workers who may have direct contact with service user s blood or blood-stained body fluids. This includes any care workers who are at risk of injury from blood-contaminated sharp instruments, or of being deliberately injured or bitten by patients. Antibody titres for hepatitis B should be checked one to four months after the completion of a primary course of vaccine. Such information allows appropriate decisions to be made concerning post-exposure prophylaxis following known or suspected exposure to the virus. Influenza Influenza immunisation helps to prevent influenza in care workers and may also reduce the transmission of influenza to vulnerable service users. Influenza vaccination is therefore recommended for front line care workers. Influenza immunisation should be offered on an annual basis. NHS Stoke on Trent Infection Prevention and Control Team

82 Varicella Varicella vaccine is recommended for susceptible care workers who have direct contac with service users. Those with a definite history of chickenpox or herpes zoster can be considered protected. Care workers with a negative or uncertain history of chickenpox or herpes zoster should be serologically tested and vaccine only offered to those without the varicella zoster antibody. Further information on immunisations for care workers can be obtained from the Occupational Health Department on or from the Green Book on the Department of Health website: Exclusion from work When necessary, care workers may need to be excluded from work until they have recovered or results of specimens are available. Staff with vomiting and or diarrhoea should be advised to remain off work until at least 48 hours have elapsed since their symptoms ceased Inoculation (sharps) injuries and bites There should also be a clear policy regarding action to be taken in the event of a blood contamination incident (e.g. needle-stick, sharps, inoculation injury or bite). Where possible this should be provided in a poster format, as well as written policy, so an injured party can take action promptly Skin and soft tissue infections Care workers with recurrent skin and soft tissue infections should report this to their manager and be referred to the Occupational Health department. 25. NEW BUILD AND SERVICE DEVELOPMENTS Department of Health guidelines have emphasised the role of the environment as a potential source of infection for service users. Therefore it is important that infection prevention and control principles and issues are considered whenever planning new or upgraded buildings. Designers, engineers, architects, facilities managers and planners must collaborate with the local infection prevention and control team to ensure that infection risks are reduced to a minimum. The infection prevention and control team should be consulted during the planning process in order to identify and minimise infection risks. This principle also applies when planning service developments and new contracts. Key considerations include: Size of rooms; Availability of treatment rooms; Availability and design of clinical hand wash basins; Design and features of ancillary areas; Engineering services; Storage facilities; Finishes for walls, floors, ceilings, doors, windows, fixtures, fittings and furniture; Interior design and designs of fixtures and fittings; Decontamination facilities; Kitchen and rest rooms; NHS Stoke on Trent Infection Prevention and Control Team

83 Waste segregation, storage and disposal; Changing facilities; Service lifts Construction and the role of cleaning. Further information on all these aspects may be found in the publication: Infection prevention and control in the Built Environment: Design and Planning. HFN INFECTION PREVENTION AND CONTROL TRAINING 26.1 Induction Practice Managers must ensure that all newly employed care workers are introduced to the infection prevention and control policies and procedures on induction and by the end of their first week of employment Ongoing training Care workers must also be updated on an annual basis and / or when new matters arise. Managers should also periodically undertake an assessment of the infection risks in their workplace and ensure that everything necessary is in place to manage those risks. An infection prevention and control link person should be identified to act as a link between the infection prevention and control/health protection team and the place of work. Infection prevention and control training can be obtained from a variety of sources, access may vary and a variety of charges apply. Examples of potential sources of infection prevention and control training include: BTEC courses; Distance learning packages; Health Protection Units; PCT/Hospital Infection prevention and control Teams; Local colleges/universities; NVQ courses; NHS Core Learning Programmes Unit Infection prevention and control e learning training programme is available on-line. Further information and a link to the programme can be found at: BIBLIOGRAPHY (FROM THE HEALTH AND SOCIAL CARE ACT 2008) The following bibliography taken from the Health and Social Care Act 2008 represents current guidance, best practice and legislation that sets the standard of care that should be applied in the prevention and control of infection in both health and social care. The bibliography includes current guidance for those providing health and social care in all settings and across all organisations. This means that providers of care whether in hospital or community settings can be aware of each other s needs and priorities. It is not expected that carers become experts in both sectors only that in the interests of service users safety and high standards a greater awareness is achieved. NHS Stoke on Trent Infection Prevention and Control Team

84 However, when a medical procedure is carried out in a social care setting, the relevant healthcare guidance should be consulted. Procedures should be performed only by carers who have demonstrated the appropriate competency and who are able to work to standards that may be indicated in the following publications. Department of Health guidance on management and organisation for the prevention and control of infection Department of Health (2009) The Health and Social Care Act 2008: Code of Practice for health and adult social care on the prevention and control of infections and related guidance. London DH. Available from Department of Health (2008) Board assurance: a guide to building assurance frameworks for reducing health care associated infections. London: DH. Available from: Department of Health (2008) Board to Ward how to embed a culture of HCAI prevention in acute trusts. London: DH. Available from: Department of Health (2008) Director of Infection Prevention and Control Role Profile. Available from: Department of Health (2008). The operating framework for the NHS in England: 2009/10. London: DH. Available from: dance/dh_ Department of Health (2008) Clean, safe care: reducing infections and saving lives. London: DH. Available from: dance/dh_ Department of Health (2006) Essential steps to safe, clean care: reducing healthcareassociated infections. London: DH. Available from: dance/dh_ Department of Health (2007) Saving Lives: reducing infection, delivering clean and safe care. London: DH. Available from: dance/dh_ Department of Health (2006) Standards for better health. London: DH. Available from: dance/dh_ NHS Stoke on Trent Infection Prevention and Control Team

85 Department of Health (2004) Towards cleaner hospitals and lower rates of infection: a summary of action. London: DH. Available from: ance/dh_ Department of Health (2003) Winning ways: working together to reduce healthcare associated infection in England. Report from the Chief Medical Officer. London: DH. Available from: H_ Department of Health (2002) Getting ahead of the curve: a strategy for combating infectious diseases (including other aspects of health protection). A report by the Chief Medical Officer. London: DH. Available from: dance/dh_ Department of Health (1995) HSG (95) 10: Hospital infection control. London: DH. Available from: dance/dh_ Ambulance guidelines Department of Health (2008) Ambulance guidelines: reducing infection through effective practice in the pre-hospital environment. London: DH. Available from: dance/dh_ Antimicrobial prescribing BMJ Group and RPS Publishing (2009) British National Formulary. Available from: Health Protection Agency Antimicrobial prescribing template for primary care. London: HPA. Available from: Department of Health, Specialist Advisory Committee on Antimicrobial Resistance (2007) Antimicrobial Framework, Journal of Antimicrobial Chemotherapy 60 (Supplement 1). Available from: Scottish Medicines Consortium/Healthcare Associated Infection Task Force (2005) Antimicrobial prescribing policy and practice in Scotland: recommendations for good antimicrobial practice in acute hospitals. Edinburgh: Scottish Executive. Available from: NHS Stoke on Trent Infection Prevention and Control Team

86 Department of Health, Standing Medical Advisory Committee, Sub-Group on Antimicrobial Resistance (1998) The path of least resistance. London: DH. Available from: Audit Infection Control Nurses Association (2005) Audit tools for monitoring infection control guidelines within the community setting. Infection Prevention Society. Available from: AuditTool-Booklet--CD-Rom Infection Control Nurses Association (2004) Acute audit tools for monitoring infection control standards. Infection Prevention Society. Available from: Audit-tools-for-monitoringInfection-Control-Standards-2004 Care of deceased persons Health and Safety Executive (2003) Safe working and the prevention of infection in the mortuary and post-mortem room. London: HSE. Available from: Clinical practice and patient management National Patient Safety Agency (2008) Patient Safety Alert: clean hands save lives. London: NPSA. Available from: Department of Health (2008) Ambulance guidelines reducing infection through effective practice in the pre-hospital environment. London: DH. Available from: dance/dh_ Pratt RJ, Pellowe CM, Wilson JA, Loveday HP et al (2007) epic2: National evidence-based guidelines for preventing healthcare associated infections in NHS hospitals in England. Journal of Hospital Infection 65 (Supplement). Available from: National Institute for Health and Clinical Excellence (2003) Infection control: prevention of healthcare-associated infections in primary and community care. London: NICE. Available from: Department of Health (2003) Winning ways: working together to reduce healthcare associated infection in England. Report from the Chief Medical Officer. London: DH. Available from: ance/dh_ NHS Stoke on Trent Infection Prevention and Control Team

87 Department of Health (2002) Good practice guidelines for renal dialysis/transplantation units: prevention and control of blood-borne virus infection. London: DH. Available from: dance/dh_ Confidentiality Department of Health (2003) Confidentiality: NHS Code of Practice. London: DH. Available from: dance/dh_ National Information Governance Board (2009) The Care Record Guarantee: Our guarantee for NHS care records in England. London: NIGB. Available from: National Information Governance Board (2009) The Social Care Record Guarantee: The guarantee for social care records in England. London: NIGB. Available from: Control of infections associated with specific alert organisms Acinetobacter and other antibiotic resistant bacteria Health Protection Agency (2006) Working party guidance on the control of multiresistant acinetobacter outbreaks. London: HPA. Available from: p= Clostridium difficile Department of Health/Health Protection Agency (2009) Clostridium difficile infection: how to deal with the problem. London: DH. Available from: dance/dh_ Department of Health (2005) Infection caused by Clostridium difficile, Professional Letter from the Chief Medical Officer and the Chief Nursing Officer. London: DH. Available from: etters/chiefnursingofficerletters/dh_ Health Protection Agency (2003) National Clostridium difficile Standards Group, Report to the Department of Health. London: HPA. Available from: Brazier JS and Duerden BI (1998) Guidelines for optimal surveillance of Clostridium difficile infection in hospitals, Communicable Disease and Public Health 1(4): Available from: NHS Stoke on Trent Infection Prevention and Control Team

88 Diarrhoeal infections Health Protection Agency (2004) Preventing person-to-person spread following gastrointestinal infections: guidelines for public health physicians and environmental health officers, Communicable Disease and Public Health 7(4): Available from: Chadwick, PR, Beards G, Brown D, Caul EO, et al (2000) Management of hospital outbreaks of gastro-enteritis due to small round structured viruses, Journal of Hospital Infection 45(1): Available from: Glycopeptide resistant enterococci Health Protection Agency Glycopeptide-resistant enterococci (GRE) general information. London: HPA. Available from: Meticillin-resistant Staphylococcus aureus (MRSA) Coia JE, Duckworth GJ, Edwards DI, Farrington M, et al, for the Joint Working Party of the British Society for Antimicrobial Chemotherapy, the Hospital Infection Society, and the Infection Control Nurses Association (2006), Guidelines for the control and prevention of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities, Journal of Hospital Infection (Supplement): 63 S1 44. Gemmell CG, Edwards DI, Fraise AP, Gould FK et al, for the Joint Working Party of the British Society for Antimicrobial Chemotherapy, the Hospital Infection Society, and the Infection Control Nurses Association (2006). Guidelines for the prophylaxis and treatment of meticillin-resistant Staphylococcus aureus (MRSA) infections in the UK, Journal of Antimicrobial Chemotherapy 57(4): Available from: Brown DF, Edwards DI, Hawkey PM, Morrison D, et al, for the Joint Working Party of the British Society for Antimicrobial Chemotherapy, the Hospital Infection Society and the Infection Control Nurses Association (2005). Guidelines for the laboratory diagnosis and susceptibility testing of meticillin-resistant Staphylococcus aureus (MRSA), Journal of Antimicrobial Chemotherapy 56(6): Available from: MRSA Screening Department of Health (2008) MRSA screening operational guidance. London: DH. Available from: tters/dh_ Department of Health (2008) MRSA screening operational guidance 2. London: DH. Available from: NHS Stoke on Trent Infection Prevention and Control Team

89 tters/dh_ Department of Health (2006) Screening for MRSA colonisation: a summary of best practice, Professional Letter from the Chief Medical Officer and the Chief Nursing Officer. London: DH. Available from: /Chiefmedicalofficerletters/DH_ Panton-Valentine leukocidin (PVL) associated and community associated Staphylococcus aureus Health Protection Agency (2008) Guidance on the diagnosis and management of PVLassociated Staphylococcus aureus infections (2nd edition). London: HPA. Available from: 10?p= Nathwani D, Morgan M, Masterton R, Dryden M et al for the British Society for Antimicrobial Chemotherapy Working Party on Community-onset MRSA Infections (2008). Guidelines for UK practice for the diagnosis and management of meticillinresistant Staphylococcus aureus infections (MRSA) presenting in the community, Journal of Antimicrobial Chemotherapy 61(5): Available from: Respiratory viruses National Institute for Health and Clinical Excellence (2008) Respiratory tract infections antibiotic prescribing. NICE Clinical Guideline 69. London: NICE. Available from Department of Health (2006) Immunisation against infectious disease ( The Green Book ). London: DH. Available from: Creutzfeldt-Jakob disease (CJD) and other human prion diseases Advisory Committee on Dangerous Pathogens TSE Working Group guidance Transmissible spongiform encephalopathy agents: safe working and the prevention of infection guidance from the Advisory Committee on Dangerous Pathogens. London: DH. Available from: Tuberculosis Department of Health (2007) Tuberculosis prevention and treatment: a toolkit for planning, commissioning and delivering high-quality services in England. London: DH. Available from: dance/dh_ NHS Stoke on Trent Infection Prevention and Control Team

90 National Institute for Health and Clinical Excellence (2006) Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control. NICE Clinical Guideline 33. Available from: Viral haemorrhagic fevers Advisory Committee on Dangerous Pathogens (1996) Management and control of viral haemorrhagic fevers. ACDP. Available from: Decontamination of reusable medical devices Department of Health (2009) HTM 01-06: Decontamination of flexible endoscopes. London: DH. Available from: Department of Health (2008) HTM 01-05: Decontamination in primary care dental practices. London: DH. Available from: dance/dh_ British Dental Association (2008) Infection control in dentistry, BDA advice sheet A12. London: DH. Available from: Department of Health (2007) Clarification and policy summary decontamination of reusable medical devices in the primary, secondary and tertiary care sectors. London: DH. Available from: dance/dh_ Department of Health (2007) HTM 01-01: Decontamination of reusable medical devices: Part A Management and environment. London: DH. Available from: Department of Health HTM 01-01: Decontamination of reusable medical devices. Part B Additional management guidance and common elements; Part C Sterilizers; Part D Washer disinfectors and ultrasonic cleaners (was the subject of stakeholder consultation which closed in May 2009). Available from: Medicines and Healthcare products Regulatory Agency (2006) DB 2006 (05): Managing Medical Devices. London: MHRA. Available from: Medicines and Healthcare products Regulatory Agency (2006) Sterilization, disinfection and cleaning of medical equipment: Guidance on decontamination from the Microbiology Advisory Committee to Department of Health. London: MHRA. Available from: NHS Stoke on Trent Infection Prevention and Control Team

91 438 NHS Estates (2004) HBN 13: Sterile services department. Available from: Medical Devices Agency (2002) DB 2002 (05): Decontamination of endoscopes. London: MDA. Available from: Medical Devices Agency (2002) DB 2002 (05): Benchtop steam sterilizers guidance on purchase, operation and maintenance. London: MDA. Available from: NHS Estates (1997) HTM 2031: Clean steam for sterilization. Available from: Education of care workers National Patient Safety Agency (2008) Patient Safety Alert: clean hands save lives. London: NPSA. Available from: National Patient Safety Agency. Cleanyourhands campaign website: NHS Core Learning Unit (2005) Infection control e-learning programme for healthcare and social care staff. Available from: Skills for Care (2005) Common Induction Standards Social Care (Adults, England). Leeds: Skills for Care. Available from: mmon_induction_standards.aspx Skills for Care (2005) Knowledge set for infection prevention and control Social Care (Adults, England). Leeds: Skills for Care. Available from: n_and_control.aspx Health Protection Agency (2009) Introduction to infection control in care homes A series of short films. London: HPA. Available from: ?p= Environmental disinfection Department of Health/Health Protection Agency (2009) Clostridium difficile infection: how to deal with the problem. London: DH. Available from: dance/dh_ NHS Stoke on Trent Infection Prevention and Control Team

92 Department of Health (2003) Winning ways: working together to reduce healthcare associated infection in England. Report from the Chief Medical Officer. London: DH. Available from: dance/dh_ Guidance on the environment Department of Health (2007) Improving cleanliness and infection control, Professional Letter from the Chief Nursing Officer. London: DH. Available from: Chiefnursingofficerletters/DH_ NHS Estates (2006) HBN 26: Facilities for surgical procedures: Volume 1. Available from: NHS Estates (2004) A matron s charter: an action plan for cleaner hospitals. Available from: cyandguidance/dh_ NHS Estates (2002) HFN 30: Infection control in the built environment: design and planning. Available from: Cleaning National Patient Safety Agency (2009) The national specifications for cleanliness in the NHS: a framework for setting and measuring performance outcomes in ambulance trusts. London: NPSA. Available from: National Patient Safety Agency (2009) The revised healthcare cleaning manual. London: NPSA. Available from: National Patient Safety Agency (2007) The national specifications for cleanliness in the NHS: a framework for setting and measuring performance outcomes. London: NPSA. Available from: National Patient Safety Agency (2007) Safer practice notice 15: Colour coding hospital cleaning materials and equipment. Available from: www. NHS Estates (2004) Revised guidance on contracting for cleaning. London: DH. Available from: NHS Stoke on Trent Infection Prevention and Control Team

93 Building and refurbishment, including air-handling systems NHS Estates (2008) HBN 04 01: Adult in-patient facilities. Available from: Department of Health (2007) HTM 03-01: Heating and ventilation systems: Specialised ventilation for healthcare premises. Part A Design and validation. Available from: Department of Health (2007) HTM 03-01: Heating and ventilation systems: specialised ventilation for healthcare premises. Part B Operational management and performance verification. Available from: NHS Estates (2005) HBN 4: Supplement I: In-patient accommodation: options for choice. Isolation facilities in acute settings. Available from: Planned preventive maintenance NHS Estates (2002) HFN 30: Infection control in the built environment: design and planning. Available from: Healthcare waste Department of Health (2006) HTM 07-01: Environment and sustainability: safe management of healthcare waste. Available from: Department of Health (2003) NHS Standard Service Level Specifications. Service specific specification waste management. Available from: Health and Safety Executive (2009) Managing offensive/hygiene waste. London: HSE. Available from: Pest control Department of Health (2003) NHS Standard Service Level Specifications. Service specific specification pest control version 2. Available from: Management of water supplies Health and Safety Executive (2009) Controlling legionella in nursing and residential care homes INDG253(rev1) Available from: NHS Stoke on Trent Infection Prevention and Control Team

94 Department of Health (2006) HTM 04-01: Water systems: the control of Legionella, hygiene, safe hot water, cold water and drinking water systems. Part A: Design, installation and testing. Available from: Department of Health (2006) HTM 04-01: Water systems: the control of Legionella, hygiene, safe hot water, cold water and drinking water systems. Part B: Operational management. Available from: British Standards Institution (1997) Specification for design, installation, testing and maintenance of services supplying water for domestic use within buildings and their curtilages. London: BSI. Available from: Food services, including food hygiene and food brought into the organisation by patients, staff and visitors Hospital Caterers Association Better Hospital Food programme. Available from: NHS Estates (2005) Managing food waste in the NHS. London: DH. Available from: Department of Health (1996) HSG (96) 20: Management of food hygiene and food services in the NHS. London: DH. Available from: delines/dh_ Health and safety Health and Safety Executive (2008) Blood-borne viruses in the workplace, Guidance for employers and employees INDG342. London: HSE. Available from: Health and Safety Executive (2006) Five steps to risk assessment INDG163(rev2). London: HSE. Available from: Health and Safety Executive (2005) COSHH: a brief guide to the Regulations: what you need to know about the Control of Substances Hazardous to Health Regulations 2002 (COSHH). London: HSE. Available from: Health and Safety Executive (2005) Biological agents: managing the risks in laboratories and healthcare premises. London: HSE. Available from: NHS Stoke on Trent Infection Prevention and Control Team

95 Health and Safety Executive (2005) Respiratory protective equipment at work: a practical guide. HSG53. London: HSE. Available from: Health and Safety Executive (2003) Health and safety regulation a short guide. London: HSE. Available from: Health and Safety Executive (2001) A guide to measuring health & safety performance. London: HSE. Available from: Health and Safety Executive (1999) Management of Health and Safety at Work Regulations. Management of health and safety at work. Approved code of practice and guidance. Statutory Instrument No Available from: Health and Safety Executive (1999) A guide to the reporting of injuries, diseases and dangerous occurrences regulations (RIDDOR) London: HSE. Available from: Health and Safety Executive (1992) Personal Protective Equipment at Work Regulations. London: HSE. Available from: Health and Safety Executive (1974) Health and Safety at Work etc. Act London: HSE. Available from: Healthcare workers infected with a blood-borne virus Department of Health (1993) HSG 93 (40): Protecting health care workers and patients from hepatitis B. London: DH. Available from: dance/dh_ Department of Health (1993) Protecting health care workers and patients from hepatitis B: recommendations of the Advisory Group on Hepatitis. London: DH. Available from: dance/dh_ Department of Health (1996) Addendum to HSG 93 (40): Protecting health care workers and patients from hepatitis B. Available from: H_ NHS Stoke on Trent Infection Prevention and Control Team

96 Department of Health (2000) HSC 2000/020: Hepatitis B infected health care workers. London: DH. Available from: culars/dh_ Department of Health (2000) Hepatitis B infected health care workers. Guidance on implementation of Health Service Circular 2000/020. London: DH. Available from: culars/dh_ Department of Health (2007) Hepatitis B infected healthcare workers and antiviral therapy. London: DH. Available from: dance/dh_ Department of Health (2002) HSC 2002/010: Hepatitis C infected health care workers. London: DH. Available from: culars/dh_ Department of Health (2002) Hepatitis C infected health care workers. Guidance on implementation of Health Service Circular 2002/010. London: DH. Available from: culars/dh_ Department of Health (2005) HIV-infected health care workers: guidance on management and patient notification. London: DH. Available from: dance/dh_ Health and Safety Executive (2008) Blood-borne viruses in the workplace, Guidance for employers and employees INDG342. London: HSE. Available from: Immunisation Health and Safety Executive (2008) Blood-borne viruses in the workplace, Guidance for employers and employees INDG342. London: HSE. Available from: Department of Health (2006) Immunisation against infectious disease ( The Green Book ). London: DH. Available from: Health and Safety Executive (2006) Five steps to risk assessment INDG163(rev2).London: HSE. Available from: NHS Stoke on Trent Infection Prevention and Control Team

97 Isolation of service users with an infection Department of Health/Health Protection Agency (2009) Clostridium difficile infection: how to deal with the problem. London: DH. Available from: dance/dh_ Department of Health (2008) Guide to best practice: isolation of patients. London: DH. Available from: NHS Estates (2005) HBN 4: In-patient accommodation: options for choice. Supplement 1: Isolation facilities in acute settings. Available from: NHS Estates (2002) HFN 30: Infection control in the built environment: design and planning. Available from: Linen, laundry and dress Department of Health (2003) NHS Standard Service Level Specifications. Service specific specification linen. Available from: Department of Health (1995) HSG (95)18: Hospital laundry arrangements for used and infected linen. London: DH. Available from: elines/dh_ Management of occupational exposure to blood-borne viruses and post-exposure prophylaxis Health and Safety Executive (2001) Blood-borne viruses in the workplace. London: HSE. Available from: Department of Health (2008) HIV post-exposure prophylaxis: guidance from the UK Chief Medical Officers Expert Advisory Group on AIDS. 4th edition. London: DH. Available from: dance/dh_ PHLS Hepatitis Subcommittee (1992) Exposure to hepatitis B virus: guidance on postexposure prophylaxis, CDR Review 2(9): 1 5. Available from: NHS Stoke on Trent Infection Prevention and Control Team

98 Ramsay, ME (1999) Guidance on the investigation and management of occupational exposure to hepatitis C, Communicable Disease and Public Health 4 (4): Available from: Health Protection Agency (2005) Reporting of occupational exposure to blood borne viruses history and how to report. London: HPA. Available from: az/bbv/occ_exp.htm Medical devices directives/regulations Medicines and Healthcare products Regulatory Agency (2006) Bulletin No 17: Medical devices and medicinal products. London: MHRA. Available from: x.htm Statutory Instrument 2002 No. 618: The Medical Devices Regulations Available from: Medicines and Healthcare products Regulatory Agency Changes to the registration of medical devices. Available from: dance/con Council Directive 93/42/EEC of 14 June 1993 concerning medical devices. Available from: Microbiology laboratory Department of Health (2007) Health, safety and security measures for microbiology laboratories. London: DH. Available from: dance/dh_ Department of Health (2007) Transport of infectious substances best practice guidance for microbiology laboratories. London: DH. Available from: dance/dh_ Clinical Pathology Accreditation (UK) Ltd (2007) Standards for the medical laboratory. Sheffield: CPA. Available from: Movement of service users Department of Health (2008) Clean, safe care: reducing infections and saving lives. London: DH. Available from: NHS Stoke on Trent Infection Prevention and Control Team

99 dance/dh_ Department of Health (2004) Standards for better health. London: DH. Available from: Department of Health (2003) Winning ways: working together to reduce healthcare associated infection in England. Report from the Chief Medical Officer. London: DH. Available from: dance/dh_ Occupational health NHS Employers (2007) The healthy workplaces handbook. Available from: Department of Health (2007) Health clearance for tuberculosis, hepatitis B, hepatitis C and HIV: New healthcare workers. London: DH. Available from: dance/dh_ Health and Safety Executive (1985) Reporting of Injuries, Disease and Dangerous Occurrences Regulations (RIDDOR). London: HSE. Available from: Health and Safety Executive (2005) Control of substances hazardous to health (Fifth edition); The Control of Substances Hazardous to Health Regulations 2002 (as amended); Approved Code of Practice and guidance. London: HSE. Available from: Outbreaks of communicable infection Department of Health (2008) Guide to best practice: isolation of patients. London: DH. Available from: Department of Health (2003) Winning ways: working together to reduce healthcare associated infection in England. Report from the Chief Medical Officer. London: DH. Available from: dance/dh_ Department of Health (1995) HSG (95) 10: Hospital infection control. London: DH. Available from: dance/dh_ NHS Stoke on Trent Infection Prevention and Control Team

100 Prevention of occupational exposure to blood-borne viruses, including the prevention of sharps injuries NHS Employers (2007) The healthy workplaces handbook. Available from: Health Protection Agency (2008) Examples of good and bad practice to avoid sharps injuries. London: HPA. Available from: Department of Health (1998) Guidance for clinical health care workers: protection against infection with blood-borne viruses. London: DH. Available from: dance/dh_ Advisory Committee on Dangerous Pathogens (1995) Guidance on protection against blood-borne infections in the workplace: HIV and hepatitis. PL CO (95)5. Available from: s/chiefofficerlettere/dh_ Provision of information to the patient, the public and other service providers National Patient Safety Agency (2005) Being open communicating patient safety incidents with patients and their carers. London: NPSA. Available from: Renal care Department of Health (2002) Good practice guidelines for renal dialysis/transplantation units: prevention and control of blood-borne virus infection. London: DH. Available from: dance/dh_ Safe handling and disposal of sharps Health Protection Agency (2008) Examples of good and bad practice to avoid sharps injuries. London: HPA. Available from: Department of Health (2008) Ambulance guidelines reducing infection through effective practice in the pre-hospital environment. London: DH. Available from: dance/dh_ Pratt RJ, Pellowe CM, Wilson JA, Loveday HP et al (2007) epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. NHS Stoke on Trent Infection Prevention and Control Team

101 Journal of Hospital Infection 65 (Supplement). Available from: National Institute for Health and Clinical Excellence (2003) Infection control: Prevention of healthcare-associated infections in primary and community care. London: NICE. Available from: NHS Employers (2007) The healthy workplaces handbook. Available from: Single-use devices Medicines and Healthcare products Regulatory Agency (2006) Single-use Medical Devices: Implications and Consequences of Reuse. Medicines and Healthcare products Regulatory Agency Device Bulletin DB 2006 (04). London: MHRA. Available from: Surveillance of HCAI Department of Health (2008) Changes to the mandatory healthcare associated infection surveillance system for Clostridium difficile infection (CDI) from 1 January Professional Letter from the Chief Medical Officer and the Chief Nursing Officer. London: DH. Available from: Chiefmedicalofficerletters/DH_ Department of Health (2007) Changes to the mandatory healthcare associated infection surveillance system for Clostridium difficile associated diarrhoea from April Professional letter from the Chief Medical Officer and the Chief Nursing Officer. London: DH. Available from: /Chiefmedicalofficerletters/DH_ Department of Health (2005) Mandatory surveillance of methicillin resistant Staphylococcus aureus (MRSA) bacteraemias. Professional Letter from the Chief Medical Officer and the Chief Nursing Officer. London: DH. Available from: Chiefnursingofficerletters/DH_ Department of Health (2003) Surveillance of healthcare associated infections, Professional Letter from the Chief Medical Officer and the Chief Nursing Officer. London: DH. Available from: Brazier JS and Duerden BI (1998) Guidelines for optimal surveillance of Clostridium difficile infection in hospitals, Communicable Disease and Public Health 1(4): Available from: NHS Stoke on Trent Infection Prevention and Control Team

102 Uniform and dress code Department of Health (2007) Uniform and workwear: an evidence base for developing local policy. Available from: idance/dh_ NHS Stoke on Trent Infection Prevention and Control Team

103 APPENDICES NHS Stoke on Trent Infection Prevention and Control Team

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105 DEFINITIONS USED IN THE HEALTH ACT 2008 APPENDIX 1 Adult Social Care Social care includes all forms of personal care and other practical assistance provided for individuals who, due to age, illness, disability, pregnancy, childbirth, dependence on alcohol or drugs or any other similar circumstances, are in need of such care or assistance (Refer to section 9 of the Act). For the purposes of the CQC, it only includes care provided for, or mainly for, adults in England. Alert organism surveillance Alert organism surveillance is used widely to detect and prevent outbreaks of infection. These organisms are reported to infection prevention and control teams on a regular basis to identify possible outbreaks of infections and serious infections. The organisms that are surveyed will depend on the local epidemiology of infection. Examples of alert organisms may include Meticillin Resistant Staphylococcus aureus (MRSA), Clostridium difficile and other antibiotic resistant organisms. Antimicrobials Antimicrobials are substances which are used in the treatment of infections caused by bacteria and viruses. Aseptic technique This describes the clinical procedures that have been developed to prevent contamination of wounds and other susceptible body sites. Assurance framework A system for informing third parties that a process of due diligence is in place to assure safety and quality exists in that setting. Audit Audit is a quality improvement process that aims to improve service user care and outcomes by carrying out a systematic review and implementing change. These are not necessarily complex and in their simplest form show compliance with a single protocol. Their value is in showing improvement or maintenance of a high standard. Blood borne viruses (BBVs) Organisms such as hepatitis B, hepatitis C and HIV that are potentially transmissible in the occupational setting via percutaneous (sharp) or mucocutaneous (mucous membrane/broken skin) routes. Care worker Any person whose normal duties concern the provision of treatment, accommodation or related services to service users and who has access to service users in the normal course of their work. This term includes not only front-line clinical care and support staff, but also some staff employed in estates and facilities management, such as cleaning staff and maintenance engineers. Care Quality Commission The Care Quality Commission (CQC) is the new, integrated regulator of health and adult social care, replacing the Healthcare Commission, the Commission for Social Care NHS Stoke on Trent Infection Prevention and Control Team

106 Inspection and the Mental Health Act Commission. It was established by section 1 of the Health and Social Care Act, CCDC Consultant in Communicable Disease Control. Cohort nursing This describes the physical separation of service users with the same infection or those displaying similar signs and symptoms of infection in a designated area usually in a hospital ward or a designated bay on a ward. In a care home this may be in a shared room or designated location. Decontamination The combination of processes (including cleaning, disinfection and sterilisation) used to make a re-usable item safe for further use on service users and handling by care workers. Decontamination Lead The senior member of staff with the responsibility for managing all aspects of decontamination. It is expected that this officer will report directly to the chief executive or registered provider. It is not intended that this post should always be filled by a technically competent individual, merely that their level of seniority within the organization is sufficient to encompass all aspects of delivery and thus ensure compliance with best practice. Director of Infection Prevention and Control (DIPC) The Director of Infection Prevention and Control who has overall responsibility for infection prevention and control and is accountable to the registered provider. Disinfection A process used to reduce the number of viable infectious agents but which may not necessarily inactivate some microbial agents such as certain viruses and bacterial spores. Disinfection does not achieve the same reduction in microbial contamination levels as sterilization. Domiciliary care Homecare that helps people cope with disability or illness and allows them to maintain independence. Health and Social Care Act 2008 ('the Act') The legislation that established the CQC and lays out the framework for its powers and responsibilities. ICD Infection control doctor ICN/ICP Infection control nurse/infection control practitioner. ICT Infection control team NHS Stoke on Trent Infection Prevention and Control Team

107 Invasive device A device which, in whole or part, penetrates inside the body, either through a body orifice or through the skin. Infection Prevention and Control Lead The Infection Prevention and Control Lead for an organisation has overall responsibility for infection prevention and control and is accountable to the registered provider. Isolation facilities Separation of a service user with a suspected or confirmed infection from other service users. In healthcare setting this will usually be a single room with hand washing facilities, ideally with en-suite lavatory and bath/shower. In some instances, isolation rooms will require additional special ventilation. In an adult social care setting, a service user can usually be safely isolated in their own room LINks Local Involvement Networks (LINks) aim to give citizens a stronger voice in how their health and social care services are delivered. Run by local individuals and groups and independently supported the role of LINks is to find out what people want, monitor local services and to use their powers to hold them to account. Each local authority (that provides social services) has been given funding and is under a legal duty to make contractual arrangements that enable LINk activities to take place. Low-risk single (specialty) facility A provider unit delivering care around a single specialty. Managed premises Any premises where regulated activities are delivered, but excluding a service user s home where domiciliary care is provided and, offices used purely for managerial services. Medical device A healthcare product other than medicines used for the diagnosis, prevention, monitoring and treatment of disease, injury or disability. This means everything from artificial hips to wound dressings, incubators to insulin delivery devices, scanners to scalpels, and wheelchairs to commodes. NHS provider A primary care trust (PCT), an NHS trust where all or most of its hospitals, establishments and facilities are situated in England, or an NHS foundation trust. PALS The Patient Advice and Liaison Service, which has been introduced to ensure that the NHS listens to service users, their relatives, carers and friends, answers their questions and resolves their concerns. Personal care Physical assistance given to a person in connection with eating and drinking, toileting (including in relation to the process of menstruation), washing and bathing, dressing, oral care, or the care of skin, hair and nails; or the prompting and supervision of a person, in relation to the performance of any of the activities where that person is unable to make a decision for themselves in relation to performing such an activity without such prompting and supervision. NHS Stoke on Trent Infection Prevention and Control Team

108 Primary healthcare teams Health services primarily based in the local community, including community matrons, district nurses, GPs, pharmacists, dentists, optometrists and podiatrists. This includes people employed by PCTs and primary medical care contractors. Registered manager An individual who is registered with the CQC to manage regulated activity at particular premises where the registered provider is not in day-to-day control. Registered person Any person who is the service provider or registered manager. Registered provider Any person, partnership or organisation that provides one or more of the regulated activities and is registered with the CQC, as a registered provider of that service or those services. Regulated activities Broad service areas or types of care that are set out in regulations under section 8 of the Health and Social Care Act They will include those health and adult social care activities that an organisation needs to register with the CQC to provide care or treatment in England. Risk assessment An important step in deciding the policies and practices necessary to protect service users and care workers from the risks of infection. It requires a careful examination of the service users environment and the procedures that they may undergo that might cause them harm to enable an assessment to be made of whether sufficient policies and precautions are in place to prevent infection. Serious Untoward Incident (SUI) The principal definition of a serious untoward incident (SUI) is in general terms something out of the ordinary or unexpected, with the potential to cause serious harm, and/or likely to attract public and media interest. This may be because it involves a large number of people, there is a question of poor clinical or management judgement, a service has failed, a service user has died under unusual circumstances, or there is the perception that any of these has occurred. SUIs are not exclusively clinical issues for example; an electrical failure may have consequences that make it an SUI. Service user This covers patients and users of adult social care e.g. clients. Single-use device A medical device that is intended to be used on an individual service user during a single procedure and then discarded. It is not intended to be re-processed and used on another service user. The labelling identifies the device as disposable and not intended to be reprocessed and used again. Specific alert organism These are micro organisms which have the potential to cause harm and disease in individuals and which can lead to an outbreak of infection. The organisms which should be subject to specific surveillance will be selected by local need. NHS Stoke on Trent Infection Prevention and Control Team

109 Traceability In respect of medical devices, primarily surgical instruments traceability relates to instrument sets, as distinct from individual instruments, being tracked through use and decontamination processes and traced in terms of identification of service users with whom sets have been used. An exception is noted in that traceability of individual instruments or devices is recommended where these have come into contact with certain tissues (CNS brain and posterior ophthalmic), which are classified as carrying a high risk of potential transmission of prion disease should the infectious agent be present. (Note- this partly follows the text used in Coding for Success a report from the Deputy Chief Medical Officer DCMO). NHS Stoke on Trent Infection Prevention and Control Team

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111 APPENDIX 2 CHECKLIST FOR HEALTH AND SOCIAL CARE ACT NHS Stoke on Trent Infection Prevention and Control Team

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117 APPENDIX 3 TEMPLATE FOR AN INFECTION PREVENTION AND CONTROL POLICY Introduction and background Information Why the policy is required Any relevant legislation Aims /Purpose of the Policy What the policy will achieve Scope Who the policy applies too Implementation Mechanism for dissemination to relevant care workers Responsibilities Corporate and Individual responsibilities Registered provider Practice Manager GPs Practice Nurses Infection Control Lead Infection control links Other staff/employees Procedural guidance Any procedure guidance that will need to be followed to implement the policy, Monitoring and review How the organisation will monitor and review the policy in accordance with the review date stated. This section may include data such as external and internal audit reports, local induction and training figures and key performance indicators. Monitoring arrangements for compliance and effectiveness i.e. audit, training update and whose responsibility this is. Training Training required to update care workers on the content of the policy. To include frequency and training records. NHS Stoke on Trent Infection Prevention and Control Team

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119 SUGGESTIONS FOR STATEMENT FOR INCLUSION IN JOB DESCRIPTIONS APPENDIX 4 Suggestion A Infection Prevention and Control In accordance with the Health and Social Care Act 2008, infection control is everyone s responsibility. All care workers both clinical and non clinical, are required to adhere to the (insert name of organisation) Infection Prevention and Control Policies and Procedures and make every effort to maintain high standards of infection prevention and control at all times thereby reducing the burden of Infections including MRSA. All care workers employed by the (insert name of organisation) have the following key responsibilities: Care workers must wash their hands or use alcohol gel between each service user contact. Care workers have a duty to attend mandatory infection control training provided for them by (insert name of organisation). Care workers who develop recurrent skin, soft tissue and other infections that may be transmittable to service users, have a responsibility to report this to their line manager and occupational health advisor. Suggestion B Infection Prevention and Control In accordance with the Health and Social Care Act 2008, the post holder will actively participate in the prevention and control of infection within the capacity of their role. The Act requires the post holder to attend infection prevention and control training on induction and at regular updates and to take responsibility for the practical application of the training in the course of their work. Infection prevention and control must be included in any personal development plan or appraisal. NHS Stoke on Trent Infection Prevention and Control Team

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121 Infection Control Audit Tool General Practices (Adapted from the ICNA Audit Tools 2005) APPENDIX 5 The tool is broken down into four sections: 1 Management and organisation 2 General environment and equipment 2.1 General environment and equipment 2.2 Dirty utility 2.3 Domestics Room 2.4 Staff kitchens/rest room 3 Infection Control Practices 3.1 Hand hygiene 3.2 Personal protective equipment 3.3 Spillages 3.4 Disposal of waste 3.5 Handling of sharps 3.6 Specimen handling 3.7 Vaccine handling and storage 3.9 Decontamination and disinfection 4 Clinical procedures 4.1 Aseptic procedures Scoring: All the criteria should be marked either yes/no or non- applicable. It is not acceptable to enter a non applicable response where an improvement in a standard may be achieved. Add the total number of yes answers and divide by the total number of questions answered (all the yes and no answers) excluding the non applicable, multiply by 100 to get the percentage total number of yes answers x 100 = % total number of yes and no responses Compliance Levels: 85% and above Compliant 76 84% Partial compliance 75% or less Minimal compliance NHS Stoke on Trent Infection Prevention and Control Team

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123 Audit tools INFECTION CONTROL AUDIT TOOLS General Practices Date: Practice. Auditors... Section 1 Management and organisation Standard Statement: There are management structures in place to ensure that all staff throughout the organisation are engaged to promote and secure the implementation of best practice in the prevention and control of infection 1 The Registered Provider and Management Team accept responsibility for infection Prevention and control. 2 There is a designated lead for infection control within the practice. 3 The designated lead has received appropriate training in infection control 4 Care workers are aware of where to obtain 24 hour infection control advice 5 There are policies/procedures in place for infection prevention and control that are endorsed by local infection prevention and control specialists 6 Policies are reviewed and updated every two years in line with new evidence and guidance 7 Roles and responsibilities for infection control are outlined in the infection control policy 8 There are structures in place to ensure distribution, compliance and monitoring of infection prevention and control policies to all care workers. 9 There is an annual programme of audit of infection control policies and procedures 10 Infection control policy is accessible to all care workers 11 Care workers are aware of the content of the policy 12 GPs are aware of the notification procedure for notifiable diseases 13 Infection control is included in induction programmes for all new staff 14 All care workers receive annual infection control training 15 Records of all infection control training kept Yes No N/A Evidence/Comments 16 Infection control is included in care workers job descriptions 17 Infection control is included in care workers appraisals 18 Infection control issues are taken into consideration at the planning and design stage of refurbishment /new build NHS Stoke on Trent Infection Prevention and Control Team

124 19 Infection control advice is sought as necessary for services that have implications for infection control (laundry and waste) Totals Yes No N/A Evidence/Comments Comments: Total number of yes answers Potential total (Number of Yes and Nos) Percentage Status Review Date Section 2 Environment and equipment Standard Statement: The environment and equipment will be managed appropriately to reduce the risk of cross infection 2.1 General environment and equipment Yes No N/A Comments 1 The organisation has access to NHS document Infection Control in the Built Environment. 2 The organisation has comprehensive procedures for cleaning based on up to date guidance/best practice (NPSA 2009). 3 Organisational structures are in place to ensure compliance and auditing of cleanliness 4 Overall appearance of the environment is tidy and uncluttered with only appropriate, clean and well maintained furniture used. 5 All high and low surfaces are free from dust and cobwebs 6 All chairs and stools in clinical/communal areas are covered in an impermeable washable materials e.g. vinyl 7 Furniture, fixtures and fittings are visibly clean (no body substances, dirt or dust) and in a good state of repair (surfaces and fabric intact) 8 There are rooms designated for clinical practice/minor surgery 9 Rooms allocated for clinical practice are not carpeted 10 Fabric of the environment and equipment smells clean, fresh and pleasant 11 Floor coverings are washable and impervious to moisture and sealed regularly 12 Floors including edges and corners are free of dust and grit 2.1 General environment and equipment Yes No N/A Comments NHS Stoke on Trent Infection Prevention and Control Team

125 (continued) 13 Curtains and blinds are free from stains, dust and cobwebs 14 There is a procedure in place to regularly clean blinds/change curtains (minimum yearly)or when soiled. 15 Fans are clean and free from dust 16 Air vents are clean and free from excessive dust 17 Work station equipment in clinical areas are visibly clean e.g. phones, computer keyboards 18 Furniture that cannot be cleaned is condemned 19 Tables and surfaces are tidy and uncluttered to enable cleaning 20 Couch covers are covered in impervious, material, clean and in a good state of repair. 21 Disposable paper is used to protect couches 22 Where used pillows are sealed in wipe clean washable covers. 23 Water coolers are mains supplied, visibly cleaned and on a planned maintenance programme. 24 Soft toys are not available for communal use 25 Toys are wipe clean 26 Toilets are visibly clean with no body substances, dust, lime scale stains or smears (check under toilet seat) 27 Changing mats are wipe clean with wipe clean covers and free from stains 28 Baby weighing scales are visibly clean and lined with disposable paper. Totals Comments: Total number of yes answers Potential total (Number of Yes and Nos) Percentage Status Review Date NHS Stoke on Trent Infection Prevention and Control Team

126 2.2 Dirty utility Yes No N/A Comments 1 A dirty utility is available 2 A separate sink is available for decontamination of service user equipment 3 A sluice hopper is available for the disposal of body fluids 4 The integrity of fixtures and fittings are intact Totals Comments: Total number of yes answers Potential total (Number of Yes and Nos) Percentage Status Review Date 2.3 Domestics Room Yes No N/A Comments 1 Separate hand washing facilities are available including soap and paper towels 2 Floors including edges and corners are free of dust and grit 3 Equipment used by the domestic care workers is clean, well maintained and stored in a locked area 4 Vacuum cleaners are clean and fitted with HEPA filters 5 Machines used for floor cleaning are clean and dry 6 No inappropriate materials or equipment are stored in the domestic s room 7 Products used for cleaning and disinfection comply with policy and are used at the correct dilution 8 Diluted products are discarded after 24 hours 9 The floor is clean and free from spillage 10 Floors including edges and corners are free of dust 11 Cleaning equipment is colour coded 12 Mops and buckets are stored according to the local policy 13 Mop heads are laundered daily or are disposable (single use) 14 Shelves and cupboards are clean inside and out and free of dust, litter or stains Totals Comments: NHS Stoke on Trent Infection Prevention and Control Team

127 Total number of yes answers Potential total (Number of Yes and Nos) Percentage Status Review Date 2.4 Staff Kitchen and rest rooms Yes No N/A Comments 1 Separate hand wash basin is available 2 Liquid soap and paper towels are available in wall mounted dispensers 3 Foot operated waste bin available 4 No evidence of infestation in the kitchen 5 Floor is visibly clean, free of dust and debris 6 Cleaning materials accessible and away from food 7 Cleaning equipment is colour coded and stored separately from other cleaning equipment (green in kitchen) 8 Drying cloths are disposable (paper roll) 9 Opened foods are labelled with name, date of opening and stored in pest proof container 10 Milk is stored in a fridge 11 Food within expiry date 12 Fridge is free from specimens and drugs 13 Hands are washed prior to handling food 14 Cooking appliances are visibly clean (toaster, microwave, cooker) 15 There are no inappropriate items in the kitchen Totals Comments: Total number of yes answers Potential total (total Number of Yes and Nos) Percentage Status Review date 3 Infection Control Practices NHS Stoke on Trent Infection Prevention and Control Team

128 3.1 Hand hygiene Standard Statement: hands will be decontaminated correctly and in a timely manner using a cleansing agent to reduce the risk of cross infection 3. 1 Hand hygiene Yes No N/A Comments 1 The hand hygiene policy/procedure guidance is available to all care workers. 2 Hand hygiene is an integral part of induction for all care workers. 3 Care workers have received training in hand hygiene procedures (ask a member of staff) workers) 4 Care workers providing care have short nails which are clean and free from nail extensions and varnish 5 Staff are aware of practice Bare below the elbow Short sleeves, no wrist watches, stoned rings or other wrist jewellery is worn by care workers delivering hands on care 6 Hand hygiene is encouraged and alcohol rub are made available for visitors 7 Posters promoting hand hygiene are available and on display 8 Hand wash facilities are visibly clean and intact (check sinks, taps, splash backs, soap and towel dispensers) 9 Hand wash basins are dedicated for that use only and free from inappropriate items 10 There is easy access to hand wash basins 11 Hand wash basins in clinical areas complies with HTM 64 i.e. no plugs or overflows and the taps are not directly situated above the plughole 12 Hand wash basins in clinical areas have mixer taps that elbow/sensor operated. 13 Liquid soap is available at each hand wash basin 14 Liquid soap is in single use wall mounted dispensers 15 Alcohol hand rub is available at the point of use. Portable dispensers acceptable 16 Soft paper towels in wall mounted dispensers are available at all hand wash basins 17 Soap, towel and alcohol dispensers are clean 18 Reusable towels are not used by care workers 19 Re usable nail brushes are not used 20 Hands free bins are available close to hand wash basins 21 Care workers clean their hands before and after each care activity. Observe different groups of care workers NHS Stoke on Trent Infection Prevention and Control Team

129 22 Totals Comments: Total number of yes answers Potential total (Number of Yes and Nos) Percentage Status Review Date 3.2 Personal protective equipment (PPE) Standard Statement: Personal protective equipment is available and is used appropriately to reduce the risk of cross infection 1 The organisation has comprehensive procedures and a policy for the appropriate use of PPE 2 Care workers have received training in the use of PPE as part of local induction 3 Sterile and non sterile gloves (powder free) and conforming to European Community standards are fit for purpose and available for care workers 4 Alternatives to natural latex rubber (NLR) are available for use by care workers and on service users with NRL sensitivity 5 Gloves are worn if there is a risk of exposure to blood and body fluids, cleaning fluids or chemicals 6 Powdered and polythene gloves are not used for clinical procedures 7 There are a range of sizes available 8 Gloves are worn as single use items 9 Hands are decontaminated after the removal of gloves 10 Gloves are stored appropriately 11 Disposable plastic aprons are worn when there is a risk that clothing or uniforms may become exposed to body fluids or become wet 12 Disposable plastic aprons are worn as single use items for each clinical procedure or episode of patient care. 13 Aprons are stored appropriately 14 Eye and face protection is worn where there is a risk of splashing into the face and eyes Totals Yes No N/A Comments NHS Stoke on Trent Infection Prevention and Control Team

130 Comments: Total number of yes answers Potential total (Number of Yes and Nos) Percentage Status Review Date 3.3 Spillages and or contamination with blood and body fluids Standard Statement: Body fluid spillage or contamination is dealt with in a way that reduces the risk of cross infection. 1 There is a policy/procedure for dealing with spills of body fluids 2 Care workers have received training in dealing with body fluid spills 3 Care workers who come into contact with body fluid spillages have been immunised against hepatitis B 4 Care workers are aware of the action to take in the event of an inoculation incident 5 Equipment used to clear body is disposable Yes No N/A Comments 6 Appropriate disinfectants/spillage kits for cleaning body fluid spillages such as sodium hypochlorite 10,000 ppm (Milton diluted 1in 10) 7 Medical Equipment that has been contaminated with body fluids has been cleaned appropriately. 8 PPE is worn to clean up body fluid spillage 9 Furniture and equipment that has been contaminated with blood and body fluids and cannot be cleaned is condemned Totals Comments: Total number of yes answers Potential total (Number of Yes and Nos) Percentage Status Review Date NHS Stoke on Trent Infection Prevention and Control Team

131 3.4 Waste disposal Standard Statement: All waste from premises providing health care is segregated and identified at source, transported and disposed of safely without risk of contamination, infection or injury to care workers and the general public and in accordance with legislation. 1 There is a comprehensive policy/procedure in place for waste disposal 2 The practice is registered to generate clinical waste. 3 The practice has a contract with a licensed waste contractor (check records) 4 Care workers have received training about the correct and safe disposal of healthcare waste (check training records) 5 Waste is correctly segregated (according to current regulation) 6 There are posters demonstrating correct segregation 7 Correctly colour coded waste containers/bags are in use 8 Waste bags are securely sealed and labelled and dated and no more than 2/3rds full 9 Clinical waste is not decanted from one container to another 10 Waste bags are removed from clinical areas daily 11 Waste bins are foot operated, lidded and in good working order 12 Waste bins are clean and in a good state of repair 13 There is no storage of waste in inappropriate areas 14 There is a dedicated area for the storage of healthcare waste,which is under cover, free from vermin and pests, kept locked and inaccessible to animals and the public 15 The storage area is clean and tidy 16 All waste is collected on a regular basis by a licensed contractor at least once a week 17 Consignment notes are kept and up to date 18 The producer of the waste is aware of their duty of care Totals Comments: Yes No N/A Comments Total number of yes answers Potential total (Number of Yes and Nos) Percentage Status Review Date 3.5 Prevention of blood/body fluid sharp injuries bites and splashes. NHS Stoke on Trent Infection Prevention and Control Team

132 Standard Statement: Sharps/needle stick injuries and splashes involving blood or other body fluids are managed in away that reduces the risk of injury or infection. 1 The organisation has comprehensive procedures and a policy for the management of sharps/needle stick injuries or splashes and bites in a way that reduces injury or infection 2 There are arrangements in place to ensure that care workers who have contact with blood and body fluids are immunised against hepatitis B 3 There are arrangements in place to ensure that care workers are dealt with appropriately in the event of needle stick/bite or splash injury 4 All care workers have received training in sharps/bites/splash management and are aware of the actions to take following an injury. (ask a member of care workers) 5 All needle stick/sharps/bites/splash injuries are recorded 6 There are appropriate devices to use to reduce the risk of needlestick injuries,=. 7 There is a poster displayed for the management of needle stick/sharps/bites/splash injuries 8 Sharps containers comply with BS 7320/UN Sharps containers are correctly assembled Yes No N/A Comments 10 All sharps containers in use are labelled with date and locality and signed 11 Sharps containers are available at the point of use (e.g. small community bins) 12 Sharps containers are stored safely away from public access and out of children s reach 13 Sharps containers are not overfilled 14 There are no inappropriate items in the sharps containers 15 Needles and syringes are disposed of as a single unit 16 Syringes with a residue of prescription only medication are disposed of in line with current legislation 17 The temporary closure mechanism is used when the bin is not in use 18 Full sharps containers are sealed correctly tape or stickers are not used 19 Sharps containers are not placed in waste bags prior to disposal 20 Sealed and locked bins are stored in a locked facility away from public access 21 Sharps containers are available for use and located within easy reach 22 Sharps containers are visibly clean 23 Needles are not resheathed Yes No N/A Comments NHS Stoke on Trent Infection Prevention and Control Team

133 24 The person using the sharps disposes of it themselves Totals Comments: Total number of yes answers Potential total (Number of Yes and Nos) Percentage Status Review Date 3.6 Specimen handling Standard Statement: Specimens are handled in a way that negates the risk of cross infection 1 There is policy/procedure in place for specimen handling 2 All staff handling specimens including reception staff are trained to handle specimens safely 3 Specimens are collected in appropriate containers 4 Specimens are processed in a CPA accredited laboratory 5 Service users are provided with appropriate containers to collect at home 6 Specimens are sealed in appropriate bags (Request card separate from specimen) 7 Specimens awaiting transport are in a designated area away from the public and staff rest areas 8 Specimens are transported in lidded leak proof containers 9 Specimen transport containers are visibly clean 10 Specimens tested on site in an appropriate designated area 11 Specimens tested on site are discarded in a toilet or sluice. 12 Totals Yes No N/A Comments Comments: Total number of yes answers Potential total (Number of Yes and Nos) Percentage Status Review Date NHS Stoke on Trent Infection Prevention and Control Team

134 3.7 Vaccine storage and transport Standard Statement: Vaccines are stored and transported safely. 1 There is a procedure /policy in place for the storage and transport of vaccines 2 There is a designated person that has overall responsibility for the safe storage and handling of vaccines 3 Vaccines are stored immediately on delivery in to a dedicated refrigerator 4 The refrigerator is fit for purpose not a domestic fridge 5 The refrigerator has an uninterrupted electrical supply 6 The refrigerator is used for vaccine storage only 7 Refrigerator fitted with a thermometer that shows external and internal temperatures 8 Temperatures checks are performed and recorded daily 9 The temperature is between 2 o C and 8 o C Yes No N/A Comments 10 There is a validated system for maintaining the cold chain 11 Vaccines are not stored in the door or in a separate drawer at the bottom of the fridge 12 Storage of vaccines is adequate i.e. up to 50% 13 Alternative arrangements are in place in the event of breakdown or repair of the vaccine fridge 14 All vaccines are in date 15 There is a system in place for safe disposal of expired/surplus or damaged vaccines 16 Vaccine stocks are rotated and used according to date 17 Care workers have attended training which includes guideline and information on vaccine use, storage and maintenance of the cold chain Totals Comments: Total number of yes answers Potential total (Number of Yes and Nos) Percentage Status Review Date NHS Stoke on Trent Infection Prevention and Control Team

135 3.8 Decontamination of equipment Standard Statement: Decontamination of re usable medical devices is managed to ensure that the risk to service users are minimised. 1 There is a procedure /policy in place for the decontamination of medical devices 2 There is a designated lead that has overall responsibility for decontamination 3 Equipment is decontaminated between service users. 4 Deep sink designated for cleaning equipment Yes No N/A Comments 5 There is no evidence of local reprocessing of sterile items. (no bench top autoclave, hot air oven). 6 Care workers are aware of the symbol for single use 7 There is no evidence that single use items are reused. Check: cautery probes sigmoidoscopes proctoscopes vaginal speculae forceps scissors 8 If the practice contracts decontamination services the service provider complies with the Medical Devices Directive 93/42 EEC and is registered with a MHRA approved notified body 9 Transport containers for used items have a lid, are leak proof, clean and in a good state of repair 10 Inappropriate items e.g. sharps, swabs and tissue are removed before items are returned to CSSD. 11 Workflow system separates clean from dirty procedures 12 Effective segregation of clean and dirty instruments 13 Appropriate PPE is available 14 Sterile equipment/packs in date 15 Sterile packs are stored off the floor 16 Instruments are not washed prior to return to CSSD 17 Equipment is cleaned before being sent for inspection and repair and is accompanied by a declaration of contamination status form Totals Comments: Total number of yes answers NHS Stoke on Trent Infection Prevention and Control Team

136 Potential total (Number of Yes and Nos) Percentage Status Review Date 4 Clinical Practices Standard Statement: clinical practices will be based on best practice and reflect infection control guidance to reduce the risk of cross infection to service users whilst providing appropriate protection to care workers NB: This section should be undertaken over a period of time to allow for the observation of as many practice elements as possible. 4.1 Aseptic Technique 1 There is a policy/ procedure for aseptic technique 2 Hands are decontaminated prior to the procedure 3 Exposure of the susceptible site is kept to a minimum 4 Sterile/non sterile gloves are used as appropriate 5 A clean plastic apron is used for each procedure 6 Only sterile equipment comes into contact with the susceptible site 7 Sterile packs are in date and undamaged Yes No N/A Comments 8 Care workers are aware of the item for single use 9 Single use items are not reused 10 Dressing trolleys are clean and in a good state of repair Totals Comments: Total number of yes answers Potential total (Number of Yes and Nos) Percentage Status Review Date NHS Stoke on Trent Infection Prevention and Control Team

137 INFECTION CONTROL AUDIT SUMMARY FEEDBACK GP Practice: Date of Audit: Auditors: Standard audited % Score 1 Management and organisation 2 Environment and equipment 2.1 General environment and equipment 2.2 Dirty utility 2.3 Domestics room 2.4 Staff kitchen 3 Infection control practices 3.1 Hand hygiene 3.2 Personal protective equipment 3.3 Spillages 3.4 Waste disposal 3.5 Handling of sharps 3.6 Specimen handling 3.7 Vaccine Transport and Storage 3.8 Decontamination of equipment 4 Clinical practices 4.1 Aseptic procedures Level of compliance NHS Stoke on Trent Infection Prevention and Control Team

138 INFECTION PREVENTION AND CONTROL ACTION PLAN GP Practice : Date of Audit: Auditors: Criteria of non compliance Action taken Completion/review Date Managers signature Date completed. NHS Stoke on Trent Infection Prevention and Control Team

139 APPENDIX 6 Role Specification for an Infection Prevention and Control Link/Liaison Person Role profile The role of the Infection Prevention and Control Link Person (IPCLP) is to act as a resource in their organisation and to liaise with the Primary Care Trust Infection Prevention and Control Nurse (PCT IPCN) and Community Matron. They promote best practice in the prevention and control of infection by being an informed resource and role model for colleagues. They are not seen as a substitute for adequately resourced infection prevention and control service. Summary To help create and maintain an environment which will ensure the safety of the service users, care workers and others by sing infection prevention and control knowledge, communication, clinical, nursing and teaching skills. Qualifications They should be a qualified nurse at a senior level within the organisation with the authority to enable them to implement changes in practice to improve infection prevention and control. They should have completed additional training in infection prevention and control either an accredited Infection prevention and control course or training approved by the local Infection Prevention and Control Nurse Specialists/Practitioners. Responsibilities 1. To liaise between their clinical area and the PCT IPCN. 2. To be directly responsible for liaising with the PCT IPCN with regard to the working of infection prevention and control policies and procedures in their organisation. 3. To liaise with the person in charge of the organisation and the PCT IPCN with regard to the implementation of infection prevention and control policies and procedures. 4. To provide information for care workers concerning infection prevention and control related problems. 5. To assist in the education of new and existing care workers in the principles of infection prevention and control as it relates to their organisation. 6. To carry out infection prevention and control audits and feedback results to the management team and highlight any problems that need to be discussed with the PCT IPCN. NHS Stoke on Trent Infection Prevention and Control Team

140 7. To participate in the writing, reviewing, updating and auditing of infection prevention and control procedures and standards in relation to the practice. 8. To inform the PCT IPCN of any alert organisms/conditions/outbreaks to ensure appropriate infection prevention and control precautions are implemented and to ensure that there are mechanisms in place to ensure this happens in their absence. 9. To provide teaching for care workers on infection prevention and control. 10. To be knowledgeable regarding the purchase/introduction and use of equipment in their clinical area in relation to:- a) Infection prevention and control hazards; b) Care and maintenance; c) Decontamination and storage. Professional responsibilities 1 To take every opportunity to update and extend his/her knowledge of infection prevention and control. 2 To meet agreed objectives NHS Stoke on Trent Infection Prevention and Control Team

141 Infection prevention and control Link Person Objectives No. OBJECTIVE DATE ACHIEVED OR COMMENTS 1 Update infection prevention and control knowledge 2 Agree with the practice manager how infection prevention and control training and audit are to be implemented. 3 Ensure all care workers attend infection prevention and control training on appointment and annually. Document attendance and retain records. 4 Train all care workers in hand hygiene, including correct hand washing technique and appropriate use of alcohol hand rub at least annually. 5 Complete: Essential Steps self assessment Review self assessment monthly practice manager. Audit I C practice at least annually 6 Record audit scores, action any non compliance and highlight problems to practice manager and community IPCN if necessary. Discuss results with the management team. 7 All new care workers must have infection prevention and control training included in their induction programme If you need any help or advice please contact NHS Stoke on Trent Infection Prevention and Control Nurse on telephone NHS Stoke on Trent Infection Prevention and Control Team

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143 Standard Precautions Leaflet APPENDIX 7 NHS Stoke on Trent Infection Prevention and Control Team

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145 APPENDIX 8 NHS Stoke on Trent Infection Prevention and Control Team

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147 APPENDIX 9 NHS Stoke on Trent Infection Prevention and Control Team

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149 MRSA Information leaflet for Care Workers APPENDIX 10 NHS Stoke on Trent Infection Prevention and Control Team

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151 MRSA Information leaflet for Service Users and Visitors APPENDIX 11 NHS Stoke on Trent Infection Prevention and Control Team

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153 APPENDIX 12 MRSA Screening Leaflet NHS Stoke on Trent Infection Prevention and Control Team

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155 Clostridium difficile leaflet APPENDIX 13 NHS Stoke on Trent Infection Prevention and Control Team

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157 APPENDIX 14 Medicines which can produce diarrhoea Diarrhoea is a common adverse drug reaction with many medications. Antimicrobials account for about 25% of drug induced diarrhoea. (Lee 2006) Whilst diarrhoea has been seen with most medicines, the most commonly associated ones are listed below. Alternative diagnoses for the diarrhoea are important, therefore careful attention should be paid to the temporal relationship between the time that the medication was first taken and when the diarrhoea first appears. (DoH & HPA 2008). Acarbose Antimicrobials Biguanides Bile salts Colchine Cytotoxics Dipyridamole Gold preparations Iron preparations Laxatives Leflunomide Magnesium preparations, such as antacids Metoclopramide Misoprostol Non steroidal anti-inflammatory drugs, such as aspirin and ibuprofen Osalzine Proton pump inhibitors Ticlopidine NHS Stoke on Trent Infection Prevention and Control Team

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159 BRISTOL STOOL CHART APPENDIX15 NHS Stoke on Trent Infection Prevention and Control Team

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161 Escherichia coli (E coli) 0157 APPENDIX 16 What is E Coli 0157? E. coli 0157 is one of hundreds of strains of the bacterium Escherichia coli. Most strains are harmless and live in the intestines of humans and animals, but this strain produces a powerful toxin, which can cause severe illness. Escherichia coli (VTEC) is known as E. coli 0157 is found in the intestines of some cattle and other domesticated animals such as goats and also in the intestines of infected people. What are the symptoms of infection with E. coli 0157? E. coli O157 is often very mild, but some people develop diarrhoea, which can be severe and bloody, with abdominal cramps. A few cases (especially in children under 5 years of age and older people) may develop a complication called haemolytic uraemic syndrome, which is a form of kidney failure. They may need admitting to hospital for renal dialysis. How is E. coli 0157 spread? There are 3 main ways in which the infection can be spread to humans. The bacteria are present in the faeces of some farm animals and this can contaminate the carcass during slaughter. E. coli 0157 present on the surface of meat can become mixed into the meat during the mincing process. The bacteria present in faeces may also contaminate udders and milking equipment and get into the raw milk. The infection can be acquired during visits to farms and fields where farm animals live. Their micro organisms can be found in the general environment (e.g. gates, fences and soil) or contaminate salads and vegetables being grown in the vicinity. Faeces may also be picked up on shoes, clothing and fingers. Infection can develop if the bacteria are able to get into the mouth through poor hygiene or eating poorly washed salads and vegetables. The infection can be passed from person to person by direct or indirect contact with the faeces of people with E. coli 0157 infection. This may happen within families, households, care homes and nurseries where equipment and the environment may become contaminated. Ingestion of a small number of organisms can cause illness. How can the spread of E. coli 0157 be prevented? Don t eat undercooked meat products, e.g. beef burgers and minced beef. Thoroughly cook meat until the juices run clear. Drink only pasteurised milk. Wash hands before handling food, after using the toilet or changing nappies. Wash animal faeces from shoes and clothing, followed by hand washing. Follow recommended precautions for school visits to farms. In residential care, nurse in a single room with en-suite, or dedicated toilet facilities until diarrhoea has stopped for 48 hours (may need negative stools see below). When can people with E. coli 0157 infection return to work/school/playgroup? Most people must remain away until well and symptom free for 48 hours. Certain individuals in high risk groups including service users and care workers in care homes and food handlers must remain away until 2 samples of faeces, obtained at least 48 hours apart, are negative. Any household contact in a risk group will need to be tested and excluded from work or school. The Health Protection Unit will advise if this is necessary. NHS Stoke on Trent Infection Prevention and Control Team

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163 Pulmonary Tuberculosis APPENDIX 17 What is Tuberculosis? Pulmonary Tuberculosis (TB) is caused by Mycobacterium tuberculosis and Mycobacterium bovis. It usually affects the lungs, although it can occur elsewhere in the body. TB infection occurs when the bacteria are inhaled. The bacteria are usually overwhelmed by the body's immune system, but may become active again later in life. In the UK many of the elderly may develop TB following an infection earlier in life. People with TB infection generally complain of a cough lasting more than one month, chest pain, coughing up sputum that may be blood-stained, loss of appetite, weight loss, tiredness and weakness and night sweats. How is TB spread? Only people with "open" TB infection affecting the lungs are an infection risk to others. These individuals expel the bacteria into the air during coughing; and others may inhale the bacteria. Those most susceptible to infection are those who have had prolonged close contact, particularly members of the same household. In the care home setting this may include many of the other service users and care workers with whom they have close contact over a long period of time. However TB is difficult to catch and the disease develops slowly and may take several months for symptoms to appear. Many people are immune to TB especially if they have had BCG vaccination. Some people are at greater risk of developing TB including children, the elderly, diabetics, people taking steroids, people taking other drugs affecting the immune system, people living in overcrowded or poor housing, people who are dependent upon drugs or alcohol, people with chronic ill health, people with HIV infection or leukaemia. How is spread prevented? Care workers should be immunised against TB. The Health Protection Team and the TB Clinic/Health Visitor are notified of all cases of TB and ensure that contacts are identified and followed up if necessary. As TB is slow-growing, follow-up is not a matter of urgency. Service users with open pulmonary TB should keep to their own room until they have had two weeks of effective anti-tb treatment. People with multi drug-resistant TB (MDRTB) should be nursed in a negative pressure room until they are no longer infectious. This may take some weeks or months. A high-efficiency particulate filter mask (respirator) should be worn until the service user has had two weeks of anti-tuberculosis treatment. This is particularly important if the service user is coughing. People with TB should be encouraged to cough into tissues and put their hand over their mouth to prevent airborne spread and dispose of the tissues carefully, People visiting countries where TB is endemic for more than one month should be immunised. Babies born to parents from countries where TB is endemic should also be immunised, ideally at birth. NHS Stoke on Trent Infection Prevention and Control Team

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165 Chickenpox/Shingles (varicella-zoster virus) APPENDIX 18 What is it? Chickenpox is an acute, generalised viral infection, commonly affecting children. The rash tends to affect central areas of the body, e.g. the trunk more than the limbs, also the scalp, mucous membrane of the mouth and upper respiratory tract and eye may be affected. It is infectious from about 2 days before, to 5 days after, the rash appears. Shingles only occurs in people who have previously had chickenpox infection. Following chickenpox, the virus remains dormant in the body, usually in a sensory nerve root. In later months or years the virus reactivates and causes a shingles rash at the skin site supplied by the nerve. Therefore anyone with shingles must have had chickenpox in the past, even if they don't remember it. Shingles causes a rash of tiny blisters, usually affecting a clearly defined area of the body. After a few days, the blisters crust over and form scabs. The rash is not itchy but it can be very painful. The pain may start a day or so before the rash appears. It is infectious for about a week after the blisters appear or until 48 hours after the start of anti viral treatment. How are they spread? Chickenpox is spread by contact with infected respiratory droplets or fluid from the blisters. It is very infectious to people who have not have chickenpox before. Shingles cannot be spread from person to person. However, the blister fluid contains the varicella virus and therefore people who have never had chickenpox should avoid contact with cases of both chickenpox and shingles. Who is most at risk? Certain individuals have additional risks if infected, including the immuno-compromised (e.g. those receiving steroids or cytotoxic drugs), non-immune pregnant women and neonates. If they have contact with a case during the infectious phase they may need immunoglobulin. Discuss the situation with occupational health, microbiologist or GP. Non-immune care workers should be immunised against varicella. Non-immune care workers, who are exposed to the virus, should be aware of the symptoms which they may develop 8-21 days after contact with a case (28 days if immunoglobulin has been given). The risk to the foetus/neonate depends when the mother is infected. All non immune pregnant care workers who have had contact with a case will be offered immunogloblulin. How is spread prevented? People with chickenpox should stay off work for at least 5 days from the onset of the rash. People who are not immune to chickenpox should avoid contact with cases. In care homes, keep service users with chickenpox/shingles in their room for 5 days after the onset of the rash. Wear gloves if applying lotion to the rash. In residential care settings treat laundry as infected. Seek medical advice if the rash involves the eye. NHS Stoke on Trent Infection Prevention and Control Team

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167 APPENDIX 19 SCABIES What is Scabies? Scabies is a condition of the skin caused by a tiny mite called Sarcoptes scabei. Symptoms are caused by an allergic reaction to the by-products of the mite. Scabies occurs worldwide and outbreaks in the UK often occur in care homes, elderly care wards, schools and nurseries. Most cases of scabies only have around 10 mites on their body. This is known as classical scabies. Classical scabies features itching two to six weeks after a first infection or one to four days after re-infection. The itching is often severe and worse at night or after a bath. A symmetrical allergic rash appears from the axillae to the calves and around the waist, but not the upper back. In individuals with impaired immune systems they can be infected with many hundreds of mites and this is known as crusted or Norwegian scabies. The features of crusted scabies are dry, flaky lesions that may be present in many areas of the body. The lesions can flake off and because they contain hundreds of mites, it is very infectious. How is scabies spread? To transmit classical scabies direct, prolonged skin-to-skin contact is required. Holding hands is a common route. Bedding and clothing does not contain scabies mite unless the individual has crusted scabies. How is spread prevented? Be aware of the symptoms of scabies and watch out for cases. Treat all cases and their contacts, ideally on the same day. Apply lotion to cool, dry skin including under nails and in skin creases. Leave lotion on skin for 8-24 hours. Re-apply to areas of skin that subsequently become wet e.g. after washing hands or incontinence etc. Itching can persist for several weeks after treatment. Wear gloves for contact with a case until treated. Wash hands and skin after contact. Crusted/Norwegian Scabies For crusted scabies more intensive treatment is required, handle bedding etc with gloves, and place in plastic bag until laundered. Tumble-drying kills the mites. Spread to others is very common. NHS Stoke on Trent Infection Prevention and Control Team

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169 NOROVIRUS LEAFLET APPENDIX 20 NHS Stoke on Trent Infection Prevention and Control Team

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171 APPENDIX 21 ACTION IN THE EVENT OF INOCULATION/CONTAMINATION INJURY WHEN BLOOD FROM A SERVICE USER MAY GET INTO YOUR BLOOD STREAM VIA THE SKIN, EYES & MOUTH Needle stick injury Blood/body fluid splash Bleed it Wash it Wash with copious amounts of water Do you know the source? Yes No Perform risk assessment of source on service user. Using risk assessment check list in APPENDIX 22 Consider HIV Consider Hep B Consider other blood borne pathogens: e.g. Hepatitis C Meningitis Malaria CJD Have you been shown to be immune to Hep B in the last 5 years? Source +ve Contact Medical Microbiologis t immediately Source -ve Source status unknown Do risk assessment (see Appendix 22) Consent to test the source for HIV/HBV/HCV should be sought by the GP or the person in charge not the care worker who had the exposure incident Report as an adverse incident & report to Occupational Health Yes Report to occupational Health No Report as an adverse incident and report to Occupational Health Mon Friday Or contact Microbiologist on call Weekends and bank holidays between and Report as an adverse incident & report to Occupational Health Mon Friday NHS Stoke on Trent Infection Prevention and Control Team

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173 SHARPS INOCULATION INJURY CHECKLIST CONFIDENTIAL APPENDIX 22 RISK ASSESSMENT CHECKLIST The manager or person in charge must complete this checklist WITH THE INJURED PERSON following a needle stick injury, human bite or scratch or body fluid splash to the eyes, mouth or broken skin. When completed, the injured person should take the checklist to their Occupational Health Advisor Member of Staff injured: Dept: DOB: Details necessary to assess the risk of HIV exposure. 1. Is the identity of the source person known? Yes No Source persons name: DOB: Unit No/NHS No: 2. Has the source ever been tested positive for HIV? Yes No 3. Does the source know that they are HIV positive? Yes No 4. Has the source had sexual contact or shared needles etc. with anyone known to be HIV positive? Yes No 5. Is there any other reason to suspect that the source may pose significant risk of HIV infection? Yes No 6. Consent obtained for blood sample from source to be tested for Hep B, Hep C and HIV necessary Yes No 7. If YES to questions 2,3,4 or 5, or you suspect an increased risk of HIV in the source THE CONSULTANT MICROBIOLOGIST SHOULD BE CONTACTED IMMEDIATELY AND THE INJURED CARE WORKER SHOULD ATTEND THE ACCIDENT AND EMERGENCY DEPARTMENT AT THE UNIVERSITY HOSPITAL OF NORTH STAFFORDSHIRE. 8. If no to questions 2, 3, 4, AND 5, there is no need to contact the Consultant Microbiologist, but you can contact them during normal hours to report the incident or if any concerns about the exposure incident remains. 9. Take this completed form to the Occupational Health Advisor. 10. Complete an Incident report NHS Stoke on Trent Infection Prevention and Control Team

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175 IMPORTANT MESSAGE TO ALL STAFF APPENDIX 23 Action to be taken following a needle stick or sharps injury, human bite or scratch or body fluid splash to the eyes, mouth or broken skin. Step 1 Step 2 First Aid Stop what you are doing Encourage wound to bleed. Do NOT suck. Wash with soap and running water. Dry and apply water proof dressing. Use lots of water to wash away a body fluid splash to the eyes, mouth or broken skin. Report Incident to: Line manager and the person in charge of the area in which you are working. Complete the appropriate adverse incident/accident form. Report the incident to the Occupational Health Advisor It is not necessary for you to attend A & E unless your injury requires treatment e.g. suturing Step 3 Assess Infection Risk: The manager or person in charge of the area in which you are working should carry out a risk assessment at the time of the incident A: Used/dirty sharp, human bite/scratch or body fluid splash to eyes, mouth or broken skin from a patient known or strongly suspected to be HIV positive. Seek IMMEDIATE professional advice from:- The Accident and Emergency Department at the University Hospital of North Staffordshire. B: Used/dirty sharp, human bite/scratch or body fluid splash to eyes, mouth or broken skin, and your Occupational Health Advisor within 24 hours. C: Unused/clean sharp = No risk of infection. Complete an adverse incident form and report incident following local protocol NHS Stoke on Trent Infection Prevention and Control Team

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177 PROCEDURE FOR A SHARPS FIND APPENDIX 24 If you find discarded sharps on your premises follow the procedure below. THE SHARPS FIND KIT FOR.IS LOCATED AT/IN. NEVER ATTEMPT TO PICK UP SHARPS BY HAND Needle sheathed for demonstration Purpose If you cannot deal with the problem immediately make the area safe by alerting others to the hazard. Ensure you have the correct equipment available. 1 x Household gloves (marigold type) 1 x Approved sharps container; correctly assembled 1 x Helping hand (litter picker) Alternatively long handled dust pan and brush + Procedure for Sharps Find. Wearing the household gloves and using the helping hands remove the sharps and transfer them to the sharps container. Turn the aperture into the closed position (SAFE POSITION). Please do not lock the container as the contents may be required for investigation purposes. Label the container with the location of the find date and time. Secure the container and return it to a safe location.. NHS Stoke on Trent Infection Prevention and Control Team

178 ENSURE IT IS STORED SAFELY AND OUT OF REACH OF THE GENERAL PUBLIC. Return your clean up kit to a location known to all care workers. Inform your Health & Safety Department through the usual reporting system. In the event of an inoculation injury of an employee/ contractor apply First Aid Encourage bleeding under running water Wash the wound with warm soapy water Cover with waterproof plaster Report the incident following your usual procedure If a member of the public/contractor receives an inoculation injury on your premises apply First Aid and Refer to the Procedure for Sharps Injury as above. Refer to Accident & Emergency as soon as possible. HIGH RISK INJURIES! If the is suspected or known to be contaminated from a HIV positive source complete the FIRST AID procedure and Risk Assessment Check List as detailed above. THEN only if level of risk identified is high the injured person should visit the Accident and Emergency Department at the University Hospital of North Staffordshire immediately. If the sharps find is outside the boundary of your premises contact Environmental Health: Stoke (City) NHS Stoke on Trent Infection Prevention and Control Team

179 ASEPTIC TECHNIQUE APPENDIX 25 NHS Stoke on Trent Infection Prevention and Control Team

180 NHS Stoke on Trent Infection Prevention and Control Team

181 ANTIMICROBIAL PRESCRIBING GUIDELINES APPENDIX 26 NHS Stoke on Trent Infection Prevention and Control Team

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183 APPENDIX 27 NATIONAL PATIENT SAFETY AGENCY COLOUR CODING All cleaning materials and equipment, for example, cloths (re-usable and disposable), mops, buckets, aprons and gloves should be colour coded. NHS Stoke on Trent Infection Prevention and Control Team