Stoke on Trent Supporting Local Care Homes INFECTION PREVENTION AND CONTROL GUIDELINES FOR CARE HOMES

Transcription

1 Stoke on Trent Supporting Local Care Homes INFECTION PREVENTION AND CONTROL GUIDELINES FOR CARE HOMES Date Issued: March 2010 Review Date: March 2012

2 NHS Stoke on Trent/Infection Prevention and Control Team March

3 INFECTION PREVENTION AND CONTROL GUIDELINES FOR CARE HOMES CONTENTS PAGE 1. INTRODUCTION The Health and Social Care Act 2008 and Code of Practice Definitions 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) ISOLATION OF SERVICE USERS WITH AN INFECTION 26 (TRANSMISSION BASED PRECAUTIONS) 6.1 Service user placement/isolation facilities Meticillin Resistant Staphylococcus Aureus (MRSA) Clostridium difficile Extended spectrum beta lactamase producers (ESBLs,) 34 Glycopeptide resistant enterococci (GRE) and other resistant micro organisms 6.5 Food poisoning 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 Notifiable Diseases PREVENTION OF OCCUPATIONAL EXPOSURE TO INFECTIONS Blood borne viruses and sharps Other immunisations Protection against tuberculosis ASEPTIC TECHNIQUE What is an aseptic technique? Principles of asepsis Procedure 50 NHS Stoke on Trent/Infection Prevention and Control Team March

4 CONTENTS PAGE 11. MANAGEMENT OF INVASIVE DEVICES Urinary catheters Percutaneous Endoscopic Gastrostomies (P.E.Gs) Tracheostomies Infusion devices Education of service users, care workers and informal carers WOUND CARE SPECIMEN COLLECTION CLEANING THE ENVIRONMENT General Floors and other hard surfaces Curtains and soft furnishings Pillows, duvets and mattresses Cleaning equipment and materials Colour coding Cleaning schedules Management of body fluid spillage Deep cleaning Cleaning of isolation rooms 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 Home loan equipment LAUNDRY Handling used linen Segregation of linen Laundry facilities in residential settings Laundry design Equipment During outbreaks Storage of linen Care workers uniforms Ozone systems WASTE DISPOSAL Legislation Waste categories Storage of clinical waste Disposal of sharps FOOD HYGIENE Legislation Training Hazard analysis 81 NHS Stoke on Trent/Infection Prevention and Control Team March

5 CONTENTS PAGE 18.4 Record keeping Infectious diseases in kitchen staff and care workers Hand hygiene Protective clothing High risk foods Gifts of food Storage of food Food preparation Drinking water, water coolers and ice making machines General kitchen hygiene LEGIONELLA Control measures Spa/hydrotherapy pools PEST CONTROL PETS Infection prevention and control measures Litter box care ADMISSION, DISCHARGE AND TRANSFER OF SERVICE USERS IMMUNISATION OF SERVICE USERS Influenza Pneumococcus ANTIMICROBIAL PRESCRIBING LAST OFFICES Reporting deaths Handling the deceased person Body bags UNIFORMS AND WORK WEAR OCCUPATIONAL HEALTH Occupational health advice Exclusion from work Inoculation/needle stick injuries NEW BUILD, REFURBISHMENT AND SERVICE DEVELOPMENT INFECTION PREVENTION AND CONTROL TRAINING BIBLIOGRAPHY 93 NHS Stoke on Trent/Infection Prevention and Control Team March

6 APPENDICES PAGE Appendix 1 Checklist for Health and Social Care Act Appendix 2 Policy template 121 Appendix 3 Statements for job descriptions 123 Appendix 4 Infection Control Audit Tools 125 Appendix 5 Role profile and objectives for a an Infection Control Link Person 147 Appendix 6 Standard precautions information leaflet 151 Appendix 7 5 Moments for hand hygiene 153 Appendix 8 Six stage hand washing technique 155 Appendix 9 MRSA information leaflet for care workers 157 Appendix 10 MRSA leaflet for service users and visitors 159 Appendix 11 MRSA screening leaflet 161 Appendix 12 Clostridium difficile information leaflet 163 Appendix 13 Medicines which can produce diarrhoea 165 Appendix 14 Bristol Stool Chart 167 Appendix 15 E. Coli Appendix 16 Pulmonary TB 171 Appendix 17 Chickenpox and Shingles 173 Appendix 18 Scabies 175 Appendix 19 Norovirus - Diarrhoea and vomiting leaflet 177 Appendix 20 Checklist for norovirus outbreak 179 Appendix 21 Infection records 181 Appendix 22 Flowchart- Action to take following a sharps/inoculation injury 183 Appendix 23 Checklist to assess risk following a sharps/inoculation injury 185 Appendix 24 Sharps poster 187 Appendix 25 Action to take following sharps find 189 Appendix 26 Aseptic technique poster 191 Appendix 27 National Patient Safety Agency Colour Coding 193 Appendix 28 Example of a cleaning schedule 195 Appendix 29 Discharge/Transfer form 197 NHS Stoke on Trent/Infection Prevention and Control Team March

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 visitors. These guidelines provide information that will support care homes to put in place all reasonable infection prevention and control measures that are required to protect service users from infection and enable care homes to meet the requirements of the Health and Social Care Act This document should be read alongside The Health and Social Care Act, Code of practice for health and adult social care on the prevention and control of infections and related guidance which can be accessed at 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 and is used by the Care Quality Commission to assess compliance with the registration requirements on cleanliness and infection prevention and control. Independent health and adult social care will be brought into registration under the Health and Social Care Act 2008 from October 2010 and the Code has been revised to cover all adult health and social care providers. The Code of Practice and related guidance sets out how the Care Quality Commission (CQC) 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. A check list to help care homes check their progress against these requirements can be found in Appendix 1. 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 in consultation with local care home managers. These guidelines will support providers of adult health and social care to meet the requirements of the Code. By following these guidelines providers of adult health and social care in the independent and voluntary sector 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 which were published by the Department of Health in 2006 and 2007 and which are available from the Department of Health website NHS Stoke on Trent/Infection Prevention and Control Team March

8 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. 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 actions to be taken in the event of an incident such as a needlestick or inoculation injury. This will also be underpinned by training in infection prevention and control. 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 in the care home setting. Managers have a responsibility to ensure all the elements of an infection prevention and control programme are in place in their own organisation. 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 written infection prevention and control policy (see Appendix 2 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 3) and be included in personal development plans. The Health and Social Care Act requires all registered providers of adult health and social care to have infection prevention and control programmes and infrastructures in place. The programme should include what: Infection prevention and control measures needed in the service; Policies, procedures and guidance are needed and how they will be kept up to date and how compliance is monitored; Initial and ongoing training care workers will receive. The infrastructure should: Be a record of the names and contact details of sources of infection prevention and control advice; Include guidance for care workers about the circumstances in which contact should be made. Registered providers will need to report an annual statement/report which provides a review of: Any outbreaks of infection and the action taken following these; Audits undertaken; Risk assessments undertaken for prevention and control of infection; Training received by care workers; NHS Stoke on Trent/Infection Prevention and Control Team March

9 Review and update of policies, procedures and guidance. In care settings a programme of audit (see audit tool in Appendix 4) of infection prevention and control practice and surveillance of infection should also be identified in the Annual Infection Prevention and Control Programme. In case of difficulty or problem not covered by these guidelines please contact those listed under Local Sources of Advice in Section Definitions used in the Health Act 2008 Adult Social Care Social care includes all forms of personal care and other practical assistance provided for individuals who, due to age, illness, disability, pregnancy, childbirth, dependence on alcohol or drugs or any other similar circumstances, are in need of such care or assistance (Refer to section 9 of the Act). For the purposes of the CQC, it only includes care provided for, or mainly for, adults in England. Alert organism surveillance Alert organism surveillance is used widely to detect and prevent outbreaks of infection. These organisms are reported to infection prevention and control teams on a regular basis to identify possible outbreaks of infections and serious infections. The organisms that are surveyed will depend on the local epidemiology of infection. Examples of alert organisms may include Meticillin Resistant Staphylococcus aureus (MRSA), Clostridium difficile and other antibiotic resistant organisms. Antimicrobials Antimicrobials are substances which are used in the treatment of infections caused by bacteria and viruses. Aseptic technique This describes the clinical procedures that have been developed to prevent contamination of wounds and other susceptible body sites. Assurance framework A system for informing third parties that a process of due diligence is in place to assure safety and quality exists in that setting. Audit Audit is a quality improvement process that aims to improve service user care and outcomes by carrying out a systematic review and implementing change. These are not necessarily complex and in their simplest form show compliance with a single protocol. Their value is in showing improvement or maintenance of a high standard. Blood borne viruses (BBVs) Organisms such as hepatitis B, hepatitis C and HIV that are potentially transmissible in the occupational setting via percutaneous (sharp) or mucocutaneous (mucous membrane/broken skin) routes. Care worker Any person whose normal duties concern the provision of treatment, accommodation or related services to service users and who has access to service users in the normal NHS Stoke on Trent/Infection Prevention and Control Team March

10 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 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. 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. 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. NHS Stoke on Trent/Infection Prevention and Control Team March

11 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. 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. NHS Stoke on Trent/Infection Prevention and Control Team March

12 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. Traceability In respect of medical devices, primarily surgical instruments traceability relates to instrument sets, as distinct from individual instruments, being tracked through use and NHS Stoke on Trent/Infection Prevention and Control Team March

13 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). 1.3 Roles and responsibilities The Owner (registered provider) The owner of a care home is responsible under health and safety legislation for maintaining an environment which is safe for service users, visitors and care workers alike. Suitable arrangements and procedures for prevention and control of infection would form part of the health and safety requirements The Manager (registered manager) The manager should have access to advice on infection prevention and control from a suitably qualified and competent individual. It is expected that the registered manager will produce an annual report/statement on the systems in place for the prevention and control of infection and how these are monitored. The registered manager should ensure that appropriate infection prevention and control policies and procedures exist, are readily available, understood by all members of staff and are used within the home. The registered manager should ensure that all care workers have received infection prevention and control training appropriate to their role and that training records are kept. The registered manager is responsible for designating an Infection Prevention and Control Lead for the organisation 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 IPC lead in adult social 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 NHS Stoke on Trent/Infection Prevention and Control Team March

14 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 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. The HPUs role is to monitor and investigate outbreaks of infection and give advice on the control and prevention of outbreaks in the care home. The HPU will decide if an outbreak is ongoing in the home and will initiate and co-ordinate any necessary action to limit further spread. They will advise the provider/manager of any immediate action necessary for infection prevention and control. This may require the identification of those at higher risk and separating those who have symptoms from those who do not. If the disease is primarily food-borne, the local authority Environmental Health Practitioner (EHP) may lead the investigation with the support of the HPU However, although HPUs will wish care homes to have appropriate infection prevention and control arrangements in place and will provide support in outbreak situations, they are not responsible for providing an infection prevention and control service directly to care homes Consultants in Communicable Disease Control (CCDC) and/or Consultants in Health Protection (CHP) The CCDC and the CHPs are employed by the HPA. 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 to care homes and others in the community when outbreaks and other incidents occur. The local HPU is to be informed of any suspected outbreak of infection in a care home 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 care homes by the CIPCN will be dependant 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 Infection Prevention and Control Doctor, who is usually a consultant microbiologist, and Infection Prevention and Control Nurses. NHS Stoke on Trent/Infection Prevention and Control Team March

15 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 8.2 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 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 co-ordinate 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 care home, ward etc 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 Informal carers look after their partners, spouses, relatives, friends, and neighbours on an informal basis. They often have no formal training in care, but need to be informed and trained about any care procedures they will undertake, such as managing a urinary catheter Care workers All care workers have a responsibility to follow the infection prevention and control guidance of the organisation they work for and to work in such a way that the infection risk to service users, themselves and others is minimised. They have a responsibility to keep up to date and attend infection prevention and control training. NHS Stoke on Trent/Infection Prevention and Control Team March

16 2. LOCAL SOURCES OF ADVICE NHS Stoke on Trent Kim Gunn/ Anne Gething/ Carol Lawton Head of Infection Prevention and Control Infection Prevention and Control Specialist Nurses NHS Stoke on Trent London House 4 th Floor Hide Street Stoke-on-Trent ST4 1NF Tel: Mobile (Kim): Mobile (Anne): Mobile (Carol): 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 March

17 3. WHY INFECTION PREVENTION AND CONTROL IS IMPORTANT Many infections have the potential to spread in the care home setting where service users share eating and living accommodation and are cared for by the same group of care workers. Infections acquired in care homes may have serious consequences for service users, they may worsen underlying medical conditions and in some instances may be life threatening. Service users in care homes may have an increased susceptibility to infection due to the following risk factors: Age; Immune status; Poor nutrition; Underlying medical conditions such as cancer, diabetes, heart problems; Antibiotic therapy; Incontinence; Indwelling medical devices such as urinary catheters or gastric feeding tubes; Breaks in the skin. Infection prevention and control has also become more of a challenge to all care providers due to complexity of care and the increasing numbers of organisms that have become resistant to treatment with antibiotics. Resistant organisms that have increased in recent years include meticillin resistant Staphylococcus aureus (MRSA) and Extended Spectrum Beta Lactamase producers (ESBLs). 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 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. NHS Stoke on Trent/Infection Prevention and Control Team March

18 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 be 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 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. 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; NHS Stoke on Trent/Infection Prevention and Control Team March

19 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 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. Table 1 The Chain of Infection Link 6 Person at risk Link 1 Source Link 2 Reservoir Link 5 Way into the body Link 4 Method of spread Link 3 Way out of the body 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 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 and 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 is an efficient waterproof barrier; therefore everyone should look after their skin NHS Stoke on Trent/Infection Prevention and Control Team March

20 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 may be the treatment room, bed, chair, 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, including the hand wash basin in the service user s room. A lack of appropriate facilities should be brought to the attention of the manager and the home owner. Ideally, wash basins used by care workers for clinical procedures should be designated as such and have mixer taps that are wrist, elbow or foot operated and they should not be used for any other purpose. NHS Stoke on Trent/Infection Prevention and Control Team March

21 In situations where it is not appropriate to have paper towels and liquid soap in the service user s room (in a domestic type of care setting) 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 which 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 home 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 in order 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. Alcohol hand rubs Alcohol hand rubs should be available for use at the point of care. Alcohol hand rubs are useful in many situations when caring for people in the community especially for domiciliary care and are recommended for use to compliment hand washing with soap and water when appropriate. Alcohol hand rubs also 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 8) until the hands are dry. After using on a maximum of five consecutive occasions hands should be washed with soap and water in order 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. 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 washing procedure 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 8). Rinsing under warm clean running water. NHS Stoke on Trent/Infection Prevention and Control Team March

22 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 8). The solution must come into contact with all surfaces of the hand. 3. Rinse hands under running water, holding the hands down. 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 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. 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; NHS Stoke on Trent/Infection Prevention and Control Team March

23 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. Service users, particularly the immobile, confused, older person may need assistance with the disposal of used tissues and hand hygiene Involving service users and carers Service users must be offered the opportunity to wash their hands before eating, at meal times and after using the toilet, commode or bedpan. Service users, relatives and carers should be: Educated on the importance of hand hygiene and encouraged to adopt the recommended six stage technique. (Appendix 8). Sure that care workers have decontaminated their hands prior to contact with the service user and are encouraged to report breaches in hand hygiene to the care manager. Advised to wash their hands prior to and after visiting especially when the service user is isolated due to a suspected or identified infection. Please ensure that service users, relatives or carers are provided with information, advice and a demonstration of the correct six stage hand hygiene technique. (Appendix 8) 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. 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 NHS Stoke on Trent/Infection Prevention and Control Team March

24 performed gives rise to any possibility of contact or contamination with blood or other body fluids. If the answer is yes, then appropriate protective clothing is necessary Gloves The need for gloves and the selection of appropriate ones must be based on a careful risk assessment. 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 Table shows selection of appropriate gloves: Table 2 Selection of appropriate gloves Procedure to be performed Suitable gloves 1. Invasive procedures which involve breaking the skin involving contact with blood or body fluids, e.g. surgery, for which high levels of protection for the service user and care worker are required. 2. Non-invasive procedures involving exposure to blood or body fluids, or exposure to excreta, such as urine, faeces, vomit, and where there is little likelihood of exposure to hazardous or corrosive substances. 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. 3. General cleaning procedures 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. 4. Handling chemicals, or other hazardous substances. 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. 5. Food handling Polythene if necessary NHS Stoke on Trent/Infection Prevention and Control Team March

25 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. 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 17 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 personal care and clinical procedures, and green ones for handling food and assisting service users with feeding. Another colour can be worn for domestic 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 care home setting. One possible exception to this is the use of masks during a flu pandemic. NHS Stoke on Trent/Infection Prevention and Control Team March

26 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 6.1 Service user placement/isolation facilities This is about ensuring that individual service users with specific infections are placed appropriately in single rooms, ideally with their own toilet facilities. This is not usually an issue in care homes because the vast majority of rooms are for single occupancy. However, there are a few double rooms remaining in use, and there may be occasions when care workers are unsure about whether someone with an infection can share a room. In these circumstances, please phone and discuss the situation with 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 NHS Stoke on Trent/Infection Prevention and Control Team March

27 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. 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. NHS Stoke on Trent/Infection Prevention and Control Team March

28 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. They may share a room as long as neither they nor the person with whom they are sharing has open sores or wounds, catheters or other invasive devices. They may receive visitors and go out of the home, for example to see their friends or family. They may join other service users in communal areas such as sitting or dining rooms, so long as any sores or wounds are 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) 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 Other precautions 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 user s own room. Seek advice from the CIPCN if the service user has a postoperative wound, productive cough, urinary catheter, PEG or other invasive device. Isolation of the service user in their room is not generally recommended or required and may have detrimental effects upon the mental and physical condition of the individual 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 care worker if the service user is to attend the Outpatient Department. 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. 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 NHS Stoke on Trent/Infection Prevention and Control Team March

29 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. Service users in the care home should only be screened on the advice of the Health Protection Team or the CIPCN. Care worker screening should never be undertaken except on the advice of the Health Protection Team 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 inform the service user s GP 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 NHS Stoke on Trent/Infection Prevention and Control Team March

30 6.3 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 14) or stool which takes on the shape of its container, for which no other explanation can be given; 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 14), or stool which takes on the shape of its container, and which cannot be attributed to any other cause Other causes should include dietary NHS Stoke on Trent/Infection Prevention and Control Team March

31 considerations, any medications which may alter bowel habit, (see Appendix 13), 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 Table 3 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 and consult with the GP 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. Always isolate symptomatic service users with C difficile associated diarrhoea. 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 8), alcohol alone is not sufficient. NHS Stoke on Trent/Infection Prevention and Control Team March

32 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 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. 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. The service user s GP will review any antibiotics that the service user is taking. 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 NHS Stoke on Trent/Infection Prevention and Control Team March

33 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 with diarrhoea should be isolated in their own room 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. 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 12 NHS Stoke on Trent/Infection Prevention and Control Team March

34 6.4 Extended spectrum beta lactamase producers (ESBLs), Glycopeptide resistant enterococci (GRE) and other resistant/ multi resistant micro organisms Over recent years there has been an increase in the number of micro organisms that are becoming resistant to antibiotics. These include extended spectrum beta lactamase producers (ESBLs) and Glycopeptide resistant enterococci (GRE). Glycopeptides are a group of antibiotics which include vancomycin and tiecoplanin. Although these micro organisms have the ability to cause infection most service users identified with them will be colonised rather than infected and will not require treatment. The infection prevention and control measures are similar to those for MRSA 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 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, 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 NHS Stoke on Trent/Infection Prevention and Control Team March

35 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 Who is at risk of acquiring resistant micro organisms? Frail service users in hospital or care homes particularly those with long term indwelling devices such as a urinary catheter are most at risk. The device may become colonised with bacteria creating a potential reservoir for infection. The following factors further increase the risk :- Old age; Multiple courses of antibiotics; Prolonged hospital stays or intensive care admissions; Prolonged illness or complex medical conditions e.g. renal dialysis service users; Those in long term residential care. 6.4,6 Are care workers at risk of acquiring resistant micro organisms? Care workers may pick up these micro organisms on their hands and clothing when caring for a colonised or infected service user. By following standard precautions the risk of care workers becoming colonised is minimised and these micro organisms are readily removed by hand washing and laundering. Healthy people are not at risk from these micro organisms 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? 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). NHS Stoke on Trent/Infection Prevention and Control Team March

36 6.5 Food Poisoning and other Diarrhoeal infections. 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 11) 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 How can food poisoning be prevented? Prevention of infection involves good standards of food, hand and environmental hygiene. Wash hands after before and after each episode of care. Wash hands before preparing, handling or serving food. Ensure the service users can wash their hands after using the toilet and before meals. Keep symptomatic service users in their room with their own toilet / commode until free of symptoms for 48 hours. Care workers with symptoms should stay off work until symptom free for 48 hours. A few infections require infected care workers to have microbiological clearance before returning to work. The Health Protection Team or Environmental Health Officers will inform you if this is necessary. Impeccable hygiene standards are very important. Clean and disinfect spills of diarrhoea and vomit. A chlorine-releasing disinfectant (e.g. bleach, sodium hypochlorite, NaDCC) can help to kill the micro organisms. Remove any open fruit, sweets or food which may be exposed to the organism Suspect an outbreak of gastrointestinal disease if two or more people at the home have diarrhoea and or vomiting at the same time, or if anyone is found to NHS Stoke on Trent/Infection Prevention and Control Team March

37 have salmonella etc. Inform the Care Quality Commission, Environmental Health Officers and Health Protection Unit. The HPA team will assess the situation and decide whether the outbreak is likely to be due to a food source or viral infection. If a food source is implicated the Environmental Health Department will be informed Send faecal samples from cases to the laboratory for Microscopy, Culture & Sensitivity and for Virology. 6.6 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. 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 where individuals live in a shared environment. The good news is that careful hand hygiene and environmental cleaning can easily deactivate the virus. NHS Stoke on Trent/Infection Prevention and Control Team March

38 6.6.4 How can influenza be prevented? Each year a new influenza vaccine is developed which provides immunity against the strains of influenza circulating that year. Every autumn the vaccine is offered to anyone aged over 65 years, people with a high-risk condition and their carers, people residing in care homes and front-line health and social care staff. Antiviral drugs can be offered to at-risk groups when influenza is circulating in the community. Health and social care teams should report any suspected cases in their care to the GP and any clusters to the Health Protection Team 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 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 have been offered swine flu vaccine. NHS Stoke on Trent/Infection Prevention and Control Team March

39 6.7.8 What can be done to prepare? As a provider of community care, it is important that you start now to prepare a robust plan to ensure the continuity of your business 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 and care workers should be encouraged to have the vaccine. This should minimise the impact of the pandemic on the service provision within the care home. The nature of a care home is such that an infection like flu can spread very quickly to many of the service users and care workers, so your plan should take into account the fact that more people will need more care than is usual. This 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. Try to work out now how you will cope with this situation. Identify which aspects of your 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? How many relatives and other volunteers might be able to come in and help? It will help if you start to put your plans down on paper, and look at what training and preparation will be necessary. Other very practical issues: 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 now the person in your home who should start writing your plan. If you are part of a larger organisation work on this may already have started, but you will still need to work out how to plan at a local level. A wealth of guidance has been published nationally and regionally and is updated regularly is available at: 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). NHS Stoke on Trent/Infection Prevention and Control Team March

40 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. 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. 6.8 Other infections Information on other infections that may occur in care homes and which may result in outbreaks/incidents are found in Appendices E Coli 0157 Pulmonary TB Chickenpox/shingles Scabies NHS Stoke on Trent/Infection Prevention and Control Team March

41 7. OUTBREAKS 7.1 General In the care home setting service users or care workers may become ill with an infectious disease and these can spread more readily because individuals work, live and eat together in a shared environment. When a service user develops a communicable infection extra care may need to be taken to prevent spread to other service users and care workers and to reduce the risk of outbreaks of infection 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. It is the responsibility of the person in charge of the home to ensure that all care workers are aware of prevention and control of infection guidelines, and that these are followed by all care workers at all times What is an outbreak? An outbreak is defined as two or more cases amongst service users and care workers of the same infection occurring in the care home within a short space of time. Senior care workers 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 service users or care workers is sufficient. Seek advice promptly rather than worrying about false alarms Action to take if an outbreak is suspected As soon as an outbreak is suspected the manager should inform the service users general practitioner, the Health Protection Team and the Care Quality Commission. The Health Protection Team will advise on any action that needs to be taken to manage the outbreak and prevent further spread. 7.2 Suspected food poisoning If it is suspected that the outbreak may be a result of food poisoning the person in charge must inform the Health Protection Unit, the Environmental Health Department and the Care Quality Commission immediately. 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 borne. 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 service users /care workers. Vomiting in two or more service users/care workers. 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 March

42 7.3 Closure of premises In the event of an outbreak of any gastro-enteritis or food poisoning it is advisable to stop admissions, day care and transfers to other homes or hospitals. The Health Protection Unit will also advise on criteria for restarting admissions, transfers and discharges. 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. In order to identify outbreaks at the earliest opportunity bowel movements should be recorded using the Bristol Stool Chart (Appendix 14) and specimens sent if the service user has diarrhoea that is not attributable to any known cause. e.g. aperients, P.E.G feed, other medications). 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. If service users become dehydrated the senior care worker should contact the community matron who may be able to provide support and advice to rehydrate the service user and prevent unnecessary admission to hospital thereby reducing the risk of further spread Symptoms of norovirus infection Vomiting, which may be projectile; Nausea; Diarrhoea; Headache; Fever; 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. NHS Stoke on Trent/Infection Prevention and Control Team March

43 7.5.2 Actions to take Contact Health Protection Team, the Care Quality Commission and inform the CIPCN. Keep a record of all cases and Fax or telephone daily updates to Health Protection Team on Ensure that standard infection prevention and control precautions are being followed at all times Cleaning during an outbreak Wear disposable gloves and aprons. Clean more frequently, every 2-4 hours paying particular attention to touch points e. g door handles. After cleaning, surfaces and equipment should be disinfected with a chlorine releasing disinfectant 1000 parts per million. (Milton diluted 1:10 or household bleach diluted according to manufacturer s instructions). Ensure any disinfecting agent being used is appropriate and being used at the correct dilution. Keep separate disposable cloths, mops etc for the infected area. Keep all equipment scrupulously clean. Discard gloves and aprons after use. Clean toilet and tap handles more frequently (i.e., every 2-4 hours). Seek advice from the Health Protection Nurse Specialist regarding what terminal cleaning may be necessary. A checklist for the actions to take during an outbreak of norovirus and an information leaflet for service users and visitors are found in Appendices 19 and SURVEILLANCE AND DATA COLLECTION 8.1 Infection Records Although there is no statutory requirement for care homes to keep infection records it is good practice to keep a logbook or spreadsheet (Appendix 21) with the following information on service users with suspected and confirmed infections. Name, date of birth and sex of service user Name of GP Date of admission Date of onset of symptoms Type of symptoms Details of samples sent to laboratory and results, if known Diagnosis Source of infection if known Outcome Whether the case was reported to the Health Protection Unit and date of notification/reporting Similar information should be kept for infected care workers. This information should be included in the annual report/statement of the Infection Prevention and Control Lead for the organisation or the care home. NHS Stoke on Trent/Infection Prevention and Control Team March

44 8.2 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. In residential settings the person in charge should also report such cases as soon as they occur to 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 Paratyphoid fever 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 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: NHS Stoke on Trent/Infection Prevention and Control Team March

45 AIDS Legionnaires Disease Listeriosis Psittacosis CJD 9. PREVENTION OF OCCUPATIONAL EXPOSURE All care homes 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 and sharps Blood borne viruses In NHS settings, sharps injuries are one of the most common types of injury to be reported to occupational health departments. The appropriate 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. In theory there is a risk of a blood borne infection being transmitted either from a care worker to a service user or from a service user to a care worker. In practice, care workers in the care home setting are unlikely to be undertaking procedures that present a risk to service users What are sharps? Sharps include items such as needles, blood glucose lancets, ampoules, used razor blades and disposable razors that may be contaminated with blood or other body fluids 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. 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. NHS Stoke on Trent/Infection Prevention and Control Team March

46 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 Sharps/Inoculation injuries A sharps/inoculation injury is when someone s blood or body fluid gains access to another persons blood or tissue. This may be caused by:- A cut or puncture of the skin by a contaminated sharp; Contamination of a care worker s broken skin by a service user s blood or body fluid; Bites which break the skin. Body fluids splashed into the eye or mouth may also transmit infection. Remember all sharps injuries are potentially preventable Assessing the risk Unused/clean sharp definitely no risk of infection, (except from the micro organisms on your own skin). Record incident, but no further action. 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 Health Protection Unit, or Accident and Emergency Department at the University Hospital of North Staffordshire. This should be within one hour of NHS Stoke on Trent/Infection Prevention and Control Team March

47 the incident having taken place. Out of hours the injured care worker must attend the A and E Department. Used/dirty sharp from a person known or strongly suspected to be HIV positive. During normal working hours contact the Health Protection Unit immediately. If the incident occurs out of hours the injured care worker must attend the A and E Department at the local hospital immediately. 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. This means that 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 23. Record the incident following the usual procedure. A poster and flow chart summarising the action to take in the event of a sharps find and sharps or splash injury 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 23) 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 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. NHS Stoke on Trent/Infection Prevention and Control Team March

48 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 a known, or suspected to be, hepatitis B positive, occupational health or the 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. 9.2 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. 9.3 Protection against tuberculosis Care workers history of TB and or BCG vaccination should be checked at pre employment. Please contact the Health Protection Team 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 16. NHS Stoke on Trent/Infection Prevention and Control Team March

49 10. 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 procedures as undertaking a wound dressings or performing an invasive procedure such as inserting a urinary catheter. 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 and 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. Invasive procedures - hand disinfection using skin disinfectant such as alcohol gel; 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 skin and clothing; Protect the care worker from micro organisms on the service user s body. NHS Stoke on Trent/Infection Prevention and Control Team March

50 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 used items are marked:- Dressing trolley or surface A dressing trolley or tray may be used when carrying out aseptic procedures. The trolley/tray should be cleaned daily and when soiled 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 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. 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; NHS Stoke on Trent/Infection Prevention and Control Team March

51 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 down 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, flat 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 MANAGEMENT OF INVASIVE DEVICES Invasive devices such as urinary catheters, infusion devices, trachesotomies and P.E.Gs will increase the risk of a service user developing an infection and the care home 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 users 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 Indwelling urinary catheters Inserting, changing and removing urinary catheters Suitably qualified care workers who have been assessed as competent in urinary catheterisation, must carry out these procedures. Service users and care workers should be trained in the management of urinary catheters. There should be a written policy/protocol to cover this procedure. A sterile field and sterile equipment and gloves must be used for the procedure and a strict aseptic technique adhered to. NHS Stoke on Trent/Infection Prevention and Control Team March

52 The same infection prevention and control guidelines apply to both urethral and suprapubic catheters. Good catheter care will help to avoid urinary tract infections. Micro organisms may be carried on the hands of care workers or micro organisms normally present on the service users body may track up the catheter to the bladder. If appropriate infection prevention and control measures are not taken there is the potential for infection and cross-infection that can result in serious or even life-threatening illness. The decision to use an indwelling catheter should only be made following an assessment of the service users needs by a member of the continence team. The meatus should be cleaned prior to insertion of a catheter and single use lubricants used. Unless otherwise indicated catheter balloons should be inflated with 10ml of sterile water in adults. Do not take routine catheter specimens of urine unless symptomatic. All catheter urine becomes contaminated after a few days and may look discoloured, thick, smelly etc. This does not necessarily indicate an infection or the need for a sample to be taken. Table 4 Action Daily management of indwelling urinary catheters Rationale Careful hand washing must always be carried out before and after handling the system. Use an aseptic technique and sterile gloves for insertion or manipulation of the catheter and equipment. Clean the area around the catheter daily using mild soap and water, rinsing away the soap and drying carefully. Men should clean under the foreskin. A shower or bath is adequate. Check for friction/sores around the labia, meatus and supra pubic site daily. Report any concerns to the person in charge. Prevent constipation. A fluid intake of 2-3 litres per day. Use a non-drainable night bag and discard every day. Connect indwelling catheters to a sterile, closed urinary drainage system or a catheter valve. Do not break closed system except for good clinical reasons (e.g. changing the bag). Reusable intermittent catheters should be cleaned with water and stored dry as per manufacturer s recommendations. This prevents spread of micro organisms between carers, service users and others. To prevent introducing micro organisms into the urinary system. This minimises the build up of bacteria which could lead to infection. Prevent wounds that could become a source of infection. A full bowel can press on the catheter tube and prevent free drainage of urine. Adequate fluid intake promotes good urine flow, flushing the catheter and preventing blockage. Avoids ascending colonisation of the catheter bag, which could result in Infection. Prevent infection. Prevent infection. NHS Stoke on Trent/Infection Prevention and Control Team March

53 Action Empty the drainage bag frequently enough to promote flow and prevent reflux. When emptying the drainage bag wash hands before and after the procedure and wear non-sterile disposable gloves. Empty drainage bag into a receptacle that has been washed in a bedpan washer/disinfector if possible or use disposables. If this is not possible provide each service user with their own receptacle, clean it after use with detergent and water, rinse in very hot water and dry thoroughly. When using leg bags maintain the closed system at night by connecting the leg bag to the night bag. A non drainable night bag is recommended which should be discarded daily. Keep the catheter drainage bag above the floor but below bladder level. Securely fasten bags to the leg, to a carrier on the bed or to a freestanding frame. Do not let the outlet tap trail on the floor. Change catheters when clinically indicated or as per manufacturer s recommendation. If the catheter blocks, try bladder irrigation. If unsuccessful, re-catheterise. Document problems. If the urine is cloudy, offensive smelling and/or the service user complains of a burning pain. Increase oral fluids and observe for changes. Inform a doctor if the service user has a temperature, if urine is bloodstained or the service user complains of abdominal pain. If a urine sample is required use the sampling port and an aseptic technique. Rationale The weight of a full drainage bag may pull on the catheter, causing trauma. Frequent emptying of the bag breaks the closed system. Prevents transmission of micro organisms. Prevents potentially pathogenic micro organisms multiplying in the receptacles and causing cross infection. Maintaining the closed system (i.e. avoiding unnecessary disconnections) reduces the risk of contamination thus reducing the risk of infection. Prevent urine in the tubing from backtracking into the bladder. Prevent trauma and contamination of the outflow tap. Prevent trauma and infection. Tube may be blocked with debris. Avoid washouts if possible to minimise breaking the closed system. May have an infection. May have an infection. To obtain an uncontaminated sample Summary of problem-free management of urinary catheters: Personal hygiene - to help prevent infection; A good fluid intake to promote bladder drainage; A good diet - to prevent constipation; Regular exercise - to help bladder drainage; Closed urinary catheter system - to help prevent infection; Use an aseptic technique to prevent infection. NHS Stoke on Trent/Infection Prevention and Control Team March

54 11.2 Percutaneous Endoscopic Gastrostomy (P.E.Gs) and other feeding tubes Enteral feeding Service users and care workers (including informal carers) who are involved in the management of enteral feeding in the care home should receive appropriate education and training and will be referred to the Hospital at Home service prior to discharge.. Care workers who prepare and administer enteral feeding should be deemed competent before undertaking these procedures. Enteral feeding systems are susceptible to microbial contamination, which may result in systemic infection, especially in vulnerable or immunosuppressed individuals. If service users are transferred in to your care home with enteral feeding tubes in situ the GP should refer them to the community dieticians Equipment Use sterile, single-use systems and pre-packaged, ready-to-use feeds. Minimise the number of connections to the system. Store feeds at the correct temperature in accordance with manufacturer s recommendations. Do not reuse feeding system components that are labelled for single-use only. Clean pumps daily taking special care with any areas that may trap dirt. Ensure pumps are maintained and serviced regularly by the supplier and keep clean using warm water and detergent Preparation of feeds Wash hands prior to handling enteral feeding systems, or insertion sites. Wear clean disposable gloves. Use the feed recommended by the dietician and prescribed by the GP. Do not decant feeds Administration Use an aseptic non touch technique and minimal handling when connecting the administration system to the feeding tube. Flush the feeding tube with fresh tap water before and after feeding and after administering medications. For immuno compromised individuals use sterile water from a freshly opened container or boiled, cooled water. Once boiled and cooled the water is transferred to a clean, lidded container. It is stored in a refrigerator, away from raw foods, at 5 o C or below for a maximum of 24 hours. Use a 50 ml single use a purple enteral feeding syringe that is then discarded. Do not re-use single use items Use feed within the expiry date and within permissible hanging times (the risk of contamination is increased if feed is open for longer than 24 hours). Label the feed with the name of the service user, the date and time the feed was set up. Avoid interrupting the feed once it has started. If medications are given, aqueous solutions are preferable to elixirs to avoid blocking the tube and preventing bacterial growth. On completion of the feed, flush the enteral tube in accordance with manufacturer s instructions and consider the age/size of the service user and their fluid balance status. Cover the connection point with the cap provided by the manufacturer to prevent contamination of the tube. NHS Stoke on Trent/Infection Prevention and Control Team March

55 Administration (giving) sets and feed containers are for single use and must be discarded after each session. Clinical equipment may be discarded as household waste since it poses a minimal infection risk. Place in a black bag and tie securely. Discard in a bin away from scavengers Management of the insertion site The stoma should be washed daily and kept clean and dry. Position the external fixation plate on the P.E.G. tube close enough to the abdominal wall to prevent leakage of gastric contents. P.E.G sites may become colonised with micro organisms such as MRSA. Suspect infection and send a swab if the insertion site becomes inflamed, red and painful. Report any adverse events or suspected infection to the service user s GP, or member of the Nutrition Team Tracheostomies Detailed information about the management of tracheostomies is available from ear, nose and throat and respiratory departments, many of which employ specialist nurses in this field. Those caring for someone with a tracheostomy for the first time must have some training from a specialist to ensure they are competent to deal with all the relevant situations and procedures. Tracheostomy sites sometimes become infected or colonised with micro organisms such as MRSA. If infection is suspected, send a swab to the laboratory Cleaning and dressing the tracheostomy site Hands must be cleaned before and after touching tracheostomy sites or dressing the wound. Disposable gloves are advisable. Clean the skin around the tube with 0.9% sodium chloride or warm water and lowlinting swabs. Dry the area and re-dress using a tracheostomy, or keyhole, dressing. Do not use lotions or creams without consulting a specialist or GP. Inform the GP or specialist if the skin around the tracheostomy becomes red Changing and cleaning an inner tube If there is an inner tube in place it must be kept clean and free from secretions, by cleaning 3 to 4 times per day. Wash hands. To unlock the inner cannula hold the neck plate with your fingertips insert the cannula and turn clockwise until the twist lock clicks into place i.e. until the blue dots arrows are aligned. Still holding the neck plate, remove the inner tube by pulling it downwards and outwards. Place the tube in a bowl of water with sodium bicarbonate to help loosen the secretions. Use a separate disposable foil bowl for each service user and replace every 24 hours. Carefully remove the secretions using cleaning swabs or soft brushes (available on prescription). Rinse the tube with water and dry with clean gauze. NHS Stoke on Trent/Infection Prevention and Control Team March

56 To reinsert the tube, push it firmly into the outer tube whilst holding the neck plate steady with the other hand. Lock it into position and wash hands. Wash, rinse and dry foil bowl in a sink designated for cleaning equipment. If there are any problems removing the tube contact the GP or specialist nurse at once Changing tracheostomy ties If there are tracheostomy ties in place they should be changed daily or whenever they become soiled using the following procedure:- Wash hands; Remove new tie from the packet; Remove the old tie, holding the neck plate of the tube firmly in place; Place one end of the new tie through the hole in the neck plate and secure; Do the same on the other side; Secure the tie by sealing the Velcro at the back of the neck or tying. The tie should be tight enough to hold the tube in place, but loose enough to allow two fingers to be inserted between the neck and the ties Infusion devices There has been an increasing use of medical technology in palliative care settings, care homes and even individual service users homes. These invasive devices include peripheral intravenous catheters; central venous skin tunnelled catheters e.g. Hickman lines; central lines used for total parenteral feeding (TPN); subcutaneous infusions via a syringe driver and spinal infusions. These devices provide portals for infection and place service users at increased risk of infection, therefore care should be taken in ensuring that the equipment selected and the location of insertion sites will help to prevent infection developing. The devices should be removed as soon as they are no longer clinically necessary. Accurate records relating to all aspects of the management of the devices need to be maintained. This includes when the device was inserted and by whom, details of the devices used, solutions infused, adverse effects, drugs administered, dates when equipment was changed etc Education of service users, care workers and informal carers. Care workers must be trained and deemed competent in the management of these devices. Service users and informal carers who may look after these devices should be taught any relevant techniques prior to discharge from the hospital, and know where they can seek advice if problems arise. Ongoing support for service users, informal carers and care workers must also be available from specialists. NHS Stoke on Trent/Infection Prevention and Control Team March

57 12. 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. 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. 13. SPECIMEN COLLECTION Do not take specimens for culture unless 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. NHS Stoke on Trent/Infection Prevention and Control Team March

58 Enteric (gut) infection - diarrhoea, vomiting, abdominal pain, fever, blood or mucous in faeces. 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. 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 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); Details of sample sent, including the site from which the sample was taken if the sample is a wound swab; Nature of the signs and symptoms; Duration of illness; Recent antibiotic therapy or travel history; Whether the case is part of a cluster or outbreak of similar cases. 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. Where the sample is known or suspected to be high risk a "danger of infection label must be attached to both the specimen and the request form. Specimens must be stored away from food, drink and drugs to prevent cross contamination. Send specimens to the laboratory immediately 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 NHS Stoke on Trent/Infection Prevention and Control Team March

59 14 CLEANING THE ENVIRONMENT 14.1 General The care home environment should be visibly clean, free from dust and soilage to be acceptable to service users, their visitors and care workers. 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. Door handles, flush handles, taps etc have all been implicated. Therefore, special attention must be paid to these fittings during outbreaks. In addition, 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. Contact the Health Protection Unit/Infection Prevention and Control Team 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 residential care settings Floors and other hard surfaces Hard floors should be smooth-finished, intact, durable, of good quality, washable, be impervious to fluids and should not allow the pooling of liquids. Carpets are not recommended in treatment rooms or other clinical areas. Hard flooring may be a more suitable option for other areas where spillage of food or body fluids is a problem (for example dining areas or rooms of service users that have problems with continence). Where carpets are provided 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 detergent and a mop with a detachable head that can be laundered. Mop heads should be changed daily and send to the laundry. 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 a three stage filtration) is suitable for carpets and other soft furnishings. Work surfaces should be smooth-finished, intact, durable, of good quality, washable, should not allow the pooling of liquids and be impervious to fluids. Cleaning with household 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 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. Upholstered furniture should be covered in impermeable fabrics that can be wiped clean. NHS Stoke on Trent/Infection Prevention and Control Team March

60 14.4 Pillows, duvets and mattresses Pillows, duvets and mattresses 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 5 Recommended cleaning products and disinfectants Products General purpose detergent Detergent wipes Examples of Products Hospec Fairy Use Routine cleaning of equipment and environmental surfaces, 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 Titan/Sanichlor For blood spillage on hard surfaces DO NOT USE ON URINE SPILLS the fumes released are harmful NHS Stoke on Trent/Infection Prevention and Control Team March

61 14.6 Colour Coding Colour coding of cleaning equipment has been adopted in many NHS settings, and care homes may wish to consider adopting this practice. It is especially useful when care workers work across other care providers both in the independent care sector and in the NHS. All cleaning items, for example, cloths (re-usable and disposable), mops, buckets, aprons and gloves, should be colour coded (see Appendix 27). This also includes those items used to clean catering departments. Table 6 NATIONAL COLOUR CODING SCHEME FOR CLEANING MATERIALS AND EQUIPMENT (NATIONAL SERVICE USER SAFETY AGENCY) BLUE RED GREEN YELLOW Day rooms 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. Sodium dichloroisocyanurate (NaDCC) method (not carpets and soft furnishings) using sanitising powder or granules Wearing protective clothing, cover spillage with NaDCC granules. NHS Stoke on Trent/Infection Prevention and Control Team March

62 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. 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 the following situations:- Following outbreaks and would involve cleaning - the whole environment. NHS Stoke on Trent/Infection Prevention and Control Team March

63 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. Each care establishment should have a written cleaning schedule for both routine and deep cleaning that ensures that all areas of the home are cleaned to a satisfactory standard. Deep cleaning is the thorough cleaning of all surfaces, floors and soft furnishings and reusable equipment either within the whole environment or in an individual s room. This will include: Skirting boards, picture and dado rails; Window sills and frames; All ledges, shelves and flat surfaces; Bed frames; Mattresses; Soft furnishings including curtains and blinds; Curtain rails and tracks; Floors and carpets ; Light fittings and lamp shades; Re usable equipment; Wheelchairs, Zimmer frames and hoists; 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. NHS Stoke on Trent/Infection Prevention and Control Team March

64 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 environment to another (room to room) and when the water is visibly dirty or contaminated. Remove/dispose of unwanted items (flowers, equipment etc). Take down curtains and send to the laundry. Strip the bed. Clean mattress with detergent solution and disinfect if necessary. Clean, and disinfect if necessary, all furniture and fittings or steam clean in the following order:- Fittings and furniture using detergent and water; High level surfaces and curtain rails; Door handles and horizontal surfaces; Service user equipment; Bath or shower room; Toilet; The Golden Rule for cleaning is to work from the cleanest to the dirtiest areas starting at the higher levels and working down. Soft furnishings should be shampooed or steam cleaned. Curtains should be laundered. Carpets should be vacuumed (vacuum cleaners should be fitted with a HEPA filter) and then steam cleaned. Discard waste and clean waste bin. Clean all cleaning equipment and leave to dry. Wash hands. Restock room with clean supplies Cleaning of isolation rooms Daily cleaning of isolation rooms Wear personal protective clothing (at least disposable gloves and apron). Use a fresh solution of detergent and water and disposal cloths or paper roll. If indicated, e.g. outbreaks of gastrointestinal infection disinfect with chlorinereleasing agent after cleaning or use a combined cleaner-disinfectant. Change cleaning solution frequently. Clean or damp dust in the following order, if possible:- Fittings and furniture using detergent and water; High level surfaces and curtain rails; Door handles and horizontal surfaces; Service user equipment; Bath or shower room; Toilet; Mop the floor; Discard waste as clinical waste; Empty waste bin, clean inside and out, and insert new liner Clean all cleaning equipment and leave to dry; NHS Stoke on Trent/Infection Prevention and Control Team March

65 Wash hands; Restock paper towels, liquid soap and other supplies Terminal cleaning of isolation rooms In addition to the above:- Remove/dispose of unwanted items (flowers, equipment etc); Take down curtains and send to the laundry; Strip the bed. Clean mattress with detergent solution and disinfect if necessary; Clean, and disinfect if necessary, all furniture and fittings or steam clean; Vacuum the floor; Hang clean curtains 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. 15. DECONTAMINATION OF CARE EQUIPMENT 15.1 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. In the care home setting the decontamination processes that will be normally used are cleaning and disinfection. Most of the 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 and in outbreak situations. Thermal disinfection will be used for:- crockery and cutlery in a dishwasher; linen in washing machines and tumble dryers; bedpans/commode pans in washer disinfectors. All reusable medical devices that need to sterile at the point of use should be supplied as single use disposable items. NHS Stoke on Trent/Infection Prevention and Control Team March

66 15.2 Purchase of equipment Before purchasing any new equipment, ensure that it can be decontaminated in the care home setting and that recommended cleaning solutions are available Methods of Decontamination 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 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 at least disinfected 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 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 purpose detergent and In contact with healthy skin drying Medium High 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 Items in contact with a break in the skin or mucous membrane or For introduction into sterile body areas Single use Single use items Clean item and then disinfect or sterilise (item does not need to be sterile at the point of use). Items used in the vagina must be single use or sterilised. Sterilisation in a sterile services department or single use and use item sterile Examples Floors and ceilings, walls, mattresses, beds, trolleys, wash bowls, baths, toilets, wash hand basins, furniture and fittings. Suction catheters, aurasccopes, thermometers, ambubags, masks and bedpans. Surgical instruments, urinary catheters, dressings, needles and syringes. (Adapted from the Medical Devices Agency 2005) NHS Stoke on Trent/Infection Prevention and Control Team March

67 Cleaning Thorough cleaning with 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. bedpans, commode pans, urinals and surgical instruments prior to sterilisation. Manual cleaning Medical devices and instruments must not be cleaned by hand although this is an acceptable method for cleaning the environment and low risk equipment such as beds, commodes etc. A risk assessment and records of agreed procedures must be in place to ensure that a consistent method is employed by all care workers. Disposable gloves and apron are advised, and the use of enzymatic cleaners or detergent and warm water (not exceeding 35 o C). How to clean care equipment. Clean the item in an area designated for 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 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 disposable device instead. 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. NHS Stoke on Trent/Infection Prevention and Control Team March

68 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 dishwashers, washing machines and bedpan washerdisinfectors. 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, urinals 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 will only be used in the care home setting for cleaning the environment and equipment. 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. 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 NHS Stoke on Trent/Infection Prevention and Control Team March

69 Table 8 Dilution of NaDCC and NaCIO Parts per million NaDCC NaCIO Blood spills 10,000ppm 2 x 5.0g tabs in 500mls water Milton 1% use undiluted Environment 1,000ppm 2 x 0.5g tabs in 500mls water Milton 1% diluted 1: 10 Catering x 0.5g tabs in 2 litres of water 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 render an object free from all microorganisms. It is recommended that sterile equipment should be obtained pre-sterilised from a manufacturer or via a Central Sterile Supplies Department (CSSD). In the care home setting 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 following the manufacturers instructions Decontamination of health care equipment prior to repair, service or investigation No equipment that has been contaminated with blood and other body fluids, or exposed to service users with a known infectious disease, should 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 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). NHS Stoke on Trent/Infection Prevention and Control Team March

70 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 Home loans equipment Equipment that has been used in clinical care must be safe to handle before returning to the home loans store and the principles outlined above apply equally to equipment that is loaned for clinical or social care. Empty suction machines and rinse suction bottles with warm water and detergent, rinse and dry. If soiled, clean other items with warm water and detergent and dry. If items cannot be cleaned prior to collection/delivery inform the Home Loan Stores Manager so that precautions can be taken. When selecting beds, chairs etc for service users who have incontinence problems or leaking wounds select items with waterproof covering that can easily be cleaned. Upholstered items with wipe clean covers that are superficially contaminated may be cleaned by using detergent and water followed by steam cleaning. Upholstered items that have been grossly contaminated may need to be reupholstered or condemned. Home loans staff involved in collecting used items should wear disposable gloves and aprons when handling potentially soiled items. 16. LAUNDRY The provision of clean linen is a fundamental requirement of care. Incorrect handling of linen may pose an infection risk to care and laundry workers. Small care homes that provide care in a setting similar to a domestic setting will provide laundry services similar to those in most homes and wherever possible washing machines and driers should not be sited in kitchens but in separate utility rooms. The following requirements apply to large care homes with their own laundries Handling used linen Linen may be contaminated with bodily fluids and debris and may pose a risk to those who handle it. Plastic aprons and disposable gloves should be worn for handling dirty linen. All linen (bedding and clothing) should be removed with care, avoiding the creation of dust and dissemination of skin scales, and placed in the appropriate bag at the point of use. Inspect the linen when removed. Where solid matter is present, this must be removed using disposable paper and disposed of in either a WC or slop hopper. Do not sluice by hand as this may spray micro organisms on to surfaces, uniforms and skin. Foul/infected linen should not be handled any more than is absolutely necessary. NHS Stoke on Trent/Infection Prevention and Control Team March

71 Soiled or fouled articles should be washed on the hottest cycle the fabric will allow. Those items that are not washable, should be dry cleaned or, if necessary, destroyed. Hands should always be washed after handling linen. Staff who undertake laundry work must receive training. Laundry must not be sorted on the floor. Foul or infected laundry should be laundered after all the other routine laundry has been done, using the hottest wash available for that fabric. Used linen and fouled/infected linen should not be laundered together. The washing machine must not be over loaded to ensure that the machine functions adequately. Laundry skips should be laundered after containing soiled or fouled linen or at least weekly. Kitchen items and mop heads must be washed on a separate cycle. Use separate cleaning equipment for the laundry area. Disinfect washing machines weekly by running a hot programme without a load. Prevent contamination of clean linen. Laundry bags must not be overfilled and must be securely fastened before being sent to the laundry. Bags should be stored in a designated location that is secure, cool and dry. The designated storage area should be separated from areas used for the storage of clean linen, food preparation areas, and those parts of the home frequented by service users and their guests Segregation of linen Soiled linen should be placed into the appropriate colour of laundry bag. Care homes should introduce a colour coding system for the safe handling of soiled and fouled linen. Care workers must assess the condition of used linen and clothing to decide which category it falls into. Table 9 Segregation and laundering of used linen Category Description Laundering Requirements Used linen and clothing Linen that is used but not contaminated with urine, faeces, blood, vomit, sputum or any other bodily fluid or debris White laundry bag A sluice cycle is not required. Launder at 65 o C for at least 10 minutes, or 71 o C for 3 minutes or as per care label Foul or infected linen and clothing Linen that is contaminated by bodily secretions or faeces, or from a person with a known infectious condition Remove solid waste Place in a red alginate bag using gloves and apron A sluice cycle may be needed Launder at 65 o C for at least 10minutes, or 71 o C for 3 minutes NHS Stoke on Trent/Infection Prevention and Control Team March

72 Category Description Laundering Requirements Heat sensitive fabrics Linen that is soiled or fouled and cannot be washed at high temperatures Disinfect by adding sodium hypochlorite 150ppm to penultimate rinse If fouled, disposal may be necessary Dry cleaning may be possible for some items Do not soak or sluice by hand as this may result in cross contamination on to surfaces, uniforms and clothing of care workers. Heavily soiled linen should be prewashed at low temperature Laundry facilities in residential care settings A separate laundry facility, which is used solely for that purpose or the use of a commercial laundry, is recommended for all large residential care settings. However, it is recognised that this is not always possible in small residential settings where the situation will be similar to that in a domestic setting. A risk assessment must be performed of all laundering facilities. The person in charge should review this regularly Laundry design A designated laundry area used only for that purpose, with separate ventilation and as far away as possible from anywhere food is prepared. The floor, walls, splash-backs, draining boards etc of the laundry must be easily washed with no cracks visible in the surface. It is advisable that floors are non-slip. The design of the laundry must facilitate the creation of dirty and clean areas i.e. dirty linen can be bought into one area moved through the laundry as it is processed and come out as clean laundry without crossing over the route for used laundry. Any laundry bins should be fully washable and be well maintained. Hand washing, changing facilities and PPE for laundry workers should be available. Different receptacles for clean and dirty laundry should be provided, and there should be separate areas within the laundry area to ensure no contact between clean and dirty linen Equipment Washing Machines These should be industrial washing machines with a cold sluice cycle and wash cycle temperatures that comply with current disinfection standards (71 o C for at least 3 minutes or 65 o C for at least 10 minutes). Accurate thermometers that register the true wash temperatures should be fitted. All machines should be installed professionally with a cover over the drain to prevent aerosol contamination. An industrial dryer is recommended to ensure thorough drying of linen. Ironing will provide the final process of decontamination. NHS Stoke on Trent/Infection Prevention and Control Team March

73 There should be a regular maintenance programme and a record kept of these checks as evidence of diligence and care Wash hand basin There should be a separate hand wash facility for laundry staff which has: Lever action mixer taps; Liquid soap and paper towels; A foot-pedal operated bin for paper towels. If hand washing delicate materials or other personal items is undertaken, a designated sink which is separate from the wash hand basin, must be used Drying facilities Tumble driers are recommended During outbreaks in residential care settings Use red alginate bags for fouled/infected linen to minimise contact. Alginate bags can be placed directly into a washing machine and will dissolve in contact with the water. Some residue may remain. If alginate bags are not available use red plastic bags. Empty the contents into the washing machine without handling and discard the bag. Minimise the number of people visiting the laundry. Keep the laundry room and equipment clean. Ensure contaminated linen is kept away from clean linen Storage of linen There should be a separate area for drying, ironing and storage of clean linen, well away from used linen, to prevent contamination. Clean linen should be stored in a dry area raised at least six inches above the floor level. Clean linen should not be stored in bathrooms or sluices Care worker uniforms/clothing Regardless of whether or not a uniform is provided by the employer, it should never be regarded as a substitute for protective clothing. The requirement for PPE should always be assessed as described in Section 5. When provided, a fresh uniform should be worn daily; otherwise the care worker s clothes should be changed daily. Both uniforms and/or care workers own clothing can be laundered at home in a domestic washing machine at a temperature of 40 C. One of the most important factors in determining the effectiveness of laundering is the ratio between fabric load and water volume. In order to ensure sufficient dilution, it would seem sensible to recommend that the machine is not filled to more than 75% of its capacity in order to achieve adequate dilution. This will facilitate the physical removal of micro organisms. NHS Stoke on Trent/Infection Prevention and Control Team March

74 16.9 Ozone washing machine (OTEX) Otex (Validated Ozone Disinfection) is a new laundry system that injects and dissolves ozone into the wash water throughout the wash cycle. The manufacturers claim that the product kills micro organisms even at low temperatures. The Health Protection Agency s Rapid Review Panel undertook a review of the product and recommended that, at the time, the product was insufficiently validated and more research was needed into its efficacy. 17. WASTE DISPOSAL 17.1 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 (ECW) 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 March

75 Hazardous/non hazardous waste The new national guidelines HTM07-01 further classify waste as hazardous and non hazardous waste. Table 10 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 in the care home 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 Household/domestic waste Pedal-operated bins are recommended. Any waste that is not covered under the clinical waste groupings is classed as household domestic waste, e.g. wastepaper, cans, bottles. NHS Stoke on Trent/Infection Prevention and Control Team March

76 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. Ensure service users and their informal carers are aware of the need to deal with clinical waste appropriately. Table 11 Segregation and disposal of clinical waste Type of waste Examples Containers Disposal Infectious waste (Category A) Anatomical waste: placenta, tissues, organs etc, and laboratory waste. Waste from highly infectious diseases, e.g. Ebola virus Yellow rigid lidded bin or bag Hazardous waste for Incineration Infectious waste (Category B) Assess for infection risk. Infectious: dressings, swabs, bandages, pads, suction liners, stoma bags, catheter bags, plastic disposable instruments (not sharps). Non-infectious: treat as offensive / hygiene waste Orange lidded bin or bag Licensed or permitted treatment facility or incineration Clinical sharps Not contaminated with medicinal products OR Fully discharged sharps contaminated with medicinal products (NOT cytotoxic or cytostatic medicines) Orange lidded sharps container Incineration or alternative treatment facility Clinical Sharps Partially or undischarged sharps (NOT cytotoxic or cytostatic medicines) Yellow lidded, liquid-proof sharps container. Hazardous Waste for Incineration Cytotoxic and cytostatic waste and sharps All contaminated waste. Soft waste: including gloves, swabs, packaging etc Sharps waste: needles, syringes, ampoules etc, Yellow bag or lidded bin with purple stripe. Yellow sharps bin with purple lid Hazardous waste for incineration Offensive/hygiene waste Non-infectious dressings, swabs, drains, incontinence pads, suction liners, stoma bags, catheter bags, plastic disposable instruments (not sharps). Yellow bag with black stripe Deep landfill Medicines (Not cytoxics or cytostatic) Unused drugs and other pharmaceutical products. Never discard them into the drainage system. Controlled drugs: comply with local procedures. Yellow rigid lidded box for liquids or solids Hazardous waste Incineration NHS Stoke on Trent/Infection Prevention and Control Team March

77 Table 12 Waste packaging and colour coding (from HTM 07-01) Clinical Waste (Containers may vary in size and design dependant on manufacturer) 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 NHS Stoke on Trent/Infection Prevention and Control Team March

78 Waste receptacle Waste type Example of contents Medicines in original Waste in original Packaging package with original closures Indicative treatment disposal Incineration Medicines NOT in original packaging Waste tablets not in foil pack or bottle Segregate aerosols i.e. asthma inhalers 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 NHS Stoke on Trent/Infection Prevention and Control Team March

79 17.3 Storage of clinical waste Pedal bins must be available where clinical waste and contaminated household waste are 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 or wheeled external bin awaiting collection. Bins provided for clinical waste must be kept in a secure locked location 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 containers, 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. 18. FOOD HYGIENE All foods are potentially hazardous if they are not handled correctly. Good food handling practices are essential to minimise the risk of food poisoning. This is especially important in residential care settings where food is being prepared and served to large numbers, and where consumers are at particular risk from food borne illnesses Legislation Managers and care workers must be aware of legislation relevant to food. Residential care settings should appoint or have access to a qualified catering manager. The main legislation is the Food Safety Act 1990 and its related regulations. The local Environmental Health Department can advise about rules and regulations. Environmental Health Officers of the local authority in enforcing these regulations are entitled to inspect catering facilities in residential care homes. NHS Stoke on Trent/Infection Prevention and Control Team March

80 A useful book to obtain for further information is Industry Guide to Hygiene Practice: Catering Guide. Food poisoning can cause serious illness and even death particularly in the elderly. It is important that all people involved in preparing and serving food are aware of how to reduce the risk of food poisoning Training People who handle or prepare food need an appropriate level of training in the principles of food handling depending upon whether they serve food, cook food or manage a kitchen. Where service users cook food for themselves, care workers must ensure that the individual is supported in applying the principles of food hygiene until independence is achieved. Courses may be provided by local colleges and NHS Trusts, as well as the: Royal Institute of Public Health and Hygiene (RIPHH); Royal Society of Health (RSH); Royal Environmental Health Institute of Scotland (REHIS); Society of Food Hygiene Technology (SOFHT); Chartered Institute of Environmental Health (CIEH). Essentials of food hygiene Keep yourself clean and wear clean clothing. Always wash your hands thoroughly:- before handling food; after using the toilet; after handling raw foods or waste; before starting work; after every break; after blowing your nose. Tell your supervisor, before commencing work, of any skin, nose, throat, stomach or bowel trouble or infected wound. You are breaking the law if you do not. Ensure cuts and sores are covered with a waterproof, high visibility dressing such as a blue plaster. Avoid unnecessary handling of food. Do not smoke, eat or drink in a food room, and never cough or sneeze over food. If you see something wrong - tell your supervisor. Do not prepare food too far in advance of service. Keep perishable food either refrigerated or piping hot. Keep the preparation of raw and cooked food strictly separate. When reheating food ensure it is piping hot. Clean as you go. Keep all equipment and surfaces clean. Follow any food safety instructions either on food packaging or from your supervisor. Hygiene awareness training (appropriate to the job) The business's policy - priority given to food hygiene; "Germs" potential to cause illness; Personal health and hygiene need for high standards, reporting illness, rules on smoking; NHS Stoke on Trent/Infection Prevention and Control Team March

81 Cross contamination - causes, prevention; Food storage protection, temperature control; Waste disposal, cleaning and disinfection materials, methods and storage; "Foreign body" contamination; Awareness of pests Hazard analysis The Food Safety (General Food Hygiene) Regulations 1995 make a specific requirement of organisations to undertake a hazard analysis. This is a systematic examination of how food is prepared and how food safety hazards are controlled. An Environmental Health Officer will periodically inspect kitchens in residential care settings. They will expect to see evidence of hazard analysis and any records that support it. They will also ask managers and staff questions about hazard analysis and how it is implemented. The main stages of undertaking a hazard analysis are as follows: Identify all the things in your food operation which might go wrong (hazards) and result in food poisoning or cause injury, (e.g. the presence of bacteria in raw meat, or foreign material such as glass or plastic in food); Decide the points in the food operation at which things can go wrong (e.g. places where cross-contamination between raw foods and ready to eat products may occur); Decide which of these points are critical to making sure food is safe, and therefore must be properly controlled (e.g. the cooking of raw meat or the use of sanitised equipment); Put in place procedures to stop things going wrong (controls), and make sure that you/your staff always carry them out (e.g. cooking meat for a set time and temperature which is known to kill all of the bacteria right through to the middle of the joint or ensuring that equipment has been cleaned and sanitized at proper and regular intervals); From time to time, you must examine your food business to see if anything has changed which might need your control measures to change (e.g. new menu dishes may have new hazards and need new controls, or new equipment may require different thermostat settings); It is helpful to involve key staff in developing a hazard analysis and all staff need to know the part that they have to play in making it work Record keeping Although in law you do not have to provide documents or record your policies, procedures and monitoring records, it would be difficult to show how you are meeting this requirement without records or documents. It would also be difficult, if charged with a Food Safety Act offence, to use the defence of Due Diligence to show that you have done everything possible to avoid committing an offence. It is important to provide details of procedures and retain monitoring records particularly at critical control points. The recommended documents/ records that should be retained include: Hazard analysis summary; Training records; Food temperatures records (e.g. cooking, cold storage, hot holding temperatures); Refrigeration temperatures; Cleaning schedules; NHS Stoke on Trent/Infection Prevention and Control Team March

82 Delivery monitoring records; Stock rotation records; Pest control records; Equipment maintenance schedule Infectious diseases in kitchen staff and care workers. People are a common source of food poisoning micro organisms. Kitchen staff and care workers who are suffering from sickness, diarrhoea or heavy colds should not be allowed to work with food. Kitchen staff and care workers suffering from discharges from the ears, eyes, nose or those who have septic skin conditions should not be allowed to work with food either. Kitchen staff and care workers should notify their manager before they start their shift if they are suffering from such a condition. The manager must make sure the appropriate action is taken, such as excluding someone from work altogether or allocating them other non-food duties Hand hygiene Hand wash basins in areas used for preparing, cooking and serving food should be designated for hand washing and they should have mixer taps which are elbow, wrist or sensor operated. Hand washing should be carried out on entering a kitchen and frequently throughout the working day. It should always happen after handling foods or articles that are a source of food poisoning bacteria. Such things include raw meat, raw vegetables, rubbish bins, etc. Hands should also be washed after going to the toilet, taking a break, coughing or sneezing in to hands etc. Good hand washing requires running water, liquid soap and paper towels. A disposable nailbrush may be used if hands are particularly soiled but are not recommended for routine use. If nailbrushes are used they should be single-use. Hand washing should take about 30 seconds and kitchen staff and care workers should pay attention to all parts of the hands, fingers and wrists. Hands should be dried using disposable paper towels. Hand sanitisers can also be used to compliment hand washing. These contain alcohol and dry quickly on the hands. They can be used after washing hands with soap and water or to disinfect hands that are not visibly soiled Protective clothing In large kitchens (e.g. hospitals and care homes) anybody entering the kitchen should wear suitable over-clothing, which may include a clean white coat and hair covering/hat. In smaller kitchens or the home setting, a clean plastic apron with sleeves rolled up is adequate. Kitchen staff who leave the kitchen to undertake other duties should remove their protective clothing before leaving the kitchen. No jewellery other than a plain wedding band, perfume or make-up should be worn whilst preparing food High risk foods Certain foods will be more of a risk of causing food borne illness than others. These high risk foods are those which normally need to be kept refrigerated prior to consumption. High risks foods include: NHS Stoke on Trent/Infection Prevention and Control Team March

83 Raw eggs Advice from the Department of Health on raw or lightly cooked eggs is that: -"Everyone should avoid eating raw eggs or uncooked dishes made from them, and vulnerable groups such as the elderly, the sick, babies, toddlers and pregnant women, should make sure any eggs they eat are thoroughly cooked until the white and yolk are solid. However, for healthy people there is very little risk from eating eggs which are cooked, whether boiled, fried, scrambled or poached." Once purchased, eggs should be stored in a refrigerator, below 8 o C; Caterers should continue to increase their use of pasteurised egg, particularly for dishes that are not subject to further cooking prior to consumption; Food hygiene training programmes should pay particular attention to the correct handling of eggs, and food containing eggs, and the avoidance of cross contamination; The Public Health Laboratory Service and Food Standards Agency have advised that: Eggs are kept away from other foods, while in shells or when cracked; Eggs should not be splashed onto other foods, surfaces or dishes; Hands should be washed and dried after handling or working with eggs; Surfaces, dishes, utensils etc should be cleaned thoroughly using detergent and warm water after contact with eggs. Pâté, soft-ripened cheeses and cook-chill foods Listeriosis, a disease which has been associated with the consumption of these foods, may be mild or severe and may cause septicaemia, meningitis and encephalitis. If a pregnant woman becomes infected, this can harm the developing baby. Elderly people, or those who have impaired immunity due to disease or treatment, are particularly vulnerable to infection. Particular care needs to be taken in developing diets for vulnerable service users; they should avoid soft-ripened cheeses and should re-heat cook-chill meals and ready-to-eat chicken until they are piping hot. Unpasteurised milk Only pasteurised milk and milk-based products should be offered for consumption by service users. Care should be taken with the delivery site to ensure that milk containers (bottles or cartons) are protected and that birds or rodents cannot break the seal and allow contamination to occur. If the lids have been perforated the lid, the entire contents of the bottle must be discarded. Under-cooked or raw foods Research has shown that meat, which is undercooked and still pink after cooking, may cause infection. It is therefore important that all meat and poultry is thoroughly cooked until the juices run clear before being served. Piping hot meat is safest; this can only be checked using a probe thermometer, with a minimum 75 o C being reached during cooking. Cooked food kept at room temperature and then re-heated is often implicated in outbreaks of food-borne infection. Such practice is unsafe. Cold cooked meats that are sliced some time prior to consumption may also be associated with gastro-intestinal infections if poorly handled and/or left at room temperature. Shellfish, especially if eaten raw or undercooked, is recognised as being a high-risk food. If served to vulnerable service users particular care should be taken to ensure proper preparation, cooking and handling of fresh, tinned and frozen shellfish. NHS Stoke on Trent/Infection Prevention and Control Team March

84 Salads, fruits and uncooked vegetables are a good source of vitamins, minerals and fibre but they need careful preparation to ensure that the risk of contamination is reduced. Because of possible contamination with pesticides etc, where possible, fruit and vegetables should have the skin removed providing this does not mean excessive manual handling. Leafy vegetables such as lettuce, and fruit, should be washed thoroughly in running water. All fruit and vegetables that are consumed without removing the skin must be washed prior to consumption Gifts of food In residential care settings, visitors will frequently bring in gifts of food for service users. Visitors should be made aware of the dangers posed by bringing in high-risk foods and should be discouraged from bringing these in. They should be encouraged to bring in foods that are low risk such as fruit, biscuits and pre packaged foods which do not require refrigeration. They should inform the person in charge of any gifts of food brought in. If gifts of high risk foods are brought in for service users should be kept cool between purchase and transport to the care home, be appropriately covered, then labelled with the name of the service user and the date of the gift. Such gifts should be appropriately stored, e.g. refrigerated below 5 o C if high risk, and consumed within 24 hours. If not used within 24 hours they should be discarded Storage of food Food must be stored at the correct temperature and in an appropriate place. Most food poisoning germs will grow at temperatures between 5 o C and 65 o C, and poor temperature control is an important cause of outbreaks of food poisoning. Storage needs to take account of this. The temperature of foods must be recorded using an accurate probe thermometer, which is disinfected before and after each use e.g. using probe disinfecting wipes or alcohol-impregnated wipes. For all foods there should be careful attention to stock rotation so that older stocks are used before new stocks. Food should be stored in the appropriate place as soon as possible after delivery or preparation. Dried food such as cereal must be stored in pest proof containers above floor level. Foods, which need to be kept cool, must be stored in a refrigerator. These foods should be kept at a temperature of 5 o C or below. The refrigerator must have a thermometer and the temperature should be checked daily and recorded. If the refrigerator temperature is above 5 o C this should be reported to the manager so that maintenance or repairs can be carried out promptly. Care has to be taken to avoid contamination of cooked foods with raw foods, especially raw meat and poultry. These should be stored separately. All food must be covered and labelled with the date before it is placed in the refrigerator. Drugs or specimens must not be stored in the food refrigerator. Frozen foods should be clearly labelled with the date before placing in the freezer. This is essential for efficient stock rotation. Hot foods must be kept hot at a temperature of 63 o C or higher. Sandwiches should be prepared as close to the serving time as possible (ideally one hour before they are served). They should be stored covered in the refrigerator below 5 o C before serving. NHS Stoke on Trent/Infection Prevention and Control Team March

85 18.11 Food preparation It is best practice, even in the care home setting, to have separate areas and equipment for the preparation of cooked and uncooked meat and poultry, vegetables and salad. In residential settings, equipment must be labelled or colour coded so that cooked food does not become accidentally contaminated with raw food. Germs on raw food (especially meat and poultry) may cause food poisoning if they get onto food that is going to be eaten without further cooking. Some raw foods commonly contain food poisoning germs and they must be cooked properly before serving. Meat and poultry must be thoroughly defrosted before cooking to ensure that they reach the correct temperature throughout. Defrosting should take place in a fridge rather than at room temperature. Raw shell eggs may contain salmonella, and they should not be used in dishes where they are not cooked, such as homemade mayonnaise and cheesecakes. Pasteurised egg should be used in these dishes, or alternatively use recipes, which do not contain uncooked egg. Soft boiling or poaching may not be adequate to kill all salmonella bacteria. The sick and elderly are particularly at risk from salmonella. Once prepared, foods should be kept at the correct temperature. Items that require refrigeration should be placed in the refrigerator as soon as possible after preparation. Hot foods should not be left standing at room temperature. If they are not to be served immediately they should be stored in an oven or hot plate. Cooked items, which are going to be stored cold (e.g. some joints of meat) should be cooled as quickly as possible and then stored in a refrigerator. Slicing food and spreading it over a large surface area can hasten cooling Drinking water, water coolers and ice making machines Clean, safe drinking water is essential for all to maintain health. Drinking water for water coolers and ice making machines should come directly from the mains supply. Water coolers and ice making machines should be on a planned programme of maintenance. The cleaning of these machines should be included in the cleaning schedules General kitchen hygiene Deposits of food encourage the growth of micro organisms and will attract pests. Crockery, cutlery and other kitchen equipment should be cleaned using a dishwasher where possible, Cracked or chipped crockery should be discarded. Food waste should be disposed of as soon as possible. Kitchen cleaning must be carried out regularly to prevent a build-up of food deposits behind, beneath and inside kitchen equipment. Spills should be cleared up promptly. Thorough cleaning with a general purpose detergent and drying with a clean disposable cloth will be adequate for most surfaces. For food preparation surfaces a product that is a combined cleaner/sanitiser is recommended. NHS Stoke on Trent/Infection Prevention and Control Team March

86 19. CONTROL OF LEGIONELLA 19.1 Control measures Water used in care homes for purposes other than drinking may be a source of a number of bacteria including Legionella. The frail elderly are more susceptible to Legionella infection and the care home must have measures in place to minimise the risk. Legionella bacteria are widespread in water particularly in stagnant water systems where there may be a build up of bio films. The route of infection is usually from contaminated water droplets from water cooled ventilation systems, showers and whirlpool spas. To reduce the risk water systems should be designed so that:- pipe work is as short and direct as possible; there is adequate insulation of pipes and tanks; materials used do not encourage the growth of legionella; and protecting against contamination, e.g. fitting storage tanks with lids. Operation and maintenance Water systems should be operated to minimise growth of legionella. Hot water storage should be above 60 C and distributed at above 50 C; Water systems need to be routinely checked and inspected by a competent person; and the Risk assessments should be reviewed regularly. If very hot water is not required for other reasons, e.g. for the laundry, alternative legionella control methods may be considered. This may avoid the need for very high water temperatures which carries a risk of scalding. Alternatives include ionisation, ultraviolet (UV) light, chlorine dioxide, ozone treatment or regular thermal disinfection of the system. All systems used to control legionella will need proper installation, maintenance and monitoring and records of these should be kept. You should seek professional advice when considering new or alternative treatment systems. Taps and shower heads that are not used daily should be run for 3 minutes at least weekly and this should be recorded in a log book Spa pools Spa pools must be correctly designed, constructed and installed. They should be managed to meet both legal requirements and reduce the risk of infection and the water quality checked Further advice on the management of these pools can be obtained from Environmental Health Departments. NHS Stoke on Trent/Infection Prevention and Control Team March

87 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 Kitchen and food stores provide ideal conditions for pests. The food is eaten and the pests contaminate and spoil the remaining food. 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 and off the floor; Inspecting food storage areas regularly and rotating stock; Keeping food storage areas clean and cleaning up any spillage promptly. 21. PETS 21.1 General infection prevention and control measures Service users can enjoy contact with pets and health benefits can result from this. However there may be infection risks from pets especially if service users are particularly vulnerable due to reduced immunity, age, illness or therapy. Sensible precautions can reduce the risk to an acceptable level even in the care home setting. In communal settings, a designated person should be responsible for looking after the pet. There should be written cleaning schedules for birdcages and aquariums. Wash hands after contact with pets. After animal scratches or bites, clean the area thoroughly by washing with soap under a running tap. Record the injury in the accident book. Seek medical advice for bites, which break the skin and for any bites or scratches which do not heal quickly or which appear infected. If pets appear unwell seek veterinary advice. Ensure pets receive regular veterinary care, vaccinations etc, where appropriate. Pet feeding areas should be kept clean. Pets should have their own feeding dishes, which should be washed separately from dishes and utensils used by service users. Keep pets out of the kitchen and away from all surfaces where food is prepared or consumed. Keep opened pet food containers away from food for human consumption. Food not consumed within 20 minutes should be removed or covered to prevent attracting pests. Bedding should also be cleaned regularly and insecticides used as necessary to control fleas; advice should be sought from the vet if problems occur Litter box care Pregnant women should avoid cleaning out litter boxes. Seal litter in a plastic bag and dispose of with household waste. NHS Stoke on Trent/Infection Prevention and Control Team March

88 The litter box should not be sited near food preparation, storage or eating areas. Do not use the kitchen sink or hand washbasin for cleaning litter boxes. Wash well using water and detergent, and then fill with boiling water and leave to stand for at least 5 minutes to kill toxoplasma eggs and other micro organisms. Finally leave to dry or dry with a disposable cloth or paper towel. Certain animals are more likely to carry diseases that may spread to humans:- Stray animals; Sick animals/birds; Wild animals/birds; Animals with diarrhoea; Exotic animals; Cage birds; Tropical fish; Domestic pets who hunt and eat rodents or birds; Reptiles (iguanas, lizards etc) carry exotic salmonella species that may be harmful to children under five or other vulnerable adults. Good general hygiene and hand washing are essential for risk reduction. By ensuring that all the above advice is followed, the physical and psychological benefits of having pets should improve the quality of life of the service users. 22. ADMISSION, 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 transfer to ensure the provision of optimum care and prevent further transmission of infection. An example of documentation that can be completed when discharging or transferring service users can be found in Appendix IMMUNISATION OF SERVICE USERS Care home owners should ensure that service users are up to date with relevant immunisations Influenza The Department of Health advises that all service users in residential care are immunised annually for seasonally influenza and for pandemic influenza as and when appropriate Pneumococcal vaccine A single dose of vaccine is recommended for all those aged 65 years and over and for those aged less than 65 who may be considered at increased risk from pneumococcal infection. 24. 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. NHS Stoke on Trent/Infection Prevention and Control Team March

89 All antimicrobial prescribing should be in accordance with NHS Stoke on Trent s antimicrobial prescribing guidelines 2007, 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. The prescription must include a clear stop date. 25. LAST OFFICES 25.1 Reporting deaths Regulation 37 of the Care Home Regulations 2001 requires all deaths to be reported to the Care Quality Commission without delay. A verbal notification should always be followed up in writing. If the death occurred from a serious infectious condition that may have public health implications, the clinician should inform the Health Protection Unit at the earliest opportunity. Even anticipated deaths may give rise to enquiries, and it is easier for the Health Protection Team to deal with these if they have already received information Handling the deceased person It is important to consider the cultural elements concerning death and preparation of the deceased person. Refer to any local policies or discuss this with the service user, family or informal carers even before death if possible. Inappropriate handling may cause offence. Most bodies pose little risk of infection but sensible precautions will reduce the risks even further. The infection prevention and control measures that were followed when the service user was alive should be followed after death. Disposable gloves and apron should be worn when washing and preparing the body. Clean dressings should be applied to any wounds or leakage sites and secured with tape or a loose bandage to prevent any further leakage from the site. The use of pins should be avoided since they present a potential hazard to others. It is important to contact the funeral director as soon as the death has been certified, because the body needs to be moved to a cool environment as soon as possible. Decomposition occurs rapidly, particularly in hot weather or an overheated room, and may create a bacterial hazard and be unpleasant for those handling the body. If it is anticipated that there may be a delay in certifying the death for some hours, it could be helpful to forewarn the funeral director so that plans can be made to collect the body later. Cool the room where the body lies, by turning off radiators and opening a window. In the event of a Coroner s post-mortem, any tubes must be plugged and covered with a dressing pad and secured to the body with tape or bandage. Dressings, drainage tubes etc should be removed before the body is transferred to the undertaker unless a Coroner s post-mortem is likely. Inform the funeral director if the body has a pacemaker fitted and if there is a known, or suspected, infection hazard. NHS Stoke on Trent/Infection Prevention and Control Team March

90 25.3 Body bags The body of a person who was suffering from an infectious disease at the time of death may pose a risk to those who handle it after death. If there is a known infection risk a Danger of Infection label should be attached to the outside of the body bag. Body bags should be used and the funeral director informed of the potential hazard if the individual had one of the following diseases when they died:- Blood borne viruses; Pulmonary TB; CJD; Psittacosis; Body bags are also advised when there has been no known infection but when there are large amounts of body fluids present that can not be contained by the shroud ( a Danger of Infection label is not required in this situation). 26. 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 organisations uniform and dress code. Examples of good and poor practice are shown in the following table Table 11 Examples of good and poor practice for uniform/dress code Good Practice Wear short sleeves when providing care to enable good hand hygiene. 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 Poor practice Go shopping and other public places whilst wearing uniform 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 a fabric that is able to withstand a wash temperature of 60 o C. NHS Stoke on Trent/Infection Prevention and Control Team March

91 If care workers wear their own clothes in the workplace similar hygiene measures should be followed. 27. OCCUPATIONAL HEALTH 27.1 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 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. 28. 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. Key considerations include: Size of rooms; Availability of isolation rooms or single 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; NHS Stoke on Trent/Infection Prevention and Control Team March

92 Decontamination facilities; Laundry and linen services; Catering and food hygiene; Waste segregation, storage and disposal; Changing facilities; Service lifts / pneumatic delivery systems; 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 29.1 Induction 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. In 2005, Skills for Care, the strategic development body for the adult social care workforce launched the Common Induction Standards. These are mapped to the General Social Care Council Code of Practice for social care workers which describe the standards of professional conduct and practice required of social care workers as they go about their daily work. The Common Induction Standards include a knowledge set for prevention and control of infection 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. Skills for Care have developed a knowledge set on the prevention and control of infection to support ongoing training. 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: NHS Stoke on Trent/Infection Prevention and Control Team March

93 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. 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: DH_ Department of Health (2008) Clean, safe care: reducing infections and saving lives. London: DH. Available from: DH_ Department of Health (2006) Essential steps to safe, clean care: reducing healthcareassociated infections. London: DH. Available from: DH_ NHS Stoke on Trent/Infection Prevention and Control Team March

94 Department of Health (2007) Saving Lives: reducing infection, delivering clean and safe care. London: DH. Available from: DH_ Department of Health (2006) Standards for better health. London: DH. Available from: DH_ Department of Health (2004) Towards cleaner hospitals and lower rates of infection: a summary of action. London: DH. Available from: 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: DH_ 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: DH_ Department of Health (1995) HSG (95) 10: Hospital infection control. London: DH. Available from: /DH_ Ambulance guidelines Department of Health (2008) Ambulance guidelines: reducing infection through effective practice in the pre-hospital environment. London: DH. Available from: 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: NHS Stoke on Trent/Infection Prevention and Control Team March

95 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: 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: 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: DH_ Pratt RJ, Pellowe CM, Wilson JA, Loveday HP et al (2007) epic2: National evidencebased guidelines for preventing healthcare associated infections in NHS hospitals in England. Journal of Hospital Infection 65 (Supplement). Available from: NHS Stoke on Trent/Infection Prevention and Control Team March

96 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: DH_ Department of Health (2002) Good practice guidelines for renal dialysis/transplantation units: prevention and control of blood-borne virus infection. London: DH. Available from: DH_ Confidentiality Department of Health (2003) Confidentiality: NHS Code of Practice. London: DH. Available from: 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: = Clostridium difficile Department of Health/Health Protection Agency (2009) Clostridium difficile infection: how to deal with the problem. London: DH. Available from: DH_ NHS Stoke on Trent/Infection Prevention and Control Team March

97 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: /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: 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 NHS Stoke on Trent/Infection Prevention and Control Team March

98 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: DH_ Department of Health (2008) MRSA screening operational guidance 2. London: DH. Available from: 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: medicalofficerletters/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: 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 NHS Stoke on Trent/Infection Prevention and Control Team March

99 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: DH_ 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: 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: NHS Stoke on Trent/Infection Prevention and Control Team March

100 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 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: NHS Stoke on Trent/Infection Prevention and Control Team March

101 Skills for Care (2005) Common Induction Standards Social Care (Adults, England). Leeds: Skills for Care. Available from: _induction_standards.aspx Skills for Care (2005) Knowledge set for infection prevention and control Social Care (Adults, England). Leeds: Skills for Care. Available from: _control.aspx Health Protection Agency (2009) Introduction to infection control in care homes A series of short films. London: HPA. Available from: 568?p= Environmental disinfection Department of Health/Health Protection Agency (2009) Clostridium difficile infection: how to deal with the problem. London: DH. Available from: 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: /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: ursingofficerletters/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: dguidance/dh_ NHS Estates (2002) HFN 30: Infection control in the built environment: design and planning. Available from: NHS Stoke on Trent/Infection Prevention and Control Team March

102 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: ww.nrls.npsa.nhs.uk/resources/patient-safety-topics/environment/ 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: 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: NHS Stoke on Trent/Infection Prevention and Control Team March

103 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: 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: NHS Stoke on Trent/Infection Prevention and Control Team March

104 Department of Health (1996) HSG (96) 20: Management of food hygiene and food services in the NHS. London: DH. Available from: s/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: 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: NHS Stoke on Trent/Infection Prevention and Control Team March

105 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: 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: /DH_ Department of Health (1996) Addendum to HSG 93 (40): Protecting health care workers and patients from hepatitis B. Available from: Department of Health (2000) HSC 2000/020: Hepatitis B infected health care workers. London: DH. Available from: DH_ Department of Health (2000) Hepatitis B infected health care workers. Guidance on implementation of Health Service Circular 2000/020. London: DH. Available from: DH_ Department of Health (2007) Hepatitis B infected healthcare workers and antiviral therapy. London: DH. Available from: DH_ Department of Health (2002) HSC 2002/010: Hepatitis C infected health care workers. London: DH. Available from: s/dh_ NHS Stoke on Trent/Infection Prevention and Control Team March

106 Department of Health (2002) Hepatitis C infected health care workers. Guidance on implementation of Health Service Circular 2002/010. London: DH. Available from: s/dh_ Department of Health (2005) HIV-infected health care workers: guidance on management and patient notification. London: DH. Available from: e/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: 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: e/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: NHS Stoke on Trent/Infection Prevention and Control Team March

107 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: /DH_ Management of occupational exposure to blood-borne viruses and postexposure 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: /DH_ PHLS Hepatitis Subcommittee (1992) Exposure to hepatitis B virus: guidance on postexposure prophylaxis, CDR Review 2(9): 1 5. Available from: 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: Statutory Instrument 2002 No. 618: The Medical Devices Regulations Available from: NHS Stoke on Trent/Infection Prevention and Control Team March

108 Medicines and Healthcare products Regulatory Agency Changes to the registration of medical devices. Available from: 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: DH_ Department of Health (2007) Transport of infectious substances best practice guidance for microbiology laboratories. London: DH. Available from: 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: 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: /DH_ Occupational health NHS Employers (2007) The healthy workplaces handbook. Available from: NHS Stoke on Trent/Infection Prevention and Control Team March

109 Department of Health (2007) Health clearance for tuberculosis, hepatitis B, hepatitis C and HIV: New healthcare workers. London: DH. Available from: 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: /DH_ Department of Health (1995) HSG (95) 10: Hospital infection control. London: DH. Available from: DH_ 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: DH_ NHS Stoke on Trent/Infection Prevention and Control Team March

110 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: fofficerlettere/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: 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: DH_ Pratt RJ, Pellowe CM, Wilson JA, Loveday HP et al (2007) epic2: National evidencebased 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: 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: NHS Stoke on Trent/Infection Prevention and Control Team March

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

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113 APPENDICES NHS Stoke on Trent/Infection Prevention and Control Team March

114 NHS Stoke on Trent/Infection Prevention and Control Team March

115 THE HEALTH AND SOCIAL CARE ACT 2008 In order to help you assess the position of your organisation in meeting the requirements of Health and Social Care Act 2008 available from the Infection Prevention and Control Team of NHS Stoke have devised the following checklist for you to complete. Completion of this check list should assist you and your organisation to action plan to meet the requirements of the Health and Social Care Act. The check list is for the registration requirement Cleanliness and Infection Control This requires providers to protect people against the risks of acquiring infections, using compliance guidance set out in the Code of Practice for health and adult social care on the prevention and control of infections and related guidance. All health and social care providers will need to comply with the Act from October If you need any further information please contact the Community Infection Prevention and Control Team on Criteria 1 Have in place 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 the other users may pose to them. Requirement Yes No Examples of evidence to demonstrate compliance Yes No Registered provider has an agreement within the organisation that outlines its collective responsibility to minimise the risks of infection and the general means Risk assessments for infection prevention and control Notes of board/management team meetings by which it will prevent and control such risks Infection control included in Statement of Purpose Job descriptions for DIPC/IPC lead A designated Director of Infection Prevention and Control(DIPC)/Infection Prevention and Control Lead(IPC Lead) who is accountable directly to the registered provider. The DIPC/IPC Lead produce an Annual report/statement on infection prevention and control Assurance framework to demonstrate that infection prevention and control is an integral part of quality assurance Notes of meetings between IPC Lead and registered provider Infection prevention and control links Role profile and objectives for infection control links Training records for IPC Lead and IC links Annual statement/reports and records of discussion with registered provider Risk assessments relating to infection prevention and control Infection prevention and control policies and procedures appropriate to the organisation Action plans following occurrences of infection Reports of outbreaks/incidents of infection to the CQC and the HPA Action plans following review of IPC Leads statement/report 1 NHS Stoke on Trent/Infection Prevention and Control Team March

116 Requirement Yes No Examples of evidence to demonstrate compliance Yes No Infection prevention and control programme Annual infection control programme that identifies priorities for action, clear objectives and reports progress. Audit programme for infection prevention and control Audit programme Audit results Infection control training programme for all staff Audit action plans Copy of training programme/training materials Training records to cover all staff groups Joint working between staff and care organisations to share information on infection status when moving service users between care providers Admission, discharge and transfer policy or procedure Completed paperwork for admission, discharge and transfer of service users Criteria 2 Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections Requirement Yes No Examples of evidence to demonstrate compliance Yes No Premises and facilities provided are in accordance with best practice guidance. Infection prevention and control advice is obtained planning new build or refurbishing existing premises Notes of meetings with infection prevention and control specialists Designated lead for cleaning and decontamination Job description for designated lead Lead managers access appropriate expert on aspects of cleaning services. Notes of meetings with appropriate experts.. Cleaning guidelines endorsed by local experts Clear roles and responsibilities for cleaning Job description 2 NHS Stoke on Trent/Infection Prevention and Control Team March

117 Requirement Yes No Examples of evidence to demonstrate compliance Yes No All parts of the premises from which it provides care are suitable for the purpose, kept clean and maintained in good physical repair and condition. Policy for cleaning the environment and equipment Cleaning schedules and frequencies for the environment and equipment Audit results and action plans Appropriate provision of linen/laundry services Policy and procedures for the provision of linen and laundry appropriate to the type of care Adequate provision of hand washing facilities and antimicrobial rubs Hand wash facilities to include paper towels and liquid soap available at all hand wash sinks Antimicrobial rubs available for use at point of care Person in charge of area responsible for maintenance o cleaning standards Job description Criteria 3 Provide suitable accurate information on infections to service users and their relatives Requirement Yes No Examples of evidence to demonstrate compliance Yes No Information for service users and visitors to help them assist in the prevention and control of infections Annual report/statement from IPC Lead Information leaflets for service users and visitors on how they can help prevent infection Posters Criteria 4 Provide suitable accurate information on infections to any person concerned with providing further support or nursing/medical care in a timely fashion. Requirement Yes No Examples of evidence to demonstrate compliance Yes No Accurate information communicated in an appropriate manner between care providers Admission, discharge, transfer policy/procedure to include details on infection risks/status Copies of completed documentation Infection records 3 NHS Stoke on Trent/Infection Prevention and Control Team March

118 Criteria 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 other people Requirement Yes No Examples of evidence to demonstrate compliance Yes No Registered providers of accommodation receive advice from suitably informed Infection control experts and the consultant in communicable disease control. Service user s notes with details of advice given by infection prevention and control experts. Contact details available Service users care plans and care pathways Records of reports of outbreaks to the HPA Outbreak reports with outcomes and lessons learnt Criteria 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 Requirement Yes No Examples of evidence to demonstrate compliance Yes No All staff, contractors and others are aware of their responsibilities for infection control Job descriptions Role profile and objectives for IPC Lead and IC links Service level agreements and contracts Training records Induction and training packs Criteria 7 Provide or secure adequate isolation facilities Requirement Yes No Examples of evidence to demonstrate compliance Yes No Adequate isolation facilities Isolation Policy/Procedure Single rooms with en suite facilities Protocol for securing single room accommodation for service users when required 4 NHS Stoke on Trent/Infection Prevention and Control Team March

119 Criteria 8 Secure access to laboratory support as appropriate Not Applicable to care homes Criteria 9 Have and adhere to policies designed for the individuals care and provider organisations that will help to prevent and control infections Requirement Yes No Examples of evidence to demonstrate compliance Yes No Evidence based policies/procedures are in place for infection prevention and control to include: Standard infection prevention and control precautions Hand hygiene; Personal Protective Equipment Aseptic technique Outbreaks of communicable infection Isolation of service users with an infection Safe handling and disposal of sharps Blood borne viruses including prevention of occupational exposure to blood borne viruses and management of post exposure prophylaxis Closure of premises to new admissions Disinfection and decontamination of equipment and the environment. Including purchase, cleaning maintenance and disposal of equipment. Single use medical devices Management of outbreaks and infection with specific alert organisms Safe handling and disposal of waste Packaging, handling and delivery of laboratory specimens Care of deceased persons (Last offices) Use and care of invasive devices Surveillance and data collection Dissemination of information Uniform and Dress Code Immunisation of service users Copy of policies /procedures marked with a review date (electronic or paper copies) 5 NHS Stoke on Trent/Infection Prevention and Control Team March

120 Requirement Yes No Examples of evidence to demonstrate compliance Yes No Audit of compliance with policies and procedures Audit results and action plans Each policy/procedure indicates ownership, authorship and scope. There a system in place to monitor and review policies and procedures at least every two years including updating with new published evidence and guidance Care workers have access to the policies/procedures and is there a system for dissemination of information Copy of policies and procedures Policies with review date within the last 2 years Electronic/Paper copies of policies and procedures Notes of staff meetings Criteria 10 Ensure so far as is reasonably practical, that care workers are free of and 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. Requirement Yes No Examples of evidence to demonstrate compliance Yes No Care workers can access occupational health services or occupational health advice Occupational health policies in place: Service level agreement with provider of occupational health service advice via insurance company, GP or occupational health agency Copy of policies Pre employment screening for communicable diseases Immunisation of staff where appropriate if there is a risk of occupational exposure to infection Responsibilities of staff to report illnesses Circumstances under which staff may need to be excluded from work There is a programme of ongoing education in prevention and control of infection for new and Pre employment screening questionnaire Occupational health records Training programme existing staff Training records for all staff groups Staff are aware of their responsibilities for the prevention and control of infection Job descriptions and personal development plans 6 NHS Stoke on Trent/Infection Prevention and Control Team March

121 APPENDIX 2 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 Management Board/Registered provider Care Home Manager Infection Control Lead Infection control links Care workers 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. frequency and training records. To include NHS Stoke on Trent/Infection Prevention and Control Team March

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123 SUGGESTIONS FOR STATEMENT FOR INCLUSION IN JOB DESCRIPTIONS APPENDIX 3 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 March

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125 Infection Control Audit Tool Care Homes (Adapted from the ICNA Audit Tools 2005) APPENDIX 4 The tool is broken down into four sections: 1 Management and organisation 2 Environmental audit 2.1 General environment and equipment 2.2 Surfaces 2.3 Kitchens 2.4 Bathrooms and toilets 2.5 Dirty utility 2.6 Domestics room 2.7 Bedrooms 3 Infection control practices 3.1 Hand hygiene 3.2 Personal protective equipment 3.3 Spillages 3.4 Laundry 3.5 Waste disposal 3.6 Handling of sharps 3.7 Isolation 3.8 Outbreaks 4 Clinical practices 4.1 Enteral feeding 4.2 Urinary catheters 4.3 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 Compliance Levels: total number of yes answers x 100 = % total number of yes and no responses 85% and above Compliant 76 84% Partial compliance 75% or less Minimal compliance NHS Stoke on Trent/Infection Prevention and Control Team March

126 Audit tools INFECTION CONTROL AUDIT TOOLS Care Homes Date: Organisation. 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 Chief Executive/Managing director/home owner receives regular reports regarding infection prevention and control 2 There is a designated lead for infection control within the home 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 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 is a system in place for dissemination of policies to care workers. 9 Care workers have access to the infection control policies/procedures. 10 There is an annual programme of audit of infection control policies and procedures 11 There is local infection control guidance on the transfer of patients in and out of the home 12 Care workers are aware of the need to report signs and symptoms of infection 13 There is written guidance for service users with MRSA 14 There is written guidance for service users with Clostridium difficile 15 Infection control policy is accessible to all care workers 16 Care workers are aware of the content of the policy 17 Care workers are aware of the notification procedure for notifiable diseases 18 Infection control is included in care workers induction programmes 19 All care workers receive annual infection control training 20 Records of all infection control training kept Yes No N/A Evidence/Comments NHS Stoke on Trent/Infection Prevention and Control Team March

127 21 Infection control is included in care workers job descriptions 22 Infection control is included in care workers appraisals 23 Infection control issues are taken into consideration at the planning and design stage of refurbishment /new build 24 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 comprehensive cleaning schedules based on current guidance/best practice 2 Organisational structures are in place to ensure compliance and auditing of cleaning schedules 3 Overall appearance of the environment is tidy and uncluttered with only appropriate, clean and well maintained furniture used. 4 All chairs and stools in clinical/communal areas are covered in an impermeable washable materials e.g. vinyl 5 Furniture is in a good state of repair (surfaces and fabric intact) 6 Rooms allocated for clinical practice are not carpeted 7 Fabric of the environment and equipment smells clean, fresh and pleasant 8 Furniture, fixtures and fittings are visibly clean with no visible body substances, dirt or debris 9 Floors including edges and corners are free of dust and grit 10 Curtains and blinds are free from stains, dust and cobwebs NHS Stoke on Trent/Infection Prevention and Control Team March

128 11 There is a procedure in place to regularly clean blinds/change curtains (minimum yearly)or when contaminated with blood and body fluids and following outbreaks of diarrhoea and vomiting 12 Fans are clean and free from dust Yes No N/A Evidence/Comments 13 Air vents are clean and free from excessive dust 14 Service user call bells are clean and free from debris 15 Equipment is decontaminated between service users use (hoists, commodes) 16 Equipment sent for repair is accompanied by a declaration of contamination status form 17 Care workers are aware of the single use symbol 18 There is no evidence that single use items are reused 19 There is no evidence of local reprocessing 20 Work station equipment in clinical areas are visibly clean e.g. phones, computer keyboards 20 There is an identified area for the storage of clean and sterile equipment 21 The area is clean and there are no inappropriate items of equipment 22 Hand hygiene facilities are available in the clean store 23 Shelves, bench tops and cupboards are clean inside and out, and are free of dust and spillage 24 All products are stored above floor level Totals Comments: Total number of yes answers Potential total (Number of Yes and Nos) Percentage Status Review Date 2.2 Surfaces Yes No N/A Comments 1 All high and low surfaces are free from dust and cobwebs 2 Carpets vacuumed daily NHS Stoke on Trent/Infection Prevention and Control Team March

129 3 Carpets deep cleaned every 6 months Yes No N/A Evidence/Comments 4 Hard floors vacuumed daily/or microfibre system used 5 Hard floors damp mopped daily 6 Mops stored dry/inverted 7 Mop heads machine washed daily 8 Flat surfaces damp dusted daily 9 Correct dilution of disinfectants used 10 Dilution chart/information available 11 Disinfectants stored in a locked cupboard 12 Carpets cleaned after body fluid spillage Totals Comments: Total number of yes answers Potential total (Number of Yes and Nos) Percentage Status Review Date 2.3 Kitchens Yes No N/A Comments 1 Kitchen is regularly inspected by Environmental Health Department 2 Separate hand wash basin is available with mixer elbow/foot/remote operated taps 3 Liquid soap is available in wall mounted dispenser 4 Paper towels available in wall mounted dispenser 5 Foot operated waste bin available 6 No evidence of infestation in the kitchen 7 Floor is visibly clean, free of dust and debris 8 Cleaning materials accessible and away from food 9 Cleaning equipment is colour coded and stored separately from other cleaning equipment (green in kitchen) 10 Drying cloths are disposable (paper roll) NHS Stoke on Trent/Infection Prevention and Control Team March

130 2.3 Kitchens Yes No N/A Comments 11 Opened foods are labelled with name, date of opening and stored in pest proof container 12 Milk is stored in a fridge 13 Food within expiry date 14 Cooking appliances are visible clean (toaster, microwave, cooker) 15 Kitchen trolley is clean and in a good state of repair 16 Kitchen free from left over food 17 There is a satisfactory system for cleaning crockery and cutlery e.g. dishwasher and planned maintenance programme 18 Water coolers are visibly clean and on a planned maintenance scheme 19 Fridge freezers are clean and free of ice build up 20 Fridge freezers have thermometers, temperatures are checked daily and appropriate action is taken if fridge temperature is less than 5 o C and freezer temperature is less than -18 o C 21 Fridge is free from specimens and drugs 22 Hands are washed prior to handling food 23 There is a policy for reporting care workers sickness 24 Care workers and kitchen staff are aware of the policy for reporting sickness e.g D and V and rashes 25 There are no inappropriate items in the kitchen 26 Fly screens are in place where required Totals Comments: Total number of yes answers Potential total (Number of Yes and Nos) Percentage Status Review Date 2.4 Bathrooms and toilets Yes No N/A Comments 1 Bathrooms/washrooms/toilets are clean 2 Baths and bath mats are cleaned after use by each service user NHS Stoke on Trent/Infection Prevention and Control Team March

131 2.4 Bathrooms and toilets Yes No N/A Comments 3 Cleaning materials available and stored correctly (red for bathrooms) 4 There is evidence that bath and sink taps and showers not in use are run through at least weekly 5 Paper towels are available in wall mounted dispenser 6 Liquid soap is available in wall mounted dispenser 7 Waste bins are foot operated 8 Shower curtains and bath mats are free from mould and stored clean and dry 9 Service users have their own toiletries 10 Bathrooms are not used for equipment storage 11 Baths, sinks and accessories are clean 12 Wall tiles and wall fixtures (including soap dispensers and towel holders) are clean and free from mould 13 Floors including edges are free of dust and grit 14 Hoists are cleaned after use 15 Hoist slings are dedicated for each service user/disposable/laundered after each use 16 Toilets are clean including under the seat 17 Commodes are clean and in a good state of repair Totals Comments: Total number of yes answers Potential total (total Number of Yes and Nos) Percentage Status Review date 2.5 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 NHS Stoke on Trent/Infection Prevention and Control Team March

132 5 Separate hand washing facilities are available including soap and paper towels 6 The room is clean and free from inappropriate items 7 The floor is clean and free from spillage Yes No N/A Comments 8 Floors including edges and corners are free of dust 9 Cleaning equipment is colour coded 10 Mops and buckets are stored according to the local policy 11 Mop heads are laundered daily or are disposable (single use) 12 There is a macerator/bed pan washer in each sluice 13 Macerators and bed pan washers are clean and in working order 14 Shelves and cupboards are clean inside and out and free of dust, litter or stains Totals Comments: Total number of yes answers Potential total (Number of Yes and Nos) Percentage Status Review Date 2.6 Domestic s room Yes No N/A Comments 1 Floors including edges and corners are free of dust and grit 2 Equipment used by the domestic care workers is clean, well maintained and stored in a locked area 3 Vacuum cleaners are clean and fitted with HEPA filters 4 Machines used for floor cleaning are clean and dry 5 No inappropriate materials or equipment are stored in the domestic s room 6 Products used for cleaning and disinfection comply with policy and are used at the correct dilution 7 Diluted products are discarded after 24 hours Totals Comments: NHS Stoke on Trent/Infection Prevention and Control Team March

133 Total number of yes answers Potential total (total Number of Yes and Nos) Percentage Status Review date 2.7 Bedrooms Yes No N/A Comments The following areas are all clean and free from stains and dust 1 Beds 2 Furniture, lockers and wardrobes 3 Bedside tables and chairs 4 Floors and carpets including edges and corners 5 Curtains and blinds 6 Hand wash basins 7 Mattresses and pillows 8 Bed Linen 9 Mattresses and pillows are covered in sealed waterproof covers in good condition (select a bed at random and undertake mattress test). 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 March

134 3 Infection Control Practices 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 Organisational structures are in place to ensure distribution, compliance and monitoring of the hand hygiene policy and procedure 3 Hand hygiene is an integral part of induction for all care workers. 4 Care workers have received training in hand hygiene procedures (ask a member of care workers) 5 Care workers providing care have short nails which are clean and free from nail extensions and varnish 6 No wrist watches, stoned rings or other wrist jewellery is worn by care workers delivering hands on care 7 Hand hygiene is encouraged and alcohol rub are made available for visitors 8 Posters promoting hand hygiene are available and on display 9 Hand wash facilities are clean and intact (check sinks, taps, splash backs, soap and towel dispensers) 10 Hand wash basins are dedicated for that use only and free from inappropriate items 11 There is easy access to hand wash basins 12 The hand wash basin complies with HTM 64 i.e. no plugs or overflows and the taps are not directly situated above the plughole 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 Reusable towels are not used by care workers 18 Re usable nail brushes are not used 19 Hands free bins are available close to hand wash basins 20 Care workers clean their hands before and after each care activity Totals Comments: NHS Stoke on Trent/Infection Prevention and Control Team March

135 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 Organisational structures are in place to ensure distribution, compliance and monitoring of PPE 3 Care workers have received training in the use of PPE as part of local induction 4 Sterile and non sterile gloves (powder free) and conforming to European Community standards are fit for purpose and available for care workers 5 Alternatives to natural latex rubber (NLR) are available for use by care workers and on service users with NRL sensitivity 6 Gloves are worn if there is a risk of exposure to blood and body fluids, cleaning fluids or chemicals 7 Powdered and polythene gloves are not used for clinical procedures 8 There are a range of sizes available 9 Gloves are worn as single use items 10 Hands are decontaminated after the removal of gloves 11 Gloves are stored appropriately 12 Disposable plastic aprons are worn when there is a risk that clothing or uniforms may become exposed to body fluids or become wet 13 Disposable plastic aprons are worn when preparing or serving food 14 Disposable plastic aprons are worn as single use items for each clinical procedure or episode of patient care. 15 Aprons are stored appropriately 16 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 March

136 Comments: Total number of yes answers Potential total (Number of Yes and Nos) Percentage Status Review Date 3.3 Spillages Standard Statement: The care worker will demonstrate safe handling and disposal of body fluids 1 There is a policy/procedure for dealing with spills of body fluids 2 Structures are in place to ensure distribution, compliance and monitoring of the body fluid spillage policy and procedures 3 Care workers have received training in dealing with body fluid spills 4 Care workers who come into contact with body fluid spillages have been immunised against hepatitis B 5 Care workers are aware of the action to take in the event of an inoculation incident 6 Equipment used to clear body is disposable Yes No N/A Comments 7 Appropriate disinfectants/spillage kits for cleaning body fluid spillages such as sodium hypochlorite 10,000 ppm (Milton diluted 1in 10) 8 Furniture that has been contaminated with body substances 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 March

137 3.4 Laundry Standard Statement: Linen is managed and handled appropriately to prevent cross infection 1 Clean linen is stored away from dirty linen and in a dust free environment 2 There is a flow of dirty to clean with no clean items passing through the dirty area 3 Soiled linen is washed immediately and kept in a designated dirty area prior to washing 4 Soluble alginate bags are used for foul and or infected linen contaminated with blood and body fluids 5 Linen is washed at 65 o C for at least 10 mins or as high as the fabric manufacturers recommended temperature 6 A sluice cycle is available on machines Yes No N/A Comments 7 Laundry care workers receive training and are competent in the use of machines 8 Gloves and aprons are worn for handling soiled linen 9 Linen is transported in designated linen bags 10 Linen is ironed before use 11 Personal linen is designated for each service user 12 The washing machine (industrial) is operated according to the manufacturers guidance and is regularly maintained (see service record) 13 The tumble dryer (industrial) is operated according to the manufacturers guidance and is regularly maintained (see service record) 14 Designated hand washing facilities are available within the laundry room 15 Cleaning schedule for the laundry. 16 All surfaces damp dusted daily 17 Walls and floors are in a sound condition and clean with no evidence of body fluid contamination 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 March

138 3.5 Waste disposal Standard Statement: All waste from premises providing health and social 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 There is evidence that the home is registered with a licensed waste contractor (check records) 3 Care workers have received training about the correct and safe disposal of healthcare waste (check training records) 4 Waste is correctly segregated (according to current regulation) 5 Correctly colour coded waste containers/bags are in use 6 Waste bags are securely sealed and labelled and dated 7 Waste bags are no more than 2/3rds full 8 Clinical waste is not decanted from one container to another 9 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 10 All waste is collected on a regular basis by a licensed contractor at least once a week 11 Consignment notes are kept and up to date 12 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 NHS Stoke on Trent/Infection Prevention and Control Team March

139 3.6 Prevention of blood/body fluid sharp injuries bites and splashes. 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 away that reduces injury or infection 2 Organisational structures are in place to ensure distribution, compliance and monitoring of the sharps/needle stick injuries or splashes and bites policy and procedures 3 There are arrangements in place to ensure that care workers who have contact with blood and body fluids are immunised against hepatitis B 4 There are arrangements in place to ensure that care workers are dealt with appropriately in the event of needle stick/bite or splash injury 5 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) 6 All needle stick/sharps/bites/splash injuries are recorded 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 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 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 NHS Stoke on Trent/Infection Prevention and Control Team March

140 22 Sharps containers are visibly clean Yes No N/A Comments 23 Needles are not resheathed 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 3.7 Isolation Precautions Standard Statement: Nursing practices will be based on best practice and reflect infection control guidance to reduce the risk of cross infection to other service users whilst providing appropriate protection for care workers 1 There is an isolation policy/procedure in place Yes No N/A Comments 2 Isolation policy/procedure is accessible to all care workers 3 Single rooms are available for service users requiring isolation. 4 Single rooms used for isolation have hand hygiene facilities 5 Single rooms have wall mounted alcohol dispensers 6 Single rooms used for isolation have en suite facilities 7 Advice for service users requiring isolation is obtained from the CICN or HPU 8 Care workers are aware of the notification procedure for notifiable diseases 9 Where a service user is isolated for infection control reasons the service user is aware of this 10 Protective clothing is readily available on entering the isolation room 11 Reusable equipment which may become readily contaminated is dedicated for that service users use only (hoist sling, commode) 12 Used linen, waste etc is disposed of in a timely manner 13 Housekeeping care workers are aware of the local policy and procedures for cleaning isolation rooms NHS Stoke on Trent/Infection Prevention and Control Team March

141 14 Separate colour coded equipment is in use for isolation facilities 15 Isolation precautions are discontinued when no longer necessary 16 Appropriate information is available for care workers and service users for common infections e.g. MRSA and C difficile Totals Yes No N/A Comments Comments: Total number of yes answers Potential total (Number of Yes and Nos) Percentage Status Review Date 3.8 Outbreaks Standard Statement: There are systems in place to promptly identify and report an outbreak of so that appropriate measures can be put in place to prevent further spread 1 Care workers can define an outbreak (ask a member of care workers) 2 Outbreak plan readily available Yes No N/A Comments 3 Service users can be segregated in the event of an outbreak 4 Outbreak management is included in care workers training 5 Care workers report cases of communicable disease to the manager e. g scabies or gastroenteritis 6 Care home manager report and document outbreaks to the Health Protection Unit, CQC and the Community/PCT Infection Prevention and Control Nurse as soon as an outbreak is suspected 7 Care workers who are unwell stay off until treated/clinically well 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 March

142 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 Enteral Feeding 1 The feed is stored according to manufacturers instruction 2 Hand hygiene is performed prior to preparing the feed and/or any manipulation of the enteral feeding system. 3 A non-touch technique is used when connecting the giving set to the enteral tube. 4 The feeding tube is flushed with fresh tap water before and after use. 5 For immunosuppressed service users the tube is flushed with cooled freshly boiled or sterile water from a freshly opened container 6 Sterile water is single patient use. Yes No N/A Comments 7 The sterile water is labelled with patient details; the time and date opened and is discarded after 24 hours. 8 A sterile syringe is used each time the tube is flushed. 9 Sterile ready to use feeds are used whenever possible. 10 Single pre-packaged feeds are discontinued within 24 hours. 11 Single feeds that are not pre-packaged are discontinued within four hours. 12 The feed is within expiry date. 13 The feed is labelled with patient details, the time and date opened. 14 Administration sets are changed as per manufacturers guidelines or within 24 hours. 15 Single use equipment including syringes are not reused. 16 Aseptic technique is used for the care of the insertion site of PEGs for the first 48 hours. 17 Sterile dressings are used for PEG sites for the first 48 hours. 18 The stoma is washed daily with water and dried thoroughly Totals Comments: Total number of yes answers Potential total (Number of Yes and Nos) NHS Stoke on Trent/Infection Prevention and Control Team March

143 Percentage Status Review Date 4.2 Urethral catheter management 1 Urinary catheters and drainage bags are stored in an appropriate area (not in the sluice) 2 Indwelling urethral catheters are only inserted after considering alternative methods of management (reason for insertion should be documented) 3 There is evidence that the patient s clinical need for continuing catheterisation is reviewed and documented 4 Catheterisation is performed aseptically (ask a member of care workers to describe the procedure) 5 A single-use anaesthetic lubricant is used for insertion for males and females 6 Indwelling urethral catheters are connected to a sterile closed urinary drainage system or catheter valve 7 Catheter bags are positioned below the level of the bladder but above floor level 8 The connection between the catheter and the urinary drainage system is not broken except for good clinical reasons (for example changing the drainage bag in line with manufacturers instructions) 9 Catheters are secured to prevent trauma Yes No N/A Comments 10 Hand hygiene is performed before manipulating a patients catheter 11 When emptying the urinary drainage bag clean non-sterile disposable gloves and a plastic apron are worn 12 Hand hygiene is performed after removal of gloves 13 When emptying the urinary drainage bag, a separate and clean container is used for each patient and contact between the urinary drainage tap and container is avoided 14 Night bags are single use 15 Meatal cleanliness is maintained only as part of routine personal hygiene 16 Catheter specimens of urine (CSU) are only taken when clinically indicated (e.g. service user has system signs of infection), or for screening for antimicrobial resistant organisms if part of local protocol 17 CSU specimens are taken aseptically 18 Bladder irrigation, installation and washout are not used for the prevention or treatment of catheter-associated infection NHS Stoke on Trent/Infection Prevention and Control Team March

144 Totals Comments : Total number of yes answers Potential total (total Number of Yes and Nos) Percentage Status Review date 4.3 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 March

145 INFECTION CONTROL AUDIT CARE HOMES SUMMARY FEEDBACK Care Home: Date of Audit: Auditors: Standard audited % Score Level of compliance 1 Management and organisation 2 Environment and equipment 2.1 General 2.2 Surfaces 2.3 Kitchens 2.4 Bathrooms and toilets 2.5 Dirty utility 2.6 Domestics room 2.7 Bedrooms 3 Infection control practices 3.1 Hand hygiene 3.2 Personal protective equipment 3.3 Spillages 3.4 Laundry 3.5 Waste disposal 3.6 Handling of sharps 3.7 Isolation 3.8 Outbreaks 4 Clinical practices 4.1 Enteral feeding 4.2 Urinary catheters 4.3 Aseptic procedures NHS Stoke on Trent/Infection Prevention and Control Team March

146 INFECTION PREVENTION AND CONTROL ACTION PLAN Care Home: Date of Audit: Auditors: Criteria of non compliance Action taken Date Managers signature Date completed. NHS Stoke on Trent/Infection Prevention and Control Team March

147 APPENDIX 5 Role Specification for a Care Home 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 care home and to liaise with the Primary Care Trust Infection Prevention and Control Nurse (PCT IPCN) and Community Matron. They act under supervision of the care home manager to 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 user and their relatives, visitors and care workers using infection prevention and control knowledge, communication, clinical, nursing and teaching skills.. Qualifications They should be a qualified nurse at a senior level/senior carer within the home 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 Infection Prevention and Control Nurses. Responsibilities 1. To liaise between their clinical area and the PCT IPCN and Community Matron 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 care home. 3. To liaise with the person in charge of the care home, the Community Matron 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 in the care home. 5. To assist in the education of new and existing care workers in the principles of infection prevention and control as it relates to care homes. NHS Stoke on Trent/Infection Prevention and Control Team March

148 6. To carry out infection prevention and control audits and feedback results to the care home manager and highlight any problems with the Community Matron and PCT IPCN. 7. To participate in the writing, reviewing, updating and auditing of infection prevention and control procedures and standards in relation to care homes. 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 service users, relatives and care workers on appropriate aspects of care relating to 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 Must attend infection prevention and control link person meetings. 2 To take every opportunity to update and extend his/her knowledge of infection prevention and control. 3 To meet agreed objectives NHS Stoke on Trent/Infection Prevention and Control Team March

149 Infection prevention and control Link Person Objectives No. OBJECTIVE DATE ACHIEVED OR COMMENTS 1 Attend link person training 2 Agree with care home manager to discuss 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 home 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 with care home manager Audit I C practice using Essential steps tools 6 Record audit scores, action any non compliance and highlight problems to care home manager and community IPCN if necessary. Discuss results with the ward manager and feedback to the Community Matron. 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 March

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151 Cleaning of Equipment All service user equipment must be cleaned between service users (EPIC 2007) in accordance with manufacturer s instructions and to the NHS standards of cleanliness. Personal protective equipment should be worn when cleaning equipment. Care Environment The care environment should be kept clean and tidy at all times. Spillages should be cleaned up promptly. Blood and high risk body fluids should be cleaned with paper towels, water and detergent. The area should then be disinfected with a chlorine releasing agent, e.g. Milton, where this will not damage the finish or surface. The paper towels should be disposed of as clinical waste. Do not use a chlorine releasing agent to clean urine spills as there is a risk of a chemical reaction. Only water and general purpose detergent should be used. The national colour coding system (National Patient Safety Agency 2004) should be used to different areas. identify cleaning equipment for Red sanitary areas e.g. toilets, bathrooms Green kitchens Blue general areas. Yellow Isolation areas Your Health and Hygiene Long hair should be tied back whilst on duty. Uniforms and clothing should be changed on a daily basis and following any soiling. No jewellery other than a plain wedding type band should be worn. Any rashes or unexplained skin conditions should be reported to the occupational health advisor and your manager. In the event of experiencing diarrhoea or vomiting due to a possibly infectious cause, you should remain off work until free of symptoms for 48 hours. This leaflet should be read in conjunction with the Infection Prevention and Control Guidelines Sources of Advice Infection Prevention & Control Nurses Kim Gunn Tel (SoT ) Mobile Anne Gething Tel (SoT) Mobile Carol Lawton Mobile (SoT) Health Protection Unit Tel Review 2010 NHS Stoke on Trent SUPPORTING LOCAL CARE HOMES Infection Control Standard Precautions Information for Care Workers NHS Stoke on Trent/Infection Prevention and Control Team March

152 What are Standard Precautions? We may or may not know which service users have or are incubating an infection. Therefore a standard approach should be adopted when there is an identified or potential risk of exposure to blood, body fluids, secretions or excretions. The following precautions are intended to protect service users and care workers from potential infection risks. Hand Hygiene Hand hygiene is possibly the single most important measure in preventing the spread of infection. Hands must be decontaminated immediately before each and every episode of direct service user contact/care and after any activity or contact that potentially results in hands becoming contaminated (EPIC, 2007). Hands must be decontaminated, preferably with an alcohol hand rub unless they are visibly soiled (NICE 2003). Visibly soiled hands must be washed with decontaminated before starting and leaving work, before donning and after removing personal protective equipment, after handling potentially liquid soap and running water f ollowing the six- stage hand washing technique (see infection control guidelines). Hands should also be contaminated items e.g. dressings, bedpans et c, before handling food and drinks, after visiting th e toilet and after any procedure where the hands may be potentially contaminated. Before commencing work all cuts and abrasions on the hands or arms must be covered with a water proo dressing. f Sharps Management Needles, blades, razors, glass ampoules and other sharp instruments must be placed into an approved sharps container immediately after use. Needles and syringes should be disposed of as one unit and not separated. Needles should never be manually re-sheathed. Sharps bins must not be filled more than 2/3 full and must be securely closed before disposal. Always dispose of sharps at the point of use, never carry sharps. Whoever uses a sharp is responsible for its safe disposal. Sharps bins must be stored safely above floor level and away from members of the public. In the event of a sharps injury stop what you are doing immediately. Encourage bleeding by applying gentle pressure, wash the injury with soap and water and apply a waterproof dressing. Report the injury to your manager, occupational health advisor and the Health and Safety department. Please refer to the infection control guidelines for injuries where there has been significant exposure to blood or the donor is known or suspected of having HIV, hepatitis B or hepatitis C. Personal Protective Equipment (PPE) Personal protective equipment should be worn when-ever there is a risk of contact with blood, body fluids, excretions, secretions or hazardous chemicals. Following a risk assessment, vinyl or synthetic disposable gloves should be worn if contact with blood or body fluids is anticipated e.g. wound dressing, venepuncture, catheter care, handling soiled equipment or touching mucous membranes or broken skin. Disposable plastic aprons must be worn whenever there is a risk of clothing becoming contaminated. Eye and / or face protection should be worn where there is a risk of blood, body fluid or chemical splashes to the face. Gloves and aprons are single use items and must be disposed of between each service user or after each care procedure. PPE should be disposed of as clinical waste after use. In the care home setting PPE should be disposed of in orange clinical waste bags. Waste Disposal Clinical or Healthcare Locations - Any waste that is contaminated with blood, body fluids, excretions, secretions or any potentially infective material must be disposed of as clinical waste. Clinical waste must be disposed of in orange bags for incineration taking care to ensure there is no leakage of fluid. Clinical waste must be stored safely away from members of the public in a designated, secure storage area. Paper towels used for hand drying do not need to be disposed of as clinical waste unless contaminated with blood or body fluids. Domiciliary Settings - Healthcare workers in domiciliary settings should refer to the current Waste Policy for guidance. Laundry Clean linen should be stored in a clean area (not a bathroom). Disposable aprons should be worn for handling used linen. Used linen should not be carried through home loose. Always take the laundry bag/skip to the bedside. Wet or soiled linen should be placed in a clea r plastic bag before being placed in the laundry bag. Infected laundry should be placed in a red alginate bag before being placed inside a laundry bag. Don t shake dirty linen as this will increase the dispersal of dust and skin scales into the environment. NHS Stoke on Trent/Infection Prevention and Control Team March

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155 APPENDIX 8 NHS Stoke on Trent/Infection Prevention and Control Team March

156 NHS Stoke on Trent/Infection Prevention and Control Team March

157 Will the presence of MRSA delay or prevent discharge or transfer? NO MRSA should not prevent discharge or transfer. Any necessary information should be provided to the care workers that will be caring the patient. Are any additional precautions required in the patient s own home? The presence of MRSA should not affect other members of the family or other service users. Crockery and cutlery and personal items should be managed in the usual way. Primary care workers should use standard precautions. Swabbing Indwelling devices become colonised with bacteria such as MRSA. Swabbing long term urinary catheters or enteral feeding tubes should be avoided as the result is of little value and may prompt inappropriate antibiotic prescribing. Chronic wounds such as leg ulcers and pressure sores will also become colonised and should only be swabbed if there are documented clinical signs of infection. Screening The PCTs and Combined Healthcare have now adopted a screening programme for all hospital admissions. Please refer to the Trust s Policy for screening information. The infection prevention and control nurses (IPCNs) will be happy to advise. This leaflet should be read in conjunction with the Trust s MRSA Policy Sources of Advice Community Infection Prevention & Control Nurses (IPCNs) Anne Gething Tel (SoT) Mob NHS Stoke on Trent SUPPORTING LOCAL CARE HOMES Kim Gunn Tel (SoT) Mob Carol Lawton Mob (SoT) Meticillin Resistant Staphylococcus aureus (MRSA) in primary and community care Health Protection Unit Tel UHNS Pathology Laboratory Main office Tel Useful websites Review Date: 2010 Information for Care Home Staff NHS Stoke on Trent/Infection Prevention and Control Team March

158 Introduction What is an MRSA? MRSA is an abbreviation for Meticillin resistant Staphyococcus aureus. MRSA is a strain of Staphylococcus aureus which is resistant to Meticillin or Flucloxacillin. Staphylococcus aureus Staphylococcus aureus is a bacterium which can be carried on the skin, this is referred to as colonisation. Approximately 30% of the population are 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. Colonisation & Infection? Colonisation The micro-organism is present but the person is unaware and there are no signs of infection. Infection If MRSA enters the body and causes a host response, such as pyrexia or inflammation, this is referred to as an infection. How does MRSA affect the service user? MRSA is an opportunist organism and has the potential to cause infections ranging from a minor skin infections to fatal septicaemia. Are staff at risk of acquiring MRSA? A percentage of people, including care workers may carry MRSA on their skin and in their nose. Healthy people should not be at risk from MRSA. Which service users are at risk of acquiring MRSA in a community setting? The following factors may increase the risk of MRSA acquisition Indwelling devices Surgical Wounds or injuries Chronic wounds such as Pressure sores Repeated hospital admissions How is MRSA transmitted? The commonest route of transmission is via contaminated hands. There may also be a risk of acquisition from contaminated equipment or the environment. What can be done to prevent the spread of MRSA? Minimizing the risk relies upon care workers understanding and applying Standard Precautions (Refer to Standard Precautions leaflet and Infection Prevention and Control Guidelines). Hand hygiene is the simplest but most important measure in preventing the spread of infection. Visibly soiled hands must be washed using liquid soap and water, using the recommended six-stage technique, immediately before each and every episode of direct service user contact or care. If hands are not visibly soiled alcohol hand gel may be used (EPIC 2007). Cleaning is a key element in preventing cross infection. The environment and equipment must be cleaned to National Patient Safety Agency standards. Indwelling devices rapidly become colonised with bacteria such as MRSA. The need for indwelling devices should be clearly documented, regularly reviewed (NICE, 2003), and if possible removed at the earliest opportunity. Antibiotic Prescribing Resistant micro-organisms are a threat to patient safety, consequently, all prescribing must be in accordance with Trust antimicrobial prescribing guidelines. Will the service user require treatment? Treatments must be specific to the individual. If the service user has signs and symptoms of infection, treatment should reflect the documented assessment. Always treat the service user not the laboratory report In the care home setting does the service user require isolation? A service user with MRSA and any of the following should have a single room productive respiratory tract infection exfoliating skin condition large, open exudating wounds highly resistant strain of the organism Unless a risk assessment indicates that that this is unsafe or detrimental to the service user. NHS Stoke on Trent/Infection Prevention and Control Team March

159 Where can you get further information? Please feel free to ask the doctor, care home manager if you have any questions or queries about MRSA, or alternatively you can speak to one of the Infection Prevention and Control Nurses at NHS Stoke on Trent October 2008 (Review Oct 2010) NHS Stoke on Trent SUPPORTING LOCAL CARE HOMES Meticillin Resistant Staphylococcus aureus (MRSA) Information for service users and visitors about this infection NHS Stoke on Trent/Infection Prevention and Control Team March

160 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. MRSA is part of the Staphyococcus aureus (SA) bacteria family. SA is a type of bacteria that can live harmlessly on human skin. It is found in the nose of 20-40% of normal healthy skin and skin creases. MRSA is a particular type of SA which has developed a resistance to most antibiotics. It can live harmlessly on the skin and in some chronic wounds, but can cause problems if it gets into a skin break such as a surgical wound or sterile body cavity e.g. the bladder. How does a person get MRSA? MRSA can be caught and passed on almost anywhere. Anyone carrying the germ on their hands or skin can pass it on to someone else. Someone carrying the germ on their hands or skin can pass on the germ by touch. It can also be found in the environment or on equipment used by people carrying the germ, if high standards of cleanliness are not followed. People can carry MRSA without knowing it! Who is more at risk? Older People People who have long term health problems People with repeated hospital admissions People whose immune system is low People who are very ill where their immune system may be very low and their body not able to cope with this additional problem How is it diagnosed and treated? All treatment must be specific to the person with the germ. If the person has clinical signs of an infection e.g. a raised body temperature, the doctor treating them will decide the best, most appropriate treatment. If the MRSA is found in a chronic wound e.g. leg ulcer, but the person has no signs of infection, there may be no need for treatment. The doctor in charge of the person s care will make the decision. You may have MRSA detected through a screening process. This is where swabs are taken from areas of the body (usually the nose, throat, perineum) prior to, or at the time of admission to hospital. Care of the service User with MRSA 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. Hand washing by care workers is the most important method of preventing the spread of infection. Care workers will wear aprons and gloves when carrying out procedures. Service users may share a room as long as neither they nor the person with whom they are sharing has open sores or wounds, catheters or other invasive devices. They may receive visitors and go out of the home, for example to see their friends or family. They may join other service users in communal areas such as sitting or dining rooms, so long as any sores or wounds are covered with an appropriate dressing which is regularly changed. No additional precautions are necessary for laundry. Visitors can assist in the prevention of spread of MRSA by Washing their hands upon entering AND wash their hands upon leaving alcohol gel dispensers are available in care homes for this purpose. Adhering to the visiting times and the number of visitors allowed. Not using the service users toilet when visiting the care home. Not sitting on the beds. Not visiting if they are feeling unwell or have an infection e.g. flu, diarrhoea. If you are unsure, please telephone and ask before visiting. NHS Stoke on Trent/Infection Prevention and Control Team March

161 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 (under arms), 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 patient 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 inform your doctor. 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. Further information? Please feel free to ask your doctor, Senior Clinical Nurse (Matron) or ward staff if you have any questions or queries about MRSA, or alternatively you can speak to one of the Infection Prevention and Control Nurses. March 2009 (review March 2011) Printed by Sherwin Rivers Ltd., Waterloo Road, Cobridge, Stoke-on-Trent, ST6 3HR. Tel: (01782) Fax: (01782) Ref Stoke on Trent Community Health Services Stoke on Trent MRSA Screening - Meticillin Resistant Staphylococcus aureus Screening Information for patients and visitors NHS Stoke on Trent/Infection Prevention and Control Team March

162 What is MRSA? MRSA is an abbreviation for Meticillin Resistant Staphylococcus aureus. MRSA is a strain of Staphylococcus aureus which is resistant to commonly used antibiotics. MRSA is part of the Staphylococcus aureus (SA) bacteria family. SA is a type of bacteria that can live harmlessly on human skin. It is found in the nose of 20-40% of healthy people and is commonly found in skin creases. It can live harmlessly on the skin and in some chronic wounds, but can cause problems if it gets into a skin break such as a surgical wound or sterile body cavity such as the bladder. The majority of people who carry MRSA are not aware that they carry it, and most of them do not have any symptoms. How does a person get MRSA? Anyone carrying the germ on their hands or skin can pass it to someone else. It can also be found in the environment or on equipment used by people carrying the germ, if high standards of cleanliness are not followed. What is screening and why is it being done? It is estimated that 7% of all patients who are admitted to hospital have the bacterium on their skin or in their nose, even though they feel quite well. MRSA screening involves testing all patients 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 become infected or it is spread to other patients. By identifying those patients 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. How is the screening carried out? Swabs are taken from areas of the body (usually the nose, any open wounds, and possibly from the groin area) prior to, or at the time of admission to hospital or day care. This is usually painless, generally a tickling sensation. What happens if MRSA is found in my screening swab(s)? In such a case, the Health Professional in charge of your care will advise on what you should do. You may be advised to commence a skin decolonisation* regime usually over a 5 day period, consisting of an antiseptic skin wash and a nasal cream to apply to the inside of your nostrils. This will be explained fully, to you. Please ask to speak to your doctor or a member of the nursing team if you are concerned about any aspects of your treatment. Patients with MRSA may be cared for separately from other patients in the ward area, to reduce the chance of spreading the infection to others. Staff treating you will wear gloves and aprons as is routine, if they are carrying out any clinical procedures. Visitors will be asked to take special note of hand hygiene measures. This is standard practice. For further information, please ask for a copy of the leaflet Meticillin Resistant Staphylococcus aureus (MRSA) Information for patients and visitors about this infection. Additionally, on admission, a copy of the booklet Working to improve the Health and Welfare of Local Communities should be made available to you. * * * * * * * * *Skin decolonisation is the process by which the MRSA organisms that are multiplying on the skin are removed or the number of organisms are minimised. NHS Stoke on Trent/Infection Prevention and Control Team March

163 Where can you get further information? Please feel free to ask your doctor if you have any questions or queries about Clostridium difficile, or alternatively you can speak to one of the Community Infection Prevention and Control Nurses on April 2006 (Review April 2010) NHS Stoke on Trent Supporting Local Care Homes Clostridium difficile Information for service users and visitors about this infection NHS Stoke on Trent/Infection Prevention and Control Team March

164 What is Clostridium difficile (C. difficile)? C. difficile, or Clostridium difficile, is a bacterium (germ). Clostridium difficile lives in the gut of some people and does not normally make them ill. Why does a person develop Clostridium difficile Associated Illness? Friendly bacteria that live in the gut normally stop Clostridium difficile from growing. Some antibiotics given for infections can kill off the friendly bacteria and allow Clostridium difficile to grow and multiply. If the immune system is not able to control the Clostridium difficile, inflammation and damage of the gut follows. Who is more at risk? People who are, or have recently been treated with antibiotics People who have had bowel surgery People with feeding tubes into the stomach People who have been in hospital a long time Most of those affected are older people with serious underlying illnesses. At particular risk are those who are regular users of health services or in long term care. What are the symptoms? Some people may get one or more of the following symptoms: Watery, foul smelling green stools Temperature Abdominal pain How does it spread? People with C. difficile diarrhoea excrete large numbers of C. difficile spores into the environment. The spores can survive for a long time. Susceptible people may get C. difficile through contact with contaminated equipment or from others already infected. How is it diagnosed and treated? A sample of diarrhoeal faeces is tested for the presence of C. difficile toxins. Two antibiotics are known to be effective against the bug. Prevention and Control Care Workers There are four ways for care workers to prevent and control C.difficille Careful antibiotic prescribing and regular review to reduce the use of common antibiotics and ensure that antibiotics are appropriately used for correct length of time Isolation of service users with C. difficile, with good infection control during care, wearing gloves and aprons, away from unaffected service users in a single room. Enhanced environmental cleaning and use of a chlorine containing disinfectant to reduce environmental contamination with the bacterium and its spores. Please wash your hands whatever your job role, reducing the spread of C. difficille is everyone s responsibility. Service Users You will be asked to remain in your room until your symptoms have stopped. In doing so this will ensure that you will receive the best possible care during your illness and reduce the spread of infection to other service users. Care Workers will wear gloves and aprons when they are helping with your washing needs. If care workers are just coming into your room to talk to you, they do not need to wear gloves or aprons. An opportunity to wash your hands after you have used the toilet / commode and before your meals. Care Workers will wash their hands before and after they carry out any procedures in your room. Review of your antibiotic medication you are currently taking. Visitors People are unlikely to get infections when visiting service users in care homes. Visitors should use alcohol gel upon entering the ward AND wash their hands upon leaving the side room or bay. There is no need to wear gloves and apron, unless providing direct care. NHS Stoke on Trent/Infection Prevention and Control Team March

165 APPENDIX 13 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 March

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169 Escherichia coli (E coli) 0157 APPENDIX 15 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. NHS Stoke on Trent/Infection Prevention and Control Team March

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171 Pulmonary Tuberculosis APPENDIX 16 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 March

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173 Chickenpox/Shingles (varicella-zoster virus) APPENDIX 17 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 March

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175 APPENDIX 18 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 March

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177 Where can you get further information? Please feel free to ask your doctor if you have any questions or queries about Norovirus, or alternatively you can speak to one of the Health Protection Nurses or Community Infection Prevention and Control Nurses on December 2008 (Review Dec 2010) NHS Stoke on Trent SUPPORTING LOCAL CARE HOMES Diarrhoea and Vomiting (Norovirus) INFORMATION FOR SERVICE USERS AND VISITORS NHS Stoke on Trent/Infection Prevention and Control Team March

178 What are Noroviruses? Noroviruses Noroviruses are a group of viruses that are the most common cause of gastroenteritis (stomach bugs) in England and Wales. In the past, noroviruses have also been called winter vomiting viruses, small round structured viruses or Norwalk-like viruses. How does norovirus spread? The virus is easily transmitted from one person to another. It can be transmitted by contact with an infected person; by consuming contaminated food or water or by contact with contaminated surfaces or objects. It is transmitted by the faecal oral route, not washing hands after visiting the toilet and inadequate cleaning of contaminated surfaces. Who is at risk of getting norovirus? There is no one specific group who are at risk of contracting norovirus it affects people of all ages. The very young and elderly should take extra care if infected, as dehydration is more common in these age groups. Outbreaks of norovirus are reported frequently in semi-closed institutions such as hospitals, schools, residential, nursing homes, hotels and cruise ships. Anywhere that large numbers of people congregate for periods of time provide an ideal environment for the spread of the infection. Healthcare settings tend to be particularly affected by outbreaks of norovirus. Outbreaks are shortened when control measures in healthcare settings are implemented quickly. These include closing wards to new admissions at the beginning of the outbreak and implementing strict hygiene measures. What are the symptoms? The symptoms of norovirus infection usually begin around 12 to 48 hours after becoming infected. The illness is self-limiting and the symptoms usually last for 12 to 60 hours. A sudden onset of nausea, followed by projectile vomiting, and watery diarrhoea. Some people may have a raised temperature, headaches and aching limbs. Most people make a full recovery within 1-2 days, however some people (usually the very young or elderly) may become dehydrated and require hospital treatment. Why does norovirus often cause outbreaks? Norovirus often causes outbreaks because it is easily spread from one person to another and the virus is able to survive in the environment for many days. Because there are many different strains of norovirus, and immunity is short-lived outbreaks tend to affect more than 50% of susceptible people. How to prevent the spread If you are a service user You will be asked to stay in your own room. The care home you are in may be closed to admissions and transfers. Staff will be wearing gloves and aprons when they provide care for you. Contact with other service users will be restricted. Your visitors will be informed. Hand washing is very important after visiting the toilet and before meals. Do not share any of your food or drink with others. Open food and drink i.e. fruit bowls and water jugs will be removed. Visitors Visiting may be restricted during an outbreak, if possible children should not visit. Visitors that have symptoms of diarrhoea and/or vomiting must not visit until they have been symptom free for 48 hours. Visitors must wash their hands using the alcohol gel on entering and leaving the ward. If visitors plan to visit more than one service user, they should visit the service user affected by the norovirus last. Visitors should not eat or drink during their visit. Visitors should not socialise with other service users during their visit. Laundry If visitors are taking clothes from an infected person home to wash, they must Place the clothing in two plastic bags to transport home, ask advice from the care home staff. The clothing must be washed separately from other items. Wash at the highest temperature the clothes will tolerate. Wash hands thoroughly after placing items in the washing machine. NHS Stoke on Trent/Infection Prevention and Control Team March

179 APPENDIX 20 CHECK LIST FOR MANAGING NOROVIRUS OUTBREAKS Care Home., Please sign when control measure is in place: Date: Control Measure Signed Ensure of regular washing of hands with soap and water after caring for cases or contact with environment Isolation of symptomatic individuals Cohort nursing of symptomatic individuals Provision of gloves and aprons for wearing during contact with cases or the environment Closure of home to new admissions and closure of day care Avoid transfer to other homes/hospitals etc (unless medically indicated and after consultation with Health Protection Team) Exclusion of affected care worker from the home immediately and until asymptomatic for 48hrs Provision of notices for visitors specifying any restrictions imposed with emphasis on hand hygiene Removal of exposed food items such as fruit Cleaning and disinfection of vomit and faeces spillages promptly as per local policy Documentation of the frequency of routine ward, bathroom and toilet cleaning (increased frequency of usual practice and also cleaning of frequently touched areas) Use of freshly prepared 0.1% (1000ppm) chlorine releasing agent to disinfect hard surfaces (after cleaning with neutral detergent) Closure of home for at least 72 hrs after the last new case and 72 hrs after uncontained vomiting or diarrhoea Thorough cleaning including change of curtains Cleaning of carpets and soft furnishings with hot water and detergent or steam clean Avoidance of care worker working in affected areas from working in unaffected areas (including agency and bank care worker) Guidelines and decontamination facilities (washing, changing, and a clean uniform) available to care workers who become grossly contaminated from body fluids (blood, urine, faeces, etc) NHS Stoke on Trent/Infection Prevention and Control Team March

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181 CARE HOME.. Date Name DOB Onset date GP Admission Date INFECTION RECORDS Specimens sent Results Source Treatment Outcome NHS Stoke on Trent/Infection Prevention and Control Team March

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183 APPENDIX 22 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 23 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 Source -ve Source status unknown Do risk assessment (see Appendix 23) Yes No Report as an adverse incident & report to occupational health Care worker to attend A and E at the UHNS immediately 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 to occupational health Report as an adverse incident and report to occupational health Report as an adverse incident & report to occupational health NHS Stoke on Trent/Infection Prevention and Control Team March

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185 SHARPS INOCULATION INJURY CHECKLIST CONFIDENTIAL APPENDIX 23 RISK ASSESSMENT CHECKLIST The care home manager or immediate supervisor 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 or Health and Safety 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 INJURED CARE WORKER SHOULD ATTEND THE ACCIDENT AND EMERGENCY DEPARTMENT AT THE UNIVERSITY HOSPITAL OF NORTH STAFFORDSHIRE IMMEDIATELY. 8. If no to questions 2, 3, 4, AND 5, there is no need to contact the Health Protection Agency out of hours, 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 or your Health and Safety advisor 10. Complete an Incident report NHS Stoke on Trent/Infection Prevention and Control Team March

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

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189 PROCEDURE FOR A SHARPS FIND APPENDIX 25 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 March

190 NHS Stoke on Trent/Infection Prevention and Control Team March

191 NHS Stoke on Trent/Infection Prevention and Control Team March 2010 Dispose of dressings and gloves into the hazardous waste bag Put on clean gloves and remove dressing Basic Equipment: non-sterile gloves, sterile gloves, dressing pack, appropriate dressings, fluids for cleaning / Irrigation, hypoallergenic tape, sterile scissors, hazardous waste bag, detergent, water, paper towel & alcohol wipe 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, flat surface to put it on before applying sterile gloves Wash hands thoroughly using accepted hand washing technique, using soap and water Make sure protective apron and waste materials are disposed of as hazardous waste Wash hands after procedure thoroughly using accepted hand washing technique, using soap and water This will now be your sterile field Open sterile cleansing pack by pulling on the corners, being careful not to touch the inner surface of the sterile wrapping Check sterility and expiry dates of equipment used APPENDIX Stoke-on-Trent CHS acknowledge the development of this illustrated guideline by the University Hospital of North Staffordshire Carry out procedure i.e. clean wound and apply new dressing as necessary Gather equipment for the procedure and place on bottom shelf of trolley Clean trolley down with detergent, water, paper towel & alcohol wipe Put on clean disposable apron and disinfect hands with alcohol gel ASEPTIC TECHNIQUE

192 NHS Stoke on Trent/Infection Prevention and Control Team March

193 NATIONAL PATIENT SAFETY AGENCY COLOUR CODING APPENDIX 27 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 March