Liz Lightbown Katie Grayson, Senior Nurse Katie Grayson, Senior Nurse. All SHSC Staff

Transcription

1 Policy: Infection Prevention and Control Executive or Associate Director lead Policy author/ lead Feedback on implementation to Liz Lightbown Katie Grayson, Senior Nurse Katie Grayson, Senior Nurse Date of draft May 2015 Dates of consultation period 1 st June 15 th June 2015 Date of ratification 25 th June 2015 Ratified by Executive Directors Group Date of issue 26 th June 2015 Date for review May 2018 Target audience All SHSC Staff Policy Version and advice on document history, availability and storage Version 6: This version has changes from previous versions of this policy in all sections, including 3 new appendices providing guidance on Ebola, Carbapenemaseproducing Enterobacteriaceae & Scabies. IPC Policy June 2015 V6 Page 1 of 99

2 Section Contents Flow Chart 3 1 Introduction 4 2 Scope of this policy 7 3 Definitions 7 4 Purpose of this policy 7 5 Duties 8 6 Specific details 13 7 Dissemination, storage and archiving 13 8 Training and other resource implications 13 9 Audit, monitoring and review Implementation plan Links to other policies, standards and legislation (associated documents) Contact details References 18 Appendix 1 Standard Precautions (formerly Universal Precautions) 19 Appendix 2 Hand hygiene and guidelines for practice 24 Appendix 2a Hand washing technique 32 Appendix 3 Guidelines for the use of disposable gloves 33 Appendix 4 Prevention and management of inoculation and blood contamination injuries including bites (human) or splash injuries Appendix 5 Meticillin Resistant Staphylococcus aureus (MRSA) 37 Appendix 6 Clostridium difficile Infection 45 Appendix 7 Isolation 52 Appendix 8 Healthcare waste (formerly known as clinical waste) 58 Appendix 9 Laundry 60 Appendix 10 Staff exclusion 66 Appendix 11 Management of Specimens 67 Appendix 12 Ebola Information 72 Appendix 13 Carbapenemase-Producing Enterobacteriaceae (CPE) 74 Appendix 14 Scabies 76 Appendix 15 Management of Norovirus 79 Appendix 16 List of Diseases 86 Supplementary Sections: Section A Equality impact assessment form 94 Section B Human rights act assessment checklist 97 Page Section C Development and consultation process IPC Policy June 2015 V6 Page 2 of 99

3 Flowchart for Managing Infection Risk Ensure Standard Precautions are in Place (Refer to Appendix 1, 2 & 3) Inform Infection Prevention and Control Team on Patient Related Infection Staff Related Infection Known Organism and / or site Unknown Organism Refer to Appendix 10 to identify if staff member requires exclusion from work and duration Refer to Specific Guidance within the Appendices Administer Antimicrobial therapy in line with policy Send Sample to laboratory Refer to Appendix 11 Administer Antimicrobial therapy in line with policy If sharps related injury refer to Appendix 4 Refer to policy on the Management of Blood and Bodily Fluid Incident Form Completed Ensure that environmental cleaning, waste and laundry management appropriate (Appendix 7, 8 & 9) INFORM Caretakers & Housekeepers of any additional resources required IPC Policy June 2015 V6 Page 3 of 99

4 1. Introduction All environments that provide care to groups of patients will be conducive to the development and spread of infections. Major reservoirs of pathogens include the patient s own bacteria and other microorganisms within hospitals and community environments. Infections can be introduced through people, equipment and contaminated items. Health and Social Care Providers are required by law as laid down by The Health and Social Care Act (DH 2008) to ensure that any organisation that provides or commissions care will be able to demonstrate that the systems and processes are in place to prevent the transmission of infection or infectious diseases. Infection Prevention and Control Is expected to be at the heart of good management and clinical practice, to ensure effective protection of the public s health and minimise the risk of healthcare associated infections (HCAI s). Effective prevention and control must be embedded into everyday practice and applied consistently by everyone. All staff, both clinical and non-clinical, must be able to demonstrate good infection control and hygiene practice. For a person to become infected it must follow what can be described as the chain of infection, insomuch as there must be a source, a bacteria, virus or other organism that can cause an infection; and a means of transmission of that infection. Control methods are designed to either destroy the source or break the chain thus preventing its transmission and halting the spread & acquisition of the disease. Generally, effective decontamination, be it of hands, the environment, equipment and medical devices is core to preventing the acquisition and transmission of infections. The use of personal protective clothing and equipment provides another line of defence. For many common infections and infectious diseases, early recognition and prompt action can reduce the spread of the disease, the severity of the illness and the number of people infected. Therefore, the Trust expects its staff to adhere to the Infection, Prevention and Control Guidelines to ensure high standards of care are applied to protect patients, staff and visitors from being exposed to infection. Patients and their relatives rightfully expect care to be delivered in an environment where risks are proactively reduced and the control of healthcare associated infection is recognised in all areas of the Trust to an important aspect in the provision of care. This can only happen if all staff accepts responsibility for their role in ensuring good infection control practice is adhered to at all times. The Department of Health in the NHS Plan highlighted three key elements to achieve control. These are: SURVEILLANCE To monitor how we are doing and to provide data on resistant organisms, illness and antimicrobial usage. ANTIBIOTICS Prudent use to reduce the pressure for resistance. INFECTION CONTROL To reduce the spread of infection in general and of antimicrobial resistant organisms a clean environment with a high standard of infection control practices is required. IPC Policy June 2015 V6 Page 4 of 99

5 Prudent antimicrobial prescribing is a significant component of an effective infection prevention and control programme. Inappropriate antibiotic prescribing in some instances predisposes patients to further infections and promotes the emergence of resistant bacteria. This policy sets out the approach of SHSCT to the implementation of infection prevention and control in accordance with government directives, evidence-based research and best practice. There are legal requirements to protect service users, staff and visitors from harm. The policy should therefore be read in conjunction with the following national documents: NHSLA Risk Management Standards for Mental Health & Learning Disability Trusts 2013/2014 Department of Health (2013) UK five year antimicrobial resistance strategy 2013 to Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) (2011) Antimicrobial stewardship 'Start smart then focus'. Department of Health CFPP (2013) Decontamination of linen for Health and Social Care: Social Care Care Quality Commission (2015) How CQC regulates: Specialist Mental Health Services Provider handbook. Department of Health (2010) High impact intervention: urinary catheter care bundle. Department of Health (2010) The Health and Social Care Act 2008: code of practice on the prevention and control of infections and related guidance. National Audit Office (2009) Reducing healthcare associated infections in hospitals in England. Department of Health (2014) 2015/16 NHS Outcomes Framework. Department of Health (2015) Clinical Commissioning Group (CCG) Outcomes Indicator Set. Health and Social Care Information Centre (2013) NHS safety thermometer. Health and Social Care Information Centre Information Services Portal. Public Health England (2013) Management of infection guidance for primary care. Public Health England and Department of Health Expert Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) (2013) Antimicrobial prescribing and stewardship competencies. NICE Clinical Guideline 139 (2012) Prevention and control of healthcare-associated infections in primary and community care NICE Quality Standard 61 (2014) Infection Prevention and Control IPC Policy June 2015 V6 Page 5 of 99

6 Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) (2011) Antimicrobial stewardship 'Start smart then focus. Control of Substances Hazardous to Health Regulations (COSHH) 2002 Health and Safety at Work Act 1974 IPC Policy June 2015 V6 Page 6 of 99

7 2. Scope This is a Trust-wide policy and whilst it is relevant to all members of staff it is recognised that some staff groups have a greater exposure to infection risks than others. However, all staff groups need to be aware of infection prevention and control and no-one should consider themselves risk free. 3. Definitions Patient this term is used when referring to the NHS population as a whole Service user refers to a person who uses the services of SHSC regardless of where care is provided. A care facility is a hospital, residential/nursing home, clinic, out-patient department which provides medical and/or any type of care related services aimed at maintaining good health, (physical and mental), especially through the prevention and treatment of disease. Care staff refers to both health and social care staff including staff that support service users within the community. Risk is the chance of an undesirable outcome. Risk includes consideration of both the likelihood and severity of the outcome. (See Incident Reporting & Investigation Policy and Risk Guidance). A hazard is something that has the potential to cause harm. (See Incident Reporting & Investigation Policy and Risk Guidance). Healthcare Associated Infections (HCAI) are those that arise during any contact with healthcare, either in hospital or in the community, whether in service users themselves or in the health or social care worker undertaking intervention. HCAIs do not originate from the service users original diagnosis. An infection which becomes clinically evident after 48 hours of admission to hospital, residential or nursing home is considered to be a HCAI. Infection Prevention and Control is the prevention and management of infection through the application of research based knowledge to practices that include standard precautions, decontamination, waste management, surveillance and audit. 4. Purpose The aim of this policy is to ensure that the Trust maintains effective arrangements for Infection Prevention and Control, recognising the role of the Infection Control Team within the Trust s Risk Management and Clinical Governance framework IPC Policy June 2015 V6 Page 7 of 99

8 Arrangements for Infection Prevention and Control are set out in the annual Infection Prevention and Control programme with defined objectives, regular review and managerial support to ensure that the programme can be implemented. It is the intention of the Trust Infection Prevention and Control Team (IPCT) to promote the prevention and control of infection within all care facilities and to act as a resource for care staff, service users, carers and visitors within the Trust. In order to achieve this, the Trust accepts that the implementation of an effective Infection Prevention and Control policy will enable it to work towards reducing risks to all persons affected by the Trust's activities. Written information for patients and visitors is provided via leaflets and Ward Information Booklets which are reviewed bi-annually and the Annual Report and the Annual Programme for Infection Prevention and Control are available on the Internet for the general public. 5. Duties Trust Board The Trust Board has overall responsibility for ensuring that there are effective arrangements and adequate resources provided for infection prevention and control within the Trust and for monitoring the impact of the policies of the Trust. Chief Executive The Chief Executive on behalf of the Trust Board has overall and final responsibility for ensuring that systems are in place for the effective, safe management of infection, prevention and control within the trust. These will include: The provision of an appropriately constituted functioning Infection Prevention and Control team which provides reports on adverse incidents, infection data, progress reports against the annual plan and policies to support the process to the Infection control committee this includes determining the mechanisms by which the Board ensures that adequate resources are available to secure effective prevention and control of HCAIs, to include identification on the assurance framework, Infection Prevention and Control programme and Infection Prevention and Control infrastructure. Director of Infection Prevention and Control (DIPC) The DIPC provides the executive lead for Infection Prevention and Control and reports directly to the Chief Executive (not through any other officer) and the Board. The DIPC presents the annual Infection Prevention and Control Programme. Quarterly and annual reports are provided to the Trust Board to give information and assurance that the programme is being progressed. The annual programme is available on the Trust web site. The DIPC is an integral member of the Trust s Clinical Governance and Service Users safety structures and has overall responsibility for the management of the IPCT. The DIPC oversees local Infection Control Policies and their implementation and also has authority to challenge inappropriate clinical hygiene practice as well as antibiotic prescribing decisions. IPC Policy June 2015 V6 Page 8 of 99

9 Senior Nurse -Infection Prevention and Control (SN-IPC) The SN-IPC is responsible for leading and directing the day to day management of IPC within the organisation, this includes: Providing expert advice to all care staff on the care of service users who are at risk of, or who have infection. providing expert advice to all corporate departments whose role has the potential to influence Infection prevention within the Trust providing education and training where required in the training needs analysis A responsibility for writing, implementing and reviewing policies and guidelines relating to infection prevention and control. being responsible for ensuring appropriate strategies are in place for monitoring compliance with policies these include both audit and surveillance directly reporting verbally to the ICC these results being responsible for developing and writing the Annual programme in consultation with the DIPC and the ICC A requirement to write the quarterly Reports and an Annual Report on Infection Prevention and Control activity for the Trust Board. Provides any exceptional reports required. This is done in consultation with the DIPC. Responsibilities of the Infection Prevention and Control team (IPCT) Provide a management, consultative and advisory service to the Trust in order to enable the Trust to ensure that effective systems exist for the monitoring, prevention and control of hospital infection and ensure compliance with Assess and take steps to reduce or control infection risks within the Trust which may be recorded on the Trust Risk register and monitored by the ICC. Ensure that infection prevention and control is considered in all policy, service and premises development within the Trust including working with Estates and Facilities to ensure the provision and maintenance of a clean and appropriate environment for health care. Work closely with the Occupational Health Department and other relevant stakeholders to develop Policies and Guidelines for the protection of Health Care Workers (HCW) from exposure of communicable infections during the course of their work. Develop and produce an annual Infection Prevention and Control programme with clearly defined objectives and the DIPC s annual Infection Prevention and Control report which outlines the progress of the programme. Infection Control Doctor IPC Policy June 2015 V6 Page 9 of 99

10 Will usually be a Microbiologist with a particular interest in infection prevention and control. Will have dedicated time set aside for this role. Act as the primary source of clinical advice for practitioners on infection prevention and control issues. Directorates Directorates have a duty to ensure that the responsibilities for prevention and control of infection are reflected in all staff members job descriptions and are incorporated into annual appraisal. Directorates have a responsibility to ensure that all staff receive induction training and attend ongoing Infection Prevention and Control training in line with Trust requirements. All training must be recorded both on staff personal training records and the Trust reporting system. Directorates are responsible for infection prevention and control. It is therefore essential that Directorates produce a relevant action plan annually. This process is supported by the IPCT to align Directorates planning with the annual Infection Control Programme. The action plan should be produced in March with a review of progress by September and completion by the following March. Action plans should be incorporated into Directorate Governance reports ready to feedback on process and exception to the ICC; which ultimately reports to the Quality Assurance Committee with progress reports against proposed actions. Directors and Assistant Directors Directors and Assistant Directors are responsible for ensuring the implementation of Infection Prevention and Control policies and procedures, guidance, local/national initiatives such as the and the Health Act 2010 Code of practice for the Prevention and Control of Healthcare Associated Infections within their relevant area. They also must: Attend ICC meetings and provide feedback to the Committee members any issues relating to infection prevention and control within their Directorates. Ensure that Senior Nurses/Matrons/Senior Clinical Practitioners provide a three monthly progress report to the DIPC via the ICC. IPC Policy June 2015 V6 Page 10 of 99

11 Ensure the Senior Nurses/Matrons/Senior Clinical Practitioners contribute to the annual Infection Prevention and Control report to the Trust Board. Ensure that all operational matters raised by Senior Nurses/Matrons/Senior Clinical Practitioners in their area are reviewed and actioned via the DIPC at the ICC meetings. Following risk assessments or audits, they must ensure adequate allocation of funds to facilitate remedial action. Senior Nurses/Matrons/Senior Clinical Practitioners Senior Nurses/Matrons/Senior Clinical Practitioners must ensure that an annual infection prevention and control action plan is developed and the progress of the plan is monitored on a three monthly basis. They are to provide the DIPC with quarterly progress reports via the IPCT. To work closely with Department/Ward Managers, Infection Control Link Personnel and Hands Champions to ensure all actions are achieved e.g. audits, teaching, hand hygiene training, reporting serious occurrences relating to infection prevention and control. Department/Line Managers Department/Line Managers are responsible for ensuring the implementation of advice, policies and procedures within their department. This includes Being responsible for the inclusion of Infection Prevention and Control in every relevant employee s induction and personal development plan. Inclusion of Infection Prevention and Control responsibilities in every relevant employee s job description and contract of employment. Ensuring that all seconded staff, Bank and Agency staff and any contracted workers are made aware of all policies and procedures relating to Infection Prevention and Control during local induction. Ensure that all staff attends relevant Infection Prevention and Control training sessions or access the NHS Infection Control e-learning package through the Human Resources web site or via the Internet. Ensure up to date records are maintained regarding staff attending training. Responsibilities of all employees All employees are responsible for ensuring that they undertake relevant Infection Prevention and Control training available to them. All employees are personally accountable for their actions and responsible for ensuring that they comply with Infection Control policies. IPC Policy June 2015 V6 Page 11 of 99

12 All employees, including Sheffield City Council staff that are seconded to SHSC, all Bank and Agency staff together with any contractors employed by the Trust, will be personally accountable for their actions and are responsible for ensuring that they comply with Infection Prevention and Control policies and procedures. Employees have and must understand their legal duty to take reasonable care of their health, safety and security and that of other persons who may be affected by their actions and for reporting incidents and areas of concern. Care workers are responsible for identifying infectious conditions and circumstances that may lead to outbreaks of infection that require specific controls to protect themselves, their service users or others. They are responsible for notifying the Infection Control Team of such circumstances or a breakdown of Infection Prevention and Control Procedures. It is the responsibility of care workers to ensure that they utilise safe working practices as outlined in Infection Prevention and Control policies and procedures. Any breach in Infection Prevention and Control policies or practice will place staff, service users and visitors at risk. Staff should also refer to the Incident Reporting & Investigation Policy which can be accessed on the Risk Management Team web site on the Trust Intranet. All care workers have a duty to act on and report to the IPCT, at the earliest opportunity, an infection that may be deemed infectious to others i.e. communicable/notifiable diseases or resistant organisms. Also staff have a responsibility to report incidents following the Trust Incident Reporting and Investigation Policy. All employees of the Trust have a duty of care to adhere to all Trust policies and protocols applicable to infection prevention and control. All Trust staff also have a duty to ensure that visitors to the Trust are made aware of the Infection Prevention and Control policy by producing protocols/policies relevant to their visit or area of work. Infection Control Link Worker (ICLW) Are care workers selected by their managers to receive additional training in Infection Prevention and Control. The key role of these staff members is to develop best practice within their clinical area. It is therefore important that the staff selected for this role have the capabilities to influence practice and support delivery of the Infection Control programme of audit and education. Most importantly these staff provide a resource at the point of care to ensure consistency of practice is being delivered to reduce the risks of HCAIs. Managers must support ICLW by meeting the terms established with the role. This includes ensuring protected time is allocated to deliver their duties. IPC Policy June 2015 V6 Page 12 of 99

13 6. Specific details The aim of this policy is to reduce HCAIs, within the limitations of available resources, providing the highest possible standards of infection prevention and control. This policy is designed to encourage Directorates to accept responsibility & ownership for the prevention and control of infection with the intention of improving the quality and safety of patient care. As a consequence of this, failure to comply with this policy may result in disciplinary procedures against that member of staff. 7. Dissemination, storage and archiving (Control) The policy will be disseminated via the Service Development Directorate governance systems, its managers, the Infection Prevention and Control Team and planned training events. The policy will be managed by the Integrated Governance and Patient Experience Department and will be available for all staff on the Infection Control web page via the SCT intranet. 8. Training and other resource implications Capability and knowledge of staff The Trust will ensure all staff have the capabilities necessary to carry out their jobs without unreasonable risk to themselves and others. Due to the range of work undertaken by the Trust different staff groups will require different capabilities and differing levels of knowledge. Each service will undertake an assessment of the required capability and knowledge required by its staff. Staff in posts for which Infection Prevention and Control is considered low risk are expected to attend the mandatory training designed for this group Services with staff with significant Infection Prevention and Control risks should ensure that all staff attend training days appropriate to each staff group. On induction, both corporate and local, all staff must receive infection prevention and control education. Training The Trust will provide training in several different ways designed to suit the needs of the differing staff groups. This may be in the form of face to face training or through the use of e- learning programmes. All induction training must include hand hygiene, standard precautions and First Aid for Inoculation Injuries. Anyone undertaking direct patient care should receive regular infection control training arranged via the Practice Development Department. Services with a significant amount of direct patient care will identify staff within the service who will undertake the roles of Infection Control Link Workers (ICLW). The line manager and the Infection Control Team will support the ICLW in their role. There is a role description to support the link worker with their remit. The Trust intranet will display the options for the delivery of training for different staff groups. Staff who are employed via agencies must receive infection prevention and control training as part of their induction to the work area. All induction training must include hand hygiene, Standard Precautions and First Aid for Inoculation Injuries. This must be recorded and signed by the person conducting the induction and also IPC Policy June 2015 V6 Page 13 of 99

14 the agency staff member. Flexible Workforce staff must complete the infection prevention and control training provided by Flexible Workforce and ensures it is recorded in their file. These staff can also access any infection prevention and control training sessions held by the Trust and also the e-learning via the Trust Intranet as well as the Internet. Infection Prevention and Control instruction to be made available to anyone working in the Trust, paid or unpaid and it is the responsibility of the individual manager accountable for such workers to ensure that this is undertaken. This may be delivered by the IPCT or by the staff member responsible for the individual and a record of the training to be kept by the individual s manager. Frequency of Training All staff must undertake Infection Control training as outlined in the Trust Training needs Analysis. The above training to be recorded by the Training Department and non attendance for training with to be followed up via the Line Manager system. 9. Audit, monitoring and review Individual staff Services that have significant infection prevention and control risks are to ensure staff attendance at infection prevention and control training sessions and must ensure the attendance is recorded in an appropriate manner. This information is to be used as part of the staff members Personal Development Review (PDR) and the requirements for training and skill and knowledge levels should be reflected. This process will also be used for the induction of new staff and for the wider appraisal of the infection prevention and control training needs of staff within that service. The process will result in training that is relevant and timely. Individual members of staff are to take responsibility for their training record being kept up to date and to be stored as part of their personal file. These records will also provide evidence that the Trust is:- - assessing the risks associated with each post - assessing the capabilities of its staff to undertake the roles for which they have been employed, and - Is providing the necessary training to bridge any gaps. Compliance with the Infection Prevention and Control policy will be measured by the following means: Assurance Framework Standard for Infection Control: annual score and three monthly review of the action plan. Internal auditors annually External auditors annually Review by the Infection Control Committee quarterly Training records Surveillance Data Surveillance Monitoring of infections and outbreaks of infection on a routine basis will provide additional information to support and interventions or changes that are proposed, while services are encouraged to include varying aspects of infection prevention and control in planned audit programmes (see policies/guidelines on IPC Policy June 2015 V6 Page 14 of 99

15 Standard Precautions, Hand Hygiene and Personal Protective Equipment). Refer to the Infection Control web site via the Trust intranet for all policies referring to infection prevention and control. Surveillance is the key component of an infection prevention and control programme. It consists of the routine collection of data on infections among service users and staff, its analysis and dissemination of results to those who need to know in order that the appropriate action can be taken. Surveillance aims to produce timely information on infection rates and trends, detect outbreaks, helps inform evaluations of, and changes in, clinical practice, and assist the targeting of preventative actions. SHSCT will undertake the following surveillance as part of its infection prevention and control programme: MRSA Bacteraemia, MSSA Bacteraemia; Eschericia coli bacteraemia Clostridium difficile cases In addition areas where there are individuals who are resident both short term and long term additional surveillance will take place. This will predominantly:- Adherence to the Trust infection prevention and control guidance Observational and self-assessment audits The full plan for the year is stated in the Annual Infection Prevention and Control Programme. To support the Infection Control Team an ICLW for each team to be recruited and trained in infection prevention and control with the aim of maintaining raised awareness of infection control issues. The Policy The policy will be reviewed on a regular basis to ensure it remains compliant with changes to legislation, regulation and guidance and Department of Health Standards. It will be subject to a formal review three years after the date of ratification but does not exclude the option to review and update the policy should a significant change in legislation, regulation and guidance and Department of Health Standards occur. Monitoring and evaluation NHSLA Risk Management Standards - Monitoring Compliance Template Standard 4 Criterion 6,7 Minimum Process for Frequency Requirement Monitoring of Monitoring A) Safe Environment Audit and Training Records Responsible Individual/ group/ committee Infection Prevention Team and Education & Training Quarterly Review of Results process (e.g. who does this?) Infection Control Committee, Quality Assurance Committee, Board Responsible Individual/group/ committee for action plan development Infection prevention Team Responsible Individual/group/ committee for action plan monitoring and implementation Infection Control Committee IPC Policy June 2015 V6 Page 15 of 99

16 10. Implementation plan Dissemination, storage and archiving The policy will be disseminated via Directorate governance systems, its managers, the Infection Prevention and Control Team (IPCT), team managers and planned training events. All SHSCT staff alert Single policies site on Trust Intranet and the Infection Control web page on the Trust Intranet Team managers to ensure easy access to the policy is available at all times either via electronic access and/or a paper copy. Training and Development An element of the main body of the policies to be incorporated with training plans. New roles and Responsibilities The IPCT, Department Managers and all staff will implement the policy which will be monitored by internal audit, training records and incident reports The lead for the policy is the Senior Nurse -Infection Prevention and Control. Action / Task Responsible Person Deadline Progress update New policy onto intranet and Chief Nurse 30/09/2014 remove old version All Trust employees to be aware of new policy Deputy Chief Nurse and Directorate Leads 17/10/2014 Policy Review to support Trust s application for CHAS Accreditation Senior Nurse 31/05/ Links to other policies, standards and legislation (associated documents) This policy is to be read in conjunction with the more specific policies relating to infection prevention and control listed below. Decontamination Policy IPC Policy June 2015 V6 Page 16 of 99

17 Major outbreaks of communicable infection Management of Occupational Blood and Body Fluid Exposure Antimicrobial prescribing Control of Tuberculosis, including multi-drug resistant tuberculosis Water Quality and Legionella Waste Management ECT policy Incident Reporting and Investigation Policy Decontamination and Disinfection Core Clinical Protocol procedures Royal Marsden Clinical Procedures relating in particular to Aseptic Technique Hand washing technique Use of disposable gloves MRSA Clostridium difficile Isolation 12. Contact details Title Name Phone Senior Nurse Katie Grayson Mobile via Switchboard Infection Control Jill Perlstrom Mobile via Switchboard Co-ordinator Deputy Chief Nurse Giz Sangha Mobile via Switchboard Infection Control Doctor Dr. Olawale Lagundoye Consultant Microbiologist Dr. Rob Townsend, Consultant References Health and Safety at Work Act Control of Substances Hazardous to Health Regulations (COSHH) Care Quality Commission (2014) Fundamental Standards The Health and Social Care Act 2008: Code of Practice for the Prevention and Control of Infections and related guidance pdf NHSLA Risk Management Standards for Mental Health & Learning Disability Trusts 2014/ IPC Policy June 2015 V6 Page 17 of 99

18 Department of Health (2014) 2015/16 NHS Outcomes Framework. Department of Health (2015) Clinical Commissioning Group (CCG) Outcomes Indicator Set. IPC Policy June 2015 V6 Page 18 of 99

19 Appendix 1 Guidelines to be read in conjunction with the Infection Control Policy Standard Precautions (formerly Universal Precautions) Introduction The general principles of infection control are applied during working practices which protect other service users and staff from infection. All blood and body fluids are capable of transmitting infection therefore universal precautions are applied to all service users in all wards/departments/community and at all times. Selection of Personal Protective Equipment (PPE) must be based on an assessment of the risk of transmission of micro-organisms to the service user or carer, and the risk of contamination of the care practitioners clothing and skin by a service user s blood, secretions or excretions. Everyone involved in providing care should be educated about standard principles and trained in the use of protective equipment. Adequate supplies of disposable plastic aprons, single use gloves and face and eye protection MUST be made available wherever care is delivered. Certain body fluids should be handled with the same precautions as blood. Examples of such body fluids which care workers may come into contact with are: Amniotic fluid Semen Vaginal secretions Human breast milk Any body fluid containing visible blood, including saliva in association with dentistry Cerebrospinal fluid Pericardial fluid Pleural fluid Peritoneal fluid Synovial fluid Unfixed human tissues and organs Exudate or other tissue fluid from burns or skin lesions Refer to the Protocol for Management of Occupational Blood and Body Fluid Exposure Incidents if any contact with the above is made. Other body fluids which are not likely to pose a risk of blood borne virus transmission: Nasal secretions Sweat Urine Vomit Faeces Sputum Tears IPC Policy June 2015 V6 Page 19 of 99

20 Hand hygiene Refer to hand hygiene policy and guidelines for practice - APPENDIX 2 Protective Clothing Examination Gloves The use of gloves does not replace a correct and high standard of hand hygiene between procedures. Intact skin is itself a valuable defence mechanism. Consideration should be given to appropriate glove use, as overuse can lead to skin and allergy problems. Gloves provided should be latex and powder free. Any reported adverse reactions to glove use must be addressed immediately and reported to Occupational Health. Always cover cuts and lesions on hands with a waterproof dressing whilst on duty. Use of examination gloves: if contamination of hands with body substance is likely. if hands have a skin disease. must be changed between service user contacts. for aseptic technique and ANTT (Aseptic Non-Touch Technique) procedures. not generally required for food preparation use. disposed of as healthcare waste. change between dirty & clean procedures even if carried out on the same patient Hands must be washed after the removal of gloves. Gloves should be removed correctly. Use one glove to remove the other and turn them inside out as they are removed. Refer to guidelines for use of disposable gloves and policy on glove usage by employees. Aprons Plastic aprons must be worn when it is likely that body substances could soil clothing. Plastic aprons must be worn during all close service user contact including stripping of bed linen (see also food handling policy sections). Plastic aprons afford more protection to uniforms/clothes than cloth gowns because they are water repellent and impervious to microbial contamination and can prevent the redisposal of microorganisms from uniforms/clothes to service users. They must be changed between each service user contact. Disposable aprons should also be used by food handlers. Face, respiratory and eye protection Expert opinion recommends that face and eye protection reduce the risk of occupational exposure of care workers to splashes of blood, body fluids, secretions or excretions. Face masks and eye protection must be worn where there is a risk of blood, body fluids, secretions or excretions splashing into the face and eyes. Each area should have ready access to eye/mouth protection for when required. Respiratory protective equipment, i.e., An FFP-3 mask, must be correctly fitted and used when recommended for the care of a service user with respiratory infections transmitted by airborne particles, (i.e. pandemic influenza). The IPC team will arrange fit testing as and when required. IPC Policy June 2015 V6 Page 20 of 99

21 Spillage Management Any blood or bodily spillage should be dealt with safely as soon as possible as they are considered a potential infection hazard. For spillages, whether caused by patients, staff or visitors, the responsibility is as follows: Clinical areas Nursing or Support Workers first initial clean-up of the spillage followed by routine cleaning of the area by housekeeping/domestic staff (when on duty otherwise clinical staff) Main entrances, reception areas, waiting room, main corridors, communal areas outside wards/clinical areas, meeting rooms initial clean-up of the spillage is undertaken by Housekeeping staff (when on duty otherwise clinical staff) followed by routine cleaning of the area. All staff have responsibility to ensure that spills are cleaned up as soon as possible wherever they occur on Trust premises or grounds. SPILLS MUST NEVER BE LEFT FOR ANOTHER MEMBER OF STAFF TO DEAL WITH. The preferred method for cleaning up spillages is to use a Clinell Spill Kit. These are safe to use on all spillage types (blood, urine, vomit, faeces) on hard surface floors only. The spill pad can soak up to a litre of fluid. The packet has clear guidance on how to use the spill kit to perform the initial clean-up procedure. Follow initial clean-up with a routine domestic clean using hot water and detergent (e.g. Hospect) or Virusolve+ in areas where used. Disposable mops & cloths should be used wherever possible. The staff member dealing with the spill should wear a plastic disposable apron, disposable gloves and based on risk assessment of anticipated splash; then face & eye protection maybe required. Traditional Spillage Kits For areas still using these types of kits please ensure you use the correct kit on the spillage. A number of companies produce spillage kits which are designed to help staff manage a range of spillages. Additionally they contain all the items required to undertake the initial cleaning up procedure such as disposable gloves, apron, scoop, scraper, waste bag etc Follow the instructions carefully and adhere to any COSHH regulations for the safe handling of any products. N.B. Never use Hypochlorite (bleach solution) directly onto spillages as they can release vapours when used. It must NOT be used directly on urine or vomit. The room or area must be well ventilated when using this substance. Eye protection may be necessary to prevent splashing into eyes. Once traditional kits have expired, please replace with a Clinell Spill Kit Carpets and Fabric Soft Furnishings In some settings management of spillages will be compromised by the presence of items such as carpets and fabric upholstery. The use of chlorine solutions on carpets and fabrics can cause damage beyond repair therefore use of chlorine in such circumstances must be avoided. In these cases soak up as much of the spillage as possible using disposable absorbent roll/paper and discard appropriately. Clean the area with hot water and detergent, followed by drying with absorbent paper/roll The above procedure can be followed in all carpeted areas as an emergency, however it is essential that thorough carpet cleaning occurs within 24 hours. A regular carpet cleaning programme must be in place, regularity is determined by risk. Where there are areas that have frequent incontinence or body fluid spillage it is not appropriate to have carpets as a floor covering. They are not impervious to IPC Policy June 2015 V6 Page 21 of 99

22 moisture and thus pose a high contamination risk. Existing carpets must be subject to regular and rigorous cleaning and for future replacement coverings; a more suitable alternative should be sourced. When dealing with a spillage in a service user s home, the use of detergent and water alone is advised; following soaking up the spill as far as possible with disposable towels or cloths, use the detergent and water, rinse and dry Safe disposal of waste contaminated by body substances This is classed as healthcare waste and must be placed into the appropriate bag for safe disposal see waste policy. For contaminated sharps disposal see guidelines on the safe handling and disposing of contaminated sharps..safe disposal of linen contaminated with body substances Linen heavily contaminated with body substances should be placed into a water soluble bag. Ensure the appropriate alginate bags are used as not all will disintegrate in particular types of washing machine. Wet linen will start the disintegration of the alginate bag therefore place the alginate bag in a colour-coded plastic bag prior to placing in the colour-coded cloth linen sack. This will prevent cross-contamination onto other items. Transfer to the laundry facility promptly. Where Linen is very heavily soiled with blood, the decision may be taken to dispose of it completely via the clinical waste stream. When handling soiled linen, gloves and a protective apron should be worn. Hands must be decontaminated afterwards. Refer to Laundry Guidance in Appendix 9 Decontamination of equipment It is crucial that all equipment is subject to regular and effective decontamination. This will depend upon the type of equipment, its purpose, how often it is used and by whom. There are three levels for decontamination cleaning, disinfection and sterilization. A risk assessment based upon guidelines provided in the decontamination policy will determine the level required. Equipment consists of all items provided to facilitate care or therapy within the healthcare setting. Clean commodes and bed-frames should be marked as such with a suitable label. Any equipment awaiting inspection, service, repair, replacement or disposal must be decontaminated prior to this occurring and a dated label attached to indicate this process has taken place. Any decommissioned equipment that remains in place situ must still be kept in a clean state and must pose no infection control risk. For more information Refer to Policy for Decontamination and Disinfection. References AYLIFFE G.A.J. et al (4 th Ed) 2000 Control of Hospital Infection: A Practical Handbook Arnold, London EPIC3: National Evidence-Based Guidelines for Preventing Healthcare-associated Infections in NHS Hospitals in England. Pratt et al Journal of Hospital Infection 86S1 (2014) S1 S70 Infection Control Nurses Association (ICNA) 2002 Protective Clothing Guidelines. UK Health Departments 1998 Guidance for Clinical Healthcare Workers: Protection against infection with Bloodborne Viruses. Recommendations of the Expert Advisory Group on AIDS and the Advisory IPC Policy June 2015 V6 Page 22 of 99

23 Group on Hepatitis. Department of Health, London. Department of Health CFPP (2013) Decontamination of linen for health and social care: Social care Appendix 2 Hand Hygiene Policy and Guidelines for Practice Introduction The importance of hand hygiene in the prevention of cross-infection was clearly demonstrated in the 19 th century (Ayliffe & English 2003). Effective hand hygiene is recognised as an essential aspect in the battle against healthcare associated infections (HCAI). Increasing staff compliance with hand hygiene at the point of care can dramatically reduce the risk of a service user acquiring a HCAI, which are most frequently spread from one service user to another via the hands of healthcare workers. Unfortunately staff compliance with guidance for hand hygiene is often poor (Hand Hygiene Liaison Group1999, Pittet et Al 1999). Some reasons quoted for non-compliance include lack of available products, time constraints and the personal belief that they will not spread infection. The World Health Organisation (WHO) first Global Patient Safety Challenge Clean Care is Safer Care expanded on the tools originally developed for this strategy making them suitable for global use and from this a concept IPC Policy June 2015 V6 Page 23 of 99

24 known as My Five Moments for Hand Hygiene was developed (Sax et all, 2007). Hand hygiene greatly reduces the risk of transfer of micro-organisms. Most infections in health and social care are spread via the hands of care workers. Transient micro organisms are picked up by contact with people and/or the environment. Resident micro organisms are those which live on the skin as normal flora. Hand hygiene is the most important method of preventing the spread of infection to Patients/Services Users Management Responsibilities To provide adequate facilities and supplies of related products to enable effective hand hygiene to take place. To ensure staff are aware of the importance of hand hygiene. To ensure staff receive education on hand hygiene in accordance with the Trust training analysis. To identify a hand champion for their area.(dual role with ICLW) Individual Responsibility Staff must follow the guidelines on Hand Hygiene, hand care and use of disposable gloves which is mandatory. Staff must refer to the training needs analysis document for levels and frequency of training required. Hand Hygiene Facilities Facilities within care settings must be clean, appropriate and well maintained. Ample supplies of good quality mild liquid soap preferably in wall mounted cartridge dispensers, paper towels in wall mounted dispensers, alcohol hand rubs and moisturiser to be provided. The World Health Organisation (WHO) The Trust supports the use of the WHO Five Moments as a useful framework to guide staff s decisionmaking on when to decontaminate their hands. IPC Policy June 2015 V6 Page 24 of 99

25 Hand hygiene Hand washing facilities must be adequate and easily accessible at all times. Designated hand wash basins must be accessible in all clinical and consultation areas and where appropriate i.e. kitchen and sluice. The hand wash basin should not have a plug or overflow. Taps should be of the elbow or wrist opening type in clinical areas. Where twist style taps exist, staff should be aware of how to turn them off using the paper towel method. Nail brushes should not normally be used. If required, they must be single use (disposable). All hand wash basins must be designated for hand washing only and not used for any other purpose i.e. cleaning instruments and equipment. Use only wall mounted liquid soap dispensers with disposable soap cartridges and keep clean (including underneath & nozzle) and replenished. Bar soap must not be used unless for use by individual service users. Staff must not wash their hands with bar soap. There should be a foot operated lidded pedal bin of the appropriate size positioned next to the hand wash basins. Service users may require assistance and encouragement with hand hygiene. It may be appropriate to offer service users the opportunity to clean their hands using a trust approved skin friendly sanitising wipe. There should be full facilities within service user bedrooms for staff to be able to clean their hands using liquid soap, water and paper towels and a refuse bin. All staff should be able to clean their hands at the point of care. They should carry individual bottles of alcohol gel on their person. Where this is not appropriate a risk assessment must be carried out to identify how staff can effectively decontaminate their hands. It is a requirement that all visitors should have access to equipment supporting their ability to clean their hands on entering and leaving the ward/service. The provision of alcohol gel in a suitable dispenser should be introduced for this purpose. If not possible an alternative arrangement should be clearly signposted. Bare Below the Elbows (BBTE) All clinical staff will need to comply with "BBTE" when providing direct care to patients or touching the immediate patient environment (see 5 Moments diagrams previously). A clinical area is any location in Trust premises or off site at an outreach facility (including patients/service user s home); in which a healthcare colleague undertakes physical examination, talking therapies or direct hands on care. e.g. providing personal care. All clinical & support worker staff to remove wrist watches/bracelets when attending to a patient or when likely to touch the immediate patient environment. This is because it impedes effective hand hygiene techniques; especially cleaning the wrist area. Jewellery for staff who work in clinical areas must be kept to a minimum; a plain wedding ring and one pair of discreet stud earrings are permitted. Other staff disciplines will need to comply with BBTE principles e.g. housekeeping, food handlers & laundry staff. Wrist watches must not be worn in a clinical area where staff can reasonably expect to come into contact with patients or the immediate patient environment. This will include inpatient wards, IPC Policy June 2015 V6 Page 25 of 99

26 care home settings, residential accommodation, clinical treatment rooms, patient own homes or anywhere healthcare interventions are taking place. Clinical, housekeeping, laundry and food handlers are not permitted to wear nail varnish (including clear varnish), nail art or false nails, including silk wraps or gel infills. Nails should be short and clean. IPC Policy June 2015 V6 Page 26 of 99

27 Examples of when to perform Hand Hygiene: 1 When hands are visibly soiled/dirty 2 The patient is experiencing any type of vomiting and/or diarrhoea illness 3 There is direct hand contact with bodily fluids; i.e. if gloves have not been worn. 4 There is an outbreak of Norovirus, Clostridium Difficile or other diarrhoeal illnesses 5 After using the toilet 6 Before and after preparing, handling or eating food 7 At the start of a shift and at the end of a shift 8 After removal of gloves 9 After completing a task i.e. cleaning equipment 10 Before and after administering medication When to hand wash and when to hand rub An alcohol-based hand rub should be used for hand hygiene before and after direct contact or care except in the following situations when soap & water must be used: When hand are visibly dirty or potentially contaminated with body fluids When caring for patients with any type of vomiting or diarrhoeal illness regardless of whether gloves have been worn. Hand Hygiene in the Domiciliary Care Setting In the domiciliary care setting, hand washing facilities differ significantly, therefore must be based on risk assessment prior to use. In the community, perform hand hygiene in the following situations listed above using either liquid soap and running water or alcohol hand rub based on risk assessment. The type of hand hygiene required will be based on a) the care activity that has just been performed and b) that which is about to take place. Community healthcare workers should order and carry their hand hygiene supplies (liquid soap, paper towels, alcohol hand rub and moisturiser in their Physical Health Bags) from normal trust stock supplies department. Individuals are responsible for replenishing stock in their own kit bag/boxes for use whilst undertaking duties in the domiciliary care setting. Hand Hygiene Technique A good technique at the correct time, which covers all surfaces of the hands, is more important than the cleanser used or the length of time taken. Hands should be rubbed together vigorously for a minimum of seconds, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers. The duration of hand hygiene needs to be as long as required to ensure all areas of hands have been covered. Hands should be systematically rubbed ensuring all parts of the hands and wrists are included taking particular care to include the areas of the hand which are most frequently missed; following the 6 step technique Whether you hand wash or hand rub, the same technique is used to cover all hand surfaces. When hand washing ensure that all areas of the hands are wet thoroughly prior to applying soap. Ideally water temperature should be luke-warm. Ensure all residue of soap is rinsed thoroughly from the IPC Policy June 2015 V6 Page 27 of 99

28 surface of the skin. Alcohol hand rub should be applied to a cupped hand and vigorously rubbed to cover all the surfaces of the skin; allow to air dry. Hand Hygiene using liquid soap & running water 1. Remove hand jewellery to access skin for cleansing and to help reduce the bacterial count. NB in line with the bare below the elbows trust policy and the department of health work wear guidelines, the wearing of jewellery with the exception of one plain finger band is not permitted. 2. Finger nails must be short (not extending beyond the fingertips). False nails or nail jewellery must not be worn. Long finger nails harbour dirt and damage gloves. False nails harbour microorganisms. 3. Finger nails must be free from nail varnish/gel and hardener. Nail varnish prevents examination of nails for cleanliness. Chipped or cracked nail varnish may harbour microorganisms. 4. Select running water at a warm temperature. A warm temperature facilitates lather. Hot water can cause skin damage and hinder the decontamination process by causing the worker to flinch and thus fail to sufficiently clean the hands. 5. Wet hands under warm running water to the wrists before applying soap to moisten skin prior to application of cleanser to prevent skin damage. 6. Apply soap to wet hands. With friction, gently rub all surfaces of the hands, the palms, the backs of the hands, the tips of the fingers, the inter-digital spaces, wrists and thumbs (see Appendix 2a). Friction will loosen dirt, organic material and transient microorganisms. All hand surfaces need attention. 7. Rinse off all lather under running water to remove loosened microorganisms, to remove lather and to prevent skin irritations. 8. Dry thoroughly using disposable paper towels to remove residual microorganisms. Leave skin dry to prevent multiplication of skin flora and prevent chapping. Hand Drying Good quality wall mounted paper towels should be used and positioned in close proximity to the hand wash basin. Communal cotton hand towels must not be used. If elbow operated taps are not provided, use a paper towel to turn off the tap after washing to avoid re-contamination. Hot air hand dryers must not be used in healthcare facilities. Alcohol hand rub Alcohol (60-80%) is an effective alternative when hand washing facilities are not easily accessible or available. It is useful when there is a need for rapid hand disinfection. IPC Policy June 2015 V6 Page 28 of 99

29 Alcohol hand rubs may also be used for social and antiseptic levels of hand hygiene. Alcohol is not recommended if hands are physically soiled (i.e. apply to clean hands). All alcohol hand rubs are ineffective against spores and some viruses. Therefore, when dealing with Clostridium Difficile and/or Norovirus, patients/clients and the hands of staff should be decontaminated with soap and running water. Alcohol Hand rubs & Religious Considerations According to some religions, alcohol use is prohibited or considered an offence. However, in general, despite alcohol prohibition in everyday life, most religions give priority to health principles to ensure patient safety. Consequently, no objection is raised against the use of alcohol-based products for environmental cleaning, disinfection or hand hygiene by any religion (World Health Organization, 2006; Allegranzi et al, 2009). Alcohol Hand rub Risk Assessment: A risk assessment must be carried out regarding: Positioning of the alcohol hand rub and moisturisers. Amounts to be available and stored Risks to service users The risk assessment to be included in the general environment risk assessment carried out by the ward routinely. Hand Hygiene with alcohol hand rubs 1. Apply as directed on the container so that optimal amount is used. 2. Ensure all parts of the hands are covered including finger tips. Contact with all parts of the hands is required to reduce microorganisms. 3. Rub vigorously with friction. Rub all areas of the hands, the palms, the backs of each hand, tips of fingers, inter-digital spaces, wrists and the thumbs (see Appendix 2a steps 3 to 8). This is to ensure contact with all the surfaces of the hands. This will evaporate the alcohol and therefore destroy microorganisms leaving the skin dry. 4. Continue rubbing until solution has completely evaporated. This ensures hands are decontaminated. Promoting good standards of hand hygiene Sheffield Health and Social Care Trust is committed to promoting good standards of hand hygiene among all staff, service users and visitors. This is achieved by: o o o The assistance of local Infection Control Link Workers/Hand Champions Completing hand hygiene audits. Training, in correct hand hygiene technique using a UV light box, to be carried out in the work place or by attendance on infection prevention training by designated and appropriately trained staff according to the Trust Training needs analysis document. All major Trust bases have Lightboxes on site. IPC Policy June 2015 V6 Page 29 of 99

30 o o o All hand hygiene training to be recorded electronically and monitored by the IPCT. Completed registers should be forwarded to the IP&C Co-ordinator who will ensure this occurs. Staff not complying or participating in hand hygiene training or up-dates to be referred to their Department Managers and Clinical Directors. Non-compliance to be taken into account by Department Managers when carrying out Personal Development Reviews. Hand Care Guidelines 1. Check hands and finger nails for abrasions and cuts before each SHIFT. 2. Everyday pursuits including gardening, washing, DIY and caring for pets may cause abrasions which require covering with a waterproof dressing whilst on duty. The wearing of protective gloves whilst gardening etc. is advisable. 3. Keep nails short and smooth to facilitate good hand hygiene and minimise the chance of accidental damage. False nails including overlays must not be worn because these prohibit good hand wash technique and harbour microorganisms. (Department of Health 2007). 4. Finger nails must be kept free from nail varnish/gel. Chipped or cracked nail varnish/gel may harbour microorganisms. 5. The use of emollients and moisturisers will help to prevent skin problems, irritations and drying and have been shown to increase compliance with hand hygiene. These should be applied and if possible, left on the skin for minutes when off duty or during breaks whilst on duty. Alternative moisturisers are available for those with sensitive skin. Seek Occupational Health or GP advice for persistent skin irritations. 1. Practice good hand hygiene before, during where applicable and after service user care activities. 2. Avoid cracked skin which is vulnerable to infection by applying hand cream. ALL YEAR ROUND. 3. Your skin acts as a barrier when intact. If not intact, non-sterile disposable gloves would be required to protect against direct contact with body substances. 4. If you have a skin problem on your hands such as eczema or dermatitis seek advice from Occupational Health/GP. Patients, Services Users & Visitors It is important that service users and visitors also practice good hand hygiene. When in a healthcare setting service users can easily pick up transient micro organisms on their hands which can then be transferred to a more susceptible site where they may cause an infection. Please take every opportunity to emphasize the importance of hand hygiene to service users and visitors. IPC Policy June 2015 V6 Page 30 of 99

31 Always encourage service users and visitors to wash their hands thoroughly before entering the area, before meals, after using the toilet/commode/urinal and before and after clinical procedures. Visual prompts should be in situ including siting of the Trusts corporate hand hygiene posters and signage at hand hygiene dispensers and facilities. If service users, carers or relatives are unable to access a hand wash basin then alcohol hand rub, moist hand wipes or an alternative must be offered. Monitoring and Reporting of Compliance Records of training delivered to be kept by department areas, within practice development and records of local training to be sent to the Infection Prevention and Control Co-ordinator. Annual audit of equipment to be carried out by IPCT. For the convenience of hand hygiene champions, there are lightboxes provided for training purposes which are located at the Longley Centre, Michael Carlisle Centre, Forest Close and Hurlfield View. Please ensure the protocol for borrowing the boxes is completed and that the equipment is returned promptly, ensuring it is decontaminated prior to return. Audit of staff technique PLEASE FORWARD COPIES TO THE INFECTION PREVENTION AND CONTROL TEAM. Observational Audit of compliance to be carried out by nominated and trained staff Review date on or before December 2017 References Allegranzi B, Memish Z A, Donaldson L and Pittet D (2009) Religion and Culture: Potential undercurrents influencing hand hygiene promotion in health care. American Journal of Infection Control. 37 (1), Ayliffe G & English M (2003) Hospital Infection: From Miasmas to MRSA. Cambridge University Press. British Standards Institution (1994,) EN455 BSI, London. Department of Health (2001) Department of Health (2007) epic 2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England (2007). Journal of Hospital Infection 65S, S1-S64 Epic2: National Evidence-Based Guidelines for Preventing Healthcare-associated Infections in NHS Hospitals in England. Pratt et al. Journal of Hospital Infection (2007) 65S, S15-S19 Hand Hygiene Liaison Group (1999) Hand Washing: A Modest measure with Big Effects. British Medical Journal. 318:686 Infection Control Nurses Association (ICNA) (2001), Guidelines for hand hygiene, Fitwise, Bathgate. ICNA (2002), Protective clothing, principles and guidance, Fitwise, Bathgate. ICNA (2002), Hand decontamination guidelines, Fitwise, Bathgate. Sax H, Allegranzi B, Uçkay I, Larson E, Boyce J and Pittet D (2007) My five moments for hand hygiene : a user-centred design approach to understand, train, monitor and report hand hygiene. Journal of Hospital Infection. 67: 9-21 IPC Policy June 2015 V6 Page 31 of 99

32 Appendix 2a Hand Washing Technique Hand washing is the simplest and easiest way of preventing spread of infection and disease. The following technique is recommended and need only take 20 seconds IPC Policy June 2015 V6 Page 32 of 99

33 APPENDIX 3 Guidelines for the use of disposable gloves Aim To provide asepsis or protection at a level unachievable by other methods of hand decontamination. Principles Inappropriate use of gloves is a waste of resources and gives opportunity for sensitisation to latex or nitrile for service users and staff. Once sensitisation occurs it is irreversible and remains with the individual for life. Latex gloves will not be available to Trust. Non-sterile nitrile gloves only to be used unless sterile gloves are required for an aseptic procedure e.g. wound care Gloves to be removed and hands decontaminated immediately between service user contact or procedures. HANDS MUST NOT BE DECONTAMINATED WHILST GLOVES ARE STILL BEING WORN. Sound clinical judgment is to be used to assess the need for gloves. Management Responsibility Appropriate gloves will be provided for staff which must be latex and powder free. Different size gloves must be provided. Gloves will be available for appropriate use by staff. Education will be given on correct use of gloves. Individual Responsibility Sterile gloves will only be used for aseptic and invasive procedures Non-sterile gloves will be used when contamination of hands with blood or other body substances is anticipated. Inappropriate use of gloves will not take place as this is a waste of resources. Staff with skin complaints should report to Occupational Health Department/GP for advice. Used gloves will be disposed of as healthcare waste in offensive waste stream into TIGER BAGS, unless contaminated with bodily fluids (known infected patients) then they are disposed in ORANGE bags. NB The use of gloves is not a substitute for hand hygiene perform hand hygiene before applying and after removing gloves. (See Appendix 2a) IPC Policy June 2015 V6 Page 33 of 99

34 References British Standards Institution (1994,) EN455 BSI, London. Department of Health (2001) Epic 3 : National Evidence-Based Guidelines for Preventing Healthcare-associated Infections in NHS Hospitals in England. Loveday et al. Journal of Hospital Infection (2014) ICNA (2002), Protective clothing, principles and guidance, Fitwise, Bathgate. National Institute for Clinical Excellence (2003), Guidelines for preventing healthcare associated infection in primary and community care: summary of the recommendations and development of guidelines. British Journal of Infection Control December Wilson, J. (2001), Infection Control in Clinical Practice, Bailliere Tindall, London. RCN (2012) Wipe it out WTTO (2009) Guidelines on Hand Hygiene in Heathcare HSE (2014) Choosing the right gloves to protect skin: a guide for employers IPC Policy June 2015 V6 Page 34 of 99

35 Appendix 4 Prevention and Management of inoculation and blood contamination injuries including bites (human or animal) or splash injuries policy Aim To protect Care Workers and the general public from inoculation injury by contaminated sharps, bites or splash injuries. Principles It is the right of Care Workers and the general public to be protected from contaminated sharps, bites or splash injuries which are a potential source of agents causing a number of conditions i.e. Hepatitis B, HIV, Hepatitis C and bacterial infection. Management Responsibility Approved sharps boxes i.e. comply with BS7320 are available in clinical areas. Safer Sharp technology is utilised where appropriate in accordance with EU Legislation (2013) All Care Workers are made aware of the procedures required to practice the safe handling and disposal of sharps. Occupational Health Department promotes safe working conditions and practice. Vaccination is available for service users or staff at risk of Hepatitis B Procedures and guidance are in place in the event of an inoculation or blood contamination injury. Access to staff training in sharps management provided in accordance with the Trusts training needs analysis document. Individual Responsibilities To adhere to this policy. To correctly use the procedures and guidance given. To report incidents using the Trust Incident Reporting and Investigation Policy Failure to follow this policy resulting in injury will be seen as negligence. For action in the event of an inoculation injury and blood contamination including bites (human) or splash injuries involving incidents to staff refer to the Blood and Body Fluids Exposure Incident Protocol. Guidelines on the safe handling and disposing of sharps Where Safety Sharps are available these MUST be used Sharps must be handled in a manner which protects self and others from injury. Needles not to be bent or broken. Needles must NOT be re-sheathed. IPC Policy June 2015 V6 Page 35 of 99

36 Scalpel blades should always be removed from the scalpel using a needle holder or other appropriate instrument and placed onto a sharps disposal pad. Used suture needles should be placed onto a sharps disposal pad using the needle holder. All used sharps to be discarded into a designated sharps box. Authorised sharps bin (with a kite mark) of appropriate size to be used. Use the correct size of bin for the disposed object. Sharps bin to be assembled correctly according to manufacturer s instructions, person assembling to complete and sign the label on the box. Sharps bin to be taken for use at point of care. Users to discard the contaminated sharps directly into the sharps bin. Nursing/medical staff to remove & replace sharps bin when the contents reaches the fill indication line or 3 monthly whichever is soonest. Sharps bins to be closed securely and person closing to complete and sign the label on the bin. The bin is not to be sealed with tape. Do not attempt to press down sharps to make more room in the sharps containers. If the sharps bin cannot be locked it must be placed inside a large sharps container and that must be locked. Never attempt to retrieve items from sharps containers. Never empty out the contents of the bin. The locked bin must be safely stored until it is removed. Sharps bins must not be placed inside orange clinical waste bags. Giving sets to be disposed into the clinical waste bag whilst still connected to the infusion bag. Sharps boxes must be positioned in a place which is easily accessible for staff but out of the reach of service users, members of the public and children. The temporary closure mechanism must always be activated whenever the bin is left unattended Monitoring and Reporting arrangements Annual audit of equipment to be carried out Surveillance of sharps related incidents carried out continuously Verbal report back to Infection Control Committee Written report provided to the Trust Board quarterly Infections will be reported to external agencies where required via RIDDOR and in line with the Trusts Incident Reporting Policy. For examples of RIDDOR reporting see References UK Chief Medical Officers Expert Advisory Group on AIDS July RCN (2013) Sharps Safety HSE (2013) Health and Safety (Sharp Instruments in healthcare) Regulations 2013 DH (2008) HIV: Post exposure prophylaxis! Guidance from the CMO expert Advisory Group. IPC Policy June 2015 V6 Page 36 of 99

37 Appendix 5 Meticillin Resistant Staphylococcus aureus (MRSA) Introduction Staphylococcus aureus is a common bacteria that is frequently found on the skin or in the nose of healthy people without causing infection. If the bacteria invade the skin or deeper tissues and multiply, an infection can develop. This can be minor (such as pimples, boils and other skin conditions) or serious, (such as bacteraemia, wound infections or pneumonia). Meticillin is an antibiotic that was commonly used to treat Staphylococcus aureus, until some strains of the bacteria developed resistance to it. These resistant bacteria are called Meticillin resistant Staphylococcus aureus (MRSA). Strains identified as Meticillin resistant in the laboratory will not be susceptible to flucloxacillin the standard treatment for many staphylococcal infections. These strains may also be resistant to a range of other antibiotics. Resistance to antibiotics is a global problem and incidence is increasing. Treating service users with MRSA infections should involve discussion with the Microbiologist. Who is at risk? Service users with an underlying illness Immune compromised service users The elderly particularly if they have a chronic illness. Those with open wounds or who have had recent surgery Service users with invasive devices such as a urinary catheter or PEG Where does MRSA occur? MRSA is more commonly identified in health care settings than in the general community and particularly where there are more susceptible patients. MRSA can easily be passed from person to person directly and via environmental contact. What can we do? The Department of Health has issued guidelines around screening service users when admitted. An Assessment and MRSA Screening Protocols for In Patient Service users has been developed together with a flow chart. Colonized or Infected? Colonization means that MRSA is present on or in the body without causing an infection (usually on the skin, skin folds, nasal passages, perineum and umbilicus). Infection means that the MRSA is present on or in the body and is multiplying causing clinical signs of infection e.g. inflammation, pus, pain, etc. IPC Policy June 2015 V6 Page 37 of 99

38 How is MRSA transmitted? Hands direct and indirect contact Skin conditions - eczema, psoriasis, skin lesions Equipment inadequately decontaminated (e.g. bed pans, commodes) Airborne - the organism can be carried on skin scales of the service user. Environment MRSA can survive in the environment therefore high standards of cleanliness are important. The management of MRSA service users Assessment and MRSA Screening Protocols for In Patient Service users In general service users that are admitted to mental health and learning disability facilities should not require screening for MRSA. However, in recognition that many of these groups of service users have other physical illnesses, The Department of Health (2009) have requested that patients fulfilling specific criteria must be screened on admission to our units. The groups of service users affected: Are those admitted to mental health units following surgical procedures Transfers from another hospital Individuals transferred from residential or nursing care homes Intravenous drug users Those who self harm People with a possible diagnosis of delirium People with chronic wounds. e.g. leg ulcers, People with indwelling devices such as urinary catheters, PEG etc Full MRSA Screen consists of: Nose Groin OR perineum Invasive devices e.g. catheters, tracheotomy, PEG s All broken/ compromised skin areas pressure sores ulcers surgical wounds eczema, psoriasis, dermatitis cuts and abrasions tracheostomy sites Urinary catheter exit site only if producing exudates Catheter Specimen Urine if catheterised Sputum if patient has a productive cough NB Axilla and throat swabs are NOT required for routine screening Swabbing When swabbing dry sites please ensure swab is moistened with sterile water. Large areas that require screening. i.e. wounds. The swab should cover the entire area in a continuous movement. Please ensure that laboratory forms are fully completed with identifying information and requests a IPC Policy June 2015 V6 Page 38 of 99

39 MRSA screen and that the sites swabbed are clearly identifiable both on the swab and the form. IPC Policy June 2015 V6 Page 39 of 99

40 MRSA Screening Flow Chart In line with Department of Health (2009) recommendations FULL MRSA SCREEN REQUIRED within 48 hours On all patients who fall into the categories below Full Screen consists of: Nose, Groin, Broken skin, CSU, PEGS, Urinary catheters Tracheotomy sites. Service users currently or previously MRSA positive Transfer in from another hospital - STHFT - UK - Abroad Known Intravenous drug users Service Users who Self Harm Service Users who are admitted with a surgical wound still present following a recent surgical procedure being performed in another facility. Service Users with a diagnosis of delirium Service Users with chronic wounds (leg ulcers etc) or with indwelling devices (urinary catheters) If possible, service user to be care for in a single room with barrier precautions unless 3 consecutive negative screens have been obtained prior to admission If 3 consecutive negative screens have been obtained patient may be admitted to a main bay but admission screening is still required Take swabs according to protocol and in line with SHSC policy for consent Complete a Laboratory form. State MRSA screen. Place swabs in bag and send immediately to lab. Use separate swabs for each site. Swab protocol: 1 swab per site Moisten swab in sterile water prior to swabbing dry sites Use a continuous motion to sweep across larger areas. Document in nursing records date swabs taken and sites If positive please contact the ICN for advice about further management. If negative no further action required. If colonised, decolonisation will be recommended: Using anti-microbial body washes and nasal ointments. If deemed to have an infection treatment with appropriate anti-microbials may be required IPC Policy June 2015 V6 Page 40 of 99

41 Transfers, admissions and discharges Inform the Infection Prevention and Control Team if a service user with MRSA has been admitted or is to be admitted. Admit service user to single room. Communication regarding infection or colonization must be included in the information to other providers of health and social care. MRSA is not a reason to refuse admission to a care setting or nursing/residential home. There is no reason not to discharge service users to their own homes. Service users can also attend day centres, visit relatives, friends and share communal facilities. However, lesions/wounds must be covered with an appropriate dressing. Treatment Where treatment is required i.e. service user has clinical signs of infection avoid the use of Beta lactam antibiotics (Penicillin and Cephalosporin) and seek advice from Consultant Microbiologist. In certain situations it may be appropriate to use topical preparations to eradicate colonisation. Decolonisation As soon as a patient is identified as an MRSA carrier, a decolonization regimen can be started. This comprises of an antibacterial shampoo and body wash daily and the application of an antibacterial nasal cream three times a day for five days. This should be done irrespective of whether facilities are available to isolate the patient. The aim of decolonisation is to reduce the risk of: The service user developing an MRSA infection or Bacteraemia from their own MRSA during medical or surgical treatment Transmission of MRSA to another service user The decolonization regimen is only 50-60% effective for long-term clearance but as soon as the procedure is implemented the presence of shedding MRSA are reduced significantly and the risk of the service user infecting themselves or transmitting MRSA to another service user is much reduced. Isolation of patients When a service user is identified as MRSA positive, they should be isolated, if possible, to reduce the risk of transmission to other service users. Where isolation will be detrimental to the service users mental health a risk assessment should be made and the infection prevention and control team contacted for further advice. If appropriate the decolonization regimen should be applied as soon as a positive result is known, irrespective of the availability of isolation facilities. Precautions The service user should be nursed in a single room with the door closed for activities such as bed making, bed bathing, dressing changes or other clinical procedures. IPC Policy June 2015 V6 Page 41 of 99

42 The service user, once clothed and wounds covered, may leave the room for mobilization and social contact. However, if the service user has MRSA in their sputum and have a productive cough and/or having chest physiotherapy, they must remain in their room. NB It is noted that in mental health and learning disability healthcare isolation of a patient may not always be possible. Refer to Isolation Policy. Hand hygiene is essential before and after service user contact. The Hand Hygiene guidelines must be adhered to. Disposable gloves and disposable plastic aprons must be worn when handling items contaminated with blood/body fluids. (Please refer to Standard Precautions policy.) A disposable plastic apron must be worn when in close physical contact with the service user and bed making. The apron must be changed when moving on to other procedures with different service users. All linen should go into water soluble bag/s in the same way as foul linen is managed (Please refer to laundry policy). High standards of hygiene are required to prevent MRSA contaminating the environment. Dust should be removed and kept to acceptable levels. Ensure curtains and soft furnishings are well maintained (i.e. regular cleaning programme) No special precautions are required for crockery/cutlery and they should be dealt with in the normal manner. All waste that is known to be contaminated with MRSA, is deemed to be infectious and must be segregated and disposed of into the infectious waste stream. Refer to Waste Management Policy for disposal of this waste stream. There is no need to restrict visitors but they should be advised to wash hands on leaving. Management of wounds colonised or infected with MRSA Where treatment for MRSA with systemic antibiotics is deemed necessary i.e. service user has clinical symptoms of infection, avoid the use of Beta-lactam antibiotics (penicillins and cephalosporins). Not all locally infected wounds need systemic antibiotic therapy. Management of wounds colonised/infected with MRSA may be treated topically: Contact the Infection Prevention and Control team for specific advice. After completion of treatment three clear specimens are required from wound site. IPC Policy June 2015 V6 Page 42 of 99

43 MRSA Care Plan and Eradication (Decolonisation) Regime for MRSA Care plans for MRSA and the Eradication Regimen are available on the Infection Control web page on the Trust Intranet. For further information or advice contact the Infection Control Team. Management of PEG sites/suprapubic catheters colonised/infected with MRSA For information or advice contact the Infection Control Team. Staff health issues The screening of nursing/care staff for the carriage of MRSA is unnecessary unless an MRSA outbreak becomes apparent. If screening is necessary this will be managed by Occupational Health. The decision to screen will jointly be made by the Consultant Microbiologist, Infection Control & Occupational Health (OH). Care staff with skin conditions such as psoriasis, eczema or dermatitis should carefully monitor their skin condition carefully and respond to any deterioration quickly and these staff should discuss the risks of working in a clinical environment with Occupational Health. Care staff with skin conditions can help to prevent colonization e.g. by wearing semi-occlusive dressing over lesions or avoiding clinical care of people who have MRSA. The Occupational Health Department can help to assess the risks. Following any positive results arising from staff screening, OH will provide decolonisation therapies as necessary and will undertake the necessary follow-up re-screening and management all staff results. OH will inform the staff member when they can return to work. Some staff will ultimately become unwell & potentially admitted as patient s themselves. Should staff be admitted to hospital they will be screened as part of their admission process depending on whether or not they meet DH MRSA screening criteria. If MRSA is isolated from their specimens, decolonisation therapies will be offered. Staff members should follow the advice given by the healthcare professional responsible for their care about returning to work; alternatively discuss with OH or registered GP. References Department of Health (2013) UK Antimicrobial Resistance Strategy and Action Plan Department of Health (2007) Saving Lives: reducing infection, delivering clean and safe care. Screening for meticillin-resistant Staphylococcus aureus (MRSA) colonization. A strategy for NHS trusts: a summary of best practice. NHS Executive HSC 1999/049 Resistance to Antibiotics and Other Antimicrobial Agents. March DoH (Government response to the House of Lords Select Committee on Science and Technology) Standing Medical Advisory Committee (SMAC) 1998 The Path of Least Resistance DoH. London Simpson, A.H.R., et al The value of routine screening of staff for MRSA. The Journal of Bone &Joint Surgery (Br) VOL. 89-B, No. 5, May 2007 Infection Control Services Ltd. MRSA Methicillin-resistant Staphylococcus aureus (MRSA). Guidance for Nursing Staff. April IPC Policy June 2015 V6 Page 43 of 99

44 Appendix 6 Clostridium difficile Introduction Clostridium difficile Infection (CDI) is a major healthcare associated infection, and is recognised as a major cause of diarrhoea. This infection is associated with antibiotic use and environmental contamination: the elderly, the immunocompromised and chronically ill service users are most vulnerable. It is a legal requirement that surveillance of all cases of Clostridium difficile in patients over the age of two years is performed and reported to the Public Health England (PHE) Clostridium difficile is an anaerobic, Gram positive spore forming bacilli. These spores are resistant to exposure to air, drying, heat and survive in the environment for a considerable period of time. Following antibiotic therapy the intestinal flora is altered which allows the Clostridium difficile bacteria to proliferate. The bacteria produces a toxin that irritates the colon and causes what is commonly known as antibiotic associated diarrhoea, which can lead to pseudomembranous colitis (PMC). The source may be the patient themselves (endogenous) if they are a carrier or acquired from the environment (exogenous). Scope of Guidelines This document provides guidance for those caring for service users who are identified as likely to have a CDI and for care areas where there appears to be a period of increased incidence (PII) which is defined as 2 or more new cases of CDI occurring within a 28 day period and where symptoms have occurred more than 48 hours after admission (not relapses). An outbreak of CDI is 2 or more cases caused by the same strain related in time & place over a defined period that is based on the date of onset of the first case. Prevention of CDI There are a number of active interventions that can be incorporated into daily care to reduce the risk of a CDI occurring. Comply with the antibiotic policy Use relevant infection control precautions for all service users with diarrhoea. Perform hand hygiene pre and post contact with all service users. Encourage hand washing with service users particularly before eating and following use of toilet De clutter and clean and the environment. Management and Treatment of CDI Clinicians are expected to apply the following mnemonic protocol (SIGHT) when managing suspected potentially infectious diarrhoea (DH 2009) S Suspect that a case may be infective where no clear alternative cause for diarrhoea IPC Policy June 2015 V6 Page 44 of 99

45 I G H T Isolate the patient and consult with the infection prevention and Control team (IPCT) while determining the cause of diarrhoea Gloves and aprons must be used for all contacts with the patient and their environment Hand washing with soap and water should be carried out before and after each contact with the patient and the patients environment Test the stool for toxin, by sending a specimen immediately. Diagnosing Clostridium difficile: Symptoms One or more episode of diarrhoea, defined either as stool loose enough to take shape of container or as Bristol Stool chart types 5-7 (available on the intranet) Foul smelling diarrhoea check for the presence of blood & mucus Nausea, rarely vomiting Investigations and management: Commence patient on the CDI Care Pathway (on the intranet) If Clostridium difficile is suspected please send urgent faecal sample for MC&S (microscopy and sensitivities). Please specify if service user has had recent antibiotictherapy, providing dates where known. Confirmation of diagnosis by detection of the toxin produced by Clostridium difficile bacteria. In some patients the result may be inconclusive and discussion with the Consultant Microbiologist will be needed before treatment. Do not automatically retest patients, within 28 days, with a positive diagnosis unless the symptoms have resolved and it is required to confirm recurrent infection. Infection Control Measures Routes of transmission are: Direct spread from service user to service user by the faecal/oral route Direct spread through the hands of care workers Indirect spread from the service user to the environment and from the environment to the service user Isolation/Barrier Precautions National guidance recommends that isolation is the most successful method of preventing the spread of Clostridium difficile to other service users. Only where a service user is at a high risk Read these measures in conjunction with Barrier precautions guidelines (Appendix 7) Ensure each individual has their own toilet/commode. This must be cleaned thoroughly with neutral detergent and water and disinfected using either a chlorine based agent or Virusolve+ after each use. Increase the cleaning to twice a day. Ensure thorough cleaning of area is carried out after isolation has ended Non sterile nitrile disposable gloves and plastic aprons must be worn when dealing with body fluids, wash hands Hands must be thoroughly washed with warm water and liquid soap and dried with paper towels following removal of gloves and before and after service user contact or their environment. IPC Policy June 2015 V6 Page 45 of 99

46 Service users should be encouraged to wash their hands after using the toilet and before meals. Carers and visitors must always wash their hands on leaving the isolation room/area. Alcohol hand rub must not be used as an alternative; it is ineffective against Clostridium difficile Where items are contaminated with bodily fluids, dispose of all items and threat the waste as hazardous by infection in line with the Waste Management Policy. Linen should be placed into an alginate bag prior to being transferred to the laundry facility. Discontinue barrier precautions once the service user has been asymptomatic for 48 hours and has passed a normal stool. Cleaning Protocol Clostridium difficile spores may survive for many months and are spread in the healthcare environment. Service user care & therapy equipment can easily become contaminated with the organism. Clostridium difficile is resistant to many disinfectants. It will be necessary to contact the Infection Prevention and Control Team (IPCT) and housekeeping services for advice. (Refer to Decontamination and Disinfection Policy) The following steps should be taken: During Symptoms The room/bed area to be cleaned twice daily using chlorine releasing agent, Virusolve+ or an approved alternative (e.g. Clinell Sporicidal Wipes) good care and storage of cleaning equipment Clean toilet/commode thoroughly, top and bottom, after each use with a chlorine releasing agent or Virusolve+ (ensure the arms and under seat are included on commodes) Allocate where possible specific equipment for the infected service user e.g. moving and handling slings. All service user care & therapy equipment must be decontaminated after each use Post Symptoms The room/bed area must be thoroughly cleaned, paying special attention to the bed frame and mattress, en-suite- toilet/commode and frequent touching surfaces e.g. door handles. All equipment that has come into contact with the service user, including medical & therapy equipment should be cleaned and disinfected in accordance with the Decontamination policy e.g. commodes Bedding and cotton duvets must not be washed in a domestic washing machine. They can be placed in water soluble bags and outer bag for infected linen and sent to the laundry. Personal clothing can be washed at the highest temperature possible in the washing machine but NOT with other service users clothing If room carpeted, steam clean using an additional chemical to provide a higher level of decontamination. Contact IPCT for advice. Curtains are removed for laundering. Any doubts arising from infection prevention and control procedures contact the Infection Control Team (IPCT). IPC Policy June 2015 V6 Page 46 of 99

47 Treatment Discuss with Consultant Microbiologist Antibiotics should be reviewed and stopped wherever possible Monitor risk of dehydration by maintaining a fluid balance chart and the Bristol Stool chart (available on intranet) Encourage oral fluids to be taken. If mildly symptomatic oral Metronidazole 400 mg, 3 times a day can be given for 10 to 14 days. If oral Metronidazole is not effective after 1 week discuss further treatment options with the Microbiologist. Communication and documentation It is essential that everyone is aware of the Infection Control precautions that need to be in place and that this is documented on the areas monthly Prevalence Form Explanation to service user and relatives is essential; leaflets can be obtained from the intranet. It is also important to maintain the service user s dignity and confidentiality at all times. Complete an Incident Form (refer to Incident Reporting and Investigation Policy) Symptomatic patients / service users should not be moved unless unavoidable. Recurrence of CDI Recurrences of Clostridium difficile diarrhoea are common, occurring in at least 20% of cases. Immediate actions: Regard the service user as infectious, inform the IPCT Re-instate appropriate infection control measures and CDI Pathway Medic/GP to consider treatment options for CDI recurrence following discussion with microbiology. Transfer/Discharge of Service Users Service users with symptomatic Clostridium difficile infection (CDI) should not be transferred to other areas without discussion with the IPCT. Where emergency investigations and treatment is necessary communication with the receiving area is required and the following principles adhered to: Infected service users should be seen at the end of the working session. Service users should not be left in waiting areas with other service users if they are symptomatic. Disposable equipment should be used whenever possible; non-disposable equipment must be thoroughly cleaned and decontaminated with Virusolve+ Staff should adhere to strict infection control procedures during the investigation or treatment The service user should return to their ward/home following the procedure All equipment is cleaned and decontaminated in accordance with the Decontamination guidance. IPC Policy June 2015 V6 Page 47 of 99

48 Service users can be discharged/ transferred after being asymptomatic for 48 hours (72 hours if this is a reoccurrence). If service user is transferring to a care/nursing home then the receiving staff MUST be informed of the recent diagnosis and who to contact if symptoms reoccur. Laundry practices Hospitals All laundry to be placed in water soluble (alginate) bag and sent to the laundry in red linen sacks. Care/Residential Homes All laundry to be placed in water soluble bag and placed immediately into washing machine on a sluice cycle then wash at 71 degrees centigrade, hold for 3 minutes or wash at 65 degrees hold for 10 minutes, and tumble dry and iron. Refer to personal clothing below NB: Wash all infected linen separately Own Home Where possible laundry to be placed in soluble bag, (suitable for domestic machines), and started on pre-wash cycle, then washed at the highest temperature the fabric will withstand using bio- logical detergent and if possible tumble dried and ironed Personal Clothing Personal clothing can be washed at the highest temperature the fabric will withstand in the washing machine with laundry detergent and tumble dried and ironed wherever possible. Refer also to the Laundry Policy. Surveillance and Audit Continuous local surveillance of the incidence of CDI is mandatory and any incidence requires reporting to NHS Sheffield CCG as part of governance. All incidence of CDI require a full Root Cause Analysis investigation. Management of a period of increased incidence (PII) on an in-patient area. Urgently inform senior management team of the area, including clinical director, assistant clinical director, service director, ward manager Pharmacist to review all antibiotic prescribing practices. IPC Policy June 2015 V6 Page 48 of 99

49 Clean entire in-patient area with a chlorine releasing agent, Virusolve+ or an agreed alternative product. An incident meeting should be held with input from the DIPC, SN-IPC, relevant clinical director An incident should be logged and the situation closely monitored. Staff Issues Staff who suspect that they may have CDI should send a stool sample via their own registered GP. If treatment is required this will be managed via their GP. Staff can return to work after 48 hours post symptomatic episode and when normal bowel habits have returned as well as feeling physically fit to be on duty. References: Department of Health and Health Protection Agency (2009) Clostridium difficile infection: How to deal with the problem. DH Publications January 2009 Public Health England(2013) Updated Guidance on the Management and treatment of Clostridium difficile Infection NHS England 2014/15 Costridium difficile Objectives Wilson J. 8th Ed (2000) Clinical Microbiology. An Introduction for Healthcare Professionals. Balliere Tindall, London Wilcox M H. et al (1996) Financial Burden of Hospital Acquired Clostridium difficle. Journal of Hospital Infection Vol 34 (2330) IPC Policy June 2015 V6 Page 49 of 99

50 Appendix 7 Barrier Precautions including Isolation Introduction Barrier precautions refers to any method used to reduce contact with potentially infectious bodily fluids, including use of protective equipment. Isolation is an infection control measure that can be used as a further barrier to transmitting infections to and from service users when standard infection control precautions may not be adequate. As with standard precautions the aims of isolation are to minimise transmission occurring from: Patient to patient Patient to staff Staff to patient It can be divided into 3 different levels: Strict Isolation this is required only for very infectious organisms such as viral hemorrhagic fever (VHF) and would be carried out in the Acute Trust infectious diseases unit. Source Isolation refers to the use of standard precautions plus the physical separation of a service user within a contained area such as a single room, though where there are more than one service user with the same organism it may be able to cohort them together. Protective isolation this is required to protect an immunocompromised service user from staff and other service user s micro-organisms. Identifying the need to isolate. Isolation is recognised as being potentially stressful to service users. Staff must understand that it is the infection NOT the person who requires isolation. Prior to deciding to isolate a service user consideration of a number of factors is required and a risk assessment made to identify whether isolation is the required infection control precaution. Consent to Care and Treatment Policy The organism involved and its method of transmission (contact, airborne, droplet, enteric or blood borne) Service user s clinical condition e.g. mental health, learning disability or other issue. The risk of spread to other service users and staff and their care environment. The safety of the service user The availability of rooms suitable for isolation. Consider service user status in applying Advice should be sought from the Infection Prevention Control Team on the appropriateness of isolating service users and any decision taken must documented in full within the electronic or paper care records. IPC Policy June 2015 V6 Page 50 of 99

51 Where it is deemed to be either impracticable or is likely to be detrimental to the service user to isolate them. A risk assessment of the other service users, and where appropriate staff, must be made. Identifying specific risk factors: i.e. presence of open wounds/sores, chronically ill etc. Requirements Application of barrier precaution, (Isolation nursing) will normally be carried out in a single room. The room should ideally have its own toilet and hand basin. If en suite facilities are not available, a designated toilet/commode must be identified for the infected person s use. Should the service user develop a condition which requires isolation and a single room is not available, Standard Precautions should be strictly adhered to and notional barriers observed i.e. the identification of a toilet for sole use. The Infection Control Team should be contacted for further advice. Essential Equipment Small amounts of basic equipment should be easily assessable to facilitate compliance with guidelines. Consideration as to how this will be managed locally needs to be determined via a risk assessment of the area and service users. Recommended equipment: Charts Disposable apron Disposable gloves Orange bags for clinical waste Notice for the door (if applicable) with advice to see nurse in charge before entering (obtainable from the Infection Control web site on the Trust Intranet). Alcohol hand rub/gel FFP3 Masks (if appropriate for the service users condition) Eye protection where there is a possibility of splashing of body fluids to the eyes/face A soluble laundry bag for foul/infected linen A red linen laundry bag for transportation to the laundry room (within areas where service acquired from Sheffield Teaching Hospitals NHS Foundation Trust). Lidded pedal operated bin with orange bag for clinical waste Disposable Wash Bowls Liquid soap Paper towels Commode (if en suite facilities are not available) ensuring there is a fitted lid for the commode pan or appropriate covers for disposable commode inserts for safe removal of waste from the service users room. Principals of Barrier Precautions Standard Precautions should be followed (see Standard Precautions Guidelines) Protective clothing needs to be easily assessable and worn when having direct contact with the service user and/or their environment. o Gloves o Aprons IPC Policy June 2015 V6 Page 51 of 99

52 o Masks o Visors/goggles Hand hygiene must be practiced both on entry to the area and on exiting the area. This includes where contact is of a social nature. All staff should perform hand hygiene and change their gloves as identified in the hand hygiene policy. On completion of the episode of care, whilst still in the room, protective clothing e.g. gloves and apron should be removed and disposed of as clinical waste, remove protective eye wear/visor or mask if applicable (if protective eye wear/visor are not disposable they should be placed in a bag for removal to the dirty utility room for decontamination). Perform hand hygiene before exiting the room. Care workers with moist lesions on hands (e.g. eczema) should seek advice from the Occupational Health Department on what procedures they can perform. The lesions must be covered with an impermeable dressing and disposable gloves worn. Disposable gloves are not an alternative to effective hand hygiene. Hand hygiene should always be performed before and after removal of gloves and other items of Personal Protective Equipment (PPE). The door to the room should only be kept closed for airborne infections e.g. Influenza, Pulmonary TB, and Norovirus. In certain other circumstances door closure may be advised by the IPCT. Care must be taken not to over stock a single room used for isolation room. Visitors suffering from an infection should be discouraged from visiting. Wherever possible disposable equipment should be used inside the room. Precautions for visitors All visitors should be made aware that the service user they are visiting requires them to take additional precautions and should be encouraged to perform hand hygiene before and after visiting the service user. Please consider issues around client confidentiality, seek advice from senior management as required. Protective clothing i.e. aprons and gloves are not required, unless visitor is providing direct care. Consideration should be given to the appropriateness of children visiting and advice on a case by case basis can be sought from the Infection Control Team. Disposal of faeces/urine Standard Precautions should be used when disposing of faeces and urine. IPC Policy June 2015 V6 Page 52 of 99

53 Where bedpans/commode inserts and urine are to be taken to the dirty utility room the following procedure should be followed: Put on disposable gloves and a disposable plastic apron and cover the bed/commode pan or urinal with paper immediately prior to leaving the room On entering the sluice dispose of the contents carefully in order to avoid splashing in either a macerator or washer/disinfector Place the paper cover into a clinical waste bin which should be foot operated Remove protective clothing and discard as clinical waste Wash hands immediately Commodes should be left in the service user s room for their use only, and should be cleaned after each use with Clinell Universal Wipes; pay particular attention to underneath the seat & arm rests. If the service user has infective diarrhoea and or vomiting a chlorine releasing agent or Virusolve+ should be used to clean daily ensuring that all surfaces are thoroughly cleaned. At the end of isolation these items should be thoroughly cleaned using a chlorine re-leasing agent or Virusolve+. Disposal of clinical waste Clinical waste (e.g. soiled dressings, used gloves and aprons) from all service users in isolation should be placed in an orange waste bag inside the room. When 2/3 full the neck of the bag should be securely tied and the bag labelled and removed to the designated storage area. If there is an offensive odour or for service user safety remove bag immediately from the room and transfer to the designated storage area. Clinical waste bags do not require double bagging unless the outside of the bag is visibly contaminated. (See Waste Management Policy for further details). Crockery and cutlery There are no specific precautions for crockery and cutlery. Used crockery and cutlery should be washed as usual in the dishwasher. Where there is no dishwasher is present. Wash in the hottest water that can be tolerated when wearing rubber gloves. Disposable crockery and cutlery are not required. Medical and therapeutic devices All Items of medical & therapeutic equipment in the room should be cleaned with a Virusolve+ solution or a Clinell Universal Wipe before being removed (but refer also to Decontamination and Disinfection Policy and manufacturers guidance All linen should be treated as infected. (See Laundry Policy). IPC Policy June 2015 V6 Page 53 of 99

54 Room cleaning All isolation rooms must be cleaned daily. Housekeeping staff are responsible for cleaning the environment and the care staff the medical & therapy equipment. Staff should wear the appropriate PPE whilst undertaking cleaning duties and perform hand hygiene in line with policy. The isolation room should be cleaned after all other areas have been cleaned with Yellow disposable coloured-coded cleaning equipment (mop heads & cloths). Disposable cloths should be used and disposed of as clinical waste (orange infectious) after cleaning the room. Cleaning should be undertaken using a clear workflow of clean to dirty; top to bottom approach working form outer surfaces towards inner surfaces of items & objects Horizontal hard (including mattresses) surfaces should be washed with a solution of Virusolve+ or hot water and detergent (if the service user has diarrhoea thought to be due to a gastrointestinal infection this should be followed by a chlorine re-leasing agent if using hot water & detergent). Hard floors should be cleaned using disposable yellow colour-coded equipment as per above. The mop handle and bucket should be washed and dried after each use and stored inverted in the sluice/utility room. Carpets require daily vacuuming ideally with a hoover which is fitted with a HEPA filter. En-suites / Bathrooms clean as above. Toilets should be cleaned with Hospect Sanitizer in the toilet bowl and the cistern, flush handle, seat, and the outer surfaces of the bowl with Virusolve+ or hot water and detergent followed by a chlorine containing agent. PPE to be discarded within the room and perform Hand hygiene prior to leaving the room. Terminal cleaning Following the discharge/transfer of the service user, or when isolation is discontinued the room should be cleaned as follows, following the principles above: All surfaces in the room should be cleaned using a disposable cloth with either a Virusolve+ solution or hot water, detergent and a chlorine-releasing agent. Hard surface floors should be washed as above. Carpeted rooms should be vacuumed, then shampooed or steam cleaned. Window curtains & nets should be removed and washed. The bed frame, mattress, table furniture, toilet seat, commode, hand basins, and toilet bowl should be cleaned as above. Following terminal cleaning if a reusable mop head has been used the mop head should be discarded as clinical waste. The mop handle & bucket should be cleaned thoroughly with hot water and detergent and stored inverted. IPC Policy June 2015 V6 Page 54 of 99

55 Transfer of isolated service users within and between hospitals/care facilities Transfers should only take place if unavoidable, and in the service user s best interest, i.e. the health of the service user should take priority over the infection problem. The receiving ward/ care facility must be informed and a single room arranged. In case of difficulty please discuss with the Infection Control Team. References Ayliffe GAJ, Fraise AP, Bradley,C, (2009) Control of Healthcare -associated Infection: a practical handbook, 5 th Edition, Arnold, London Chin J. Editor 2000 Control of Communicable Diseases Manual. Seventeenth Edition. American Public Health Association Department of Health. Memorandum on leprosy. Department of Health, 1997 Hawker J, Begg N, Blair I, Reintjes R, Weinberg J Communicable Disease Control Handbook. Blackwell Publishing, Oxford. NPSA (2009) The Revised Healthcare Cleaning Manual Royal Marsden Manual of Clinical Procedures Lawrence J. and May D. (2003) Infection Control in the Community, Churchill Livingstone, London. IPC Policy June 2015 V6 Page 55 of 99

56 Appendix 8 Healthcare waste NHS Trusts have a statutory duty of care which applies to everyone within the waste management chain. It requires the producer/care professional involved in the management of waste to ensure that it is dealt with appropriately from the point of production to the point of disposal. Refer to the Waste Management Policy for detailed information. All staff working in areas where healthcare waste arises must adopt safe working practices and adhere to the Infection Control Policy and Guidelines and the Waste Management Policy. Protective clothing & avoidance of injury when dealing with waste People who handle the filled bags requiring disposal should be made aware of the hazards of handling hazardous waste. Careful consideration must be given by all staff to the methods used for transferring clinical waste at all stages of the disposal route, so that the risk of injury is reduced to a minimum. People who are repeatedly moving bags from one small receptacle to a large container may become complacent with the routine activity. Risk of injury is therefore increased for those staff handling the waste in large quantities within a relatively short time period when loading the container. The hazard most likely to endanger health is injury through a sharp such as a hypodermic needle which may have been wrongly disposed of into a bag instead of the correct sharps container. When moving sacks hold them by the closure end only and wear heavy duty gloves to protect the hands. Gloves should also be worn when handling sharps containers. To protect the feet against bags or containers that might be accidentally dropped, sturdy shoes should be worn. The soles of such footwear will also offer protection in the storage areas where the spillage of sharps must be guarded against. Avoid body contact with bags of healthcare waste. If there is the slightest risk of brushing against clothing when being transferred then an industrial apron or leg protectors will need to be worn. All waste containers either partially full or awaiting collection must be stored safely and be inaccessible to service users, children and members of the public. All sharps and healthcare waste being disposed of in receptacles (bags/bins) must only be filled to 2/3 full and secured. Where there is a risk of contamination with blood or body fluids when cleaning up spillage protective clothing must be used. This will include visor or mask and goggles, disposable gloves and disposable apron/overall. When an incident has occurred involving sharps or contamination of blood or body fluids, however small, it must be reported to the immediate superior. If possible retain the item causing the injury to IPC Policy June 2015 V6 Page 56 of 99

57 help in the identification of the risk (Please refer to the Blood and Body Fluid Exposure Incident Policy.) A course of anti-tetanus/hepatitis B vaccinations is offered by the Occupational Health Department and must be considered for all operatives carrying out waste transfer to the final disposal or collection point within the Care Trust premises. References Health and Safety at Work etc. Act 1974 SI 1974/1439 The Stationery Office 1974 ISBN X The Control of Substances Hazardous to Health Regulations (as amended). Approved Code of Practice and Guidance L5 (Fifth edition) HSE2005 ISBN Workplace health, safety and welfare. Workplace (Health, Safety and Welfare) Regulations Approved Code of Practice L24 HSE Books 1992 ISBN Management of Health and Safety at Work. Management of Health and Safety of Work Regulations Approved Code of Practice and guidance L21 (second edition) HSE Books 2000 ISBN Manual handling. Manual Handling Operations Regulations Guidance on Regulations L23 (second edition) HSE Books 1998 ISBN Infection at work: controlling the risks ( Infection at work: Controlling the risks, produced by the Advisory Committee on Dangerous Pathogens and published on Health and Safety Executive (HSE) website RCN (2014) The Management of Waste from health, social and personal care. IPC Policy June 2015 V6 Page 57 of 99

58 Appendix 9 Laundry Policy Introduction This guidance should be applied to all laundry facilities including launderettes and on-premise laundries associated with small units. All used linen must be managed in such a way as to protect service users, care workers and laundry staff from contamination or injury and to avoid damage to laundry machinery. Linen used in care environments can become soiled with blood, excreta or other body fluids, containing microorganisms. Decontamination of linen is by a combination of detergent, dilution and mechanical action to remove particles and temperatures that destroy micro-organisms. Failure to give sufficient time to this process has resulted in outbreaks of infection notably with spore forming bacteria e.g. Bacillus cereus (food poisoning). Micro-organisms that remain after washing may be destroyed by tumble drying and ironing. Categorisation of linen for laundering Clean/unused linen Any linen that has not been used since it was last laundered must be stored off the floor in a clean closed cupboard, and must be segregated from used/soiled linen. Linen cupboard doors must be kept closed to prevent airborne contamination, and must not be stored within the sluice/laundry room. Clean linen must be monitored to ensure it is a good state of repair, as tearing or roughness can damage the skin of service users. Soiled/Used linen white sacks Any used linen or clothing which has been used or worn and is NOT soiled with blood or any other body fluids. Foul Linen red sacks Any used linen or clothing which is visibly contaminated with blood or body fluids or all linen from infectious clients. This also includes linen which maybe infested with lice or fleas. All foul linen & clothing MUST be placed into a water soluble (alginate bag) prior to placing into a red laundry sack. This is to protect laundry & caretaking staff and prevent contamination of the environment. All foul linen must be processed on wash cycles which include both a sluice cycle followed by thermal temperatures to disinfect the linen. If the washing machine does not have a sluice cycle then select a pre-wash setting on the machine. Washing machines should not be overloaded. Laundry sacks must be stored in a secure area away from public & patient access whilst waiting for collection and transferring to the laundry. Securely fasten the linen bag when ¾ full. Manual sluicing must never be carried out be staff or service users. IPC Policy June 2015 V6 Page 58 of 99

59 . Procedure Service users and staff must not be put at risk during the handling, disposal and transportation of used linen. Staff handling any linen should wear protective clothing i.e. disposable gloves and aprons, and cover any skin lesions. Take a linen skip/trolley with appropriately colour-coded laundry bag to the bedside to dispose of any used laundry. Always separate linen when stripping beds and placing into linen bags as any foreign objects e.g. sharps, syringes etc. can be identified and dealt with appropriately. Handle linen with minimum fuss in order to reduce risk of environmental contamination. Do not place used linen on floors, or carry it against uniforms/clothing or about clinical areas. Always wash hands thoroughly after handling used linen and disposing of gloves. Ward/Unit washing machines Laundry facilities should be separate from clinical areas and an accessible hand wash basin must be available. Laundry facilities (except small units on wards for service user use) must have an entrance and an exit and flow dirty to clean to prevent cross contamination from used laundry. All purchases of washing machines must be discussed with and approved by the Infection Control Team and the Estates Manager before an order is placed. All washing machines must comply with HSG (95) 18 and be WRAS approved, provide a sluice cycle for fouled laundry and reach satisfactory disinfection temperatures and holding times. Domestic-type washing machines are not appropriate. The washing process should have a disinfection cycle in which the minimum temperature in the load is maintained at 65ºC (150ºF) for not less than 10 minutes or preferably at 71ºC (160ºF) for not less than 3 minutes. With both options, mixing time must be added to ensure heat penetration and assured disinfection. For machines of conventional design and a low degree of loading (for example, below 0.056kg/l) four minutes should be added to these times to allow for mixing time. For machines with a heavy degree of loading (for example above 0.056kg/l) it is necessary to add up to 8 minutes. The ward/unit must have the ability to dry the laundry as well as wash it. Records of calibration and annual maintenance of the washing machine and dryer should be kept by Estates. It is the responsibility of the ward/unit Manager to ensure these checks are kept up to-date. The machine is not to be used for clothes of staff or relatives. Laundry from each service user must be washed and dried separately. Frequency of linen change Bedding must be changed and laundered between service users. The frequency of change will depend on the individual case e.g. daily for service users nursed in isolation or immediately if fouled. However all bedding should be changed as a minimum at least weekly. Pillows and duvets IPC Policy June 2015 V6 Page 59 of 99

60 The interior filling for pillows and duvets is an efficient incubator of microorganisms if contamination occurs. Bedding interiors become colonised with bacteria and become a reservoir of infection. All pillows and duvets used within the care setting should be decontaminated appropriately. Polyurethane coated fabric with welded seams pillows and duvets should be routinely wiped clean between service users with hot water and detergent. If surface contamination with blood occurs clean with virusolve + or a solution of hypochlorite diluted to 10,000ppm. Fabric pillows and duvets must be laundered on-site or sent to the Trust laundry system on service user discharge. Curtains Housekeepers on individual wards/units arrange for the changing and laundering of curtains. However, it is the responsibility of the Ward/Unit Manager to ensure this occurs. All areas should have curtains laundered regularly as per an agreed programme for the area. Foul curtains need laundering as soon as possible, also see individual infection policies and Isolation policy. Shower curtains should be washed and laundered monthly and when visibly dirty in the interim period. Moving and handling equipment All manual handling equipment (hoist slings) which can be laundered should be single person use i.e for the use of one service user during their stay and laundered when visibly fouled or between service users. Equipment must be laundered in accordance with the manufacturer s instructions and should be checked for damage before laundering. IPC Policy June 2015 V6 Page 60 of 99

61 EMPATHY DOLLS - Protocol for Empathy dolls Dolls should be kept as single patient use. Dolls should be washed weekly at 80 degrees followed by tumble drying. It is acknowledged that the hair might degrade over time due to washing at thermal temperatures. When a patient is discharged or no longer requires it, the doll should be washed at 80 degrees followed by tumble drying and can then be put back into circulation for others to use. Otherwise store in a clean plastic bag in a cupboard to protect from dust until required. Where a patient has a known infection requiring barrier precautions e.g. MRSA, Norovirus, C-difficile (both toxin positive cases and PCR positive carriers), infective diarrhoea of any cause etc. NB these are examples and the list is not exhaustive the doll should be single use whilst the patient is in any of our care settings; then either sent home with the patient or disposed of. Where a doll becomes visibly contaminated with blood or body fluids in the interim period between weekly washes; it should be sent for laundering as above. Where stains etc cannot be removed the doll should be disposed of. Dolls in use for community clients in their own homes (i.e. not in communal living settings); are to be laundered upon return when the client no longer needs it, rather than weekly washing. Obviously if visibly soiled it would require laundering in the interim period. All dolls must be laundered on site at one of the Trusts laundry facilities. Transportation of linen Clean and dirty laundry should be transported in vehicles used exclusively for this purpose. The interior of vehicles after transporting dirty linen will require cleaning with detergent and water. If clean and dirty linen is to be transported in the same van, there must be a fixed partition to ensure that the clean linen is not contaminated. Staff issues Staff involved in reprocessing laundry must receive appropriate training, including aspects of infection control such as the use of personal protective equipment. Hand washing facilities must be available. Eating and drinking should not be allowed in a laundry room. Staff must not take Trust laundry home to wash. Laundering of uniforms & work wear In Mental Health and Learning Disability care settings not all staff are required to wear uniforms. The following guidelines provided by the Department of Health Working Group on Uniforms and Laundry therefore apply to clothing worn in the care setting as well as uniforms. There is no conclusive evidence that uniforms (or other work clothes) pose a significant hazard in terms of spreading infection although the public appears to believe there is a risk. The public do not like to see uniforms out of the workplace. Staff must wear a disposable plastic apron to reduce the risk of contamination with blood and body fluids but a uniform can still harbour a significant number of harmful microorganisms by the end of a shift. IPC Policy June 2015 V6 Page 61 of 99

62 However, home laundering still requires appropriate care and attention to ensure potential pathogens on uniforms or clothing are removed or killed, protecting both the service users and the staff members home and family. The following guidelines therefore apply: A freshly laundered uniform /work wear should be worn for each shift or work session. Where facilities are available staff must change out of their uniforms/work wear promptly at the end of a shift and before leaving their place of work Hand hygiene must be performed before contact with patient regardless of whether contact with uniform fabric has occurred Uniforms should be carried separately from other items clean & dirty uniforms must not be transported together. Never hand wash uniforms, this is unacceptable. Physically soiled uniforms or work wear must first receive a pre-wash cycle prior to the main wash cycle taking place. Entering commercial premises in uniform e.g. supermarkets should be avoided; consider your professional image and public perceptions. A wash at 60ºC is sufficient to remove most micro-organisms. Always use fabric detergents/softener and never overload the washing machine. For effective disinfection and prevention of cross contamination, uniforms/clothing should be washed separately from other household laundry in an automatic washing machine using the hottest temperature the material of the uniform/clothing will withstand and on the full load setting. Uniforms/clothing should be tumble-dried or air dried followed by ironing with a hot iron to further disinfect the uniform/clothing. Staff should have a clean spare uniform or clothing available in case of visible contamination whilst on duty. IPC Policy June 2015 V6 Page 62 of 99

63 References Ayliffe G. et al (1989) Laundering of Nurses Uniforms at Home. Journal of Hospital Infection. 13,91-94 Blyth PL. Infection connection. Keeping your laundry germ-free. Health Facilities Management 1999 Nov;12(11):32-4 Department of Health. Hospital laundry arrangements for used and infected linen, HSG (95) 18. Department of Health, Department of Health. (2007) Uniforms and Workwear An evidence base for developing local policy Royal College of Nursing (2009) Guidance on uniforms and work wear Report of the PHLS Clostridium difficile Working Group. PHLS Microbial Dig 1994; 11(1):22-4 Wilson J, (2001) Infection Control in Clinical Practice. Bailliere Tindall, London IPC Policy June 2015 V6 Page 63 of 99

64 APPENDIX 10 Staff exclusion Aim To prevent Staff transmitting infection. Principles Symptoms of diarrhoea and/or vomiting require exclusion until the member of staff has fully recovered i.e. 48 hours symptom free. Infective lesions require covering and exclusion from some duties may be required. Rashes and septic lesions should be reported to Occupational Health. Members of staff who are suffering from an infectious disease must inform the Occupational Health department. Enquiries out of office hours to be made to the on-call Occupational Health Consultant Physician. Management Responsibilities Occupational Health and Infection Control will provide advice and guidance on exclusion. Managers will accommodate any recommended exclusions for their staff. Individual Responsibilities To notify any possible infectious condition to their Manager, Occupational Health and the Infection Control Team To notify any contact with an infectious condition. To seek appropriate Medical Treatment from their GP. To comply with the advice given by Occupational Health and Infection Control, i.e. providing samples. SERVICES PROVIDED Flexible service including 24 hour cover (Occupational Health Consultant Physician contact via switchboard) An accessible advisory service Confidentiality assured Monitoring of practices and standards of care Influence care practice by implementing procedures and protocols Implementing procedures and protocols Co-ordinating and managing outbreaks of infections. Facilitating channels of communication for both hospital and community. Provide education and information to all grades of Care Workers. Advice and information, as required, to members of the public IPC Policy June 2015 V6 Page 64 of 99

65 APPENDIX 11 Protocol for the Management of Specimens Introduction A specimen is a body substance, such as blood, sputum, pus, urine or faeces, taken from a person for the purpose of analysis. The aim of such analysis is to identify microorganisms that cause disease and to provide direction for appropriate treatment. Specimens, if not handled and transported safely, can pose a risk of infection to all people involved, including care workers, patients and their carers, reception staff and transport personnel. All staff managing clinical specimens should receive relevant training and be covered by the appropriate vaccination. Accurate analysis is crucial in determining the correct diagnosis, or detecting an infectious agent, so that appropriate and timely treatment can be commenced. To support this, factors such as the correct collection technique, storage conditions, interval before reaching the laboratory, supporting information and patient details should be observed. In the community, specimens are collected in a wide variety of settings including the patient s home. Patients are frequently required to collect their own specimens. Patient education in the specimen collection method, along with instructions for handling and prompt return of the specimen, will serve to promote more accurate results and patient safety Purpose This protocol is intended to provide guidance in the correct management of microbiological specimens to promote accurate diagnosis of infection and prevent infection transmission. This protocol applies to all services directly provided by Sheffield Health and Social Care Trust (SHSCT) and all clinical staff involved in the collection and handling of laboratory specimens should familiarise themselves with it. It is the responsibility of each independent contractor to reduce Healthcare Associated Infection (HCAI) and the transmission of infection during interventional procedures. SHSCT recommends that contractors apply the principles of the Infection Control policy and procedures as minimum standards within their practices to ensure that their professional and contractual responsibilities are discharged. SHSCT will expect commissioned services to also apply the principles of the Infection Control policy as minimum standards within their services, which should be adapted to specific interventions and service needs. Risk Assessment Specimens, if not handled, stored and transported safely, can pose a risk of infection to all, including Care Workers, patients and their carers. Where specimens are collected or stored incorrectly, the patient may be at risk of misdiagnosis. IPC Policy June 2015 V6 Page 65 of 99

66 All staff involved in handling specimens should receive training and be covered by the appropriate vaccination. Containers should be leak proof and correctly sealed Gloves must be worn when collecting and handling specimens Gloves must be removed and hands washed on completion of the procedure. Procedure When collecting laboratory specimens, please ensure that: Specimens obtained should be appropriate for the clinical condition Specimens should be collected in an appropriate container The container is completely sealed to avoid leakages. If the patient is to be asked to provide a specimen they should be given advice on how to collect the specimen. They should be advised to fasten the lid securely and place in the specimen bag provided. The collection procedure should not expose the patient to further risk of infection. If contamination does occur, and the specimen is unable to be repeated, the container should be changed. A contaminated container must be disposed of according to the safe management of healthcare waste policy. The label on the sample container and laboratory request form are fully completed including NHS Number Care must be taken not to contaminate the outside of the container or the environment with the specimen. An adequate amount of the substance to be tested is collected Staff handling of specimens should be kept to a minimum. Protective clothing is worn when collecting all specimens. Biohazard/Infection risk/hazard group 3 labels are attached to specimen containers and laboratory forms where the patient has a group 3 hazard pathogen (e.g. HIV. Hepatitis B. TB). If you are unsure about the infection risk of the clinical sample, please phone Microbiology at Sheffield Teaching Hospitals Tel: Northern General Hospital (NGH) Staff transporting specimens in their vehicles should ensure that they are transported in a rigid, sealable, waterproof container which has a biohazard/ infection risk label on the outside. Staff transporting specimens should ensure that they are aware of the procedure in case of spillage of the specimen (see spillage management section) Specimens taken by staff visiting patients in their own home or by staff caring for service users in an in-patient setting who are managed medically by a GP should ensure the specimens are taken to the GP practice (for collection) within two hours of obtaining the specimen Staff handling specimens should have up to date immunisation cover Specimens should be stored away from food and drink never in the same fridge. If the specimen is obtained from a patient prescribed cytotoxic drugs or those who have undergone radiation treatment, contact the laboratory for labelling advice. IPC Policy June 2015 V6 Page 66 of 99

67 Documentation The following information must be included on the request form: The patient s name, date of birth, Insight/NHS number on both the container and request form Name/signature of person requesting collection Name and address of GP surgery/clinic/ward/home Nature of specimen and test required Specific information regarding body site including indicating if from the left or right hand side of the body e.g. sacrum, left hand, etc. Date and time of collection Clinical details e.g. symptoms of infection, date of onset and current medication, e.g. antibiotic treatment. If a diarrhoeal outbreak is suspected this should be written on the request form Biohazard/Infection risk/hazard group 3 labels are attached to specimen containers and request cards where the patient has a group 3 hazard pathogen (e.g. HIV./Hepatitis B./TB). Patient diagnosis should not be specified, additional details may be provided to the microbiologist by the GP if required. Transportation of Samples Transportation boxes to be used when sending specimens to the laboratory. This is particularly important if staff or non-sth transport is being used to transport the specimens Specimens must be placed into the specimen transport bag with the request form in a separate pouch, which is attached. They are not be transported in mail envelopes Staples and pins should not be used Specimens should reach the laboratory as soon as possible Arrangements should be made for the specimen to be transported to the hospital by a courier service, on a daily basis as a minimum standard. (Transportation of samples is undertaken by Sheffield Teaching Hospitals) Accidents involving specimens should be dealt with immediately High risk specimens should be labelled with danger of infection Patients confidentiality should be maintained at all times Training Requirements All staff dealing with laboratory specimens within the organisation should receive training every two years which updates them in specimen management. Responsibilities Managers should ensure that: Staff are aware of the correct method of collecting specimens to be sent to the laboratory Appropriate transportation boxes are available for transporting specimens which are not being sent via the SHSC daily collection system e.g. taken by staff or taxi service. Staff receive education and up-dates on the management of specimens IPC Policy June 2015 V6 Page 67 of 99

68 Guidelines for storage of microbiology specimens Specimen Fridges - overnight storage of microbiology samples does not require a medical grade fridge. Where samples cannot be delivered on the day of collection the fridge used to store them needs to be able to maintain 2 to 8 C. Ideally the fridge temperature should be checked on a daily basis, using an independent thermometer, and the temperature logged. Vaccines, drugs and food/drink items must not be stored in a specimen s fridge. Up to a 24-hr delay is not too much of a problem for most samples as long as they are held correctly - see below. However, urgent or unrepeatable samples (e.g. if antibiotics are to be started) collected during out of hours at the weekend i.e between 5.00 pm Friday and 9.00 am Monday should be sent to the appropriate laboratory as soon as possible rather than being held over the weekend. URINE SAMPLES should be refrigerated after collection to preserve the cells and prevent overgrowth of infecting organisms and contaminants. Boric acid containers for adult samples can be used as these will help to preserve the white cells and prevent overgrowth- the samples must still be refrigerated however. Samples where a 30mls volumes is difficult to guarantee should not be collected in to boric acid containers, as the borate is inhibitory if only a small volume of urine is available, a plain sterile container should be used instead and sent the same day. WOUND, EAR, THROAT ETC SWABS are generally best held at room temperature. Refrigeration can kill some fastidious organisms and the charcoal transport medium allows cultures to be marinated for a least 24hrs. GENITAL SWABS should also be held at room temperature and most will be fine for 24hrs. However, delicate organisms such as Neisseria gonorrhea perish quickly even under optimal conditions and if you are seriously suspecting gonococcal infection, even 24hrs delay is unacceptable. The swabs should be sent to the laboratory on the day of collection. SPUTUM is more difficult and should ideally be examined on the same day, refrigeration will kill Strep. Pnuemoniae, one of the target organisms, so room temperature storage for up to 24hrs is the best option. ASPIRATES can normally be refrigerated in a similar way to urines unless you are seriously suspecting gonococcal infection when the specimen should be sent to the laboratory as soon as possible. The validity of a cell count (normally only performed on ascetic fluid) is unknown on a refrigerated sample. CHLAMYDIA swabs use antigen detection rather than culture, so delays are not really a problem- even over the weekend. Just keep the samples in the fridge. Related Policies Waste Management Policy The Royal Marsden Clinical Nursing Procedures References Health & Safety Commission (1986) Safety in Health Service Laboratories: The Labelling,Transport and Reception of Specimens HMSO, London ICNA (2003) Infection Control Guidance for General Practice ICNA Liverpool PCT Policy for the Collection, Storage and Transportation of Laboratory Specimens 2007 IPC Policy June 2015 V6 Page 68 of 99

69 McCulloch J (2000) Infection Control. Science, Management and Practice Whurr Publishers, London Sheffield PCT Laboratory Specimen Management Policy 2008 IPC Policy June 2015 V6 Page 69 of 99

70 Appendix 12 Ebola Information Introduction: Ebola virus disease (EVD), a viral haemorrhagic fever (VHF), is a rare but severe infection caused by Ebola virus, which is classified as a Hazard Group 4 pathogen. Since March 2014, there has been a large outbreak of Ebola virus in West Africa, with widespread and intense transmission in Guinea, Liberia and Sierra Leone. This is the largest ever known outbreak of this disease prompting the World Health Organization (WHO) to declare a Public Health Emergency of International Concern in August Cases have also occurred in Mali, Nigeria, Senegal, Spain, the UK and the US. There remains an expectation that a handful of further cases may occur in the UK in the coming months. Thus, although the risk of imported cases remains low, it is possible that further persons infected in Guinea, Liberia, or Sierra Leone could arrive in the UK while incubating the disease (the incubation period is 2-21 days) and develop symptoms after their return. Awareness: All frontline staff including receptionists should be aware of potential risk, and of simple screening questions to ask, including most importantly travel history. This is vital not only to ensure that the patient receives the care they need but that the risk to any staff who come into contact with a patient who may have Ebola is minimised, and the public health risks Ebola transmission: Ebola virus is transmitted among humans through close and direct physical contact with infected body fluids. This means that the body fluids from an infected person (alive or dead) have touched someone s eyes, nose or mouth, or an open cut, wound or abrasion. Infection can also occur if broken skin or mucous membranes of a healthy person come into contact with environments that have become contaminated with an Ebola patient s infectious fluids. Unlike infections like flu or measles, which can be spread by virus particles that remain in the air after an infected person coughs or sneezes, Ebola is not spread by the airborne route. People infected with Ebola can only spread the virus to other people once they have developed symptoms. In the early symptomatic phase virus is present in the blood, however, the level of virus in body fluids such as saliva is very low and unlikely to pose a transmission risk1. In the late symptomatic phase, when vomiting and diarrhoea are present, all body fluids (such as blood, urine, faeces, vomit, saliva and semen) should be considered infectious, with blood, faeces and vomit being the most infectious. General advice: The risk of community health and social care professionals coming into contact with a possible case of Ebola in the community is low. Ebola should be suspected in a patient with a fever of 37.5 C or a history of fever in past 24 hours, and who has travelled to an affected area within the last 21 days OR has come into contact with the body fluids or clinical specimens of an individual known or strongly suspected to have Ebola. Should you suspect that an individual you are caring for has Ebola infection, the individual should be isolated immediately and the attending health or social care professional should contact 111, who will arrange for appropriate transfer to a IPC Policy June 2015 V6 Page 70 of 99

71 healthcare facility where they will be assessed clinically. The local health protection team (HPT) should also be notified ( ), and will advise regarding further follow-up and decontamination of the premises where necessary. Identifying patients at risk of Ebola virus disease: Ebola should be suspected in patients presenting to primary care or our services who have a fever of 37.5 C OR have a history of fever in the past 24 hours AND have recently visited any of the affected areas within the previous 21 days OR Have a fever of 37.5 C OR have a history of fever in the past 24 hours AND have cared for/come into contact with body fluids of/handled clinical specimens (blood, urine, faeces, tissues, laboratory cultures) from an individual or laboratory animal known or strongly suspected to have VHF Latest Algorithms & Guidance on Ebola: The latest versions of all the relevant guidance documents in how to manage suspected cases of Ebola can be found at the following link. Information is updated regularly; please use the web address below IPC Policy June 2015 V6 Page 71 of 99

72 Appendix 13 Carbapenemase-producing Enterobacteriaceae (CPE) Please refer to the following document on the SHSC intranet Infection Control page: Carbapenemase Producing Enterobacteriaceae (CPE) Sheffield Community Information Pack Introduction: This information has been produced by Infection Prevention & Control and Public Health England professionals working across Sheffield in the absence of any national community guidance. The full guidance document referred to above provides useful information for staff, below is a brief explanation of what CPE s are and common questions asked by clients/patients and is useful for staff awareness. What are Carbapenemase-Producing Enterobacteriaceae (CPE)? Enterobacteriaceae live harmlessly in the gut of humans and animals and help us digest our food. This is called colonisation. If the bacteria get into the wrong place, such as the bladder or bloodstream, they can cause an infection. Some strains of Enterobacteriaceae have become very resistant to some antibiotics including those called carbapenems. These are called Carbapenemase-Producing Enterobacteriaceae (CPE) Patients colonised by CPE would still not usually have any symptoms or illness caused by them as they would continue to live harmlessly in the gut. If infection develops due to CPE, these infections can be more difficult to treat with antibiotics. This is why it is so important to prevent their spread from person to person. How will I know if I am at risk of a CPE? You may be at risk of carrying CPE if you have been in a hospital abroad, or in a UK hospital which has had patients carrying these bacteria, or you have been exposed to other carriers of these bacteria. If you have these risk factors we will ask you to be screened and we will inform you of the results. People in hospital are generally more at risk of infections because their body defences are already weakened by illness, surgery, medication and the presence of invasive devices like drips and urinary catheters. How do you screen for CPE? The screening method requires a sample of faeces (poo) or rectal swab. The specimen will be sent to the laboratory to see which germs grow. If you have a urinary catheter, we will need a sample of urine If you have a wound, we will also need this to be swabbed. The results of the tests will normally be available between hours after taking the sample. We will let you know the results of all the specimens that are taken. Does colonisation (carrier status) with CPE need to be treated? As CPE normally lives in the gut without causing problems they do not normally need to be treated. Treating an infection caused by CPE If this bacteria causes symptoms this may show an infection is present and treatment is required. Your GP will discuss this with a consultant microbiologist (an expert in antibiotic treatment) before prescribing antibiotics for you. If you are in hospital you may not have to stay in hospital until the infection has cleared up. You will be able to go home when your general condition allows regardless of whether you are still carrying the bacteria or not. Will I get all the care I need if I am colonised with these bacteria? YES You will still be able to have rehabilitation and any other tests that you require. IPC Policy June 2015 V6 Page 72 of 99

73 Sometimes you may have to have investigations or therapy at the end of the day or separate room other patients. What happens when I m at home? The presence of the bacteria (which may disappear quite naturally) should not affect you or your family at home. This type of bacteria (CPE) does not normally affect healthy individuals. Hand washing is essential for all those looking after you (this is if you have community healthcare staff, such as District Nurse, Community Matron who is visiting you to stop transmission of germs to other patients who they may be visiting later). You may wish to provide a separate hand towel for friends or family visiting you. Staff caring for you may wear gloves & aprons depending on the care activity been undertaken It is especially important for you to wash your hands well with soap and water after going to the toilet and before cooking or eating. Clothes, towels, crockery & cutlery etc, can all be washed as normal. You should avoid touching medical devices (if you have any) such as your urinary catheter tube and your intravenous drip, particularly where it is inserted into your body. You should ensure your toilet is cleaned with bleach regularly and maintain a good standard of bathroom cleanliness with your usual household cleaning products. There are no restrictions to daily social & work activities or visitors to your home. What happens if you are attending or admitted to hospital? If you are going into hospital or attending outpatient appointments; please inform hospital staff that you have or had previous CPE colonisation and/or infection. You will be moved to a side room whenever possible with its own toilet facilities. All staff will wear gloves and aprons or long sleeved gowns when caring for you. This is to prevent the spread of bacteria (CPE) to other patients. Hand washing is essential for all those looking after you. It is especially important for you to wash your hands well with soap and water after going to the toilet, before eating and before leaving your room. You should avoid touching medical devices (if you have any) such as your urinary catheter tube/intravenous drip/ PEG / tracheostomy site, particularly where it is inserted into your body. All Visitors will be asked to wash their hands with soap and water when they come into your room and also when leaving your room. If any of your visitors are helping you with personal care they may also be asked to wear gloves and an apron. Where can I find more information? If you would like any further information please speak to your GP or healthcare professional caring for you. Public Health England website is another source of information: IPC Policy June 2015 V6 Page 73 of 99

74 Appendix 14 Scabies Introduction: Scabies is an infestation caused by a tiny mite which lives in the top layer of the skin. The scabies mite is not particular about its host and can affect anyone who it comes into contact with regardless of standards of hygiene. The Scabies Mite: For the Scabies mite to survive and reproduce requires constant contact with human skin. The mite seldom lives outside its human host, as it becomes rapidly dehydrated. Transmission: Transmission requires direct prolonged skin to skin contact i.e. holding hands, cuddling, and sexual contact to enable the mite to migrate and burrow into its new host before drying out. Transmission most frequently occurs in residential settings, and within families. Transmission does not normally occur via clothes and bedding but can occur if these items have been contaminated by an affected person immediately before contact. The exception to this is Norwegian, or crusted Scabies. Persons with Norwegian Scabies are highly contagious because of the large number of mites present in the exfoliating skin scales. Incubation Period: It can take up to 6-8 weeks from the time scabies is first acquired to the itch and the rash developing. However as the itch is due to an allergic reaction, the onset of symptoms is much more rapid i.e. 1-4 days on average, with fewer mites present, when a person is in reinfected. Clinical Presentation: Primary symptoms include the characteristic lesion of a wavy line burrow, sometimes with a dark speck inside (the mite and her eggs). Most burrows however are destroyed with the intense itching. The commonest sites these are found are in the skin folds of the finger webs and wrists, but also the arms, upper trunk area (especially in children), legs, the breasts, and male genitalia A symmetrical rash consisting of red papules, vesicles, crusted lesions and eczematous patches may also be present and can affect almost any part of the body. In adults the head is usually not affected 6-8 weeks after infection, generalised itching may occur which is often worse in the evening or at night. The itching is largely due to the mite depositing its waste (saliva and faeces) under the skin causing an allergic reaction. Scabies can present in more florid forms in sick or immunocompromised individuals. The extreme, known as Crusted or Norwegian scabies presents with an atypical rash with much higher numbers of mites in the skin. Treatment: Treatment of scabies in a residential care setting, respite, units, wards etc is a major undertaking and it is important that an accurate diagnosis is made. If scabies is suspected, medical confirmation of the diagnosis and prompt treatment should be sought from the patient s GP or Medic responsible who may, if required, request advice from a Consultant Dermatologist The distribution of the rash is not related to the location of the mites and burrows. It is for this reason that the whole body needs to be treated. As the incubation period can be up to 8 weeks it is important to consider any person who has had prolonged skin-skin contact within the last 8 weeks as requiring treatment. All treatments should be applied to cool dry skin. Hot baths before applying treatment is not advised as it will limit the effectiveness of the treatment by increasing the rate of absorption and any possible toxicity the treatment may have. A careful and thorough application of the lotion or cream is required. A second application 5-6 days later must applied to those individuals diagnosed with Scabies. The first choice of treatment should be Lyclear cream (Permethrin 5%). Allow two tubes of Lyclear cream per person. IPC Policy June 2015 V6 Page 74 of 99

75 Nursing or support staff treating patients are advised to apply the lotion using gloved hands. Gloves must be changed after each patient contact Notification of a Singular Scabies Case: If there is a case of Scabies in any SHSC trust bed staff should contact the medic responsible for the patient or the GP covering that area for treatment & diagnosis. Inform the infection control team and the ICT will inform the Consultant Communicable Disease - PHE If there is a singular case of Scabies within the home/unit/ward then that patient alone can be treated. They do not need to be isolated or barrier nursed. Staff should however be extremely vigilant for signs and symptoms of scabies in the following weeks in other clients & patients. Outbreak: Two or more cases in a nursing or residential home, unit or ward constitutes an outbreak. Inform Infection Control In cases of doubt or concern about the diagnosis, advice may be sought from the Department of Dermatology During an outbreak of scabies there may be both symptomatic and asymptomatic patients/clients and staff. Failure to treat infected but asymptomatic cases will lead to re-infection and prolongation of the outbreak For this reason it is important that all residents and all members of staff (based on risk assessment by Occupational health) are treated irrespective of signs and symptoms. It is vital that all treatments are carried out on the same day to prevent re-infection Bare prolonged skin to skin contact should be avoided wherever possible until 24 hours after the application of treatment. Contact Tracing: see PHE guidance available from the ICT. Linen: There is no special treatment required for linen and it should therefore be treated in the normal way. The exception to this would be for Norwegian Scabies, where the linen would be treated as though infected i.e. red alginate bags prior to go to the laundry Prevention: Regularly check the skin of all new and existing residents/patients and seek medical advice if necessary For care homes - When receiving new residents to the home always check prior to admission whether the resident has recently been exposed to scabies Treat outbreaks of scabies promptly and thoroughly Untreated staff and family members can be a source of reinfection. Advise family members of any resident or member of staff who has scabies to see their GP Visitors should wash their hands after contact with the residents/patients/clients All gloves are single patient use, therefore after each use they must be discarded and a new pair used for the next patient All disposable aprons are single use and single patient use. They should not be worn for more than one patient contact Perform hand hygiene after all patient contacts Reference: SOUTH YORKSHIRE HEALTH PROTECTION UNIT (2012) Guidance for Management of Scabies In Nursing and Residential Homes IPC Policy June 2015 V6 Page 75 of 99

76 Appendix 15 Guideline for the Management and Control of an Outbreak of Diarrhoea and Vomiting Introduction Norovirus is the most common cause of gastro-intestinal infection in England and Wales. There is a peak incidence of the disease in winter months, hence the term Winter Vomiting disease, although cases occur throughout the year. Infection can be spread very easily and outbreaks often occur across communities, affecting healthcare facilities, educational establishments and the population who live and work in affected areas. Healthcare staff can minimise transmission by ensuring they are familiar with local infection control policies and procedures. Prompt notification and regular communication between staff is also important in the control of outbreaks. Signs and Symptoms The following may occur: Nausea and vomiting (often projectile in nature) Abdominal cramps Diarrhoea Typical duration of symptoms is 1 2 days and can range from mild to severe. The very young, elderly and seriously ill are particularly vulnerable to more severe episodes. Infectivity Norovirus is highly infectious, hence the rapid spread of the disease An extremely low infectious dose produces illness possibly as low as one viral particle. During the diarrhoeal phase of illness, stools typically contain 10,000,000 viral particles. Infectivity normally lasts for 48 hours until after symptoms have resolved, though the virus has been detected after longer periods. Transmission route of spread primarily via the faecal oral route Direct person to person contact e.g. during nursing care especially hygiene care; Contaminated hands of staff caring for service users or of affected service users Contaminated surfaces especially toilets, door handles, taps etc. Commodes Airborne spread due to viral particles remaining suspended in the air, especially after vomiting; although the research into this still continues Consumption of contaminated food e.g. shellfish or contaminated water (not usually relevant in hospital outbreaks) IPC Policy June 2015 V6 Page 76 of 99

77 Outbreak Management The most important aspects of outbreak control are: Outbreak recognition and reporting Implementation of strict enteric precautions to minimise spread. Recognition of an outbreak An outbreak may be defined as having more linked cases with similar symptoms than would normally be expected. In healthcare settings an outbreak is defined as 2 or more related cases. It is important to exclude other causes of diarrhoea, for example faecal impaction, reaction to medication, changes in diet. Outbreaks affecting staff only must also be reported to the infection control team or Criteria for suspecting Norovirus outbreak Vomiting in > 50% of cases Duration of illness hours Service users AND staff affected. Cases often occur in clusters up to 48 hours apart due to the incubation period of hours Reporting / Recording an outbreak As soon as an outbreak is suspected within the ward/unit, the person in charge should contact the Infection Prevention and Control Team (IPCT) for further guidance and support, and also inform the executive director on call. The Infection Control Team will send an initial outbreak report to the chief nurse, the relevant senior nursing team, the appropriate department managers and follow up reports as required. In the event of a serious outbreak it may be necessary to convene the wider outbreak management group in line with the Major Outbreak Plan. Please complete the Risk Assessment Tool and Bristol stool Chart for each affected service user and fax or the IP&C Team on Please complete a daily log sheet one for service users, one for staff. Please fax to IP&C upon first suspicion of an outbreak situation developing and then each morning by whilst ever the outbreak is continuing. All forms can be found at the bottom of this policy. Investigation of specimens Faecal specimens should be taken from affected service users and staff within 48 hours of symptoms developing. Only a small sample is required - do not fill container to top. It is acceptable to obtain a specimen from a bedpan that also contains urine, as this will not affect results. Specimens do not need to be taken sterilely and can be obtained from bed sheets, etc. Request forms should be sent for both MC&S and virology, and should be marked possible outbreak. Vomit specimens can be tested for Norovirus. N.B. Ensure that request forms and sample pots are fully completed with relevant information. The laboratories will NOT test samples that are not labelled correctly. During an outbreak it is advisable to send batches of samples to the laboratory. The IPCT will notify the laboratory of a potential outbreak as the increased number of samples can have a significant impact on laboratory workload. IPC Policy June 2015 V6 Page 77 of 99

78 Remember to send specimens PROMPTLY for investigation as virus particles deteriorate rapidly leading to difficulty in identification of the virus. For areas that are covered medically by a GP practice, samples should still be sent directly to microbiology at the Northern General Hospital if possible. Enteric precautions: The most important actions during an outbreak of diarrhoea and vomiting are: Effective hand hygiene Isolation of affected service users Exclusion of affected staff Restriction of movement of staff, service users and visitors Enhanced cleaning of the environment and equipment Effective hand hygiene Effective hand hygiene is vital to prevent the transmission of infection, and must be actively encouraged. Managers must ensure that staff are properly trained in hand washing technique and that they have easy access to hand hygiene facilities including warm water, liquid soap and paper towels. Remember to always provide service users with hand washing facilities i.e. detergent wipe or bowl of warm water, soap and towel after they have used a commode and prior to meal times. Visitors must also decontaminate their hands on arrival and before leaving the care area. Please note: Alcohol-based products are NOT as effective in controlling the spread of norovirus due to its characteristics. Thorough washing with soap and drying with paper hand towels is the most important aspect of control. Isolation of affected service users It is necessary to isolate service users with symptoms of diarrhoea and / or vomiting. This means that they have to remain in their own bay or room, i.e. away from service users who IPC Policy June 2015 V6 Page 78 of 99

79 are well (asymptomatic). Symptomatic service users must have their own toilet facilities and designated cleaning equipment. Where en suite facilities are not available, specific toilet areas should be designated for their use only. It is very important that strict isolation procedures are implemented by staff i.e hand washing, environmental cleaning, and safe handling of infected linen and waste for the duration of the illness. Service users must remain isolated until 48 hours after diarrhoea and / or vomiting has stopped. Ward/Unit quarantine /closure If the IPCT confirm an outbreak, then a decision will be made to close the ward/unit to new admissions. This will be communicated to relevant external agencies by the Team. At such times, restrictions on movement of staff, service users and visitors are of paramount importance in order to limit spread both within the affected care area and to other care settings. Wards/Units will remain closed for 48 hours after the detection of the last new case and the decision to re-open an affected area will be made by the IPCT in consultation with an executive director and the affected clinical area. No ward/unit will be re-opened to admissions until a thorough terminal clean of the entire ward/unit has taken place, including the changing and cleaning of all curtains and screens. Staff movement Certain groups of staff move from ward to ward i.e. allied medical professionals and medical staff. Such staff should be reminded of the importance of hand hygiene both before and after service user care and should consider visiting affected wards / service users AFTER visiting non-affected areas and service users. Uniforms/Clothes should be changed DAILY and laundered at 60 if possible. Exclusion of affected staff Exclusion is vital for any symptomatic staff member who should be sent home immediately they become affected. They should not return to work until 48 hours after symptoms have discontinued. This includes flexible workforce staff and agency staff as well as any visiting staff. It is the responsibility of the individual to ensure that they are fit to work. Exclusion of Visitors It is important that visitors to wards/units during an outbreak are advised of the fact by affixing notices to all ward / department doors. If visiting more than one area e.g. visiting clergy, they should be advised to visit affected areas at the end of their visiting schedule to avoid unnecessary transmission to unaffected areas / service users. In addition visitors should be advised that if they (or members of their household) have symptoms of diarrhoea and / or vomiting they should not visit the ward/department until 48hours after normal bowel habits have returned to normal and / or vomiting has stopped. Essential visitors MUST comply with the requirement to decontaminate their hands before entering and leaving the ward. Movement of service users on affected wards/units Segregation (co-horting) may be necessary in an outbreak, when single rooms may not be available for all affected persons. In general, however, it is important that symptomatic people are kept apart from those without symptoms. IPC Policy June 2015 V6 Page 79 of 99

80 In practice, this means nursing affected service users in the same bay and not admitting or transferring into empty beds in affected bays unless the service user is already symptomatic or has recovered from symptoms. Staff caring for affected service users should, where possible not care for asymptomatic service users and should be allocated workload by bay / room where staff numbers allow. Service users with an existing physical health need may be particularly vulnerable to acquiring Norovirus, which may worsen their underlying medical condition. In such cases it is advisable to isolate these vulnerable service users in side-rooms in order to minimise risk as much as possible. All unnecessary items of equipment should be removed from rooms to minimise the risk of contamination. This includes medical equipment and foodstuff such as fruit. Transfers out of affected ward/units During an outbreak, symptomatic service users should NOT leave the ward/units to visit other areas. This includes visits to rehabilitation and outpatient departments. If it is considered necessary, the receiving department MUST be notified in advance and the service users should be accommodated at the end of a session. Following care, the service user environment including equipment should be thoroughly washed with a chlorine based product prior to use by another service user. Transfer to and from other hospitals The transfer of service users to and from other hospitals during an outbreak of diarrhoea and vomiting should be avoided other than in a medical emergency. In such instances, staff MUST inform the receiving hospital that they are transferring a service user from an area closed due to a diarrhoea and vomiting outbreak. This will allow the receiving hospital / institution to take the necessary infection control precautions to avoid transmitting the outbreak there. It is essential that an Inter Healthcare Transfer form is completed. Transfer to nursing / residential homes No service users should be transferred out to nursing or residential homes during an outbreak unless they have been asymptomatic and subsequently symptom-free for a minimum of 48 hours. If transfer is planned, it should be with medical approval, and only with the full knowledge of the nursing or residential home manager. Service users who have not been affected should NOT be transferred as they may be incubating the virus and could easily spread this to other vulnerable elderly and frail residents. These recommendations are not exhaustive, and each discharge should be assessed on an individual basis Discharge to service users own home Service users affected during an outbreak should not be discharged home until clear of symptoms. IPC Policy June 2015 V6 Page 80 of 99

81 Service users who have not been affected should ONLY be discharged home if the service user s carer(s) are fully aware of the likelihood of becoming symptomatic and feel able to cope in such a situation. Any community care providers e.g. district nursing team should be fully informed that the service user has been discharged from an affected ward/unit so that they can make suitable visiting arrangements Ward/Unit/Department cleaning Cleaning staff should be made fully aware of the outbreak situation and supervisory staff / managers notified immediately there is the suspicion of an outbreak, to ensure that they are able to respond to the increased demand for cleaning in the affected areas and for additional demand for cleaning supplies etc. Cleaning should be increased to twice daily in all areas, using a chlorine based product made up as per manufacturer s policy. Toilets and commodes should be checked and cleaned after each use with a chlorine based product or Virusolve+ or Clinell Universal Wipes. When the area has been free of symptoms for 48 hours cleaning can commence using a solution of a Virusolve+ based product for floors and all equipment. (If Virusolve+ cannot be used on equipment advice must be sought from IPCT). Curtains should be taken down and laundered at the hottest temperature the fabric can withstand, and replaced with clean curtains. Carpets must be steam cleaned or shampooed. Spillages and decontamination of equipment 1. Any body fluid spillage occurring in clinical areas must be decontaminated promptly by the nursing team caring for the service user. Spillages occurring in non-clinical areas may be dealt with by Hotel Services staff using the following procedure. All staff must be aware of the procedure for effectively cleaning up body fluid spillages. 2. Disposable gloves and an apron must be worn for cleaning the spillage and these should be disposed of in a clinical waste bag once the task is completed. 3. Clinell Spill wipe kits are available via NHS Supplies which enable spillages to be cleaned up effectively and are particularly useful for community based staff. IPC Policy June 2015 V6 Page 81 of 99

82 References: CHADWICK, PR., BEARDS, G., BROWN, D., CAUL, WO., CHEESEBRIUGH, J., CLARKE, I., CURRY,A., O BRIEN, S., QUIGLEY, K., SELLWOOD, J., WESTMORELAND, D. (2000). Report of the Public Health Laboratory Service Viral Gastroenteritis Working Group. Management of hospital outbreaks of gastro-enteritis due to small round structured viruses. Journal of Hospital Infection. 24:1-10. HEALTH PROTECTION AGENCY. (2008). Norovirus frequently asked questions HEALTH PROTECTION AGENCY. (2006). Norovirus Outbreaks in England and Wales. Epidemiological data p= Lopman BA, Andrews N, Sarangi J, Vipond IB, Brown DW, Reacher MH. Institutional risk factors for outbreaks of nosocomial gastroenteritis: survival analysis of a cohort of hospital units in South-west England, J Hosp Infect Jun;60(2): IPC Policy June 2015 V6 Page 82 of 99

83 Summary Guideline for Viral Diarrhoea and Vomiting Infection control measures will help to reduce the potential spread of D & V to other service users. The most common cause of a viral outbreak is Norovirus. Symptoms Frequent watery liquid stools (Bristol stool chart measurement 5 and 7) Vomiting Symptoms usually last for hours but the affected person may remain infectious for longer Infection Control Precautions Isolation of symptomatic service users. If the number of service users with symptoms exceeds the number of side rooms it is advisable to put affected service users together (cohort) in bays. Maintain Bristol Stool chart whilst symptoms persist. Hand hygiene is the most effective method of controlling cross infection. Hand rub must be used on entering the ward/unit o Hands should be washed with soap and water between service user contact and on leaving service user care areas o Visitors to wash their hands before leaving the clinical area. o Service users must wash their hands after visiting the toilet and before meals. Gloves and aprons must be worn when dealing with vomit and faeces. Food must not be kept in service user areas. Staff must not eat or drink in clinical areas. Each bed space and all clinical areas must be thoroughly cleaned with chlorine based or Virusolve + product on a daily basis during the outbreak. Liaison with hotel services is essential. Frequent disinfection of surfaces, door handles sinks, taps, toilet seats and toilet doors with chlorine based or Virusolve + product are required. Decontamination of Items contaminated with either vomit or faeces Hazardous disposal of waste from any symptomatic service user. Symptomatic service users must not be discharged to nursing, residential, or social care homes. Transfers and investigations should be delayed if the service user has symptoms unless to do so would cause more harm to the service user. Asymptomatic recovered individuals who are 48 hours or more symptom free can be transferred or discharge based on risk assessment. Exposed & potentially incubating individuals who are medically fit for discharge and who haven t developed symptoms of infection within 48 hours since last exposure, can be transferred. The receiving area must be agreeable to this; aware of the potential risks and able to manage the individual if subsequent infection develops. The patient should be isolated & observed for a further 24 hours upon admission to the receiving area where possible. Investigations Faecal specimens must be sent for culture and sensitivity and viral studies as soon as possible. Vomit can be tested for Norovirus. IPC Policy June 2015 V6 Page 83 of 99

84 Staff Symptomatic staff must go off duty and not return until 48 hours after their last symptom. Ideally staff should be provided with specimen pots which should be sent to the laboratory via their own registered GP. Non-essential staff should be discouraged from entering the ward/unit. Wherever possible NHS professionals or agency staff should not care for affected service users Wherever possible staff from affected areas must not transfer to unaffected areas. Ward/Unit Closure The IPCT or the on call executive director will advise when wards/units or beds are to be closed and will review this on a daily basis. The ward/unit may be closed to all admissions and opened only on the advice of the IPCT or Executive director on call. Once the decision has been made to reopen a whole or part of a ward/unit, all bays must be thoroughly cleaned using Chlorine based product and all curtains changed. Other information All visitors to the ward/unit must be informed of the outbreak and asked to follow the hand washing procedure on entering and leaving the ward/unit. It is advisable to restrict visitors to 2 per bedside. Visitors should not visit if they are unwell If advice is required please contact your Infection Prevention & Control Team. If out of hours contact the on-call microbiologist via switchboard. IPC Policy June 2015 V6 Page 84 of 99

85 VISITORS AND STAFF The ward/unit currently has an outbreak of Diarrhoea and Vomiting. Visitors: Do not visit if you have had diarrhoea or vomiting within the last 48 hours Visitors: Please wash your hands on entering and leaving the ward/unit Staff: Wash your hands on entering and leaving the ward/unit Staff: Wear an apron every time you have contact with a service user or service users environment This applies to all healthcare staff For further information please speak to the Nurse in Charge or contact the Infection Prevention & Control Team IPC Policy June 2015 V6 Page 81 of 99

86 Risk assessment tool for undiagnosed diarrhoea and vomiting (please complete for all patients suspected of having viral gastroenteritis) Surname DoB Insight N o Consultant/GP First Name Ward Bed N os Admission Date Diagnosis: Diarrhoea? Vomiting? Nausea? Date of onset Time of onset No. of episodes Does the patient have flu like symptoms Yes/No Is a loose or occasional fluid stool normal for this patient? Does the patient have irritable bowel syndrome, crohns etc? Yes/No If yes please give details Is there any medical reason for diarrhoea and vomiting? Eg antibiotics Yes/No If yes please give details.. Is the patient receiving laxatives? Yes/No Has the patient suffered from a bacterial infection causing diarrhoea in past month? This includes Salmonella, campylobacter and clostridium difficile. Yes/No If yes please give details... Has the patient had any known contact with anyone (family, friends, and other persons on the ward) with symptoms of diarrhoea and vomiting in preceding 72 hours? Yes/No If yes please give details Has a stool sample been sent to the microbiology laboratory requesting viral studies? Yes/No If yes please give dates of samples sent..... For infection prevention use only: Suspicion of Norovirus: Probable Possible Unlikely In the light of circumstance please treat as a case of Norovirus Yes/No IPC Policy June 2015 V6 Page 82 of 99

87 Bristol Stool Monitoring Chart Please record type of stool for each motion passed using the chart below: Name number DOB.. GP/Consultant. Insight Ward. Bed number. Name Insight number DOB.. GP/Consultant. Ward. Bed number. Date /Time Type of stool (using chart) Date specimen sent to laboratories Comments: Relevant medication/laxatives/antibiotics Laboratory result Initials IPC Policy June 2015 V6 Page 83 of 99