INFECTION PREVENTION & CONTROL GUIDELINES FOR CARE HOMES

Transcription

1 INFECTION PREVENTION & CONTROL GUIDELINES FOR CARE HOMES Page 1 of 56 Review date: March 2014

2 CONTENTS Preface Introduction Why infection control is important Who is there to help? The Chain of Infection Standard Infection Control Precautions What are standard infection control precautions (SICPs) Transmission based precautions...9 (a) Placement of Residents...10 (b) Hand Hygiene...10 i. What are your hands carrying...10 ii. When should you decontaminate hands?...10 iii. Routine hand hygiene...11 iv. Protection of broken skin...12 (c) Respiratory Hygiene & Cough Etiquette...12 (d) Personal Protective Equipment...12 i. Gloves...13 ii. Aprons...16 iii. Face mouth/eye protection...16 (e) Management of Care Equipment...17 i. Cleaning...17 ii. Disinfection...18 iii. Sterilisation...19 (f) Control of the Environment...21 i. Floors...21 ii. Colour coding...22 (g) Management of Linen...23 i. What is needed?...23 ii. How should linen be handled?...23 iii. How should linen and clothing be washed?...24 iv. Risks to Staff...24 v. Storage of Linen...24 vi. Staff uniforms/clothing...25 vii. Home laundry of residents clothing 25 Page 2 of 56 Review date: March 2014

3 (h) Management of Blood and Other Body Fluid Spillages...25 i. Equipment for all blood & body fluid spillages except urine, vomit & faeces..25 ii. Spillage of Urine, Vomit or Faeces...26 (i) Disposal of Waste...26 (j) Occupational Exposure Management...28 i. Skin care...28 ii. Blood borne viruses...28 iii. Hepatitis B immunisation...29 iv. Other immunisations...30 v. Protection against tuberculosis Collection of Specimens Food Hygiene Outbreaks General Viral Outbreaks MRSA Clostridium difficile Immunisation of Residents Care of Urinary Catheters Last Offices Education Resources Education for the infection control key worker Hand hygiene Induction training...47 Appendix 1 How to hand wash...48 Appendix 2 Appendix 3 Appendix 4 How to hand rub...49 Terminal cleaning...50 Stool record chart 53 Bibliography...55 Page 3 of 56 Review date: March 2014

4 PREFACE As a result of the Regulation of Care (Scotland) Act 2001 there are now no legal differences between residential homes and nursing homes; all are care homes. At the same time in 2001 Scottish Ministers set up the National Care Standards Committee (NCSC) to develop national standards, which included those applicable to care homes for older people. These were revised in November 2007 and are available at: These Standards are used by the Care Inspectorate ( ) to monitor the quality of the services. Standard 4 stipulates that the home is run in a way that protects residents from any avoidable risk or harm, including physical harm and infection; and that residents can expect that the premises are kept clean, hygienic and free from offensive odours and intrusive sounds throughout; and that there are systems in place to control the spread of infection, in line with relevant regulation and published professional guidance. The purpose of these NHS guidelines is to ensure that you are aware of relevant infection control advice and guidance that is applicable in care homes and can be confident in its implementation. Page 4 of 56 Review date: March 2014

5 1. INTRODUCTION 1.1 Why infection control is important Many infections have the potential to spread in a care home, due to the sharing of eating and living accommodation, and the fact that residents may have an increased susceptibility to infection due to various factors: Age Immune status Poor nutrition Underlying medical conditions such as cancer, diabetes, heart problems Antibiotic therapy Incontinence Indwelling medical devices such as urinary catheters or gastric feeding tubes Breaks in the skin Infection control has also become more important due to the increasing numbers of organisms that have become resistant to treatment such as meticillin resistant Staphylococcus aureus (MRSA), Clostridium difficile, the emergence of relatively new organisms such as E.coli O157, and the potential for the spread of blood borne viruses. Healthcare-associated infections may worsen underlying medical conditions and lead to avoidable admission to hospital, and may occasionally be life-threatening. Prevention of infection is everyone s business! 1.2 Who is there to help? The Health Protection Team of NHS Highland is based within the Public Health Department at Assynt House, Beechwood Park, Inverness. See below for contact details. They are responsible for the prevention, surveillance, investigation and control of communicable disease in the Highlands. Advice and guidance can be obtained on all matters relating to infection prevention and control, including disinfection, laundry, waste management, and individual client management. You may also have concern when individuals, either clients or staff, suffer from specific infectious diseases. The following list gives some examples of infections, the occurrence of which may mean you wish to consult the Health Protection Team: Blood borne viruses (HIV, Hepatitis) Campylobacter Clostridium difficile E.coli O157 Influenza Legionnaires disease Lice MRSA Salmonella Scabies ( in either residents or staff) Streptococcal infections Page 5 of 56 Review date: March 2014

6 Tuberculosis Varicella zoster (shingles or chicken pox) Contact details: Consultant in Public Health Medicine (Health Protection): Dr Ken Oates Health Protection Nurse Specialists: Abhayadevi Tissington Lorraine McKee Tel: Environmental Health Your local Environmental Health office can provide information and advice on food safety. They can be contacted through your local Council Service Point or by ing if you are in Highland Council Area, or if you are in Argyll & Bute. Other sources of information NHS Highland provides a range of guidance about communicable disease which can be accessed at: Follow the links All Services A-Z/Health Protection Team. You will find leaflets about various gastro-intestinal diseases, and also Guidelines for the Management of Scabies. Responsibilities for the implementation of this guidance Managers must ensure that staff: Are aware of this guidance Have all received education concerning the implementation of all elements of SICPs on appointment and updates as necessary Have sufficient support and resources to implement SICPs Carers must ensure that they: Understand and are able to apply the principles of SICPs Report to managers and document any deficits in knowledge, resources, equipment; facilities or incidents that may result in the transmission of infection Have an awareness of communicable illnesses which may affect residents; know when to report symptoms; know how to care for residents who are affected Page 6 of 56 Review date: March 2014

7 2. THE CHAIN OF INFECTION In order for infection to occur several things have to happen. This is often referred to as the Chain of Infection. The six links in the chain are: Infectious Agent or the microorganism which has the ability to cause disease The Reservoir or source of infection where the microorganism can thrive. This may be a person, an animal, any object in the general environment, food or water. The Portal of Exit from the reservoir. This describes the way the microorganism leaves the reservoir. For example, in the case of a person with flu, this would include coughing and sneezing. In the case of someone with gastro-enteritis microorganisms would be transmitted in the faeces. The Mode of Transmission. This describes how microorganisms are transmitted from one person or place to another. This could be via someone s hands, on an object, or through the air. The Portal of Entry. This is how the infection enters another individual. This could be landing on a mucous membrane, being breathed in, entering via a wound, or a tube such as a catheter. The Susceptible Host. This describes the person who is vulnerable to infection. Infections can be prevented by breaking the Chain of Infection. The following page illustrates the Chain, and gives examples of actions that can be taken to break it. The overall aim of Standard Infection Control Precautions is to break the Chain. Page 7 of 56 Review date: March 2014

8 INFECTIOUS AGENT Bacteri, fungi, viruses & protozoa Rapid, accurate identification of organisms Treatment of underlying diseases Ensure staff are healthy & immunised Flu & pneumococcal immunisation Recognition & protection of high-risk patients SUSCEPTIBLE HOST Underlying illness, surgery RESERVOIRS People, equipment, food & water Thorough cleaning of the environment & equipment Disinfection & sterilisation Use of PPE Aseptic Technique Catheter Care PORTAL OF ENTRY Mucous membranes, broken skin etc PORTAL OF EXIT Excretions, secretions, skin scales Hand hygiene Safe handling of blood & body fluids, cough etiquette etc Wound Care Hand Hygiene MEANS OF TRASMISSION Direct contact, objects, contaminated food, air Isolation when appropriate Safe handling and disposal of waste Disinfection & sterilisation Safe food handling Page 8 of 56 Review date: March 2014

9 3. STANDARD INFECTION CONTROL PRECAUTIONS 3.1 What are Standard Infection Control Precautions (SICPs)? SICPs are core measures that should be used at all times, in all care settings, by all carers, when providing direct care for all residents. They apply whether infection is known to be present or not, in order to ensure the safety of residents, staff and visitors. There are ten elements: Placement of Residents Hand Hygiene Respiratory Hygiene and Cough Etiquette Personal Protective Equipment Management of Care Equipment Control of the Environment Safe Management of Linen Management of Blood and Body Fluid Spillage Safe Disposal of Waste Occupational Exposure Management (including sharps) In all situations you must assess the risk of the task that you are doing, and not the risk of the patient. 3.2 Transmission Based Precautions In some situations it may be necessary to use additional infection control precautions know as Transmission Based Precautions. This should only be when and as directed by the Health Protection Team. Page 9 of 56 Review date: March 2014

10 (a) PLACEMENT OF RESIDENTS Residents who may present a cross-infection risk e.g. have vomiting and/or diarrhoea, must be assessed and all staff informed regarding whether they are in isolation, and the significance of this. The reason for isolation must also be discussed with visitors, and they should be given relevant information about the need for hand hygiene and the use of Personal Protective Equipment if applicable. (b) HAND HYGIENE i. What are your hands carrying? In any care setting, hand hygiene is the most important activity for reducing the spread of infection from one person to another. Microorganisms found on hands may be categorised as either resident or transient. Resident organisms live within the epidermis (for example in hair follicles and sweat glands) and they protect the skin from invasion by more harmful micro-organisms. They are not easily removed. Transient organisms are found on the surface of the skin, and they are transferred by direct contact with other people, equipment or other body sites. As their name implies, who and what a person touches in the course of the day will determine which micro-organisms are on their hands. There are certainly lots of opportunities to pick up micro-organisms. They are an important cause of cross-infection, but the good news is that they are easily removed by good handwashing. ii. When should you decontaminate hands? The following list gives some examples of when hands should always be decontaminated: When you arrive at work Before preparing, handling or eating food After using the toilet Whenever hands are visibly dirty Immediately before giving personal care to a resident Between giving care to different residents After bed making Before putting on gloves After removing protective clothing, e.g., gloves After any activity which may result in contamination of the hands Before preparing/giving medication After any situation that involves direct contact with resident, e.g. bathing, assisting to move, toileting. After handling blood or other body fluids Before and after emptying urine drainage bags After handling laundry and waste Before leaving work Page 10 of 56 Review date: March 2014

11 iii. Routine hand hygiene Choice of cleansing agent The product chosen must be acceptable to the users, and not have a detrimental effect upon the skin of carers. In most care settings, handwashing with liquid soap (preferably one that contains an emollient) and water is adequate. You do not need to use harsh antiseptic soaps as these may make your hands sore with repeated use, and sore hands are more likely to transmit infection. Liquid soap dispensers should be wall mounted, maintained regularly, and operated by elbow or wrist. The dispenser should have individual cartridges that are discarded when empty in order to reduce the chance of accidental contamination. Do not re-fill bottles. Ideally, wash basins used by staff should have taps that are wrist, elbow or foot operated. Soft user-friendly paper towels should be provided for drying, in wall mounted holders that are easy to use and clean. Bare below the elbow in order to ensure effective hand decontamination, arms should be bare below the elbow i.e., when giving personal care, clothing must be above the elbow; wrist watches/jewellery and stoned rings should be removed. Correct Technique Wet hands under running water (this helps to prevent the soap from irritating your skin) Dispense one dose of soap into cupped hand Handwash for seconds vigorously and thoroughly, without adding more water To ensure that all skin surfaces are washed follow the steps illustrated in Appendix 1 Rinse hands well under running water to remove the soap and the micro-organisms that you ve loosened. Dry thoroughly with a disposable paper hand towel. Drying well removes lots more micro-organisms Dispose of paper towel into bins with foot-operated pedals. Do not touch the bin with hands General principles Keep nails short and clean, and free of false nails and nail polish Don t use nail brushes as scrubbing the skin may damage the surface leading to an increased risk of picking up micro-organisms If you wear a wedding ring wash beneath it to remove any bacteria lurking underneath. Keep your hands in good condition. Sore chapped hands will have millions more germs in the cracks that will be difficult to remove. Use your own hand cream or a pump-action communal one. Never use tubs of cream that everyone puts their hands into they grow bacteria really well! Ensure adequate facilities. Wash hand basins in residents rooms should be equipped for hand washing by both residents and carers Page 11 of 56 Review date: March 2014

12 Use of alcohol gel Alcohol handrubs may be useful in some situations when caring for people in the community, but are not recommended for routine use in care homes. They are not effective when residents have infections such as Clostridium difficle or norovirus. In circumstances where their use is recommended by the Health Protection Team they should be applied using the illustrated technique How to Handrub? (Appendix 2) After using on a maximum of five consecutive occasions hands require to be washed with soap and water in order to prevent a build up of residue on the hands. They must never be used when hands are visibly dirty as organic material can inactivate the alcohol. iv. Protection of broken skin Cuts and abrasions on the hands and forearms should be covered with a waterproof dressing which should be renewed whenever necessary. Avoid invasive procedures if suffering from chronic lesions on hands. Seek medical advice for skin conditions that may be affected by work, including conditions such as eczema and possible allergic reactions. (c) RESPIRATORY HYGIENE AND COUGH ETIQUETTE The aim of respiratory hygiene and cough etiquette is to prevent the transmission of respiratory infections, e.g. coughs and cold, influenza viruses, and also less common but more severe ones such as bacteria which may cause pneumonia. Staff should always: Cover the nose and mouth with a disposable tissue when sneezing, coughing, wiping and blowing the nose Dispose of all used tissues promptly into a waste bin Wash hands with warm water and liquid soap after coughing, sneezing, using tissues, or after contact with respiratory secretions or objects contaminated by these secretions Keep hands contaminated by respiratory secretions away from mucous membranes of the eyes and nose Staff should also assist residents to follow the above advice. (d) PERSONAL PROTECTIVE EQUIPMENT The use of Personal Protective Equipment (PPE) is essential for health and safety, and offers protection both to residents and carers. PPE is worn in addition to your normal work clothes, whether these are your own or a uniform. Inevitably, the clothes that one wears will become contaminated with microorganisms in the course of the day. However, if PPE is utilised when appropriate then there is little evidence that contamination of clothing plays a major role in the transmission of infection. PPE includes: Gloves Aprons Page 12 of 56 Review date: March 2014

13 Face, mouth/eye protection, e.g. masks/goggles/visors. In considering what protective clothing might be necessary in any situation it is necessary to carry out a risk assessment. This means asking whether the task you are about to perform gives rise to any possibility of contact with blood or other body fluids. If the answer is yes, then appropriate protective clothing is necessary. i. Gloves The need for gloves and the selection of appropriate ones must be subject to careful risk assessment. This will involve consideration of the actual task to be carried out, and the potential risks to both the resident and carer. There are two main indications for the use of gloves: To protect hands from contamination with organic matter and microorganisms To reduce the risks of transmission of microorganisms to both residents and staff Gloves must only be worn when necessary, as inappropriate use may result in adverse reactions and skin sensitivity, along with unnecessary expenditure. Risk assessment should include consideration of: Who is at risk residents or carers The potential for exposure to blood, body fluids, secretions or excretions The potential for contact with non-intact skin or mucous membranes Whether sterile or non-sterile gloves are required Please consult the algorithm: Risk assessment and glove use (page 15) Key Points All gloves marked as medical gloves for single use have to meet BS EN 455 Medical gloves are intended to be a barrier to agents responsible for the transmission of infections. In order to ensure effectiveness, it is essential that gloves fit properly, are free from holes and have adequate physical strength so as not to fail during use. All these issues are addressed by BS EN 455. The choice of material of gloves must ensure sufficient sensitivity to perform the task, be the correct size, and take allergy into consideration Alternatives to natural rubber latex gloves must be available for carers (and residents) who have a documented sensitivity to natural rubber latex Gloves should neither be re-used nor washed. Liquids may penetrate through microscopic holes in the glove, and the glove may also be damaged if it comes into contact with oils or silicone based lotions, disinfectants or alcohol gel Gloves must be put on immediately before an episode of care and removed and discarded after each care activity for which they were worn to prevent the transmission of microorganisms to other sites in that individual or to other residents Gloves must be changed between caring for different individuals and between different tasks with the same resident Polythene gloves must only be used for food handling Page 13 of 56 Review date: March 2014

14 Removing gloves Hold the wrist end of one glove and pull down gently over the hand, turning it inside out whilst doing so Hold the removed glove in the gloved hand Peel the second glove off over the first glove Dispose of the gloves into a pedal operated disposal bin. Wash hands immediately Page 14 of 56 Review date: March 2014

15 Risk assessment and glove use: Are gloves really necessary? Gloves are NOT required for procedures where there is a minimal risk of cross-infection between patients and staff, e.g. Basic care procedures without contact with blood or body fluids Transferring food from food trolleys to patient bedside Making uncontaminated beds/changing or removing residents uncontaminated clothing Taking recordings (BP, temp, pulse) Gloves ARE required for procedures where there is a risk of cross-infection between patients and staff and further risk assessment should be carried out. Is there a high risk of exposure to blood and body fluids? Yes Don t wear gloves! Is a sterile field required? yes no Surgical glove Use medical gloves for single-use that are CE marked Page 15 of 56 Review date: March 2014

16 ii. Aprons Plastic disposable aprons should be worn to protect clothing when contamination is anticipated/likely. A separate one should be worn for each occasion of care given to each individual resident. Never reuse or wash single-use disposable aprons. Change aprons between caring for different residents, and between different tasks for the same resident, if necessary to prevent cross-contamination. Removal of aprons Remove apron promptly after use by breaking the ties and touching only the inside, turn the outer contaminated side inward and rolling into a ball. Dispose of immediately into a pedal operated bin. Wash hands. When wearing both gloves and apron, remove gloves first, followed by apron. Colour coding It is recommended to use different coloured aprons for different types of tasks. For example, use white ones when required for personal care, and pink ones for food handling and feeding residents. Another colour can be worn for domestic activities. This is especially important when the same staff undertake different types of tasks. iii. Face mouth/eye protection It is unlikely that face, mouth/eye protection will be required routinely in the Care Home setting. One possible exception to this is the use of surgical face masks during a flu pandemic. Page 16 of 56 Review date: March 2014

17 (e) MANAGEMENT OF CARE EQUIPMENT Care equipment may become contaminated with blood, other body fluids, secretions or excretions and transfer microorganisms during the delivery of care. Cleaning, disinfection and sterilisation are all methods of decontamination that reduce or destroy contaminants, thereby preventing microorganisms from reaching a site where they might cause harm. General good practice All equipment must be clean, fit for purpose, and in a good state of repair All equipment must be stored in an appropriate area Before purchasing any new equipment, obtain information from the manufacturer about cleaning and decontamination recommendations and be sure that you can implement them If there are items of equipment that are not routinely cleaned on a daily basis, there should be a written cleaning schedule and records kept of cleaning undertaken Care equipment used in a care home may be classified as: Single Use used once and then discarded. Such items must not under any circumstances be reused. (MHRA 2000). They will be identified with the following symbol: Single patient use for use on more than one occasion on the same resident Re-usable non-invasive equipment (may be referred to as communal equipment) reused on more than one resident following decontamination e.g. a commode i. Cleaning Cleaning physically removes the organic material on which microorganisms feed, and will also reduce the load of microorganisms. It is suitable for equipment that comes into contact only with intact skin. How to clean Check manufacturers instructions for suitability of cleaning products, especially when dealing with electronic equipment Wear appropriate PPE, i.e., apron and gloves Remove equipment to designated cleaning area Clean equipment with disposable cloths/paper roll and a fresh solution of general purpose detergent and water or detergent impregnated wipes. It is not necessary to use cleaning products that are advertised as being antibacterial or virucidal Discard disposable cloths/paper roll Discard solution in the designated area Clean, dry and store cleaning equipment Remove and discard PPE Perform hand hygiene Page 17 of 56 Review date: March 2014

18 ii. Disinfection Disinfection is a process additional to cleaning. It does not kill all micro-organisms, but reduces their number to a level which is not harmful to health. It is suitable for items that are contaminated with infectious material, blood and other body fluids. It is not required for items that have only been in contact with intact skin. Disinfectants are readily inactivated by dirt or body fluids and therefore thorough cleaning before disinfection is essential. When is disinfection necessary? Disinfection is necessary when items: are contaminated by blood or other body fluid or have been used for a resident with a specific infection (e.g. norovirus) who is in isolation How to disinfect There are two common methods of disinfection; physical and chemical. Physical disinfection is the application of heat for example the bedpan washer-disinfector. The method of chemical disinfection that is recommended for use in care homes is use of a chlorine releasing agent. There are two widely used chlorine releasing agents, suitable for use on inanimate surfaces: NaDCC (sodium dichloroisocyanurate) e.g. Actichlor, Presept or Haz-tabs NaCIO (sodium hypochlorite) e.g. Milton NaDCC is available as tablets, granules or powders, and some also contain a compatible detergent. It is preferred to NaCIO because it is: Easier to prepare Slightly more efficacious Less damaging to surfaces Different concentrations are required in different circumstances, and it is usual to describe the required concentration in parts per million, abbreviated to ppm. See chart below: Dilution NaDCC NaCIO 10,000ppm 2 5.0g tabs in 500 mls water 1:2 Milton 2% sterilising fluid 1,000ppm 2 0.5g tabs in 500 mls water 1:20 Milton 2% (50ml Milton made up to 1 litre of water) 125 ppm 1:160 Milton 2% (15ml Milton made up to 2.4 litres of water) Chlorine releasing agents should be diluted with cold water. Once prepared, the solution should be used within the time stipulated by the manufacturer or discarded. After disinfection the item/surface must be polished dry using a paper towel. Page 18 of 56 Review date: March 2014

19 It is also possible to use just one product that will effect both cleaning and disinfection e.g. Actichlor Plus. This should not be used for routine cleaning, but only in situations where disinfection is required e.g. during a norovirus outbreak. Check manufacturers instructions for suitability of cleaning products, especially when dealing with electronic equipment Wear appropriate PPE, i.e., apron and gloves Do not remove equipment from area prior to decontamination Either: o Clean equipment with disposable cloths/paper roll and a fresh solution of detergent, rinse, dry, and follow with a disinfectant solution of 1000ppm o Or, use a combined detergent/chlorine releasing solution with a concentration of 1000ppm Discard disposable cloths/paper roll Discard solution in the designated area Clean, dry and store cleaning equipment Remove and discard PPE Perform hand hygiene iii. Sterilisation Sterilisation is a process that destroys or removes all living micro-organisms including bacterial spores. It is recommended for all items that penetrate intact skin or mucous membranes, and enter vascular systems or sterile body cavities. It will not be undertaken within care homes, though sterile items may be used on occasions. Page 19 of 56 Review date: March 2014

20 Routine decontamination of reusable non-invasive patient care equipment Routine decontamination of reusable non-invasive care equipment Check manufacturers instructions for suitability of cleaning products especially when dealing with electronic equipment. Wear appropriate PPE e.g. disposable, non sterile gloves and aprons. Yes Is equipment contaminated with blood? No Immediately decontaminate equipment No with No disposable cloths/paper roll and a fresh solution of detergent, rinse, dry and follow with a disinfectant solution of 10,000 parts per million available chlorine (ppm av cl rinse and thoroughly dry Or use a combined detergent/chlorine releasing solution with a concentration of 10,000 ppm av cl, rinse and thoroughly dry Follow manufacturers instructions for dilution, application and contact time. No Decontaminate equipment with disposable cloths/paper towel and a fresh solution of general purpose detergent and water or detergent impregnated wipes. Follow manufacturers instructions for dilution, application and contact time. Clean the piece of equipment from the top or furthest away point. Discard disposable cloths/papers roll immediately into the healthcare waste receptacle. Discard detergent/disinfectant solution in the designated area. Clean, dry and store re-usable decontamination equipment. Remove and discard PPE. Is equipment contaminated with urine/vomit/faeces or has it been used on a patient with a known or suspected infection/colonisation? Either decontaminate equipment with disposable cloths/paper roll and a fresh solution of detergent, rinse, dry and follow with a disinfectant solution of 1,000 parts per million available chlorine (ppm av cl) rinse and thoroughly dry, Or use a combined detergent/chlorine releasing solution with a concentration of 1,000 ppm av cl, rinse and thoroughly dry Yes Page 20 of 56 Review date: March 2014

21 (f) CONTROL OF THE ENVIRONMENT The Care Home environment must be: Free from clutter to facilitate effective cleaning Well maintained and in a good state of repair Clean and routinely cleaned in accordance with guidance Care Homes should access the NHS Scotland National Cleaning Services Specification, available at: The%20NHSScotland%20National%20Cleaning%20Services%20Specification.pdf Cleaning schedules can be developed based on the above, and these provide evidence that cleaning has been undertaken as prescribed. Please contact the Health Protection Team for an example of a suitable schedule. i. Floors Generally, for hard surfaces wet cleaning methods are preferable to dry ones, as with dry methods there is risk of dispersing microorganisms into the air. Moist surfaces encourage bacterial growth, and thorough drying is part of the cleaning process. Impervious flooring should be washed using a neutral detergent and a mop with a detachable, launderable head. Change mop heads daily and send to laundry in an alginate bag. Mop buckets must be washed daily after use, and stored dry and inverted. If dry dusting of floors is carried out it must be with a dust attractant mop to ensure no dispersal of bacteria. Vacuum cleaning (with a three stage filtration) is suitable for carpets. Other hard surfaces Cleaning with household detergent and hot water remains the most effective method of removing contamination including microorganisms, and therefore damp dusting with disposable paper towelling should be the norm for all hard surfaces. Do not use refillable spray cleaners as they provide a breeding ground for microorganisms. Points to remember: Wear protective clothing, i.e., apron and gloves Prepare a fresh solution of general purpose neutral detergent in warn water. This should be changed when dirty, when changing tasks, or at least every 15 minutes. Make up only the quantity required in a clean dry container. Dispose of cleaning solution promptly in a sluice or dirty utility area Ensure that equipment is stored clean, dry and in the designated place. Remove protective clothing and wash hands before carrying out other duties. Routine disinfection of the environment is NOT recommended. However, 1000ppm available chlorine should be used on sanitary fittings. Page 21 of 56 Review date: March 2014

22 ii. Colour coding Colour coding of cleaning equipment has been adopted in many NHS settings, and you may wish to consider adopting this practice. It is especially useful if you have staff that also work in the NHS. See chart below. NATIONAL COLOUR CODING SCHEME FOR CLEANING MATERIALS AND EQUIPMENT All cleaning items, for example, cloths (re-usable and disposable), mops, buckets, aprons and gloves, should be colour coded. This also includes those items used to clean catering departments. Red Blue Bathrooms, washrooms, showers, toilets, basins and bathroom floors General areas including resident s rooms, departments, offices and basins in public areas Green Catering department/ kitchens Page 22 of 56 Review date: March 2014

23 (g) SAFE MANAGEMENT OF LINEN i. What is needed? A designated laundry area used only for that purpose, with separate ventilation and as far away as possible from anywhere food is prepared An industrial washing machine with cold sluice cycle and wash cycle temperatures that comply with disinfection standards Accurate thermometers that register the true wash temperatures should be fitted All machines should be installed professionally with a cover over the drain to prevent aerosol contamination An industrial dryer is recommended to ensure thorough drying of linen There should be a regular maintenance programme and a record kept of these checks as evidence of diligence and care Hand washing and changing facilities for staff should be available Different receptacles for clean and dirty laundry should be provided, and there should be separate areas within the laundry area to ensure no contact between clean and dirty linen ii. How should linen be handled? All linen (bedding and clothing) should be handled with care, avoiding the creation of dust, and placed directly into the appropriate bag at the point of use. Always wash hands after handling linen. Linen should be divided by staff into 3 categories: Category Types of Linen Inner Bag Outer Bag Used Linen Known or Suspected Infected Linen Heat labile fabrics e.g. clothing Ordinary used bed linen, towels etc. including items soiled with urine. Linen soiled by faeces, blood, bile, pus or other potentially infected matter. Fabrics likely to be damaged by the normal heat disinfection process should be categorised as above but bagged separately. None for dry items. Water soluble bag for items soiled with urine. Water- soluble bag As required - see above categories White fabric Heavy gauge transparent polythene bag/colour coded linen bag Locally agreed colour-coded bag Heavily blood-soaked linen should be placed in double yellow clinical waste bags for incineration. All bags must be securely fastened before being sent to the laundry, and not over-filled. Bags should be stored in a designated location that is secure, cool and dry. Page 23 of 56 Review date: March 2014

24 The designated storage area should be separated from areas used for the storage of clean linen, food preparation areas, and those parts of the home frequented by residents and their guests. iii. How should linen and clothing be washed? Used linen should be laundered by a process in which the temperature in the load is maintained at 65 for not less than 10 minutes or preferably at 71 for not less than three minutes. For machines of conventional design at least four minutes mixing must be added to these times; up to eight minutes may be needed if the machine is heavily loaded. Use normal washing powder. Foul or infected linen the inner water-soluble bag should be transferred to the washer without opening, followed by the outer bag which should be washed in a similar fashion. The washing cycle is then the same as for used linen. A sluice cycle is necessary for foul linen. Do not soak or sluice by hand as this may spray bacteria onto surfaces, uniforms and staff. Heat labile fabrics that are not heavily soiled may be disinfected by adding sodium hypochlorite to the penultimate rinse. This should be of at least five minutes duration and sufficient sodium hypochlorite should be added to achieve a concentration of 150 parts per million of chlorine. Heavily soiled linen should be prewashed at low temperature before a warm or cold wash and rinse disinfection as above. iv. Risks to staff The germs in most soiled and fouled linen are unlikely to cause infection in healthy people provided that care is taken and handling minimised. It is important to ensure that: Staff are trained to carry out the necessary procedures Disposable waterproof aprons and gloves are used when dealing with soiled /fouled laundry Any skin lesions are covered with a waterproof dressing Linen received in water soluble bags should never be opened or sorted by laundry workers. Instead the water soluble bag should be placed directly into the washing machine Adequate hand washing facilities are provided and are conveniently located Protective clothing is removed and hands washed before returning to other duties v. Storage of linen There should be a separate area for drying, ironing and storage of clean linen, well away from used linen, to prevent contamination. Clean linen should be stored in a clean, designated area, preferably an enclosed cupboard. If clean linen is not stored in a cupboard then the trolley used for storage must be designated for this purpose and completely covered with an impervious covering that is able to withstand cleaning and/or disinfection. Clean linen should not be stored in bathrooms or sluices. Page 24 of 56 Review date: March 2014

25 vi. Staff uniforms/clothing Regardless of whether or not a uniform is provided by the employer, it should never be regarded as a substitute for protective clothing. The requirement for PPE should always be assessed as described in (4). When provided, a fresh uniform should be worn daily; otherwise the carer s clothes should be changed daily. Both uniforms and/or carers own clothing can be laundered at home in a domestic washing machine at a temperature of 40 C. One of the most important factors in determining the effectiveness of laundering is the ratio between fabric load and water volume. In order to ensure sufficient dilution, it would seem sensible to recommend that the machine is not filled to more than 75% of its capacity in order to achieve adequate dilution. This will facilitate the physical removal of microorganisms. Further killing of microorganisms is effected by tumble drying and/or ironing. vii. Home laundry of residents clothing If friends and/or relatives of residents wish to take clothing home to wash you may wish to provide them with the leaflet Washing clothes at home: Information for people in hospital or care homes and their relatives. Available at: (h) MANAGEMENT OF BLOOD AND BODY FLUID SPILLAGES Spillages of blood, body fluids and excreta may be hazardous to health and must be dealt with immediately by staff trained to undertake this safely. A disposable plastic apron and gloves must be worn when dealing with all blood/body fluid spillages. i. Equipment for all blood and body fluid spillages except urine, vomit and faeces PPE gloves and apron Waste bag Disposable towels and disposable scoop if appropriate Disinfectant (Solution or granules containing sodium hypochlorite or sodium dichlorisocyanurate with a concentration of 10,000ppm available). Ensure adequate ventilation when using these disinfectants. Warm water and general purpose detergent Using granules: Put on apron and gloves Cover spillage with granules Leave for three minutes (or as recommended by manufacturer) before clearing up with paper towels and/or disposable scoop Wash area with general purpose detergent and warm water and paper towels, rinse and dry. Discard disposables as clinical waste Wash hands Page 25 of 56 Review date: March 2014

26 Using sodium hypochlorite solution: A fresh aqueous solution must be prepared. The concentration used must be equivalent to 10,000 ppm ac see table on page 21. Put on apron and gloves Cover spillage with disposable paper towels Gently soak paper towels with solution Leave for three minutes (or as recommended by manufacturer)and then dispose of as clinical waste Wash area with general purpose detergent and warm water, and paper towels; rinse and dry Discard all disposables as clinical waste Wash hands Unless the risk is high, if the spillage is on carpet or soft furnishings, omit the use of disinfectant. Ensure that the area is thoroughly cleaned with warm water and detergent, and that it is allowed to dry before further use. ii. Spillages of urine, vomit or faeces Put on apron and gloves Remove any gross contamination with disposable paper towels Apply a solution of 1000ppm chlorine Leave for three minutes or as recommended by manufacturer and then dispose of as clinical waste Wash area with general purpose detergent and warm water, rinse and dry. Discard disposables as clinical waste Remove PPE Wash hands (i) SAFE DISPOSAL OF WASTE All producers of waste, other than householders, have a Duty of Care to ensure that it is dealt with appropriately from the point of production to the point of final disposal. It is important to segregate waste correctly as there are cost implications and also a carbon footprint impact. All care homes should have written procedures which clearly identify local segregation, storage, packaging and transfer arrangements for the three core waste streams: Clinical or infectious waste waste produced as a direct result of healthcare activities, e.g., dressings, sharps. Clinical waste is defined as: any waste which consists wholly or partly of human or animal tissue, blood or other body fluids, excretions, drugs or other pharmaceutical products, swabs or dressings, syringes, needles or other sharp instruments, being waste which unless rendered safe may prove hazardous to any person coming into contact with it; and 2. any other waste arising from medical, nursing, dental, veterinary, pharmaceutical or similar practice, investigation, treatment, care, teaching or research, or the collection of blood for transfusion, being waste which may cause infection to any person coming into contact with it. Page 26 of 56 Review date: March 2014

27 In normal circumstances a care home will produce no or minimal waste of this type but there should be arrangements in place for its disposal if and when required. Sharps boxes are included in this category. Hygiene waste Waste contaminated with body fluids is more suited to the offensive/hygiene classification. This category includes urine bags, incontinence pads, nappies, single use bowls, PPE. The waste will have been risk assessed as offensive, but not infected. Domestic waste waste similar in composition to waste from household premises, e.g., paper towels (NB many domestic wastes are suitable for recycling and homes should make provision for this.) Receptacles for waste should be fit for purpose, of a suitable size, and placed in convenient locations, preferably as close to the point of production as possible. Waste bag holders should be fixed, and labelled for the waste type and colour coded. Bags must be UN 3291 approved type and filled to no more than three-quarters full, weigh no more than 4kg and be securely sealed. To seal: - Hold the bag by the neck and twist until tight - Fold over the neck of the bag to form a swan neck - In the case of healthcare waste place a ratchet type tag around the folded neck of the bag and tighten until a sturdy secure seal has been made Liquid waste e.g. blood must be rendered safe by adding a self setting gel or compound before being placed in the sack, or managed as a body fluid spill. If receptacles need to be stored prior to being transported, this must be in a secure locked area. Sharps boxes Sharps boxes must be of a type UN approved, certified to BS 7320; correctly assembled and never be over-filled, i.e. above the manufacturer s fill line, or ¾ full. The container must be puncture resistant and leak proof. It must be stable and provided with a handle and an aperture which will inhibit the removal of the contents, but will ensure that it is possible to dispose of items using one hand. Sharps containers must be kept off the floor, away from children, and inaccessible to unauthorised persons. Complete the label on the container as required when it is brought into use, and again when full, prior to disposal. When ¾ full it must be sealed, the label properly completed, and sent for disposal as clinical waste. Boxes should be disposed of every three months even if not full. Medicines All unused, expired, recalled medicinal products should be returned to the pharmacy from where they were obtained. Page 27 of 56 Review date: March 2014

28 Needles and syringes used in the administration of medicines, vials (empty or partially used) must be disposed of in the appropriate clinical waste stream bin container with a blue lid. Medicinal products must never be disposed of to drains or down the sink (j) OCCUPATIONAL EXPOSURE MANAGEMENT (including sharps) All Care Homes should have policies in place to ensure that staff are protected from occupational exposure to micro-organisms, particularly those that may be found in blood and body fluids. Residents must also be protected from any communicable diseases that staff may have. i. Skin care If any worker has a skin condition that may be affected by work, or has the potential to affect residents or colleagues then they must seek medical advice from their General Practitioner. If an allergic reaction to any product used in the work environment is suspected this must be investigated by the individual s general practitioner. It is the responsibility of the employer to provide a suitable alternative in order to ensure safe working practice. ii. Blood borne viruses The occupational risk of transmission of a blood borne virus (BBV) is considered to be a potential risk. Sharps injuries are one of the most common types of injury to be reported to NHS Board Occupational Health Departments. The greatest risk of a BBV being transmitted is as a result of a sharps injury, especially those resulting from injury with a hollow bore needle which may still contain blood. Transmission of BBVs may also result from contamination of mucous membranes with splashes of blood/body fluids. There is NO evidence that BBVs can be transmitted through intact skin. In theory there is a risk of a blood borne infection being transmitted either from a member of staff to a resident, or from a resident to a carer. In practice, employees are unlikely to be undertaking procedures that present a risk to residents. A significant occupational exposure is: A percutaneous injury for example injuries from needles, bites which break the skin; Exposure of broken skin (abrasions, cuts, eczema etc); Exposure of mucous membranes including the eye from splashing of blood or other high risk body fluid Remember all sharps injuries are potentially preventable What are sharps? Sharps include items such as needles, blood glucose lancets, ampoules, used razor blades and disposable razors that may be contaminated with blood or other body fluids. It is the responsibility of the person using the sharp to dispose of it correctly. Use of sharps Wear gloves when handling sharps Discard all sharps into a sharps container at the point of use. Never leave needles or any other sharps lying around Always request assistance when using sharps with an uncooperative client Page 28 of 56 Review date: March 2014

29 Never walk about with unguarded sharps Never re-sheath needles Discard syringe and needle as one unit. Do not pass an exposed sharp to another person Do not dispose of wrappers, cotton wool, etc in sharps boxes as this may prevent the sharps being dropped in directly, and cause an injury if someone tries to force a sharp in. Never remove items from a sharps container Dispose of sealed sharps containers as clinical waste Action to take in the event of a sharps/inoculation injury: Bleeding from a small wound should be promoted for a few seconds by gently squeezing the surrounding skin. Do not suck or scrub Wash the wound with warm running water and liquid soap Cover wound with a waterproof dressing If the eyes are contaminated irrigate for 2 minutes with normal saline or running water. If contact lenses are worn, irrigate both before and after removal Contaminated mucus membrane (e.g., nose, mouth) should be washed with plenty of water. Report the injury to the person in charge Assessing the risk Unused/clean sharp definitely no risk of infection, (except from the micro-organisms on your own skin). Record incident, but no further action. Used/dirty sharp source known or unknown, also human bite/scratch/mucus membrane splash. Seek professional advice from Accident and Emergency Department at local hospital or your General Practitioner. This should be within one hour of the incident having taken place. In a hospital setting, the risk of acquiring a blood borne virus as the result of a sharps/inoculation injury from a source known to be infected has been estimated as follows: Hepatitis B - around one in three Hepatitis C - around one on 30 HIV - around one in 300 This means that the risk of acquiring an infection from a sharp/inoculation injury in a low risk population, even when the infection status of the source is unknown, is minuscule. However, this must not be used as a reason for complacency in sharps management. iii. Hepatitis B immunisation Hepatitis B immunisation is recommended for all healthcare workers who may have direct contact with individuals blood, blood-stained body fluids or tissues. All staff of residential and other accommodation for those with learning difficulties should also be offered immunisation as higher rates of hepatitis B carriage has been found in certain groups of people with learning difficulties in residential accommodation. When immunisation is required, the cost must be borne by the employer. There are no vaccines which protect against hepatitis C or HIV. Page 29 of 56 Review date: March 2014

30 iv. Other immunisations It is regarded as good public health practice for everyone to be fully immunised. Staff should be asked to consult their GPs to ensure that they are up-to-date with all routine immunisations and arrange boosters if necessary. The Scottish Government Health Department recommends that all those involved in direct care should be immunised annually against influenza. This is the responsibility of the employer to arrange and fund. However, staff should be encouraged to be immunised, for the following reasons: They personally benefit, as they reduce their chances of becoming ill The organisation benefits because there is reduced absenteeism, and last but not least, Residents benefit because they are doubly protected v. Protection against tuberculosis All staff in care homes for elderly people who are younger than 35 years of age should be screened to see whether they need BCG vaccination. Be aware that routine BCG vaccination in school ended in 2005, so you may have a number of staff in this category. Staff who have come from a high-risk country should also be screened. Please contact the Health Protection Team if you require advice on this. Page 30 of 56 Review date: March 2014

31 4. COLLECTION OF SPECIMENS The aim when collecting a specimen is to collect an adequate amount of tissue/fluid, uncontaminated by organisms from any outside source, but preserving any organisms that may be present. Use the appropriate container; if unsure, check with the laboratory at your local hospital Label the specimen container with the patient s details and date prior to collection Wash hands before and after taking the specimen, and wear PPE Collect an adequate amount in order to increase the possibility of detecting the organism When taking swabs from dry wounds/body surfaces it is advisable to moisten the bacteriology swab with sterile water or saline to allow for optimum pick-up of organisms Ensure that the specimen is not contaminated during collection, either by equipment or an individual s normal flora Specimens should be obtained prior to the commencement of antibiotic therapy. If therapy has already commenced, specify the antibiotic on the request form and date it was commenced Complete all details on the laboratory form in legible hand writing Send specimens to the laboratory immediately in order to prevent overgrowth of nonpathogens and the death of pathogenic organism Place the specimen into the sealable pocket of the plastic bag and close the pocket. Refrigerate (at 4 ) specimens which cannot be transported immediately. (NOT in a fridge used for food storage) If the specimen is being posted it must be sent first class and clearly labelled: Pathological Specimen Fragile with Care Do not take specimens for culture unless there are signs and symptoms of clinical infection. Bear in mind, for example, that any wound will be colonised with many organisms, and if swabbed in the absence of clinical infection, the culture result may lead to unnecessary treatment with antibiotics. Specific guidance on how to obtain a faecal specimen from a resident who has diarrhoea is available at: Page 31 of 56 Review date: March 2014

32 5. FOOD HYGIENE When operating a care home all food preparation operations will be covered by food hygiene legislation. This legislation covers a number of areas, including: 1. You must register your business with your local environmental health office and advise them of any changes to your business 2. Hazard Analysis - you must have a food safety management system to assess and control the food hazards associated with your operations. You must consider hazards that may arise including temperature control, cross contamination, pest control, staff illness, allergens and stock control. Systems such as 'cooksafe' available from can help you meet this requirement; 3. Cleanliness you must ensure ensure high levels of cleanliness are maintained in your premises and by your staff 4. Structural requirements - your premises must meet certain structural requirements (e.g. walls, floors, equipment, sinks, lighting); 5. Staff training - all staff must be trained in food hygiene appropriate to their duties. (see further comments below); Your local Environmental Health office can provide information and advice on all these subjects via their websites ( ). They can be contacted through your local Council Service Point, or by ing env.health@highland.gov.uk if you are in Highland Council Area, or envhealth@argyllbute.gov.uk if you are in Argyll & Bute. Staff Hygiene awareness Before being allowed to start work for the first time, a food handler must receive either verbal or written instruction in the Essentials of Food Hygiene. All other staff should also receive similar instruction as a matter of good practice. The essentials of food hygiene: Keep yourself clean and wear clean clothing. Always wash your hands thoroughly: before handling food, after using the toilet, handling raw foods or waste, before starting work, after every break, after blowing your nose. Tell your supervisor, before commencing work, of any skin, nose, throat, stomach or bowel trouble or infected wound. You are breaking the law if you do not. Ensure cuts and sores are covered with a waterproof, high visibility dressing. Avoid unnecessary handling of food. Do not smoke, eat or drink in a food room, and never cough or sneeze over food. If you see something wrong, tell your supervisor. Keep perishable food either refrigerated or piping hot. Keep the preparation of raw and cooked food strictly separate. When reheating food, ensure that it gets piping hot and over 82 C. Clean as you go. Keep all equipment and surfaces clean. Follow any food safety instructions either on food packaging or from your supervisor. Page 32 of 56 Review date: March 2014

33 Full-time kitchen staff require formal training in food hygiene, within three months of starting their employment. Contact your local Environmental Health Officer to discuss what courses are available, and what level of training is appropriate. Food preparation should not as a rule be undertaken by carers, unless they have received appropriate food hygiene training. If such trained carers have to prepare or serve food they should change into separate clean protective clothing and then wash their hands thoroughly before handling food and ensure that there is no cross contamination between raw and cooked foods. Page 33 of 56 Review date: March 2014

34 6. OUTBREAKS GENERAL What is an outbreak? An outbreak is defined as two or more cases of the same infection occurring in the home within a short space of time. Senior staff should be aware of organisms that have the potential to cause an outbreak such as norovirus, salmonella, E.coli O157, Mycobacterium tuberculosis (TB). Also be aware that a potential outbreak does not depend on having received any positive laboratory results; the presence of symptoms is sufficient. Seek advice promptly rather than worrying about false alarms As soon as any outbreak is suspected the manager should inform the resident s General Practitioner and the Health Protection Team. The Health Protection Team will advise on any action that needs to be taken to manage the outbreak. If an outbreak is confirmed you should also inform the Care Inspectorate. Page 34 of 56 Review date: March 2014

35 7. VIRAL OUTBREAKS General For information and guidance about viral outbreaks see General information and infection prevention and control precautions to prepare for and manage norovirus in care homes produced by Health Protection Scotland and available at: Please print out a copy and keep with this guidance so that all staff can access it. The above guidance should be used in conjunction with the Outbreak Monitoring Form on the following page. This form should be ed (preferably) or faxed, to the Health Protection Team each morning to record all cases in the previous 24 hours. You may also find the Aide-Memoire helpful. Terminal cleaning Please refer to Appendix 3 for guidance regarding terminal cleaning at the end of an outbreak. Page 35 of 56 Review date: March 2014

36 OUTBREAK MONITORING FORM CARE HOME: DATE: TIME: No Room No SURNAME FORENAME DOB STAFF OR RESIDENT DIAGNOSIS (if relevant to D&V) SYMPTOMS D/V/Nausea etc DATE of Onset DATE of Last Symptoms SPECIMEN TAKEN Yes/No & Date RESULTS & Date Page 36 of 56 Review date: March 2014

37 Aide-Memoire for Managing Norovirus Outbreaks in Care Home Setting Please tick when control measure is in place: Date: Ensure regular washing of hands with soap and water after caring for cases or contact with the environment Isolate symptomatic individuals in their own rooms Cohort care of symptomatic individuals Provision of gloves and aprons for wearing during contact with cases or their environment Closure of home to new admissions and closure of day care Avoid transfer to other homes/hospitals etc (unless medically indicated and after consultation with Health Protection Team) Exclusion of affected staff from the home immediately and until asymptomatic for 48hrs Provision of notices for visitors specifying any restrictions imposed with emphasis on hand hygiene Removal of exposed food items such as fruit Cleaning and disinfection of vomit and faeces spillages promptly as per local policy Documentation of the frequency of room, bathroom and toilet cleaning (increased frequency of usual practice and also cleaning of frequently touched areas) Daily use of freshly prepared 0.1% (1000ppm) chlorine releasing agent to disinfect hard surfaces (after cleaning with neutral detergent) Closure of home for at least 48 hrs after the last new case and 48 hrs after uncontained vomiting or diarrhoea Thorough terminal cleaning including change of curtains as per attached SOP Cleaning of carpets and soft furnishings with hot water and detergent or steam clean (avoid vacuum cleaning) Avoidance of staff working in affected areas from working in unaffected areas (including agency and bank staff) Guidelines and decontamination facilities (washing, changing, cleaning uniform) available to staff who become grossly contaminated from body fluids (blood, urine, faeces, etc) Page 37 of 56 Review date: March 2014

38 8. MRSA What is MRSA? Staphylococcus aureus is a type of bacteria found on human skin, and carried by up to 50% of the population. It is normally harmless, but if it gains access to tissues beneath the skin it may cause infections ranging from boils and abscesses to bronchopneumonia and septicaemia. Resistance to antibiotics has been recognised as a problem since their introduction and some strains of Staphylococcus aureus have now acquired resistance to a wide range of antibiotics. Meticillin is a type of penicillin no longer used for treatment but used in the laboratory to test for resistance, and MRSA thus stands for Meticillin Resistant Staphylococcus aureus. Neither Staphylococcus aureus nor MRSA cause illness in people who are generally healthy, and therefore do not pose a risk to the health of staff, the general public or family members (including babies and pregnant women). MRSA causes the same range of infections as non-resistant strains of Staphylococcus aureus, but may be more difficult to treat. A person is described as colonised with MRSA if it is living on their skin, (often just inside the nose) without harming their health. Some people will carry MRSA and be completely unaware of doing so. How is it spread? Care worker s hands are the main route of spread. Contaminated hands will in turn contaminate the environment. Some people who are described as staphylococcal dispersers may heavily contaminate the environment. An example of this is a person with eczema who may shed large amounts of MRSA contaminated skin scales into the environment. Points to note Carriage of MRSA should not normally prevent discharge from hospital to a patient s own home, or to a Care Home If simple hygiene measures are followed, carriers are not a hazard to relatives, staff or other members of the community The practice of Standard Infection Control Precautions in the care of all residents will prevent most cases of transmission of MRSA, and good handwashing is the most important method of preventing the spread of infection by contact. How should residents with MRSA be cared for? They may share a room as long as neither they nor the person with whom they are sharing has open sores or wounds, catheters or other invasive devices. They may receive visitors and go out of the home, for example to see their friends or family. Page 38 of 56 Review date: March 2014

39 They may join other residents in communal areas such as sitting or dining rooms, so long as any sores or wounds are covered with an appropriate dressing which is regularly changed. (An appropriate dressing is one that is impermeable such as a hydrocolloid, or a vapour permeable film or membrane.) No additional precautions are necessary for laundry. Special precautions Complete procedures for other residents before attending to residents with MRSA. Perform dressings and clinical procedures on a resident with MRSA in the resident s own room. Seek advice from the Health Protection Nurse Specialist if the patient has a postoperative wound, drip or catheter Isolation is not generally recommended, and may have adverse effects upon the mental and physical condition of the resident. Hospital appointments etc. If admitted to hospital, the receiving ward must be informed of a person s MRSA history, even if not currently positive. Inform hospital staff if the person is to attend the Out-patients Department. If an ambulance is required the service should be informed. Screening Residents should only be screened prior to a planned hospital admission if requested by the admitting hospital. The only other instance when specimens should be obtained is in the presence of clinical infection that necessitates treatment. In this case, a specimen should only be taken from the infected site; do not screen other areas. There is no justification for screening staff, except in the event of a extensive outbreak and when there is the possibility of staff being implicated in the transmission of infection (rather than colonisation). Staff screening should never be undertaken except on the advice of the Health Protection Team. Treatment and decolonisation If a resident has an infection for which treatment is indicated, then this should be on the advice of the GP who will prescribe antibiotics. If you have any queries or concerns, please speak to a member of the Health Protection Team. Generally, decolonisation of residents is not necessary in Care Homes, and you should always contact the Health Protection Team to discuss if for any reason it is being considered. Page 39 of 56 Review date: March 2014

40 9. CLOSTRIDIUM DIFFICILE What is Clostridium difficile (C.diff)? C. diff is a bacteria that is present in the intestine of about 3% of healthy adults. It is also common in babies up to two thirds of infants have it in their intestines, but it rarely causes problems. It is estimated that about 20% (one in five) of hospitalised patients over the age of 65 carry C. diff. C.diff does not like being exposed to oxygen, so when it finds itself in an conditions when it is exposed to oxygen it forms spores in order to survive. The bacterial cell becomes covered in a protective layer which enables it to survive in adverse conditions, and it is generally very difficult to kill using either heat or disinfection. If a person picks up spores from the environment and ingests them, once they reach the intestine they will germinate and flourish. Risk factors The elderly are most at risk, and in fact about 80% of the cases reported are in the over 65 age group. Immunocompromised people are also at risk, as are those who have had any bowel surgery. Taking antibiotics makes people more susceptible to develop illness, because any antibiotic will disrupt the balance of all the different bacteria that are normally in the intestine, thus making it easier for C. diff to flourish. How is it transmitted? Although some people already have C. diff in their intestines, in most cases illness develops after transmission from someone or somewhere else. This may be directly from the infected person, on the hands of carers, or from the environment. Someone who has diarrhoea caused by C.diff will excrete large numbers of spores, so cleaning and hygiene are very important to ensure they don t spread to other people. Healthy carriers can also be a source of infection. Infection can also be acquired from community sources, such as spores in the soil, carriage by pets (dogs, cats, horses), contaminated foods, or exposure to household contacts with diarrhoea. Why is it a problem? There are approximately 160 different types of C.diff. Some types produce toxins, which may cause damage to the lining of the intestine. The damage to the intestine then results in some or all of the following signs and symptoms: Watery diarrhoea (stool has a distinctive foul smell and is often green in appearance) Low grade fever Loss of appetite Nausea Abdominal pain/tenderness In severe cases the infection and inflammation of the intestine can lead to death. Page 40 of 56 Review date: March 2014

41 How is it diagnosed? If a resident has diarrhoea for which there is no obvious cause, a stool sample should be sent to the laboratory for testing. It is difficult to grow C.diff in the laboratory, so the routine test is to detect the toxin. Care of a resident with C.diff infection (CDI) The GP will review any antibiotics that the resident is taking. In mild cases of infection just stopping the antibiotics may be sufficient for the person to recover. Sometimes it is necessary to prescribe special antibiotics. Other medication such as laxatives and other drugs that may cause diarrhoea should also be reviewed. Ensure that fluid intake is recorded, and that it is adequate. Use a stool chart to record all bowel movements (See Appendix 2). If you have any resident who has a C.diff positive stool sample, please contact the Health Protection Team. Please also inform the Team if one of your residents has recently been discharged from hospital and was diagnosed with C.diff whilst there. Prevention of cross-infection All residents with diarrhoea should be isolated in their own room until they have had no symptoms for a minimum of 48 hours Re-enforce Standard Infection Control Precautions to all staff Remember to assist residents to wash their own hands after using the toilet/commode/bedpan In addition to SICPs: Wear disposable gloves and aprons when carrying out any care (i.e. not only when contact with blood and/or body fluids is anticipated) If the affected resident does not have their own en-suite toilet, use a dedicated commode (i.e for their use only) which can remain in their room until they are well Treat all linen as infected, and place directly into a water-soluble bag prior to removal from the room Pay special attention to daily cleaning of the environment. Routine cleaning with warm water and detergent is important to physically remove any spores from the environment After cleaning with warm water and detergent, wipe all hard surfaces with a chlorine based disinfectant (1000ppm) Ensure that visitors wash their hands at the beginning and end of visiting It is important to ensure that you have adequate stocks of liquid soap, paper towels, single-use gloves, plastic aprons and pedal operated bins. Please note that plain soap and water is adequate for hand washing. Alcohol gel does not kill the spores. Page 41 of 56 Review date: March 2014

42 When can these extra precautions be stopped? It is not necessary to send further stool samples to the laboratory to check whether the patient is free from infection. Additional precautions can be stopped when the resident has been completely free from symptoms for 48 hours and a normal formed stool has been achieved. Isolation can also be stopped at this time. Symptoms may recur in about one in five people, so if this happens, inform the GP and recommence all precautions. Leaflet NHS Highland has produced a leaflet, Information about Clostridium difficile for use in the community. This can be copied and given to staff, residents and visitors. It is available at: InfectiousDiseaseInformation.aspx Page 42 of 56 Review date: March 2014

43 10. IMMUNISATION OF RESIDENTS The Scottish Government Health Department recommends that all people who reside in long-stay health or social care facilities should receive annual influenza vaccination. In addition, all those over the age of 65 should receive one dose of pnuemococcal vaccine. Vaccines may be administered by a district nurse or practice nurse who is authorised to do so under a NHS Highland Patient Group Direction (PGD) which means that individual signed prescriptions are not required. However, PGDs cannot be used by nurses employed in Care Homes. In order for a nurse employed by a Care Home to administer vaccines on behalf of the GP, there must be a valid prescription, or signed order for the individual resident. This may be on a NHS GP10 form, or the medicine administration kardex, or equivalent with the resident s own name. Any nurse administering vaccines must be competent to do so. For further information see: NHS Highland Immunisation Procedure NHS Highland Policy for the Handling and Storage of Vaccines Both of the above are available at: Follow the links All Services A-Z/Health Protection Team/Public Health Guidance. Further detail about prescribing and administering flu vaccine (including helpful guidance regarding consent) can be found at: mid=378 Page 43 of 56 Review date: March 2014

44 11. CARE OF URINARY CATHETERS Indwelling urethral catheters should only be used after considering all alternative methods of managing urinary incontinence. Catheterising patients places them in significant risk of acquiring a UTI. The longer a catheter is in place, the more significant the risk is. Urethral catheterisation requires skill, knowledge and education and, because it is not without complications, careful assessment and careful consideration of the alternatives must be made. Unnecessary catheterisation should be avoided as early complications: trauma, bleeding and inflammation may lead to urethral stricture. The importance of documenting all procedures involving the catheter or drainage system in the patient s records should be emphasised and patients and/or carers should be provided with adequate information in relation to the need, insertion, maintenance and removal of their catheter. Only use indwelling urethral catheters after considering alternative methods of management. Review regularly the patient s clinical need for continuing urinary catheterisation and remove the catheter as soon as possible. Catheter insertion, changes and care should be documented A Catheter Care Resource Pack may be obtained from: Lesley Randall Continence Nurse Advisor, NHS Highland lesley.randall@nhs.net In 2004 NHS Quality Improvement Scotland published a Best Practice Statement Urinary catheterisation & catheter care, and this is available at: Guidance about the management of bacterial urinary tract infection in people with catheters is included in SIGN Guideline 88, Management of suspected bacterial urinary tract infection in adults, available at: Page 44 of 56 Review date: March 2014

45 12. LAST OFFICES In some cases the body of a resident may constitute an increased risk of infection because of a particular, active communicable disease or carrier status, known to be present during life. However, in other cases infection may have been present but undiagnosed. Common risks to staff include hepatitis B, tuberculosis and bacterial skin infections. All persons who have to handle bodies must understand that the tissues and body fluids, especially blood and blood-stained, may be capable of transmitting infection. Standard precautions for dealing with living patients also apply to all persons when handling any body. In all cases, any drainage tube sites and open wounds must be sealed using waterproof dressings. (N.B. Drainage tubes etc. must be left in situ if post mortem is to be performed). Where blood, body fluid, faecal material or stomach contents cannot be contained by the use of waterproof dressings, incontinence pads etc., the body should be placed in a leak-proof cadaver bag. If the resident is known to have a specific infection at the time of death, please contact the Health Protection Team who will advise on whether any precautions are required in addition to SICPs. Page 45 of 56 Review date: March 2014

46 13. EDUCATION RESOURCES 13.1 Education for the Infection Control Key Worker Standard 3 of the Infection Control in Adult Care Homes: Final Standards which was published by the Scottish Executive in 2005 indicates that designated Infection Control Key Workers should have formal training. The Infection Control Key Worker must be given ring-fenced time for training (their own, and that of others) and to undertake audit. NHS Education for Scotland (NES) has produced a resource specifically for care homes and care in the home environment: Preventing Infection in care Infection Prevention and Control: Older Person Care Homes and Home Environment. This programme consists of a DVD which illustrates SICPs, and an accompanying CD on which there is a workbook for student use. This programme is suitable not only for the Infection Control Key Worker, but for all staff. If you would like to discuss its implementation please contact the Health Protection Team. The Cleanliness Champions programme devised by NES is also a suitable course (though designed primarily for hospital settings) and can be accessed at: There is no charge to undertake the course online, but a nominal charge is made if the paper version is required Hand Hygiene NHS Education for Scotland has developed a web-based learning package, Promoting Hand Hygiene in Healthcare. It is available free of charge at: The estimated time for completion is two to three hours. Although it is designed to be accessed and studied online by individuals, you may wish to print off the material and use to run a group learning session. The Health Protection Team has a Hand Inspection Cabinet which is available to borrow. It is designed to demonstrate that effective hand hygiene requires the correct technique. Stickers reminding people of the need to wash hands are also available. Care Homes in Argyll & Bute Council area can arrange to borrow one from the Infection Control Nurses at Lorn & Islands Hospital, tel Page 46 of 56 Review date: March 2014

47 13.3 Induction training It is essential to include education about infection control as part of the induction of any new member of staff. This includes: Staff who give direct personal care Staff with minimal contact with residents Staff who have contact with resident-related equipment Volunteers who fall into any of the above three categories As part of induction all of the above staff should: Be informed of the person who is the Infection Control Key Worker Be given time to read this guidance provided by the NHS and any organisational policies relating to infection control Have the opportunity to discuss the above with the Infection Control Key Worker. Be given practical instruction by the Infection Control Key Worker in hand hygiene Senior staff should also be aware of the role of the Health Protection Team, and know how and in what circumstances to contact them At the end of the induction period, and preferably within two weeks of being appointed, the new staff member should be able to demonstrate knowledge of the chain of infection, all Standard Infection Control Policies, and correct practice of hand hygiene. All training given should be recorded. Page 47 of 56 Review date: March 2014

48 Appendix 1 How to Hand Wash? Based on the 'How to Handwash', URL: World Health Organization All rights reserved. Page 48 of 56 Review date: March 2014

49 Appendix 2 How to Handrub? Only use a handrub when advised to do so by the Health Protection Team! Based on the 'How to Handrub', URL: World Health Organization All rights reserved. Page 49 of 56 Review date: March 2014

50 Appendix 3 CARE HOME STANDARD OPERATING PROCEDURE Terminal clean of rooms AIM STATEMENT To minimise the risk of cross infection from the environment Ideally a terminal clean should only be commenced after the resident and his/her possessions have been removed from the room. In the event the resident is too frail to be removed from the room the Health Protection Team will discuss and advise on adjustments required to the process. COMMUNICATION The Health Protection Team will advise the care home manager/deputy when a terminal clean should be carried out in relation to residents diagnosed with Clostridium difficile infection and when suspected/confirmed Norovirus outbreaks have occurred. Timescale for commencing clean in relation to suspected viral GI outbreak should only be commenced once 48 hours have passed since the last new case and 48 hours after any episode of vomiting or diarrhoea in a public place. Timescale for commencing clean in relation to Clostridium difficile is within 48 hours of antibiotic completion. REQUIREMENTS Equipment needed: Disposable or launderable mop head and 2 buckets (ensure appropriate colour coded equipment is used) Wet Suction/vacuum cleaner with hepa filter 2 Small buckets/bowls Single use cloths Stepping stool/safety ladder Non-sterile single use gloves Single use apron Clinical waste bag General purpose detergent Chlorine based disinfectant (diluted to 1000ppm) Alginate bags Linen buggy for soiled linen Page 50 of 56 Review date: March 2014

51 If multiple rooms/areas are being cleaned, the solutions and mop head must be changed between rooms PROCEDURE Communal areas e.g. dining room/sitting rooms should be cleaned first as this will provide a clean/disinfected environment for residents to sit whilst their individual rooms are being cleaned Prior to entering the room Ensure room has been cleared of any visible contamination of blood/body fluids Check radiator covers have been removed Ensure all necessary equipment is available Carry out hand decontamination using liquid soap and water Put on the disposable apron and gloves Procedure within the room Once the room has been entered, the door must be closed and remain closed during the cleaning process Check room is clear of visible contamination of blood/bodily fluids Gather any rubbish e.g. bin liners and place in the clinical waste bin Remove any disposables e.g. toilet rolls, boxes of gloves and dispose into clinical waste Remove any linen, curtains and shower curtains and place in the alginate bags Cleaning should then be commenced working from highest levels downwards Wipe all horizontal surfaces with a detergent solution Dry the surface Wipe all horizontal surfaces with disinfectant solution (ensure the correct contact time is adhered to) Dry the surface once the contact time has elapsed if not already dried If ensuite, then move into the ensuite area Follow the aforementioned process for cleaning and disinfection for wash hand basin, shower and toilet Place used disposable cloths into clinical waste Utilising mop clean ensuite floor with detergent solution working from furthest point towards the ensuite door Then disinfect ensuite floor with disinfectant solution Disposable mop heads must be placed into clinical waste bag. Launderable mop heads should be placed into an alginate bag If carpeted the room should then be wet vacuumed, again working from furthest point towards to the door. Page 51 of 56 Review date: March 2014

52 Place equipment, alginate bags and waste bag adjacent to room door Remove apron and gloves placing into clinical waste bag Decontaminate hands with liquid soap and water Room door can now be opened Put on fresh apron and gloves Place the alginate bags into the linen buggy Tie the clinical waste bag and remove this and the equipment to designated areas e.g. domestic services room. Designated area for cleaning dirty equipment AFTER CARE Clean the equipment utilising detergent solution and then the disinfectant solution (this must be freshly made up) Dry equipment thoroughly and store correctly Wash hands with liquid soap and water Room carpet must be allowed to dry before reoccupying Return to room and replenish with sundry stocks e.g. disposable hand towels if used Replace curtains, shower curtains and bed linen Page 52 of 56 Review date: March 2014

53 Appendix 4 STOOL RECORD CHART Name: Date of Birth: Date sample sent: DATE TIME TYPE No. DESCRIPTION/COMMENTS (please refer to chart overleaf) Page 53 of 56 Review date: March 2014

54 Reproduced by kind permission of Dr K W Heaton, Reader in Medicine at the University of Bristol Norgine Ltd. Page 54 of 56 Review date: March 2014