Standard Precaution Policy ICP002

Transcription

1 Standard Precaution Policy ICP002 Table of Contents Standard Precaution Policy ICP Why we need this Policy... 2 What the Policy is trying to do... 2 Which stakeholders have been involved in the creation of this Policy... 3 Any required definitions/explanations... 3 NHFT... 3 Standard infection prevention and control precautions... 3 Transmission... 3 Personal Protective Equipment... 3 Key duties... 3 Trust Board... 3 Chief Executive... 3 Director of Infection Prevention and Control... 3 Infection Prevention and Control Team (IPCT)... 4 Managers/Clinical Leads... 4 Employees... 4 Support for patients... 5 Policy detail... 5 Hand Hygiene (Also refer to the Hand Hygiene Procedure)... 6 Alcohol handrub... 6 Personal Protective Equipment (PPE)... 7 Gloves 7 Aprons 8 Colour coding of aprons... 8 Masks 8 Eye protection... 9 Page 1 of 20

2 Spillage of blood and blood stained body fluids... 9 Waste Segregation Training requirements associated with this Policy Mandatory Training Specific Training not covered by Mandatory Training How this Policy will be monitored for compliance and effectiveness For further information Equality considerations Reference Guide Document control details Appendix 1 Putting on and Taking off PPE Appendix 2 How to use a Spill Kit Why we need this Policy Standard precautions are basic infection prevention and control principles that should underpin safe practice, in order to reduce the risk of infection to patients and staff. Standard precautions should be used routinely to prevent forward transmission of micro-organisms to other patients, staff and visitors. Standard precautions are fundamental in reducing the spread of infections within the healthcare environment. Utilising standard precautions will protect patients, visitors and staff. What the Policy is trying to do This policy outlines the standard precautions to be implemented by all healthcare staff as part of their routine practice, in order to reduce the risk of infection, transmission and environmental contamination from micro-organisms from recognised and unrecognised sources; hence protecting themselves, patients and visitors from the risk of infection. Standard precautions include:- Effective hand hygiene practices The use of Personal Protective Equipment (PPE) Safe management of blood and body fluid spillages Safe use, disposal and management of sharps Safe waste management Specimens Safe handling and laundering of used linen Appropriate cleaning/decontamination of equipment Maintaining a clean environment Page 2 of 20

3 Which stakeholders have been involved in the creation of this Policy Infection Prevention and Control Assurance Group Quality Forum Trust Policy Board Any required definitions/explanations NHFT Northamptonshire Healthcare NHS Foundation Trust. Standard infection prevention and control precautions are measures that must be implemented by healthcare staff as part of routine practice and applied consistently to prevent and control the spread of potential harmful micro-organisms from both recognised and unrecognised sources. Transmission is the passing on of a disease or an infection from a colonised/ infected individual to a previously un-infected/un-colonised individual (Pittet et al, 2001). Personal Protective Equipment equipment such as gloves, aprons, eye protection and masks that can aid the protection for the individual from potential contamination and or cross infection from blood, body fluids, excretions and secretions. Key duties Trust Board Has the overall responsibility for infection prevention and control. Chief Executive Has ultimate accountability for ensuring the provision of high quality, safe and effective services within NHFT. The Chief Executive sits on the Trust Board and ensures there are effective and adequately resourced arrangements for Infection prevention and control within the trust. Director of Infection Prevention and Control Oversees local control of infection prevention and control policies/guidance, their implementation and that the effectiveness is monitored and reviewed as necessary. Reports directly to the Trust Board/Chief Executive and a member of The Trust s Governance Committee. Is responsible for the strategic co-ordination of the infection prevention and control activities within the directorates and for ensuring the decisions are implemented in accordance with this policy and associated guidelines. Page 3 of 20

4 Infection Prevention and Control Team (IPCT) The Infection Prevention Team has a primary responsibility for all aspects of surveillance, prevention and control of infection including: The production of the annual infection prevention and control work plan through adoption of the national evidence based practice. Ensuring the development of robust infection prevention and control policies and guidance. Ensures that systems are in place to reduce the risk of health care associated infections (HCAIs). Provide expert advice to staff, service users/patients and visitors in respect to healthcare associated infections. Provide comprehensive infection prevention and control training programme in conjunction with the Learning and Development Department. Collate and report HCAI data including MRSA and Clostridium Difficile to Infection Prevention and Control, Matrons and General Practitioners in accordance with the national and local requirements. Provide expert management of infection incidents/outbreaks. Provide expert advice on all matters relating to infection prevention and control to include new builds/refurbishment programmes Reviewing and responding appropriately to adverse incidents or near misses relating to infection prevention and control and works closely with the Occupational Health Department. Managers/Clinical Leads All managers/clinical leads have a responsibility to: Ensure that all staff are aware of this policy and have received relevant induction/training Ensure staff have access to infection prevention and control guidance, highlight staff training needs Ensure that infection control is embedded in all areas of their service delivery Identify areas for audit and risk assessment Ensure that local business plans includes objectives which make a contribution to achieving national targets associated with Health Care Associated Infections Ensure that there are adequate arrangements for infection prevention and control in their area of responsibility that risks are assessed, actions monitored and improvements implemented. Employees All employees have a responsibility to: Abide by this policy and any decisions arising from the implementation of it. Any decision to deviate from this policy must be fully documented with the associated rationale stated Adhere to current policy and guidance for evidence based practice in the prevention and control of infection Seek appropriate guidance/advice if unsure of action to take Report any concerns/difficulties in relation to implementing this policy and associated guidance to their line manager Report any adverse incidents in accordance with Trust policy (DATIX reporting) Page 4 of 20

5 Attend mandatory training as identified within the organisation s Mandatory Training Matrix and detailed within this policy. Support for patients All policies and guidance will be publically available on the website. These provide information regarding general principles pertaining to infection prevention and control and the systems in place to address these. Policy detail Standard precautions are basic infection prevention and control principles that should underpin safe practice, in order to reduce the risk of infection to patients and staff. Standard precautions should be used routinely to prevent forward transmission of micro-organisms to other patients, staff and visitors. Standard precautions are applied during working practices to protect service users, family, staff and visitors from infection. All blood and body fluids are capable of transmitting infection; standard precautions are the basic minimum standard of hygiene to be applied throughout all contact with blood and body fluids from any source. It is the basis for controlling the spread of infection via blood and body fluids within clinical practice. Body fluids include: Cerebrospinal fluid synovial fluid semen vaginal fluids peritoneal fluid pleural fluid amniotic fluid blood faeces/urine/vomit breast milk Infections can complicate healthcare in any setting, therefore settings in which patients can acquire infections is diverse (Winning Ways, DH 2004). Everyone involved in providing care must be educated about standard precautions and trained in hand hygiene, the use of protective equipment and disposal of sharps (Nice 2012). Page 5 of 20

6 Standard precautions focus on providing evidence-based recommendations for the prevention of healthcare associated infections in general care settings (Epic3 guidelines, 2014). They are precautions that should be applied by all healthcare practitioners to all patients at all times. In addition, staff should be familiar with the infection prevention and control policies/guidance for safe handling of clinical waste; laundry; body fluid spillage; packaging and handling of laboratory specimens; decontamination of equipment and the prevention and management of exposure to blood-borne viruses. Patients and their carers should be given appropriate advice on the above for their safety and the safety of others who may be affected by their actions. Hand Hygiene (Also refer to the Hand Hygiene Procedure) Transmission of pathogens on the hands of healthcare workers is the most common cause of cross infection, occurring directly from patient contact or indirectly via contact with the environment (Epic3 guidelines, 2014). Hence patients should be taught the importance of good hand hygiene. Hand washing is one of the single most important procedures in the control of infection. Good hand hygiene should be undertaken by staff, service users and visitors. Liquid or foam soap is preferable to bar soap as bar soap can harbour micro-organisms. In health and social care settings, liquid & foam soap should be wall mounted with a single use cartridge or bottle. To prevent contamination of liquid soap, dispensers should not be refilled/topped up. Hands must be washed before and after contact with a service user and their surroundings and before and after all clinical procedures. Hands must be wet under warm running water, apply enough liquid soap to cover all hand surfaces and wash all areas of the hands thoroughly, rinse well and dry using disposable paper towels. Staff in care home settings should have access to liquid soap and paper towels in each service user s room. Antibacterial solutions are not recommended for routine hand washing as they dry the skin which can cause damage. They are recommended for use prior to an invasive procedure, e.g., minor surgery. All cuts and abrasions should be covered with a waterproof dressing. Staff should be bare below the elbows (please refer to hand hygiene guidance). Lesions on the hand that may be infected must be reported to the person in charge or, where available, an occupational health department. Alcohol handrub Alcohol handrubs & hand sanitizers are of particular value where hand washing facilities are limited or not available. They should be applied to dry, visibly clean hands. These products are only effective if hands are physically clean. It is important to wash hands which are visibly contaminated prior to its application. Alcohol handrub & hand sanitizers should not be used when dealing with a service user with norovirus (viral gastroenteritis) or clostridium difficile as it is not effective. Therefore, hand washing with liquid or foam soap and warm water is vital when dealing with any service user known to have had diarrhoea diarrhea within the last 48 hours. Page 6 of 20

7 Visitors should be encouraged to use alcohol handrub or hand sanitizers when entering and leaving all health and social care settings. Personal Protective Equipment (PPE) Health and safety statutory requirements explicitly state that all employees must have access to supplies of personal protective equipment (PPE) and materials in order to protect from injury and as far as possible, from the risk of infection while at work. All PPE should comply with the European Community (EC) directive on design, certification and testing of PPE, and carry the (CE) mark. It must comply with Health and Safety legislation. PPE is protective clothing and is an essential element of healthcare and includes the following:- Gloves Disposable plastic aprons Gloves Masks Eye protection If contact with blood and/or body fluids, non-intact skin or mucous membranes, is anticipated or the service user has a known infection, disposable gloves should be worn that are appropriate for the task. Clinical gloves must be powder-free and can be latex, nitrile or vinyl material. Glove selection (please refer to the glove selection guide in the hand hygiene guidance) should be based on risk assessment of: the nature of the task the risk of contamination barrier efficacy of gloves. Gloves must comply with British and en standards and be CE marked. Latex gloves are made from natural rubber and due to their elasticity provide a better fit. They have resistance to puncture and resealing properties which make them the glove of choice when handling sharps, and when dealing with blood and blood stained body fluids. Latex gloves can cause skin sensitivity. Nitrile gloves are a synthetic alternative to latex gloves. They are suitable to be worn when in contact with blood and blood stained body fluids and if a service user or member of staff is latex sensitive. Vinyl gloves are looser fitting than nitrile or latex gloves, are less durable for procedures involving twisting and more likely to tear. They are not recommended for contact with blood and blood stained body fluids. Therefore, they should only be worn when there is no risk of exposure to blood or blood stained body fluids and if tasks are short and non-manipulative. They are not associated with skin irritation. Polythene gloves are not recommended for clinical use. Gloves should be discarded after each procedure/care activity. The re-use of gloves is not recommended for the following reasons: Page 7 of 20

8 glove integrity can be damaged if in contact with substances such as isopropanol, ethanol, oils and disinfectants many gloves will develop micro-punctures very quickly and will no longer perform their barrier function there is a risk of transmission of infection washing of gloved hands or using an alcohol handrub on gloves is considered unsafe practice. All used gloves should be disposed of as clinical waste. Aprons Disposable aprons are impermeable to bacteria and water and protect the areas of maximum potential contamination on the front of the body. A disposable apron should be worn whenever body fluids or other source of contamination is likely to soil the front of the uniform or clothing, especially when: undertaking an aseptic non-touch technique assisting bathing a service user dealing with incontinent service users assisting service users with the use of a commode Emptying catheter drainage bags making beds decontaminating equipment. A disposable apron should be removed and disposed of after each task. Never wear an apron for a dirty task and then move onto a clean task without changing it. Hand hygiene should be performed after removing the apron. Colour coding of aprons white aprons for clinical duties green aprons for food handling/serving food. It is recommended that for cleaning activities, aprons worn should be in line with the national colour coding scheme for cleaning materials and equipment. Masks A surgical mask should be worn to protect staff when there is a risk of blood, body fluids, secretions or excretions splashing on to the face. Surgical masks should: Page 8 of 20

9 cover both the nose and mouth and not be allowed to dangle around the neck after use not be touched once put on Be changed when they become moist Be worn once and discarded as infectious waste. Hand hygiene must be performed after disposal. To protect staff when there is a risk of airborne transmission of infection: A disposable respirator providing a high protection factor should be used for this purpose, i.e., FFP3 disposable respirator. Examples of appropriate use are during aerosol generating/cough inducing procedures on service users with open pulmonary TB, pandemic influenza or during close contact with a service user who has MDRTB. The fit of the respiratory masks is critically important and every user should have been fit tested and trained in the use of the respirator. Additionally, a seal check should be carried out each time a respirator is worn. Eye protection If there is a risk of splashing of blood and/or body fluids to the face, safety spectacles or a visor should be worn to protect the eyes. Normal prescription glasses do not provide adequate protection and additional protection is required when splashing is anticipated. Non-disposable eye protection should be decontaminated appropriately following each use. Spillage of blood and blood stained body fluids All must be dealt with promptly. Eye protection should be worn if there is a risk of splashing into eyes nose or mouth. Please see Appendix 2. When dealing with a spillage on a carpet, the use of detergent and warm water alone is advised to avoid bleaching with the hypochlorite. For urine spills, ensure all urine is removed before using a hypochlorite to prevent harmful fumes caused by mixing hypochlorite and urine. Safe Handling and Disposal of Sharps (see Management of Sharps Procedure) Some procedures have a higher risk of causing a sharps injury. The main risks associated with used sharps are the transmissions of viruses such as Hepatitis B, Hepatitis C and HIV. It is the responsibility of the user to dispose of sharps safely into sharps containers that comply with UN3921 and BS9320 standard. Needles must not be re-sheathed unless an approved device for re-sheathing of needles is available, syringes and needles should be discarded as one unit. Sharps should be disposed of at the point of use. Page 9 of 20

10 Health care employers, their contractors and employees have legal obligations under the health and safety (sharp instruments in healthcare) regulations 2013 (the sharps regulations). All employers are required to ensure that risks from sharps injuries are adequately assessed and appropriate control measures are in place. Where it is not practicable to avoid using sharps, safer sharps incorporating protection mechanisms should be used. Do not overfill sharps containers In the event of a needlestick injury, local guidance must be followed Waste Segregation All health and social care workers are responsible for the safe management and disposal of waste. All contaminated waste in a health and social care setting must be correctly segregated and disposed of to prevent injury/ infection. Specimens All specimens are a potential infection risk therefore all specimens must: be collected in the correct container with the lid securely fastened, in a container which has not been contaminated on the label or outer surfaces by the contents care should be taken not to contaminate the outer receptacle clearly labelled with the correct service user s details be accompanied by a correctly labelled specimen form with the relevant clinical details given, including GP details and any antibiotic history Have a danger of infection sticker applied to the container and the form when required, i.e., known blood-borne virus, TB, CJD the specimen should be placed inside the specimen bag attached to the request form be transported in a rigid container to the relevant laboratory or GP practice. Collection of specimens After first washing hand SITE ACTION Nose Throat Prior to taking swabs from the nose, moisten with sterile saline. One swab should be rolled inside both nostrils. The patient should stick out their tongue whilst the swab is guided down the side of the throat to make contact with the tonsil, a tongue depressor may be required. Page 10 of 20

11 SITE ACTION Groin Eye swabs Wounds/skin lesions Catheter specimen of urine (CSU) 5-10 mls is required Mid stream specimen of urine (MSU) 5-10 mls is required Stool/faecal specimens High Vaginal Swabs Blood venous blood Indwelling devices One swab should be rolled along the area of skin on the inner part of the thighs closest to the genitalia. Moisten with sterile saline. The exudate from the eye can be swabbed to identify some bacteria but others need to be identified by conjunctival scrapings which should be taken in an eye clinic. If both eyes are to be swabbed a separate swab must be used for each eye. One swab should be rolled over the area. The wound may be irrigated with saline to remove surface debris before taking the swab. Large wounds; roll swab in a zigzag motion to include all wound surface. Wound swabs should ideally reach the laboratory on the day they are taken. However, they can be stored in a specimen fridge over night. Wound swabs must be collected using an appropriate transport medium e.g. Stewarts medium. Urine specimens must be taken from the sampling port using a sterile needle or syringe depending on type of catheter. Urine specimens must not be taken from the catheter bag, as misleading results will be obtained. The first few mls of urine should be discarded and the mid stream specimen collected into a sterile container. The value of cleaning the perineum prior to taking the specimen is questionable. Urine should ideally be examined in the laboratory within two hours. Otherwise, urine may be stored in the fridge for up to 24 hours. Bacteria will multiply at room temperature giving misleading results. 15mls of liquid or approximately the size of a walnut is sufficient. Stool specimens can be obtained from a bedpan containing urine. This does not affect results. Stools should be examined within twelve hours unless parasites are suspected when a warm fresh stool is required. Please refer to microbiology for further guidance Rectal swabs are only of value if they show the presence of faeces but stool specimens are preferred when ever possible. Do not overfill faecal bottles. A sterile vaginal speculum must be used in order to separate the vaginal walls, using a light source the swab is taken from as high in the vagina as possible. High vaginal swabs should reach the laboratory within four hours. Refer to venepuncture guidelines One swab to be rolled over the area of skin surrounding the device. Premoisten swab with sterile saline if necessary. Page 11 of 20

12 SITE ACTION Pus If pus is present, a sample obtained by aspiration with a syringe and placed into a sterile container will be the most informative. Loose debris on the wound should be removed, as this is likely to contain high levels of bacteria, which are not representative of the infective organism. If the wound is dry, moisturising the swab with sterile normal saline makes it more absorbent and increases the survival of bacteria prior to culture. A zig zag and rolling action over the wounds surface will take up the bacteria on to the swab. This should then be immediately placed into the tube, labelled and sent to the laboratory as soon as possible. The specimen transport carrier must be secure and conform to guidelines set out in the health and safety at work act (1974), the carriage of dangerous goods and use of transportable pressure equipment (2005) and the department of health transport of infectious substances best practice guidance for microbiology laboratories (2007). It is illegal to send contaminated items through the post. Specimen containers Any decision to change the type of containers purchased or used should not be made without first discussing with the local laboratory and the infection control team. The individual sending the specimen must ensure that the container used is appropriate, is securely closed and not externally contaminated. Labelling Every specimen container and request form must describe the nature of the specimen, source, and full patient information to allow the laboratory staff to identify the source quickly in the event of the specimen and form becoming separated. All specimens must be placed in a specimen bag with the request form in a separate pocket. An additional 'Danger of Infection' must be attached to specimens and request forms for known or suspected high risk pathogens. If staff do not have access to such labels then the form and specimen must be clearly identified as high risk (staff may wish to write in red or use a highlighter pen) See below. High risk biohazard specimens Specimens containing or suspected of containing high risk micro-organisms require handling and processing differently in the laboratory in order to protect laboratory staff and reduce the risk of cross infection. All such specimens and the request forms must have a biohazard sticker attached. Various stickers are available but they must be yellow in colour and state biohazard. High risk micro-organisms include: Page 12 of 20

13 Category 3 Category 4 Human Immuno-Deficiency Virus (HIV) Viral haemorrhagic fevers Hepatitis B (HBV) Rabies Hepatitis C (HCV) Anthrax etc. Tuberculosis (TB) Prions Hepatitis E E-Coli 0157 Salmonella Typhimurium NB: Swabs for MRSA carriage are not high risk. Storage of specimens Any fridge that is used for the storage of specimens MUST NOT be used for the storage of any food items or drugs including vaccines. The fridge should have a min/max thermometer and be regularly cleaned and serviced. Sputum should be sent to the laboratory immediately as respiratory pathogens will not survive for prolonged periods. Do not leave specimens, including sputum, over the weekend or bank holidays. Transport of specimens Under the Health and Safety at work act (1974) all staff have an obligation to protect themselves and others e.g. The public from inadvertent contamination from hazardous substances All specimens must be placed in a specimen bag with the request form in a separate pocket. Staff should be aware of the Trusts policy. All specimens should be placed in a designated secure collection area until ready for collection. Specimens to be transported to the GP Practice or hospital site Specimens to be transported to the GP Practice or hospital site from a patient's home will be bagged as usual and then placed in a designated secure rigid, robust and leak proof container that has a handle and a tight fitting lid. This container should be cleaned and disinfected weekly and after any spillages have occurred with hot water and detergent. Larger specimens such as 24-hour urine collections should be placed in clear plastic sacks, which are tied at the neck. The request form should be attached to the outside of the bag; DO NOT use pins or staples to attach the form to the bag. Specimens to be sent by post to specialist laboratories must be sent to the Microbiology Laboratory first, who will ensure they are sent in packaging which conforms to the current transportation of dangerous goods regulations. Specimens must not be sent through Royal Mail post under any circumstances unless the packaging conforms to current regulations. (U N Regulations in effect from Jan 2005) Management of Used Linen (see management of linen Procedure) All staff have an obligation under the Health and Safety at Work Act (1974) to reduce the possible risk of cross infection to all staff handling and/or laundering used linen. Page 13 of 20

14 Staff must take reasonable steps to reduce the possible risk of cross infection to patients and staff from used and infected linen, by using single-use products, such as paper roll for examination couches. Where a linen contract exists, local guidance applies All linen should be appropriately segregated and bagged for transport to the laundry facility. Used, soiled and fouled linen Used, soiled and fouled linen should be placed in a white bag. Soiled and fouled items should first be placed into a water soluble (red alginate) bag sealed/tied and then either placed in: a white fabric or plastic laundry bag in line with NHFT plastic bag requirement in a mental health environment for transport to the laundry. Contents should be emptied into the washing machine followed by the fabric laundry bag; or plastic bag dispose of as offensive waste. Infected linen Infected linen should be placed in a red water soluble (alginate) bag and should either be placed in: O a white fabric or plastic laundry bag in line with NHFT plastic bag requirement in a mental health environment for transport to the laundry. Contents should be emptied into the washing machine followed by the fabric laundry bag; or plastic bag dispose of as infectious waste. O the outer bag should be labelled infectious linen When handling soiled, fouled and infected linen, disposable gloves and apron should be worn. In a health and social care setting, commercial washing machines and tumble driers should be used to ensure the correct temperature for thermal disinfection is achieved. Washing processes should have a disinfection cycle in which the temperature in the load is maintained at 65 c for not less than 10 minutes or 71 c for not less than 3 minutes. Decontamination of re-usable equipment (see Decontamination Policy). All re-usable equipment should be decontaminated appropriately. To reduce the potential risk of cross infection it is essential that re-usable equipment/devices are effectively cleaned and decontaminated between each patient use. Any equipment/medical device that has been designated by the manufacturers, as single use must be used as such. A single use device must only be used on an individual patient during a single procedure and then discarded. Page 14 of 20

15 Single use devices must not be reprocessed (cleaned and used again) for use on another patient or for another procedure on the same patient. All single use devices must be disposed of after a single use. All clinical stock must be checked weekly to ensure that it is in date and rotated for use. Items sent for repair/investigation, must be accompanied by declaration of contamination status certificate (please refer to the decontamination, cleaning and disinfection guidance). Maintenance of a clean clinical environment (see Cleaning & Disinfection Procedure) The healthcare environment is a secondary reservoir for organisms with the potential for infecting patients. High standards of cleanliness that promotes regular cleaning will remove dust, soil and micro-organisms and help reduce the risk of cross infection. All staff should have knowledge and understanding of the importance of thorough cleaning. Training requirements associated with this Policy Mandatory Training Standard Precautions for the prevention and control of infections for everyday practice is included in the entire learning package for infection prevention & control including induction and annual mandatory updates for clinical staff, e-learning and workbook. Specific Training not covered by Mandatory Training Bespoke training sessions based on an individual s training needs as defined within their annual appraisal or job description. How this Policy will be monitored for compliance and effectiveness The table below outlines the Trusts monitoring arrangements for this document. The Trust reserves the right to commission additional work or change the monitoring arrangements to meet organisational needs. Aspect of compliance or effectiveness being monitored DUTIES Standard Precautions Method of monitoring Individual responsible for the monitoring Monitoring frequency Group or committee who receive the findings or report TO BE ADDRESSED BY THE MONITORING ACTIVITIES BELOW. In date Managers, Annually Infection policies and team leads Prevention Group or committee or individual responsible for completing any actions IP&CT Page 15 of 20

16 Policy guidelines. Policies and Guidelines Induction Mandatory training, and Infection Prevention & Control team Monthly Quarterly and Control Assurance Group Awareness of the importance of infection prevention and control assurance within Trust Infection Prevention and Control Mandatory training Monthly audit for inpatient services, quarterly audit for community services, biannual audit for physiotherap y & other non-invasive therapy services. Managers, team leads and Infection Prevention & Control team Monthly Infection Prevention and Control Assurance Group Managers Learning & Development Department Training will be monitored in line with the Statutory and Mandatory Training Policy. WHERE A LACK OF COMPLIANCE IS FOUND, THE IDENTIFIED GROUP, COMMITTEE OR INDIVIDUAL WILL IDENTIFY REQUIRED ACTIONS, ALLOCATE RESPONSIBLE LEADS, TARGET COMPLETION DATES AND ENSURE AN ASSURANCE REPORT IS REPRESENTED SHOWING HOW ANY GAPS HAVE BEEN ADDRESSED. For further information Please contact the Head of Infection Prevention and Control, TB, Tissue Viability and Pressure Ulcer Prevention. Equality considerations The author has considered the needs of the protected characteristics in relation to the operation of this policy and protocol to align with the outcomes with IP&C Assurance Framework. We have identified that ensuring that communication reaches all vulnerable groups. The service has been designed to ensure communication relevant to any healthcare associated infection reaches all Page 16 of 20

17 sections of the community. This includes taking into consideration communication barriers relating to language or specific needs to reach the whole population. The Infection Prevention & Control team work closely with multi agency groups and community partners where appropriate we will undertake engagement and outreach activity with targeted action to relevant groups to follow NHS Improvements communication framework. Some groups are particularly vulnerable in relation to their protected characteristics, e.g. age, ethnic minority communities and disability and where we identify that, the expectation is that staff will meet the needs appropriately. Reference Guide H.P. Loveday, J.A. Wilson, R.J. Pratt, M. Golsorkhi, A. Tingle, A. Bak, J. Browne, J. Prieto, M. Wilcox (2014) epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England; Journal of Hospital Infection 86S1 (2014) S1 S70 Department of Health (2008) The Health Act: Code of Practice for the Prevention and Control of Health Care Associated Infections London: DH Publications (2015). Department of Health (2007) Essential Steps to Safe, Clean Care. London DH publication Winning Ways Working together to reduce Healthcare Associated Infections in England, Department of Health; 2004 National Institute for Health and Clinical Excellence (NICE). Prevention and control of healthcareassociated infections in primary and community care; March Department of health (2013) choice framework for local policy and procedures (cfpp) decontamination of linen for health and social care: management and provision Department of health (2013) choice framework for local policy and procedures (cfpp) decontamination of linen for health and social care: social care Department of health (2007) transport of infectious substances best practice guidance for microbiology laboratories Document control details Author: Head of Clinical Support Unit and Lead Nurse Pressure Ulcer Prevention Approved by and date: Trust Policy Board, September 2017 Any other linked Policies: ICP000 - Infection Prevention and Control Assurance Framework ICP001 - Hand Hygiene procedure ICPr004 - Isolation procedure ICPr005 - Sharps management procedure ICP004 - Decontamination Policy HSC020 - Waste Management Policy Policy number: ICP002 Version control: Version 3 Page 17 of 20

18 Version No. Date Ratified/ Amended Date of Implementation Next Review Date Reason for Change (eg. full rewrite, amendment to reflect new legislation, updated flowchart, minor amendments, etc.) New governance of trust policies template Policy review Page 18 of 20

19 Appendix 1 Putting on and Taking off PPE Page 19 of 20

20 Appendix 2 How to use a Spill Kit Page 20 of 20