Standard Precautions Policy for Infection Control Policy PH 07 Date June 2007
Document Management Title of document Standard Precautions Policy Type of document Policy PH 07 Description Target audience Standard precautions are the underpinning principles for routine safe practices. They are precautions that should be practised by all clinical staff without exception to limit the risk of potentially harmful organisms being transmitted to a patient, healthcare worker, visitor or the environment. All staff Author Department Directorate Infection Control Team Infection Control Public Health Approved by Governance Committee Date of approval 15.08.07 Version Number 1.1 Next review date Related documents Superseded documents June 2008. Document will be reviewed annually or earlier if necessary NICE Guidelines (2003) The Health Act 2006: Code of Practice for the prevention and control of health care associated infections Essential Steps to Safe Clean Care (2006) Standards for Better Health (2004) Winning Ways (2003) Essence of Care (2001) Infection Control Policy and Guidelines for Northampton Primary Care Trust (2005) Infection Control Policy and Guidelines for Northamptonshire Heartlands Primary Care Trust (2003) Infection Control Policy and Guidelines for Daventry and South Northants Primary Care Trust (2005) 2
Internal distribution External distribution Availability All staff Health Protection Agency Northampton General Hospital Kettering General Hospital All ratified policies, strategies, procedures and protocols are published on the Trust Intranet and Public Website. Contact details (of main contact for this document) Name: Infection Control Team Address: Nene House, Isebrook Hospital, Irthlingborough Road, Wellingborough, NN8 1LP Tel: 01536 494001 E-mail: una.willis@northants.nhs.uk andrea.may@northants.nhs.uk jenny.boyce@northants.nhs.uk lin.marlow@northants.nhs.uk 3
Contents Section Number Page Number 1.0 Introduction 5 2.0 Organisational responsibilities 5 3.0 Hand Hygiene 7 4.0 Use of Personal Proective Equipment 7 5.0 Safe Management and Disposal of Sharps 7 6.0 Safe Disposal of Clinical Waste 7 7.0 Cleaning and Decontamination of Reusable Equipment 8.0 Maintenance of a Clean Clinical Environment 8 8 9.0 Safe Management of Laundry 9 10.0 Safe Management of Body Fluids 9 11.0 Training 9 12.0 Audit and Monitoring 9 13.0 References 10 Appendix 1 11 4
1.0 Introduction 1.1 Infection can complicate healthcare in any setting and the growth of treatment in primary care and community facilities means that the settings in which patients can acquire such infections is now very diverse (Winning Ways 2004). 1.2 Everyone involved in providing care in the community should be educated about standard principles and trained in hand decontamination, the use of protective clothing and the safe disposal of sharps (NICE 2003). 1.3 Standard precautions are the underpinning principles for routine safe practices. They are precautions that should be practised by all clinical staff without exception to limit the risk of potentially harmful organisms being transmitted to a patient, healthcare worker, visitor or the environment. 1.4 They are procedures undertaken to minimise the handling of blood and body fluids and are linked to the procedures undertaken, rather than the patient. 1.5 Standard precautions focus on providing evidence-based recommendations for the prevention of healthcare associated infections in general care settings (Epic Guidelines, Department of Health 2001). They are precautions that should be applied by all healthcare practitioners to all patients at all times. 1.6 Standard precautions include: Hand Hygiene Use of personal protective equipment Safe management and disposal of sharps Safe disposal of clinical waste Cleaning and decontamination of re-usable equipment Maintenance of a clean clinical environment Safe management of laundry Safe management of body fluid spillages 2.0 Organisational responsibilities 2.1 Trust Board The Trust Board will ensure that the Trust s Policy is implemented. 5
2.2 The Chief Executive The Chief Executive will ensure that this Policy is implemented in all directorates and will ensure that the effectiveness of this Policy is continually reviewed. 2.3 Executive/Clinical Directors Executive and Clinical Directors have the responsibility for the coordination of Health and Safety activities within the directorate and for ensuring that decisions are implemented in accordance with this policy and associated guidelines. 2.4 Infection Control Committee The Infection Control Committee has a responsibility to ensure that this Policy allows the Trust to comply with advice and guidance from the Department of Health and other bodies. 2.5 The Infection Control Committee will: Develop and implement a Policy on Management of Infection Control. Review the Policy on receipt of a change in advice or guidance from the Department of Health and other bodies. These guidelines will be binding on employees under Health & Safety Legislation. 2.6 The Infection Control Team The Infection Control Team are responsible for providing advice in relation to infection control aspects of care delivery to patients. The Infection Control Team takes the key role in day-to-day infection control activities and serves as a specialist source of advice. They are an active members of the Infection Control Committee and for example, assists in drawing up infection control policies and participates in and initiates infection control audits. They also provide input in identification, prevention, monitoring and control of infection in the Trust and work with the Service leads and the Infection Control Link staff and others to improve surveillance and reporting of infections to strengthen the prevention and control of infection. The Infection Control Team are proactive in the provision of infection control education for all levels of staff and in particular the development of the Infection Control Link staff. 2.7 Managers and Supervisors Managers and supervisors have a responsibility to ensure that staff are aware of their responsibilities under this Policy and associated guidelines. Managers must inform new employees of their responsibilities under this Policy. In addition they must ensure that all employees within their area of responsibility comply with this Policy and associated guidelines. 6
2.8 Employees All employees have a responsibility to abide by this Policy and associated guidelines and any decisions arising from the implementation of them. This Policy is enforceable through Health and Safety Legislation and Trust disciplinary procedures. If employees are aware that the Policy or associated guidelines are not being complied with they must first take the issue to their line manager and if the problem is not resolved they must inform the Infection Control Team. 3.0 Hand Hygiene 3.1 Hand hygiene is the single most important factor in the prevention of cross-infection and remains the cornerstone of good infection control practices (see Hand Hygiene Policy). 4.0 Use of Personal Protective Equipment 4.1 Personal protective equipment (PPE) is used to protect both the patient and the healthcare worker from the potential risks of cross infection. Uniforms are not classed as PPE (see Personal Protective Equipment Policy). Personal protective equipment includes: Gloves Aprons Masks Goggles/visors/face masks Hats and footwear (in certain situations). 4.2 Healthcare workers should base their selection of PPE on an assessment of the risk of: Potential contact with blood or body fluids Transmission of pathogenic micro-organisms to the patient Contamination of the healthcare workers clothing and/or skin If performing an aerosol generating procedure PPE must be worn 4.3 The use of PPE may also be required for potential contact with hazardous chemicals and some pharmaceuticals. 5.0 Safe Management and Disposal of Sharps 5.1 Healthcare workers are exposed daily to many potential hazards during the course of their duty. Such hazards include those posed by sharps. The main hazards associated with used sharps are the transmissions of viruses such as Hepatitis B, Hepatitis C and HIV. 7
5.2 Some procedures have a higher risk of causing a sharps injury. To reduce the possible risk of sharps injury it is essential that staff use and dispose of sharps carefully and according to local guidelines. 6.0 Safe Disposal of Clinical Waste 6.1 Producers of waste have a duty of care to ensure the safe management of waste at all steps of handling and transportation until its final disposal. All those involved in the production and management of clinical waste must take all reasonable steps to prevent its escape from the point of production to the point of disposal. 6.2 All healthcare workers should ensure that they segregate and dispose of clinical waste in a safe manner and according to local guidelines. 6.3 Nationally, waste guidelines are currently under review. Further guidance to be published shortly. 7.0 Cleaning and Decontamination of Re-usable Equipment 7.1 Under the Health and Safety at Work Act (1974) all staff have a duty of care to their patients, themselves and other members of staff to possess appropriate knowledge of their role in the prevention and containment of infection control in their area of work. 7.2 To reduce the potential risk of cross infection it is essential that reusable equipment/devices are effectively cleaned and decontaminated between each patient use. 7.3 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. Single use devices must not be reprocessed (cleaned and used again) for use on another patient or for another procedure on the same patient. 7.4 All single use devices must be disposed of after a single use. 8.0 Maintenance of a Clean Clinical Environment 8.1 Research and investigation have consistently confirmed that the healthcare environment is a secondary reservoir for organisms with the potential for infecting patients (Infection Control in the Built Environment, NHS Estates 2002, Royal College of Nursing 2004, Infection Control Nurses Association 2003). 8.2 High standards of cleanliness that promotes regular cleaning will remove dust, soil and micro-organisms and help reduce the risk of cross infection (A Matron s Charter, DoH, 2004). 8
8.3 All staff should have knowledge and understanding of the importance of thorough cleaning. Hands can transfer potentially harmful microorganisms from contaminated surfaces/equipment to patients and/or other surfaces if they are not washed or decontaminated appropriately and effectively. 9.0 Safe Management of Laundry 9.1 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. 9.1 Staff must take reasonable steps to reduce the possible risk of cross infection to patients and staff from used and infected linen. Where possible staff should use single-use products such as paper roll for examination couches. 10.0 Safe Management of Body Fluids 10.1 In clinical areas it is the responsibility of the clinical staff to ensure that spillages of blood, vomit, urine, faeces and other body fluids are cleaned and decontaminated safely. The cleaning procedure may be delegated to domestic staff under supervision. It is vital that staff take all reasonable precautions to protect themselves and patients from the transmission of infection. 11.0 Training 11.1 Any infection control education and training, provided by NtPCT s Infection Control Nurses will reinforce the importance of effective hand hygiene in preventing the spread of infection while supporting good practice with research. Training needs for staff are regularly identified through the Primary Care Trusts training needs analysis. 11.2 Infection control is also a component of the organisations corporate induction and mandatory training programmes. Every member of staff has a responsibility to attend training and to maintain their knowledge and skills in infection control. 11.3 Staff that require further training or information should contact the infection control team at Nene House, Isebrook Hospital. 12.0 Audit and Monitoring 12.1 A fundamental principle of infection prevention and control is the creation and maintenance of environments and processes that ensure safety for patients, visitors and staff. A systematic approach to this has been developed through a comprehensive programme of audit. 9
These audits are undertaken either as a questionnaire by the Infection Control Team to the relevant clinical areas for completion by the team at a local level or the Infection Control Team visit the clinical areas and undertake an observational audit. 12.2 Standard precautions are a fundamental aspect of infection Control and are audited on a rolling programme based on the Infection Control Nurses Association audit tool. This audit can be used to: Determine whether or not staff are adhering to the policy. Help determine if staff require further education or training in the area covered by the policy. Help determine if a lack of resources is an obstacle to the correct implementation of the policy. Help determine if the policy contains recommendations, which need to be modified. 12.3 All audit reports and subsequent activity and outcomes are reported to the Infection Control Committee of the PCT. 13.0 REFERENCES Department of Health (2001) Epic Guidelines. Journal of Hospital Infection 47 (supplement): S3-S4 Department of Health (2004) A Matron s Charter: An Action Plan for Cleaner Hospitals Department of Health: Winning Ways Working together to reduce Healthcare Associated Infection in England (2004) Health and Safety at Work Act (1974) Infection Control Guidance in General Practice. Community Infection Control Nurses Association (2003). Leicestershire Control of Infection Guide for Hospitals and Secondary Care, 2005 National Audit Office (2000). The Management and Control of Hospital Acquired Infection in Acute NHS Trusts in England. London National Institute of Clinical Excellence (2003). Infection Control Prevention of healthcare-associated infection in primary and community care (No.1) Standard principles. NHS Estates (2002) Infection Control in the Built Environment. Royal College of Nursing (2004). Good practice in infection control Guidance fornursingstaff.london 10
Appendix 1 Policy Impact Assessment Screening Tool Name of Directorate: Public Health Date of Assessment: 28.06.07 Policy being assessed: Standard Precautions Policy Assessment Carried out by Jenny Boyce/Keren Salt Policy Title As Above Who is affected Statutory requirements Full Assessment Needed Yes / No Staff Patients Visitors Contractors Volunteers Carers Standards for Better Health (2004) Health Act (2006) NHSLA (2007) Yes Priority High / Medium / Low High 11
Policy Impact Assessment Full Assessment Tool Name of Directorate: Public Health Date of Assessment: 28.06.07 Policy being assessed: Standard Precautions Policy Assessment Carried out by : Jenny Boyce/Keren Salt 1. What consultation process will be undertaken? 2. Where will records of this consultation be kept? Infection Control Committee, Governance Committee, SHA, Electronically, Infection Control Team records 1. What existing monitoring arrangements are in place? 2. Are these sufficient? 3. Are any additional arrangements required 1. How will the results of the assessment be published? Certain aspects of the policy are audited annually. Yes as a rolling programme. If particular issues arise we will audit these. Via Infection Control Committee 12
Policy aims and outcomes Evidence for assessment Difference in Outcomes Assessing Impact Proposed action See section 1.1 1.2, 3.1 and section 6.0 Statutory requirements. Policies reviewed annually or sooner if national guidance changes. The policy is seen as a useful reference tool when managing instances of infection and understanding the role of standard precautions and when and why they are used in the management of infection. No adverse impact identified. Review as necessary. M:\Corp\Strategies, Policies, Procedures\PH 07 Standard Precautions Policy.doc Page 13 of 13