Preventing Infection Workbook

Guidance for staff providing Care at Home Preventing Infection Workbook Guidance for staff providing Care at Home Name Job Title 1

Section 5: Content Section 4: Specific infections Section 3: Key topics Section 2: Standard precautions Section 1: Guidance for staff providing Care at Home Contents Page 1. Introduction 4 Tick when completed 2. Infection prevention and control 5 3. Standard precautions 10 4. Hand hygiene 11 5. Personal protective equipment 17 6. Sharps management 21 7. Blood and body fluids 25 8. Waste management 28 9. Laundry 30 10. Decontamination of equipment 32 11. Cleaning the environment 36 12. Personal health and hygiene 38 13. Specimen collection 40 14. Urinary catheter care 42 15. Viral gastroenteritis/norovirus 46 16. Clostridium difficile 50 17. MRSA 55 18. MRGNB 59 19. CPE 61 Commentary 65 Key references 66 Certificate of completion 67 3

Preventing Infection Workbook 1. Introduction 1. Introduction We are a community NHS Infection Prevention and Control (IPC) team based in North Yorkshire. Our aim is to support staff who provide care at home by ensuring that guidance and best practice in infection prevention and control is available in this Workbook. It is evidence-based, includes national guidance and complements a range of educational infection prevention and control resources which can be viewed at: www.infectionpreventioncontrol.co.uk This Workbook is suitable for a wide range of staff providing care at home, such as, domiciliary and rehabilitation teams, who undertake personal care or assist with daily living activities. Completion helps your organisation demonstrate compliance with the Health and Social Care Act 2008 and Care Quality Commission registration requirements in relation to infection prevention and control training. By applying the principles within the Workbook you will demonstrate commitment to high quality care and patient safety. The Francis Report 2013 states It is unacceptable for a patient to be injured by contracting certain types of infection as a result of the failure to apply methods of hygiene and infection control. The Workbook has been designed to be undertaken in stages. This will allow you to complete the Test your knowledge questions before moving on to the next section. On completion, your manager will check that you have achieved 100% competency in your infection prevention and control knowledge and then sign the Certificate of completion. You should keep the Workbook as evidence of learning and as an on-going reference guide to provide you with easily accessible advice. Dr Jenny Child Director of Infection Prevention and Control/ Consultant Microbiologist Harrogate and District NHS Foundation Trust 4

Guidance for staff providing Care at Home 2. Infection prevention and control The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance (Department of Health, July 2015), states that, Good infection prevention (including cleanliness) is essential to ensure that people who use health and social care services receive safe and effective care. Infection prevention and control is a key priority for the Department of Health, reinforced with the standards set out in the Health and Social Care Act 2008 and the Care Quality Commission (CQC) registration requirements. Infection prevention and control spans the five key questions the CQC will be asking about your service: Is it safe? Is it effective? Is it caring? Is it responsive to people s needs? Is it well-led? An infection occurs when micro-organisms (germs/bugs) enter the body and cause damage. These micro-organisms can come from a variety of sources and often take advantage of a route into the body provided by a wound or an invasive medical device, e.g., urinary catheter. Some infections can reach the bloodstream. When this occurs it is known as a bacteraemia, which can cause serious or life threatening infection and can result in death. Infection prevention and control means doing everything possible to prevent infection from developing and spreading to others. Understanding how infections occur and how different micro-organisms spread, such as bacteria and viruses, is essential in preventing infection. 5 2. Infection prevention and control

Preventing Infection Workbook The chain of infection 2. Infection prevention and control The spread of harmful microorganisms to a person is known as the chain of infection which is made up of six links. Each link represents one of the six factors required to spread infection. Each link of the chain must be present for an infection to occur. Breaking the chain will stop the infection spreading, this requires the removal of one of the six links. Good infection prevention and control practice (standard precautions) applied at all times and in all settings will break a link in the chain. Bacteria or virus Source Exit Route Entry People at risk Entry People at risk Bacteria or virus Chain of infection Route Source Exit Micro-organisms (bacteria, viruses), e.g., Clostridium difficile, MRSA, Norovirus. Where the micro-organisms are, e.g., people, animals, food, contaminated equipment or surfaces. The way in which micro-organisms leave the body, e.g., coughing, diarrhoea, blood, wound discharge. The way in which micro-organisms are transmitted, e.g., hands, equipment, airborne, injection, ingestion (eating). The way in which micro-organisms enter the body, e.g., mouth, nose, urinary tract, exposed wounds, non-intact skin, mucous membranes, needlestick injury. A person s risk to developing an infection is determined by their age, health, level of immunity, invasive devices and any medical interventions. 8

Preventing Infection Workbook 3. Standard precautions All care staff in all situations involving the care of service users or contact with their environment must use infection prevention and control standard precautions. 3. Standard precautions There are seven control measures known as standard precautions (see table below). These underpin routine safe practice and break the chain of infection which in turn protects service users, visitors and staff. There is often no way of knowing who is infected, so by applying standard precautions to all people and at all times, best practice becomes second nature and the risks of infection are minimised. In most cases, without a laboratory test, it is impossible to tell who has or is carrying an infection. Since every person is a potential infection risk, it is essential that all staff apply safe systems of working at every opportunity. Safe working practices take the guesswork out of protecting yourself and others as you provide care. Standard precautions 7 Hand hygiene Personal protective equipment Sharps management Blood and body fluids Waste management Laundry Decontamination of equipment 10

Resident Transient Guidance for staff providing Care at Home 4. Hand hygiene Hand hygiene is the process of physically removing dirt, blood or body fluids and the removal of micro-organisms from the hands. Evidence and national guidance identifies that effective hand hygiene results in significant reduction in the carriage of harmful micro-organisms on the hands. Effective hand hygiene reduces the number of healthcare associated infections (HCAIs) leading to a reduction in morbidity (disease) and mortality (death) of service users. Hand hygiene is the single most important way to prevent the spread of infection. Hands may look visibly clean, but microorganisms are always present, some harmful, some not. Hands may become contaminated by direct contact with a service user, handling equipment and contact with the general environment. Removal of transient micro-organisms is the most important factor in preventing them from being transferred to others. Removal of resident micro-organisms is only required before surgery and invasive procedures, it is not required by carers. There are two categories of micro-organisms present on the skin of the hands Transient bacteria are found on the surface of the skin. They are called transient as they do not routinely live on the hands. They are transferred to hands after contact with people or the environment and are easily removed by routine handwashing with liquid soap and warm running water. Resident bacteria are found on the hands in the deep layers and crevices and live on the skin of all people. They play an important role in protecting the skin from harmful bacteria and are not easily removed by routine handwashing with liquid soap and warm running water. 11 4. Hand hygiene (Standard precaution)

5. Personal protective equipment (Standard precaution) Preventing Infection Workbook Note To minimise the risk of cross/self-contamination, gloves, which are potentially the most contaminated item, should always be removed first, followed by the apron and then eye protection and mask. Gloves are not a substitute for handwashing. All PPE should be disposed of as soon as the activity is completed and as per local policy. Gloves are not required to be worn when serving plated food, but remember, good hand hygiene is essential. Remember Alcohol handrub should not be applied to gloves as it may affect the integrity of the gloves. Protect yourself and service users by wearing the correct personal protective equipment. Test your knowledge Please tick the correct answer 20 True False 1. Alcohol handrub can be applied to gloved hands. 2. A new disposable apron should be worn for each new task. 3. Before putting on and after removing gloves, hands must be washed. 4. Gloves should be removed before an apron.

Guidance for staff providing Care at Home In the event of a sharps or inoculation injury 1. Encourage bleeding of the wound by squeezing under running water, this will help to remove any viruses. Do not suck the wound. 2. Wash the wound with liquid soap and warm running water and dry. 3. Cover the wound with a waterproof dressing. 4. Report the injury to your manager immediately. 5. Immediately contact your GP. During out of normal office hours, attend the nearest Accident and Emergency (A&E) department. 6. If you have had a needlestick/sharps injury from a sharp instrument which has been used on a service user (source), the GP in charge of their care may take a blood sample from the service user to test for hepatitis B, C and HIV (following counselling and agreement of the service user). 7. At the A&E department or GP surgery: a blood sample will be taken from you to check your hepatitis B vaccination/antibody levels and you will be offered immunoglobulin if they are low. The blood sample will be stored until results are available from the service user s blood sample, if taken if the person (source) is known or suspected to be HIV positive, you will be offered Post Exposure HIV Prophylaxis (PEP) treatment. This should ideally commence within 1 hour of the injury, but can be given up to 2 weeks following the injury PEP treatment is only available from A&E departments. 23 6. Sharps management (Standard precaution)

Guidance for staff providing Care at Home Note *Chlorine-based disinfectants, such as household bleach, should not be used on soft furnishings, untreated wood and carpets as it will cause whitening/bleaching. Therefore, only detergent and warm water, a carpet shampoo machine or steam cleaner should be used. Splashes of blood or body fluids to the eyes or mouth must be treated as potential exposure to a blood-borne virus. Rinse eyes or mouth with copious amounts of water and then follow steps 4 to 7 on page 23. Personal protective equipment should always be worn when dealing with blood and/or body fluid spillages. Always add household bleach to cold water. If hot water is used, it breaks down the active ingredient of bleach, making the solution ineffective (meaning the bleach does not work). Test your knowledge Please tick the correct answer True False 1. It is not necessary to wear personal protective equipment when dealing with blood spillages. 27 2. The area should be ventilated when using a chlorine-based disinfectant solution. 3. A chlorine-based disinfectant solution can be placed directly on urine. 4. Splashes of body fluids to the eyes should be rinsed with copious amounts of water. 7. Blood and body fluids (Standard precaution)

Preventing Infection Workbook 8. Waste management All staff are responsible for the safe management and disposal of waste. Waste is potentially hazardous and, if not disposed of correctly, can result in injury or infection. 8. Waste management (Standard precaution) Good waste management is important to ensure: Reduction of health and safety risks from waste. Protection of the environment. Compliance with environmental legislation. Any waste that is generated during the care of a service user, e.g., catheter bags, continence pads, personal protective equipment (PPE), should be disposed of as per local policy. Waste will usually be disposed of as household waste, unless alternative arrangements are in place with the Local Authority. Disposal of waste Appropriate personal protective equipment should be worn when handling waste. All waste bags should be 2/3 full or less, this allows enough space for the bag to be tied securely. Avoid expelling air from a waste bag while leaning over it as harmful micro-organisms may be released into the air. Make sure all waste bags are securely tied using a suitable plastic tie or secure knot, as pictured. Waste should be securely bagged and disposed of as household waste. When handling tied waste bags, only hold by the neck of 28

10. Decontamination of equipment (Standard precaution) Preventing Infection Workbook Cleaning a commode Always use disposable cleaning cloths. 1. Wash hands thoroughly with liquid soap and warm running water. 3. Put on disposable gloves. 5. Remove the lid and clean the lid of the commode, topside first then underside. 7. Clean the seat frame, legs, and then foot pedals and wheels if there are any. 9. Remove apron and dispose of. 34 2. Put on disposable apron. 4. Starting from the top, clean the back rest and arms (remember to clean under the arms). 6. Remove the seat, if the design allows, and clean the top then underside. 8. Remove gloves (these should be removed before your apron) and dispose of. 10. Wash hands thoroughly with liquid soap and warm running water.

Preventing Infection Workbook 11. Cleaning the environment (Key topic) 11. Cleaning the environment Cleaning and disinfecting are different: cleaning with detergent and warm water removes dirt and reduces the number of germs to a safe level cleaning must be carried out before disinfection if disinfection needs to be performed disinfecting destroys most, but not all bacteria and also depends on the type of disinfectant used. What you need for cleaning Wear appropriate personal protective equipment. A general purpose detergent, e.g., washing up liquid, is suitable for cleaning most surfaces. Wash and leave mops and cloths to air dry after each use. Do not leave mops or cloths soaking overnight. Use separate cloths for cleaning kitchens and toilets/ bathrooms. Staff should wash their hands before putting on gloves. Re-usable domestic gloves should be worn for routine household duties, disposable gloves for cleaning toilets. Domestic gloves can be worn by other staff providing skin is intact and hands are washed before wearing them. Always wash domestic gloves before taking them off and then wash hands with liquid soap and warm running water. What you need for disinfecting The routine use of disinfectants for general home cleaning is unnecessary. A disinfectant such as household bleach may be required in some circumstances. For example, equipment soiled with body fluids, the area must first be cleaned and then be disinfected using 1,000 parts per million (ppm) household bleach (dilution of 1 in 100, e.g., 10ml of household bleach in 1 litre of cold water). 36

Preventing Infection Workbook 14. Urinary catheter care (Key topic) When detaching the used bag from the catheter, do not touch the end of the catheter. This will help prevent contamination and infection. When removing the protective cap from the new catheter bag tube, do not touch the end of the tube. This will help prevent contamination and infection. Place the used catheter bag in a plastic bag, tie the bag and dispose of as household waste. Remove disposable gloves and apron and wash hands. Always record the date when the catheter bag is changed. Overnight drainage bags If a person has a leg bag during the day, an additional larger linked drainage bag (night bag) should be used for overnight use. The night bag should be attached to the leg bag to keep the original system intact. Standard precautions must be applied. When attaching a night bag, always wash hands and wear disposable gloves and apron. Attach the night bag to a stand to ensure that the drainage tap is not touching the floor, to prevent contamination of the tap. When removing the protective cap from the new night bag tube, to prevent contamination and infection, do not touch the end before attaching it to the drainage tap on the leg bag. Remove disposable gloves and apron and wash hands. 44

15. Viral gastroenteritis/norovirus Preventing Infection Workbook 15. Viral gastroenteritis/norovirus Norovirus is the most common cause of viral gastroenteritis and between 600,000 and 1 million people in the UK are affected every year. Many people refer to it as gastric flu or winter vomiting. Viral gastroenteritis is highly infectious and can spread easily from person-to-person, therefore, it is important to use infection prevention and control precautions. What does viral gastroenteritis cause? Signs of viral gastroenteritis include: sudden onset of diarrhoea* and/or vomiting vomiting - can be projectile (forceful) nausea abdominal/stomach cramps headache and/or low-grade fever. Symptoms usually begin around 12-48 hours after being infected with the virus. (*Refer to page 53 for the definition of diarrhoea.) Illness is usually of a short duration and most people are better within 48 hours with no long-term effects. However, some people, especially the elderly and those with existing long-term illness, may have symptoms that last longer. Why does viral gastroenteritis cause outbreaks? Viral gastroenteritis often causes outbreaks because it is easily spread from person-toperson and without effective cleaning, the virus is able to survive in the environment for many days. Outbreaks tend to affect people in hospitals, schools, care homes, sheltered housing or where there is a large group of people. 46

16. Clostridium difficile Preventing Infection Workbook Standard precautions must be applied. Disposable gloves and apron should be worn when caring for a service user until they are symptom free for 48 hours and passed a formed stool. Gloves and apron should be changed after each activity is completed and hands washed with liquid soap and warm water after removal. Encourage the service user to drink fluids and ensure their fluid balance is monitored to prevent dehydration. Thorough handwashing is essential for staff using liquid soap and warm running water. Alcohol handrub does not kill spores and must not be used. Encourage service users to wash their hands after using the toilet and before meals. If unable to access hand washing facilities, moist hand wipes can be used. After an episode of diarrhoea, encourage service users to close the toilet seat lid before flushing the toilet to reduce possible spread and disinfect with household bleach. The service user should use a separate towel to dry their hands and this should not be used by other people. The towel should be washed daily. Alcohol wipes should not be used for cleaning and disinfection of equipment as they do not kill spores. Clean surfaces in toilets and bathrooms at least daily, with a household bleach, see page 36. Items such as hoists, frames and frequently used surfaces, e.g., tables, should be cleaned daily as above. Wash soiled clothing or bedding separately as soon as possible at the highest temperature advised on the label. The service user should have a shower or bath daily, as C. difficile spores may be on other areas of their body. Staff are not usually at risk of acquiring C. difficile infection. 52

17. MRSA Guidance for staff providing Care at Home Service user s in their own home can socialise in and outside of their home without restrictions. Any visitors to their home should be advised to wash their hands on leaving. If a service user has MRSA in a wound, it should be kept covered with a dressing. Linen and clothing should be washed in the service user s or communual washing machine at the highest temperature stated on the washing label. No special precautions are required for washing crockery or cutlery and they should be dealt with in the normal way, e.g., by washing with washing up liquid and warm water. When cleaning, e.g., surfaces in a service user s home, detergent and warm water are sufficient. Are staff at risk of MRSA? By applying standard precautions at all times the risk of spreading MRSA is reduced. MRSA is not usually a risk to healthy people including children and pregnant women. Research has shown that staff who do become colonised have usually acquired the bacteria through their work, but it is usually present for a short time only. Staff should ensure cuts and grazes are covered with a waterproof plaster. Report any skin conditions to your manager. Note Studies show MRSA colonisation may affect approximately 20% of service users in care home establishments. 57

19. CPE Preventing Infection Workbook Linen and clothing should be washed in the service user s or communual washing machine at the highest temperature stated on the washing label. Keep toilet and bathroom areas clean. Note There are a number of local initiatives across the country where service users found to be positive for CPE either colonised or infected, should have been given advice about CPE and a CPE card. The card should be shown to healthcare providers involved in their care. For further details visit www.infectionpreventioncontrol.co.uk. Remember Using standard precautions will minimise the spread of CPE and should be rigorously implemented, but no additional infection control precautions are required. Further advice will be given by your local Community Infection Prevention and Control (IPC) or Public Health England (PHE) team. Test your knowledge Please tick the correct answer True False 1. There are very few antibiotics for the treatment of CPE infections. 2. Hand washing is not necessary when dealing with a service user with CPE. 3. Colonisation with CPE is more common than infection. 4. Toilets should be cleaned with household bleach if a service user has diarrhoea. 64

Preventing Infection Workbook Written and produced by Community Infection Prevention and Control Harrogate and District NHS Foundation Trust Tel: 01423 557340 www.infectionpreventioncontrol.co.uk March 2016 Harrogate and District NHS Foundation Trust, Community Infection Prevention and Control 2016 68