Standard Precautions Policy IC/277/10

BASINGSTOKE AND NORTH HAMPSHIRE NHS FOUNDATION TRUST Standard Precautions Policy IC/277/10 Supersedes: Standard Precautions Policy IC/277/07 Owner Name Linda Swanson Job Title Infection Control Nurse Final approval Name Infection Control Committee committee Date of meeting 23 July 2010 Divisional Governance Boards (list date of approval) Corporate & Support Services Elective Emergency Maternal & Child Health Other specialist committee approval Authoriser Name Dr Nicki Hutchinson Job title Signature Director Infection Prevention and Control Date of authorisation 24.08.10 Review date (maximum 3 years from July 2013 date of authorisation) Audience (tick all that apply) Trust staff NHS General public Standards Standards for Better Health The Health Act 2008 EPIC 2 2007 NHSLA Related policies Policy numbers and names Glove Policy IC 354/09 Isolation Policy IC/278/07 Protective Isolation Policy IC/201/07 Principles of Asepsis and Aseptic Technique IC/372/09 Hand Hygiene Policy IC/230/10 Last Offices Policy HS/375/10 Equality Impact Assessment Date completed by policy owner 17 th May 2010 Reviewed in accordance with The Health and Social Care Act 2008: Code of Practice for health and adult social care on the prevention and control of infections and related guidance as published 16 December 2009 1 of 10

Implementation Plan Summary of changes Actions needed and owners of actions The World Health Organisation (WHO) Five Moments for Hand Hygiene Action needed and owner of action All matrons and departmental heads will be provided with copies of the policy for their areas. All managers will receive a copy of the policy. All ward managers will ensure that each staff member reads and adheres to the standards required by this policy. The Infection Prevention and Control Team will provide education with regard to standard infection control practices. Health and Safety and Occupational Health will act as a resource for information, and support and consult with managers, the Infection Prevention and Control Team and health care workers regarding personal protective equipment. Roles and Responsibilities The Director of Nursing on behalf of the Chief Executive will ensure that the Divisional Directors take clinical ownership of the policy. The Divisional Directors on behalf of the Director of Nursing will ensure that all health care workers comply with this policy and that all health care workers attend mandatory infection prevention and control training. The Heads of Nursing/Midwifery and Modern Matrons on behalf of the Director of Nursing and the Divisional Directors will ensure that all health care workers comply with this policy and that all health care workers attend mandatory infection prevention and control training. The Infection Prevention and Control Team (IPCT) will act as a resource for information and support. They will provide education in relation to this policy which includes mandatory training. They will monitor the implementation of this policy via audit within clinical areas and be responsible for regularly reviewing and updating it. All Trust staff including Clinicians will comply with this policy and inform the Infection Prevention and Control Team about any issues or concerns relating to the standard precautions. All staff will attend mandatory Infection Prevention and Control annual training annually. 2 of 10

Table of Contents Page No 1. Purpose of Policy 4 2. Key Points 4 3. Background and History 4 4. Hands 5 4.1 The World Health Organisation s Five Moments of Hand Hygiene 6 5. Cuts and Breaks to Skin 6 6. When Should Personal Protective Equipment be Worn? 6 7. Sharps Management 7 8. Dealing with a Blood or Bodily Fluid Spillage 8 9. Disposal of Waste and Excreta 8 10. Linen 8 11. Hospital Environment Hygiene 8 12. Standard Precautions in Care of the Deceased 9 13. Evaluation of the Policy 9 14. References and Further Reading 10 3 of 10

1. Purpose of this policy The objectives of this policy are to ensure that all Trust staff are aware of and adhere to the standard precautions of infection prevention and control. It is not always possible to identify people who may have infection and may potentially spread infection to others. It is therefore essential that the blood and bodily fluids of all persons without exception should be treated as potentially infectious. It is also therefore essential that precautions to minimise exposure to, and prevent the unnecessary transmission of a wide variety of micro-organisms are followed at all times. These routine procedures are known as The Standard Precautions of Infection Control (CDC, 2007). These standards are the basic principles of infection prevention and control which should underpin practice at all times. 2. Key Points The blood and bodily fluids of all persons must be treated as potentially infectious Personal protective equipment (PPE) must be worn when dealing with blood or bodily fluids Use and dispose of sharps appropriately Disinfect bodily fluid spillages in a timely and safe manner. Dispose of waste and excreta carefully Ensure linen is handled safely Recognise that some patients may have specific infection control requirements in addition to the use of standard precautions, due to the nature of their infection (refer to Isolation Policy IC/278/07 and Protective Isolation Policy IC/201/07) 3. Background and History Universal Precautions were first recommended in 1985, by the Centers for Disease Control (CDC) in America, in response to the risk of transmission of HIV to health care workers from patients whose infection status was unknown. Initially they dealt only with bodily fluids capable of containing blood borne viruses. In the late 1980s the UK adopted universal precautions but they were expanded to include all routes of transmission and all body fluids/substances capable of containing pathogenic microorganisms, which could potentially lead to cross infection between patients. Standard Precautions combine the major components of universal precautions and Body Substance Isolation. The underlying principles of Standard Precautions are that the blood, bodily fluids, excretions (excluding sweat), secretions, non intact skin, and mucous membranes may contain transmissible infectious organisms (CDC, 2007). An assessment of the risk of exposure to any of the above is an important aspect in the selection and use of standard precautions (HSE, 2003). The application of Standard Precautions during patient care should be determined by the nature of the interaction and the extent of anticipated blood, body fluid, or pathogen exposure. Some interactions (e.g. performing venepuncture), may only require the use of 4 of 10

gloves, some other interactions (e.g. intubation) require the use of gloves, gown, and face shield or mask and goggles if necessary (CDC, 2007). Health care workers may face new and challenging circumstances in their practice. It is therefore crucial that education and training is provided by the IPCT on the principles and rationale for recommended practices. This will facilitate health care professionals towards appropriate decision making regarding the selection and use of Standard Precautions. An example of the importance of the use of Standard Precautions is intubation, especially under emergency circumstances when infectious agents may not be suspected but later are identified (e.g. SARS, Pandemic Influenza). Standard Precautions are also intended to protect patients by ensuring that healthcare personnel do not carry infectious agents to patients on their hands or via equipment used during patient care. 4. Hands Hand hygiene is most effective at the point of care (World Health Organisation, (WHO) 2009). Hands must be decontaminated before and after each and every episode of direct contact with the patient and/or the patient environment (World Health Organisation, 2009; National Patient Safety Agency, 2009). Hands that are visibly soiled with contaminated dirt or organic material, i.e. blood/body fluids must be washed immediately with liquid soap and warm water. Alcohol gel alone is ineffective at decontaminating visibly soiled hands and therefore should not be used in this instance. Hands may be decontaminated with an alcohol gel hand rub (unless visibly soiled) between caring for different patients and different activities a recommended maximum of 5 times before hands need to be washed with soap and warm water. ) See Hand Hygiene Policy IC/230/10. Hands should be decontaminated at the point of patient care and at various stages in that episode of care in accordance with the World Health Organisation s Five Moments for Hand Hygiene (WHO, 2009). See Hand Hygiene Policy IC/230/10. 5 of 10

4.1 The World Health Organisation s Five Moments for Hand Hygiene Your 5 moments for hand hygiene at the point of care* *Adapted from the WHO Alliance for Patient Safety 2006 5. Cuts and Breaks in Skin Any existing cuts or lesions should be covered with a waterproof dressing, paying particular attention to hands and forearms. Any staff with chronic skin lesions to hands or forearms, or persistent skin problems should avoid undertaking invasive procedures and seek advice from the Dermatology and Occupational Health Department. 6. When should Personal Protective Equipment (PPE) be worn? Selection of personal protective equipment should be based on an assessment of the risk of transmission of microorganisms to the patient, and the risk of contamination of the healthcare worker s clothing and skin by patients blood, bodily fluids, secretions or excretions (Pratt et al, 2007). Gloves must be worn for invasive procedures (to reduce the exposure of staff to blood bourne viruses) contact with sterile sites and non-intact skin or mucous membranes and all activities that have been assessed as carrying a risk of exposure to blood, body fluids, secretions or excretions. (Pratt et al, 2007). Please also refer to the Principles of Asepsis and Aseptic Technique (policy IC/372/09). Gloves are single use items. Where deemed necessary, they must be put on immediately before an episode of patient contact or treatment and removed as soon as the activity is completed. Gloves must be changed between caring for different patients and between different care and treatment for the same patient. 6 of 10

Gloves must be disposed of as clinical waste after every procedure/episode of care and hands decontaminated thoroughly immediately following the removal of the gloves. Neither powdered nor polythene gloves should be used for patient care activities. Most gloves used in BNHFT are latex free. This includes sterile gloves. Any staff member wishing to use latex gloves must first complete a risk assessment form available in the Glove Policy IC/354/09. Any sensitivity to natural rubber latex in patients, carers and healthcare staff must be documented. Nitrile gloves must be used for exposure to chemicals. This includes the giving of chemotherapy. The wearing of gloves does not negate the need to use decontaminate hands. Disposable plastic aprons should be worn where there is a risk of exposure of clothing to blood, body fluids, secretions and excretions or when coming into contact with a patient with a known infection who is being isolated (with the exception of sweat). Full body fluid repellent gowns must be worn where there is a risk of extensive splashing of blood, body fluids, secretions or excretions onto the skin or clothing of healthcare workers. Plastic aprons should be worn as single use items for one procedure or episode of patient care and then discarded and disposed of as clinical waste. Facemasks and eye protection (goggles, visors) must be worn where there is a risk of blood, body fluids, secretions or excretions splashing into the face and eyes. (e.g. suctioning of patients) Respiratory protection (e.g. a particulate filter mask) must be correctly fitted (e.g. fit tested) and should be worn when recommended for the care of patients with respiratory infections which are transmitted by airborne particles (e.g. SARS, MDRTB). Suction waste should be disposed of in the suction box receptacles in the dirty utility. These must be removed by the waste porters in a timely manner. 7. Sharps Management Sharps must not be passed directly from hand to hand and handling should be kept to a minimum Needles must not be re-sheathed, bent, broken or disassembled prior to disposal Always dispose of sharps at the point of use in an appropriate container. Syringes/cartridges and needles should be disposed of intact. Sharps containers must comply with BS 7320 and UN3291 standards Do not fill sharps containers above the manufacturer s marked line, which indicates that they are full. Used sharps containers should be locked in accordance with manufacturer s instructions. The temporary closure mechanism should be in place whenever the sharps bin is not in use. Do not dispose of sharps with other clinical waste. Do not place used sharps containers in yellow bags for disposal. Sharps containers should be safely positioned away from children and the general public. 7 of 10

Sharps containers should be secured to avoid accidental spillage. Do not remove sharps from the clinical setting. In the event of a sharps injury or contamination of broken skin/ mucous membranes with blood or body fluids, ensure that the Needle stick injury procedure is followed. It is all staffs responsibility to ensure that they are aware of the location of the Needle Stick Injury flow chart and procedure to follow pack in the areas in which they work. (See Management of Sharps contamination injuries Policy IC/194/10). 8. Dealing with a blood or body fluid spillage All spillages of blood/bodily fluids should be dealt with immediately. Appropriate personal protective equipment must be used e.g. nitrile gloves and disposable apron for the procedure. Absorb the liquid with disposable towels. Dispose of the towels as clinical waste. Disinfect the spillage by covering with either chlorine releasing granules or a chlorine releasing solution at 10 000 ppm concentration (Actichlor +) Leave for 5 minutes; clean the area up with disposable towels and dispose of as clinical waste. N.B. For urine and vomit spillages, these will need cleaning first with paper towels and then disinfecting with the chlorine releasing solution (Actichlor +) 9. Disposal of waste and excreta Ensure items that have blood or body fluid contamination are disposed of as clinical waste and sent for incineration. Ensure that any excreta is disposed of in the sluice hopper in the dirty utility room. 10. Linen Ensure that any linen contaminated with blood or body fluids is placed into a red alginate bag and then red plastic bag. If linen is excessively wet please ensure that this item is wrapped in another item of linen or the alginate bag may leak/split. If patient s personal items (e.g. pyjamas, dressing gowns) are soiled with blood or bodily fluids please inform the families/carers of this and ensure it is placed in an alginate bag and red bag for the family/carers to take home and launder. No sluicing of clothes should occur at ward level at any time in order to reduce the exposure to bodily fluids. Only take clean linen into a room when it is needed to be used. Do not store linen at the ends of beds or on lockers for imminent bed changes. 11. Hospital Environment Hygiene The hospital environment must be visibly clean, free from dust and spillage and acceptable to patients, their visitors and staff Every Health Care Worker (HCW) must report to the domestic services manager any concerns re the cleanliness of the patient environment Every HCW must be clear about their specific responsibilities for cleaning equipment in clinical areas 8 of 10

Shared equipment used in the clinical environment must be decontaminated appropriately after each use Every HCW has a responsibility to report any sightings or problems with pests. This is done by contacting the Estates Help Desk during normal working hours. Out of working hours access pest control via Switch Board 12. Standard Precautions in Care of the Deceased The same precautions taken when the patient is alive should continue upon death Last offices are performed at ward level on all deceased patients. This procedure includes washing, tidying, identifying and shrouding the body. Staff who perform last offices should wear the appropriate protective clothing e.g. aprons and gloves and assess the risk of requiring goggles and/or facemasks if it is anticipated that there may be a risk of splashing of bodily fluids. Certain other preparations may be required at ward level in individual cases e.g. for high risk cases thought to be infected with the following: Hepatitis B, Hepatitis C, HIV (AIDS), Invasive Group A Streptococcal infection, Tuberculosis, Meningococcal septicaemia and other rare diseases e.g. dysentery, anthrax, plague, rabies, viral haemorrhagic fevers, yellow fever, typhoid and diphtheria. For all the above cases preparations may be required as previously stated plus:- Placing the body in disposable sheets with a zippable plastic body bag with a Danger of Infection Sticker on the outside of the body bay (please refer to the Last Offices Policy HS/375/10 for further details0. The inappropriate use of body bags can cause great distress to bereaved families. The Infection Control Team must be contacted for advice by the ward or mortuary staff if they are unsure if a body bag is required or not. For further details/advice please see the Last Offices Policy (HS/375/10). 13. Evaluation of the policy This policy outlines standard infection control precautions that must be followed in the care of all patients at all times to prevent transmission of infection from person to person. It is expected that all clinical staff are aware of these measures and take the correct actions as stipulated in this policy Adherence of the policy can be monitored by: Observational audits to determine whether all areas in the policy are being adhered to Auditing practice and ensuring staff feed back to improve care The IPCT will review this policy annually or more frequently if necessary. For staff who enter the clinical area it will be checked at appraisal that they have undertaken annual training 9 of 10

14. References and Further Reading Advisory committee on dangerous pathogens. 2003. Infection at work: controlling the risk. [Online] Health and Safety Executive. Available at http://www.hse.gov.uk Accessed 12 th June 2009. Centres for disease control and prevention, 2007. Standard Precautions. [Online] Centres for disease control and prevention. Available at www.cdc.gov/ncidod/dhqp/gl_isolation_standard.html Accessed 19 th June 2009. Centers for Disease Control (1987) Recommendations for the Prevention of HIV Transmission in Health Care Settings. MMWR (Aug.21) 36: (2S). Department of Health 2008. The Health Act 2008: Code of practice for the prevention and control of health care associated infections. SI 277363 1P 1K Oct06. London: Department of Health Publications. Medical Devices Agency (2001) Safe use and disposal of sharps. MDA SN2001 (19). National Patient Safety Agency responds to recent reports on the removal of alcohol hand rub dispensers. 2009. [Online] National Patient Safety Agency. Available at http://www.npsa.nhs.uk Accessed 22 nd June 2009. NICE Clinical Guideline 2 (2003) Infection Control: Prevention of healthcare associated infection in primary and community care.isbn:1-84257-303-9. National Institute of Clinical Excellence: Surrey Pratt, R G; Pellowe, C M; Wilson, J A; Loveday, H P; Harper, P J; Jones, S P L J; McDougall, C and Wilcox, M H (2007). Epic 2: National evidence based guidelines for preventing healthcare associated infections in NHS hospitals in England. http://www.elsevierhealth.com/journals/jhin UK Health Departments (1998) Guidance for Clinical Health Care Workers: Protection Against Infection with Blood borne Viruses. Recommendations of the Expert Advisory Group on AIDS and the Advisory Group on AIDS and the Advisory Group on Hepatitis. HMSO, London. World Health Organisation 2009. World Health Organisation guidelines on hand hygiene in health care. First global patient safety challenge. Clean care is safer care. [Online] World Health Organisation. Available at http://www.who.int/publications/2009 Accessed 12th June 2009 10 of 10