CLINICAL PROCEDURE PROCEDURE FOR TAKING A WOUND SWAB Issue History Issue Version Purpose of Issue/Description of Change Planned Review Date 2 To provide a standardised process of the fundamental principles required in the procedure of wound swabbing. 2016 Named Responsible Officer:- Approved by Date Tissue Viability Lead Quality, Patient Experience and Risk Group Target Audience February 2013 Section:- CP23 All Trust staff who undertake the procedure of wound swabbing within the Trust as part of their job role UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM TRUST WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION
CONTROL RECORD Title Procedure for Wound Swabbing Purpose To provide a standardised process of the fundamental principles required in the procedure of wound swabbing. Author Quality and Governance Service (QGS) Equality Assessment Integrated into procedure Yes No Subject Experts Tissue Viability Lead Document Librarian QGS Groups consulted with :- Clinical Policies and Procedures Group Infection Control Approved February 2013 Date formally approved by Quality, Patient Experience and Risk Group February 2013 Method of distribution Email Intranet Archived Date 19 th February 2013 Location:- S Drive QGS Access Via QGS VERSION CONTROL RECORD Version Number Author Status Changes / Comments Version 2 Quality and Governance Service R Wound swabbing standards clarified following results of Leg Ulcer Audit 2012. Status New / Revised / Trust Change 2/9
INTRODUCTION The purpose of this procedure is to outline the correct procedure for taking wound swabs in the community. Culture swab of a wound should only be taken if clinical infection is suspected. Many chronic wounds contain a wide variety of bacterial flora. The host s immune system is generally able to maintain the level of bacteria to a colonised level. Procedure complies with NHS Litigation Authority Risk Management Standards (2008) for Community Trusts for clinical diagnostic tests. TARGET GROUP The procedures applies to all registered members of staff and Assistant Practitioners within the Trust who are required to undertake wound swabbing as part of their job role. TRAINING All staff in the Trust are required to comply with mandatory training as specified in the Trust s Mandatory Training Matrix. Clinical Staff are also required to comply with service specific mandatory training as specified within their service training matrix. RELATED POLICIES Please refer to relevant Trust policies and procedures INDICATIONS FOR SWABBING WOUND Clinical infection may be indicated when the following symptoms are observed: 1. Swelling 2. Redness 3. Heat 4. Purulent discharge, or increase in level of exudate 5. Wound deterioration, or bridging 6. Change in appearance of tissue, e.g. normal granulation becomes dark and bleeds easily. 7. Systemic temperature There is considerable evidence suggesting that, in the absence of clinical signs of infection, wound swabs will not provide any information useful for routine treatment, routine swabbing therefore is not justified. 3/9
Swabs are the most common means by which specimens are obtained; however, the literature does not contain any single standard procedure which can be deemed the right way. TRUST WOUND SWABBING STANDARDS Wounds must be swabbed if any signs of wound infection evident Swab results must be followed up and recorded on the wound assessment form All infected wounds (confirmed following a swab) must have topical Prontosan applied for a 15 minute soak at each intervention applied directly onto the wound CONSENT Valid consent must be given voluntarily by an appropriately informed person prior to any procedure or intervention. No one can give consent on behalf of another adult who is deemed to lack capacity regardless of whether the impairment is temporary or permanent. However such patients can be treated if it is deemed to be within their best interest. This must be recorded within the patient s health records with a clear rationale stated at all times. Refer to Trust Consent Policy for further information and guidance. EQUIPMENT Cotton tipped swab with transport medium Sterile saline (optional) Single use disposable apron Single use disposable non sterile gloves Microbiology Form (with attached bag) Trust approved Transport Container NB: Collection times of swabs vary across Wirral. Please endeavor to avoid storing swab overnight as this will increase the likelihood of contamination. 4/9
Diagnostic and Screening Standards to Promote and Maintain Patient Safety a. How the Screening/Diagnostic procedure is requested b. How the clinician treating the patient is informed of the results (including timescales) c. How the patient is informed of the results (including timescales) d. Taking action on the result of diagnostic /screening tests (including timescales) :- documentation of the result interpretation of the result Description of how each step in the process is undertaken Registered staff member or Assistant Practitioner requests wound swab The laboratory informs the GP of the results within 3-5 days. The registered member of staff or Assistant Practitioner will inform the patient of their swab results after contacting the patient s GP surgery The registered staff member / Assistant Practitioner will make the GP aware of the results if treatment is required Results of the swab should be documented within the patient s health care records The laboratory confirms the presence of an infection Additional comments:- Trust staff and Assistant Practitioners will follow Trust Wound swabbing standards as stipulated in this procedure Trust Staff and Assistant Practitioners should seek to obtain swab results within the timeframe specified. Time frames may vary depending on triage processes in the microbiology laboratory and cultures being tested from the wound swab. The staff member taking the swab is responsible for obtaining the result and ensuring the patient is fully informed. This will ensure the GP is made aware of the results and appropriate action is taken in a timely manner. This will help to inform other staff members of patient status and current treatment plans in place relating to swab results how patient is followed up or referred following a screening Which staff are authorised to request this test? The patient is followed up by the GP once both the patient and GP are aware of the swab results Registered members of staff and Assistant Practitioners are authorised to undertake the procedure of wound swabbing It is the responsibility of the staff member taking the swab to ensure they obtain the results and that the patient is followed up accordingly. A clear rationale should be provided as to why wound swabbing is being undertaken and documented within the patient s health records 5/9
PROCEDURE ACTION Verbally confirm the identity of the patient by asking for their full name and date of birth. If client unable to confirm, check identity with family/carer Introduce yourself as a staff member and any colleagues involved at the contact Wear identity badge which includes name status and designation Ensure verbal consent for the presence of any other third party is obtained Explain procedure to patient including risks and benefits and gain valid consent. Decontaminate hands prior to procedure Apply single use non sterile gloves Remove dressing as appropriate The wound should be cleansed with sterile saline to irrigate any purulent debris (Stotts 2007) Moisten the swab with sterile saline before taking sample. Use a zig-zag motion whilst simultaneously rotating between the fingers. Sample the whole wound surface. Place the specimen straight into the transport medium. On completion of procedure remove and dispose of PPE to comply with waste management policy Decontaminate hands following removal of PPE RATIONALE To avoid mistaken identity To promote mutual respect and put client at their ease For patients to know who they are seeing and to promote mutual respect Students for example, as the client has the choice to refuse To ensure client understands procedure and relevant risks Reduce the risk of transfer of transient organisms on the healthcare workers hands to the patient To prevent hands from contamination with organic matter and transfer of microorganisms Enables wound bed to fully accessible for wound swabbing to take place To achieve a clean culture site and to avoid obtaining a culture from the pus on the surface of the wound In dry wounds a moistened swab will attach bacteria more effectively. Ensure all the swab will contain sufficient amounts of bacteria Where practicable bacteria from the whole wound should be sampled in order for the swab to isolate the causative pathogen. Remove the possibility of contamination. To prevent cross infection and environmental contamination To remove any accumulation of transient and resident skin flora that may have built up under gloves and possible contamination following removal of PPE 6/9
Ensure microbiology form contains relevant and specific information about the patient Document condition of wound and evidence of infection including clinical symptoms any antibiotic treatment must be recorded Document all actions including arrangements for following up the wound swab results in the nursing records. Liaise with GP as required The patient should be advised of how long they will have to wait for the results and the method by which they will be informed of it e.g. by post, by follow up visit Transfer culture swab specimen to clinic/surgery in a Trust approved Transport Container NB Forms are also coded for specific General Practitioners (GP) and Practices. To ensure correct patient information is recorded Clinical details will assist the microbiologist in making an accurate diagnosis To ensure compliance with Trust record keeping policies and provide continuity of care Patient to be fully informed of any potential changes, if required to care plan in order to give informed consent To ensure patient is informed of outcome relating to diagnostic test Ensures the safe transportation of specimens and manages risk to exposure to staff. To ensure results are sent to correct GP practice TRANSPORTATION OF WOUND SWABS Specimens if not handled safely, can pose a risk of infection to all people involved, including healthcare workers, patients, transport personnel and laboratory workers. Accurate analysis is crucial in determining the correct diagnosis, or detecting an infectious agent, so that appropriate and timely treatment can be given. To support this, all wound swabs should be transported in a Trust approved Transport Container to ensure the safe transportation of specimens and manage the risk of exposure to staff. EQUIPMENT All wound swabs should be checked that they have not have exceeded the expiration date of sterility by registered members of staff and Assistant Practitioners. This information should be documented within the patient s health care records to ensure there is documented evidence of this check being completed. Appropriate action should be taken when swabs have exceeded their expiration date and can no longer be used. WERE TO GET ADVICE FROM Staff should contact their Line Manager when advice is required relating to the procedure of wound swabbing. Staff should contact the Tissue Viability Service when available if comprehensive advice is needed. 7/9
INCIDENT REPORTING Clinical incidents or near misses must be reported via the Trust s incident reporting system. SAFEGUARDING In any situation where staff may consider the patient to be a vulnerable adult, they need to follow the Trust Safeguarding Adult Policy and discuss with their line manager and document outcomes. REFERRALS Any referrals to health professionals, therapists or other specialist services must be followed up and all professional advice or guidance documented in the patients health records. EQUALITY ASSESSMENT During the development of this procedure the Trust has considered the clinical needs of each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation). There is no evidence of exclusion of these named groups. If staff become aware of any clinical exclusions that impact on the delivery of care a Trust Incident form would need to be completed using the Trust s incident reporting system and an appropriate action plan put in place. REFERENCES NHS Litigation Authority Risk Management Standards 2012-2013 for NHS Trusts (2012) Stotts. N (2007) Wound Infection Diagnosis & Management. Chronic Wound Care. A problem-based learning approach. In Morison & Ovington et al (2007) GP6 Trust Managing the Quality of Health Records Policy 8/9
Name of Diagnostic Procedure: Wound Swabbing Date risk assessed: 8 th January 2013 Risk assessed by: Advanced Practitioner RISK ASSESSMENT FOR DIAGNOSTIC PROCEDURE Criteria Likelihood that process will fail Low Medium High Risk identified in process Mitigation/Controls a. Process for requesting the screening/diagnostic procedure Staff member may not identify evident significant signs of infection Staff should attend Trust s mandatory wound study days as per service training matrix. b. Process for informing the clinician treating the patient of the result c. Process for informing the patient of the result d/e. Process for action if referral required after a screening test Identify risks from the process of conducting the test if relevant GP may not be in practice to review results and/or Community Nurse may not contact GP surgery within the appropriate timescale to obtain results Patient may not be informed of result as Community Nurse has not obtained the result themselves GP may not send letter to relevant service/department for further assessment Swabbing may be conducted by staff without sufficient training Documentation regarding obtaining wound swab to be made in patient s notes to act as a communication mechanism for swab results to be followed up Documentation regarding obtaining wound swab to be made in patient s notes to act as a communication mechanism for swab results to be followed up and for the patient to be informed Community Nurse/Assistant Practitioner taking wound swab has overall responsibility of ensuring the patient is followed up in a timely manner Training in taking wound swabs is in place as per the relevant Service Training Matrix