Standard Operating Procedure (SOP) Neonatal Service Using the Sluice on the Neonatal Intensive Care Unit at the City Campus. Full Title of Guideline: Standard Operating Procedure for using the Sluice on the Neonatal Intensive Care Unit at the City Campus. Author (include email and role): Ellen Cutler Practice Development Matron, Neonatal Service Division & Speciality: Division: Family Health - Children Specialty: Neonatal Version: 1 Ratified by: Scope (Target audience, state if Trust wide): Review date (when this version goes out of date): Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis): Changes from previous version (not applicable if this is a new guideline, enter below if extensive): Strategic Children s and Neonatal Nursing Group, Children s and Neonatal Evidence Based Practice Council All staff working on the Neonatal Intensive Care Unit 21/02/2021 Babies and Families being cared for on the Neonatal Intensive Care Unit N/A RCN Guidance. Supports compliance with CQC and NHS Improvement Summary of evidence base this standards. Consultation undertaken with NUH Infection guideline has been created from: Prevention and Control department and Linen production Manager. This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date or outside of the Trust. Date 18/09/2017 Ellen Cutler Version 1.1 Page 1 of 6
NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST Neonatal Service SOP: Using the Sluice City Campus Reference Approving Body Neonatal Service SOP: Using the Sluice City Campus Nursing Strategy Group Date Approved 21/02/2018 Implementation Date 21/02/2018 Version 1.1 Summary of Changes from Previous Version Supersedes Consultation Undertaken Accreditation Implications Target Audience N/A N/A Neonatal Matron, Neonatal Senior Nursing Team, Neonatal Housekeeping Team, Infection Prevention and Control Team, EBPC, Strategic Children s and Neonatal Nursing Group Supports compliance with NHSI. All clinical staff in the neonatal service. Review Date 21/02/2018 Lead Executive Author Lead Manager Further Guidance/Information Ellen Cutler Barbara Linley Nottingham Neonatal Service Date 18/09/2017 Ellen Cutler Version 1.1 Page 2 of 6
Nottingham Neonatal Service Standard Operating Procedure Using the Sluice City Campus Introduction The purpose of this standard operating procedure (SOP) is to ensure all staff in the neonatal service are educated on how to safely use the sluice at the city campus neonatal unit. The objective of this SOP is to outline the roles and responsibilities expected of clinical staff when using the sluice area. The method outlined in the SOP should be used at all times. This SOP will apply to any neonatal staff member who undertakes any task which encompasses using the sluice area at the city campus Nottingham Neonatal Service, family health division of Nottinghamshire University Hospitals NHS Trust. The SOP will be widely disseminated and readily accessible. General Principles This SOP seeks to standardise practice to ensure that every one who uses the sluice area understands the processes within the area, including cleaning equipment. PROCEDURE 1:- Accessing the Pod System 01 Enter through the clean sluice door 02 Follow floor markings to POD system 03 Complete actions at the POD system 04 Exit following floor markings 05 Exit via clean sluice door PROCEDURE 2:- Emptying dirty or used milk bottles 01 Enter through the dirty sluice door 02 Follow floor markings to pan 03 Empty bottles into pan wearing gloves and apron 04 Put empty bottles into relevant container 05 Discard gloves and apron in bin in dirty area 06 Wash hands in handwashing sink 07 Follow floor markings to clean area 08 Clean trolley or plastic box at the sink using soapy water Date 18/09/2017 Ellen Cutler Version 1.1 Page 3 of 6
09 Dry trolley or plastic box and discard paper towels in clean bin 10 Exit sluice through clean door PROCEDURE 3:- Disposing of refuse, clinical waste or other materials 01 Enter through the dirty sluice door 02 Follow floor markings to appropriate refuse or clinical waste receptacle 03 Empty waste wearing gloves and apron 04 Discard gloves and apron in bin in dirty area 05 Wash hands in handwashing sink 06 Follow floor markings to clean area 07 Exit sluice through clean door 08 If using a skip OR dirty trolley please exit via the dirty exit with the skip or trolley PROCEDURE 4:- Cleaning equipment 01 Enter through the dirty sluice door (All clinical items except giraffe incubators and babytherms) 02 Follow floor markings and leave equipment in designated dirty area if not being immediately cleaned 03 Remove any sheets or waste and place in appropriate receptacle 04 Wearing gloves and apron move equipment from dirty side to clean side 05 Remove dirty parts of the equipment and place them on the work surface 06 Clean all removable parts with warm soapy water (or appropriate cleaning agent e.g. haztabs) 07 Place cleaned items on the opposite side of the sink to dry 08 Clean non-removable equipment with warm soapy water (or appropriate cleaning agent e.g. haztabs) 09 Remove gloves and apron and dispose in dirty area 10 Wash hands in handwashing sink 11 Put on new gloves and apron in the clean side 12 Dry non-removable equipment with dry paper towels 13 Dry removable items with paper towel and replace onto equipment 14 Once equipment replaced move equipment from the clean area following the floor markings and place in the store room 15 Cover equipment with plastic wrapping and I am clean label Date 18/09/2017 Ellen Cutler Version 1.1 Page 4 of 6
PROCEDURE 5:- Storing clean equipment for MESU retrieval 01 Enter through the clean sluice door with pre-cleaned equipment 02 Follow floor markings to MESU collection bay 03 Complete MESU tag and attach to appropriate equipment 04 Exit via clean sluice door NB For large equipment please follow procedure 4 before labelling with MESU tag PROCEDURE 6:- Storing CSSD equipment for retrieval 01 Enter through the dirty sluice door 02 Follow floor markings to appropriate refuse or clinical waste receptacle 03 Empty waste wearing gloves and apron 04 Bag any CSSD equipment in appropriate packaging 05 Place into CSSD bin for retrieval 06 Remove apron and gloves and place in bin in dirty area 07 Wash hands in handwashing sink 08 Follow floor markings to clean area and exit through clean door Relevant Legislation and National Guidance Royal College of Nursing. 2017 Essential Practice for Infection Prevention and Control Guidance for Nursing Staff Clinical Professional Resource. RCN, London. Date 18/09/2017 Ellen Cutler Version 1.1 Page 5 of 6
CERTIFICATION OF EMPLOYEE AWARENESS Document Title Neonatal Service SOP: Using the sluice (city campus NNU) Version (number) 1.1 Version (date) 21/02/2018 I hereby certify that I have: Identified the staff groups within my area of responsibility to whom this procedure applies. Made arrangements to ensure that such members of staff have had the opportunity to be aware of the existence of this document and have the means to access, read and understand it. Explained the mandatory nature of this procedure to my staff and I have informed them that no staff members should undertake this procedure without appropriate local training. Signature Print name Date Directorate/ Department The manager completing this certification should retain it for audit and/or other purposes for a period of six years (even if subsequent versions of the document are implemented). Date 18/09/2017 Ellen Cutler Version 1.1 Page 6 of 6