Management of Blood / Bodily Fluid Spillages Reference No: Version: 5 Approved by: G_IPC_31 LCHS Trust Board Date Approved: 14 th November 2017 Name of originator/author: Name of approving committee/responsible individual: Date issued: November 2017 Review date: October 2019 Target audience: Distributed via: Infection Prevention Team, LCHS Infection Prevention Committee LCHS All staff Website Page 1 of 16
Lincolnshire Community Health Services NHS Trust Management of blood / bodily fluid spillages Version Control Sheet Version Section/Para/Ap pendi Version/Description of Amendments Date Author/Amended by 2 Section 8, page 9 Insert tet Appendi C April 2010 Sue Silvester, IPCNS, LCHS and sentence Section 9.1, page Insert tet Appendi D April 2010 Sue Silvester, IPCNS, LCHS 10 Section 13, page Format paragraph to reflect April 2010 Sue Silvester, IPCNS, LCHS 11 current process Appendi E Addition of audit tool April 2010 Sue Silvester, IPCNS, LCHS Section 16, page 12 Addition of references to evidence base April 2010 Sue Silvester, IPCNS, LCHS 3 Headers & Updated to new version July 2013 Lynne Roberts, Infection Control footers & Advisor formatting Section 18 Linked guidelines added July 2013 Lynne Roberts, Infection Control Advisor Appendices Appendi A system for July 2013 Lynne Roberts, Infection Control guidance & policy review Advisor removed and other appendices renumbered. Appendices D & New equality analysis and July 2013 Lynne Roberts, Infection Control E monitoring forms added Section 9 Gloves Must be CE Marked, and polythene gloves healthcare waste 4 Whole document Chance Infection Prevention and Control Team to Infection Prevention Team Advisor July 2013 Lynne Roberts, Infection Control Advisor July 2015 Lynne Roberts Whole document Changed footers July 2015 Lynne Roberts Page 4 Removed NHSLA July 2015 Lynne Roberts Section 13 Amend to the main delivery July 2015 Lynne Roberts of education is via Education and Workforce Team Section 15 Added hyperlink to Leaflet July 2015 Lynne Roberts Section 16 Two knew up to date references added July 2015 Lynne Roberts 4.1 Etension agreed August 2017 Corporate Assurance Team 5 Whole document Changed Header and footer Section 13 Reworded section to reflect training is given at induction and mandatory training Sept 2018 Sept 2018 Lynne Roberts Lynne Roberts Copyright 2017 Lincolnshire Community Health Services NHS Trust, All Rights Reserved. Not to be reproduced in whole or in part without the permission of the copyright owner.
Lincolnshire Community Health Services NHS Trust Management of blood / bodily fluid spillages Contents Version Control Sheet... 2 Guidance Statement... 4 1. Background.... 5 2. Purpose of guidance... 5 3. Key personnel responsibilities... 5 4. Why manage blood and other body fluid spillages?... 6 5. Categories of blood/bodily fluids in accordance to risk... 6 6. Who should manage spillages?... 6 7. Methods of Cleaning... 7 8. Spillage Kits... 8 9. Preparation for dealing with a spillage?... 8 9.1. Spillage of blood/and blood stained bodily fluids on impervious floors and surfaces... 9 9.2. Spillages on Carpets.... 9 9.3. Spillage of low risk fluids (e.g. Urine, Faeces, Vomit)... 9 10. What to do once a spillage has been managed?... 9 11. What to do if the staff member becomes contaminated with blood or other body fluids occurs while managing a spillage?... 10 12. Risk Management... 10 13. Education... 10 14. Monitoring and Audit of spillages.... 10 15. Resources.... 10 16. Evidence Base... 10 17. Appendices... 11 18. Linked Guidelines... 11 Appendi A: Management of Spillages using spill kits... 12 Appendi B: Management of Spillages... 12 Appendi B continued: Management of Spillages... 13 Appendi C: Equality Analysis... 15 Appendi D: Monitoring... 16 Page 3 of 16
Lincolnshire Community Health Services NHS Trust Management of blood / bodily fluid spillages Guidance Statement Background The purpose of this guidance is to implement a co-ordinated approach to the management of Blood and bodily fluid spillages in line with current Department of Health and Best Practice requirements Statement This guidance is comprehensive, formally approved and ratified, and disseminated through approved channels. It will be implemented for staff of Lincolnshire Community Health Services Responsibilities Compliance with the guidance will be the responsibility of all LCHS staff. Training The Infection Prevention Team will support/deliver/disseminate any training associated with this guidance. Dissemination Via Website Resource implication This guidance has been developed in line with the Department of Health and best evidence requirements to provide a framework for staff within NHS Organisations to ensure the appropriate production, management and review of organisation-wide policies and guidance. Management of blood / bodily fluid spillages Page 4 of 16
1. Background. Spillages of blood / body fluids can occur anywhere in the health community (hospitals, clinics or in the home) and it is vital that any spillage is attended to in a safe and timely manner. Occupational eposure to blood, other body fluids, secretions and ecretions (ecept sweat) through spillages poses a potential risk of infection, particularly to those who may be eposed to these substances while providing health and social care. Under the Control of Substances Hazardous to Health Regulations 1994 (COSHH), assessment of hazards and associated risks to health must be undertaken to ensure the health and safety of employees, patients and other visitors to the primary health care premises / home. Personal protective clothing must be worn when dealing with spillages, irrespective of the nature of the incident (LCHS Standard Precautions G_IPC_26 and Hand washing Guidance G_IPC_30). 2. Purpose of guidance. Provide best evidence on how effective management of spillages can be achieved. Re-enforce the importance of risk assessment. 3. Key personnel responsibilities. 3.1. Infection Prevention Team will; Act as a resource for guidance and support when advice on managing blood and body fluid spillages is required, Provide education for staff and management of this policy where necessary, Provide advice on individual risk assessments for managing blood and body fluid spillages. 3.2. Managers must ensure that; Staff are aware of, have access to and comply with the guidance Staff apply the principle of standard precautions, Staff are adequately educated / trained and are competent in all aspects of this guidance, Ensure that adequate resources are in place to allow for managing blood and other body fluids spillages, Staff are supported in undertaking risk assessments to optimise patient/client and staff safety, consulting epert infection control guidance if/as required, Support staff in any corrective action or interventions if an incident occurs that may have resulted in cross transmission, Ensure any staff with health concerns or who have become ill due to occupational eposure is referred to the relevant agency e.g. Occupational Health or General Practitioner. 3.3. Employees. All employees have a responsibility to abide by this guidance and any decisions arising from the implementation of them. Any decision to vary from this guidance must be fully documented with the associated rationale stated. They must also; Apply the principles of standard precautions, Page 5 of 16
Report to managers any deficits in relation to knowledge/practice in the management of blood and other body fluid spillages, facilities/equipment or incidents that may have resulted in cross contamination, Report any illness as a result of occupational eposure to the line manager, Advise the patient/client, carers or visitors of any infection control requirements such as hand hygiene. 4. Why manage blood and other body fluid spillages? Blood and bodily fluid spillages must be managed promptly in order to: Reduce the eposure to blood and other body fluids, such as faeces, vomit, pus and urine. Reduce the eposure to viruses such as HIV, Hepatitis B and Hepatitis C through blood or other body fluids, Reduce the eposure to other microorganisms that may present in the spillages, Provide a quick and effective management of spillages, regardless of the setting. 5. Categories of blood/bodily fluids in accordance to risk. Bodily Fluids Risk Category Cleaning Method Blood/ any visibly blood stained fluids Breast milk Amniotic fluid Vaginal secretions Semen Cerebrospinal fluid (CSF) Synovial fluid Pericardial fluid Pleural fluid Peritoneal fluid Unfied tissues/organs Saliva (associated with dentistry) Vomit Sputum Saliva Urine Faeces Tears 6. Who should manage spillages? HIGH RISK LOW RISK (unless visibly blood stained) Chlorine releasing agent e.g.chorclean, Haz-tabs or Actichlorplus Followed by Detergent & hot water Detergent e.g. Hospec & hot water (if visibly stained or of a known infectious nature follow above; with the eception of urine) Those educated / trained in the safe and effective management of blood or other body fluid spillages. Those staff working in health or social care that may be eposed to spillages of blood or body fluids should receive education / training to ensure they are safe and effective in the management of such spillages. Local training records should be held to reflect this. Responsibilities for the cleaning of blood and body fluid spillages should be clear within each area/care setting e.g. in health clinics; Health Care Worker (Nurse/AHF or HCA) responsible for the patient. Page 6 of 16
7. Methods of Cleaning. 7.1. Detergent and water. The use of detergent (e.g. Hospec ) and water forms the basis of any cleaning procedure. It is the preferred method of cleansing where; The spillage is on a soft surface, The spillage is in the patients own home, There is a spillage of urine (initial cleaning), 7.2. Chlorine releasing agents. Chlorine-releasing agents are chemical disinfectants which are effective against blood-borne viruses and are rapid in action. They are the disinfectant of choice in the event of a spillage of blood / blood stained body fluid. However, the effectiveness of all chemical disinfectants is strongly dependant on their conditions of use. In order to be effective, they must be used in accordance with the manufacturer s instructions, at the appropriate strength for the contact time specified. Solutions made from tablets should be freshly made daily. Chlorine-releasing agents fall into two groups: Sodium dichloroisocyanurate (NaDCC), e.g. Presept, Haz Tabs, Actichlor, Chorclean. Sodium hypochlorites, e.g Milton, Domestos. The use of NaDCC is recommended for blood / blood stained body fluid spillages. It is less resistant than hypochlorite s are to organic matter, less corrosive, and has a longer shelf life, as it is manufactured as tablets or granules. COSHH (Control of Substances Hazardous to Health Regulations, 1999) assessments must be carried out for all chemical disinfectants in use, and staff should be aware of the implications of these for storage and use of the product, and first aid in the event of eposure, e.g. splash to the eye. Storage must meet COSHH guidelines. Chlorine-releasing agents are corrosive to many materials, e.g. metals, and will bleach carpets, fabrics and soft furnishings. Chlorine-releasing agents can damage the skin and mucous membranes, therefore gloves and aprons should be worn for any contact. If there is risk of splashing, eye protection should be worn. Chlorine-releasing agents should never be mied with acids or used on spills of urine as chlorine gas will be released. Chlorine-releasing agents should not be mied with hot water or any other cleaning agents; use warm or cold water. 7.3. Chlorine concentrations. Strength Uses 1,000 parts per million (ppm)* Disinfection of surfaces following contamination with body fluids e.g. commodes (to be used after cleaning with Page 7 of 16
detergent). 10,000 parts per million (ppm)* Decontamination of spillages of blood or body fluids stained with blood. * Always refer to manufacturers instructions to ensure appropriate concentration is achieved when making up the solution. 7.4. Chlorine releasing preparations. Presentation NaDCC Granules* e.g. Presept NaDCC Tablets (2.5g)* e.g. Presept To make a dilution of 1,000 ppm Not applicable 1 tablets in 1.25 litres of cold water To make a dilution of 10,000 ppm. Use directly (do not dilute) 8 tablets in 1 litre of cold water Hypochlorite* e.g. domestos or other household bleach (for use in patients homes only) Dilute in 1 part bleach solution to 100 parts water (add solution to water) Dilute 1 part bleach solution to 10 parts water (add solution to water) * Always refer to manufacturers instructions to ensure appropriate concentration is achieved when making up the solution. 8. Spillage Kits. A spillage kit (Appendi A) should be kept in each clinical area (at least one per clinic, ward or surgery), so that all the equipment for dealing with a spillage of blood is available in one place. Staff dealing with spillages is responsible for ensuring that the equipment is replenished after the kit is used. The IP Team can advise on the most appropriate spill packs. Because of the presence of a chemical disinfectant, the spillage kit must be stored in accordance with COSHH guidance. A COSHH data sheet should be held locally and a local risk assessment undertaken. Staff are responsible for ensuring kits are in date. 9. Preparation for dealing with a spillage? Gather all necessary equipment to deal with the spillage: Personal protective equipment: Apron and gloves. Eyewear, masks/visor should be worn if there is a risk of splashing to eyes, mouth and/or body. Gloves must be CE marked. Polythene gloves must not be used when dealing with healthcare waste. Spillage Kit OR Waste receptacle: check the correct waste stream is available particularly in clinical/care settings e.g. Hazardous waste stream for healthcare waste. Disposable towels Water and general purpose neutral detergent. Disinfectant (appropriate solution or granules at the correct concentration). If necessary, a sign which can be displayed or the use of a physical barrier to ensure all other persons avoids the spillage while it is being dealt with. Page 8 of 16
9.1. Spillage of blood/and blood stained bodily fluids on impervious floors and surfaces (Appendi B). Wear protective clothing (gloves, apron must be worn and goggles if any risk of splashing into the eyes). Cover spillage with NaDCC (chlorine-releasing) granules, e.g. presept. Leave for 2 minutes (prepare bucket with hot water and neutral detergent solution). Scoop of the spillage with paper towels/scoop and discard as hazardous waste. Clean area with hot water and neutral detergent using disposable clothes, rinse and dry. Clean bucket in fresh water, rinse and dry. Dispose of protective clothing and cloth s as clinical waste and wash hands. Replenish Spillage Kit, where used. Request a domestic clean/ shampoo of the area as soon as practicably possible. 9.2. Spillages on Carpets. Spillages of blood or body fluids on carpets or furnishings should be dealt with using hot water and neutral detergent only. Chlorine-releasing agents will bleach the colour from the fabrics. Wear protective clothing (gloves, apron must be worn and goggles if risk of splashing). Soak up as much of the spillage as possible using absorbent, disposable material, e.g. newspapers, kitchen roll, and place directly into hazardous waste plastic carrier bag or bin liner (if in patients home). Clean area with hot water and neutral detergent using disposable clothes, rinse and dry. Clean bucket in fresh water, rinse and dry. Dispose of protective clothing and clothes into hazardous waste (or plastic bag/bin liner, dispose into the normal household waste). Wash hands. Request a carpet shampoo as soon as is practicably possible. 9.3. Spillage of low risk fluids (e.g. Urine, Faeces, Vomit) onto any flooring or surface. Ensure area is well ventilated. Wear protective clothing (gloves, apron must be worn and goggles if risk of splashing). Use paper towels to absorb/remove as much of the spillage as possible. Clean area thoroughly using hot water, neutral detergent and disposable clothes, rinse and dry. Impervious flooring wipe over the area with chlorine solution, e.g. presept tablets made up to 1,000 ppm strength, and paper towels. Dispose of all materials as hazardous waste. Clean the bucket with fresh water and neutral detergent, rinse and dry. Dispose of the personal protective clothing as clinical waste and wash hands. Replenish spillage kit, where used. 10. What to do once a spillage has been managed? Ensure the area is decontaminated and is safe, with all items that have been used to clear the spillage removed and disposed of into healthcare waste or cleaned where appropriate. Hand hygiene should be performed. Page 9 of 16
11. What to do if the staff member becomes contaminated with blood or other body fluids occurs while managing a spillage? The contamination must be addressed immediately; this may involve washing the skin and / or replacing items of clothing / uniform. Any eposure incidents: breeches to the mucous membranes or skin must be management as per local Prevention and management of inoculation eposure injuries policy. A Dati report must be completed. 12. Risk Management. A Dati report (IR1) must be completed if either of the following is eperienced: Non compliance with this guidance Issues raised in relation to management of spillages. 13. Education. The Education and Workforce Team will provide/facilitate education to all staff via induction, clinical and mandatory training (attendance at induction and mandatory programmes). Advice and any additional training may be provided by Infection Prevention Team and Link Champions. Bespoke training is provided to nominated leads through the LCHS link champion scheme. These link champions will in turn be responsible for cascading relevant training to staff within the team, clinical area/ department. 14. Monitoring and Audit of spillages. Audit and monitoring of spillages will be carried out as part of a pre-planned infection prevention and control audit programme and via the trusts incident reporting system. The Infection Prevention Team will support managers in the auditing and monitoring spillages, where required 15. Resources. Best Practice Guidance and monitoring tools: Up to date information may be obtained from the Lincolnshire NHS web site. Posters and Leaflets: Up to date information may be obtained from the Lincolnshire Community Health Services Infection Prevention Web page J:\2014-2015\LCHS\Infection Prevention\Core documents\policies and guidelines\approved leaflets in 2014\Inoculation injuries.doc 16. Evidence Base. Ayliffe, Coates, Hoffman (1993) Chemical Disinfection in Hospitals. Department of Health (2002) Keep Safe: Practical, everyday advice for HIV infected people and their carers. Page 10 of 16
Department of Health (2008) HIV post-eposure prophylais: Guidance from the UK Chief Medical Officers Epert Advisory Group on AIDS. Health Protection Scotland (2009) Standard Infection Control Precautions (SICPs) Policies, April 2009. Public Health England (2012) Blood borne viruses in healthcare workers: report eposures and reduce risks [Accessed: 27/07/15] Royal College of Nursing (2013) Sharps Safety: RCN Guidance to support the implementation of the Health and Safety (Sharp Instruments in Healthcare Regulations [accessed 27/07/15] UK Health Departments. (1998) Guidance for clinical Health Care workers: Protection against infection with blood-borne viruses. Recommendations of the Epert advisory Group on AIDS and the Advisory Group on Hepatitis. 17. Appendices. Appendi A. Management of Spillages using spill kits. Appendi B. Management of Spillages Appendi C. Equality Analysis Appendi D. Monitoring 18. Linked Guidelines Standard Precautions Hand Washing Prevention and Management of Inoculation Eposure Injuries Page 11 of 16
Appendi A: Management of Spillages using spill kits. Management of Spillages using the Spill Kit Appendi B: Management of Spillages Page 12 of 16
Management of Spillages Spillage of blood/and blood stained bodily fluids on impervious floors and surfaces Wear protective clothing (gloves, apron, goggles) Cover spillage with NaDCC (chlorine-releasing) granules, e.g. Presept. Leave for 2 minutes (prepare bucket with hot water and neutral detergent solution e.g. Hospec ). Scoop of the spillage with paper towels/scoop and discard as hazardous waste. Clean area with hot water and neutral detergent using disposable clothes, rinse and dry. Clean bucket in fresh water, rinse and dry. Dispose of protective clothing and cloth s as clinical waste and wash hands. Replenish Spillage Kit, where used. Request a domestic clean/ shampoo of the area as soon as practicably possible. Spillages on Carpets Wear protective clothing (gloves, apron and goggles). Soak up as much of the spillage as possible using absorbent, disposable material, e.g. newspapers, kitchen roll, and place directly into hazardous waste plastic carrier bag or bin liner (if in patients home). Clean area with hot water and neutral detergent using disposable clothes, rinse and dry. Clean bucket in fresh water, rinse and dry. Dispose of protective clothing and clothes into hazardous waste (or plastic bag/bin liner, dispose into the normal household waste). Wash hands. Request a carpet shampoo as soon as is practicably possible. Appendi B continued: Management of Spillages Management of Spillages Page 13 of 16
Spillage of low risk fluids (e.g. Urine, Faeces, Vomit) onto any flooring or surface 1. Wear protective clothing (gloves, apron must be worn and goggles if risk of splashing). 2. Use paper towels to absorb/remove as much of the spillage as possible. 3. Clean area thoroughly using hot water, neutral detergent and disposable clothes, rinse and dry. 4. Impervious flooring wipe over the area with chlorine solution, e.g. presept tablets made up to 1,000 ppm strength, and paper towels. 5. Dispose of all materials as hazardous waste. 6. Clean the bucket with fresh water and neutral detergent, rinse and dry. 7. Dispose of the personal protective clothing as clinical waste and wash hands. 8. Replenish spillage kit, where used. Page 14 of 16
Appendi C: Equality Analysis A. Briefly give an outline of the key objectives of the policy; what it s intended outcome is and who the intended beneficiaries are epected to be B. Does the policy have an impact on patients, carers or staff, or the wider community that we have links with? Please give details C. Is there is any evidence that the policy\service relates to an area with known inequalities? Please give details D. Will/Does the implementation of the policy\service result in different impacts for protected characteristics? The purpose of this guidance is to implement a co-ordinated approach to the management of Blood and bodily fluid This document is relevant to all staff employed by LCHS NHS Trust None known Disability Seual Orientation Se Gender Reassignment Race Marriage/Civil Partnership Maternity/Pregnancy Age Religion or Belief Carers Yes If you have answered Yes to any of the questions then you are required to carry out a full Equality Analysis which should be approved by the Equality and Human Rights Lead please go to section 2 The above named policy has been considered and does not require a full equality analysis Equality Analysis Carried out by: L Roberts Date: 13 Sept 2017 No Page 15 of 16
Appendi D: Monitoring Minimum requirement to be monitored Process for monitoring e.g. audit Responsible individuals/ group/ committee Frequency of monitoring/audit Responsible individuals/ group/ committee (multidisciplinary) for review of results Responsible individuals/ group/ committee for development of action plan Responsible individuals/ group/ committee for monitoring of action plan Complianc e Audit Managers / Link champion s/ IP&C Team Annual Infection Prevention Control Committee and Infection Prevention and Control Committe e Infection prevention and control committee Page 16 of 16