Universal/Standard Infection Control Precautions

Transcription

Universal/Standard Infection Control
Precautions
Reference Number:
622
Author & Title:
Yvonne Pritchard
Senior Infection Prevention and Control
Nurse
Responsible Director:
Director of Nursing
Review Date:
19 December 2017
Ratified by:
Helen Blanchard
Director of Nursing and Midwifery
Director of Infection Prevention and Control
Date Ratified:
19 December 2014
Version:
2.0
Related Policies
and Guidelines
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Antibiotic Resistant Micro-organisms Policy
Aseptic Non Touch Technique Policy
Blood Borne Virus Policy
Clostridium difficile Policy
Hand Decontamination Policy
Isolation Policy
Influenza A, Control and treatment of
Linen Policy
Diarrhoea and /or Vomiting Policy, Management of
Waste policy, Management and disposal of
Sharps Policy
Meningitis Policy
MRSA Policy
Scabies Policy
Skin Management, Protective Gloves and Latex
Sensitivity Policy
Tuberculosis Policy
Document name: Universal Standard Infection Control Precautions
Issue date: 23 December 2014
Author: Yvonne Pritchard
Ref.: 622
Status: Final
Page 1 of 26
Index:
1.
Policy Summary _______________________________________________ 4
2.
Policy Statements _____________________________________________ 4
3.
Definition of Terms Used _______________________________________ 4
4.
Duties and Responsibilities _____________________________________ 5
4.1. Chief Executive___________________________________________________ 5
4.2. Director of Infection Prevention Control (DIPC) ________________________ 5
4.3. Infection Prevention and Control Team _______________________________ 5
4.4. Consultants, Managers/Matrons and Senior Sisters ____________________ 5
4.5. All staff _________________________________________________________ 6
5.
Universal Standard Infection Control Precautions ___________________ 7
5.1. Risk assessment _________________________________________________ 7
5.2. Hand decontamination_____________________________________________ 7
5.3. Personal protective equipment ______________________________________ 8
5.4. Gloves __________________________________________________________ 9
5.5. Disposable aprons and gowns _____________________________________ 10
5.6. Blood/body fluid spillage__________________________________________ 13
5.7. Waste disposal __________________________________________________ 14
5.8. Segregation of waste _____________________________________________ 14
5.9. Sharps _________________________________________________________ 15
5.10.
Inoculation (Sharps) injury ____________________________________ 15
5.11.
Preventing inoculation injury __________________________________ 15
5.12.
Linen disposal ______________________________________________ 16
5.13.
Pathology specimens_________________________________________ 16
5.14.
Decontamination of equipment _________________________________ 17
5.15.
Last offices _________________________________________________ 17
5
Monitoring Compliance ________________________________________ 18
6
Review _____________________________________________________ 19
7
Training_____________________________________________________ 19
8
References __________________________________________________ 20
Appendix 1: Risk assessment Guide for Selection of Protective Equipment
based on risk of Exposure to Blood or Body Fluid ______________________ 21
Appendix 2:
Moments for Hand Hygiene ____________________________ 22
Appendix 3: Guidance for the Selection of Masks ______________________ 23
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Status: Final
Page 2 of 26
Document Control Information ______________________________________ 24
Ratification Assurance Statement _____________________________________ 24
Consultation Schedule _______________________________________________ 25
Equality Impact: (A) Assessment Screening ____________________________ 26
Amendment History
Issue Status
1.0
Approved
Date
April 2011
Reason for Change
Re-ratification
2.0
Dec 2014
Review and Update
Approved
Authorised
Operational Governance
Committee
Helen Blanchard –
Director of Nursing
Ref.: 622
Status: Final
Page 3 of 26
1. Policy Summary
Universal/standard precautions are the practices that must be adopted by all
healthcare workers (HCWs) when potentially coming into contact with any patient’s
blood, tissue or body fluid. They are based on a set of principles designed to
minimise exposure to and transmission of a wide variety of micro-organisms.
Since every patient is a potential infection risk it is essential that universal/standard
precautions are used for all patients all of the time.
The purpose of this policy is to provide guidance for staff within the Royal United
Hospitals Bath NHS Foundation Trust about the requirements and processes for
implementing universal/standard Infection Control Precautions.
There are a number of key elements to universal/standard control precautions, all of
which when appropriately implemented are designed to reduce the risk of
transmission of micro-organisms.
The application of transmission based precautions when patients are managed with
known infections will support the prevention of the spread of healthcare associated
infections.
This policy applies to all individuals in the employ of the Royal United Hospitals Bath
NHS Foundation Trust.
2. Policy Statements
Universal/standard precautions are fundamental in reducing the spread of infection.
The precautions are effective in reducing the risk of transmission of infection to
patients, staff and visitors.
Staff must follow the guidance within this policy to ensure that patient safety is
maintained at all times and that members of staff are also not put at risk of acquiring
an infection whilst working within the Trust.
3. Definition of Terms Used
Universal/standard precautions underpin all infection prevention and control
practice. The precautions must be used for all patients whether they are known to
have an infection or not. Universal/standard precautions are a collection of essential
practices that when used together will reduce the risk of patients, visitors and staff
from developing transmissible infections.
Personal protective equipment (PPE) is the equipment that must be worn by
HCWs to protect patients and staff against the risk of infection.
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4. Duties and Responsibilities
All staff have a responsibility for ensuring that the principles outlined within this
document are universally applied.
The key organisational responsibilities are identified as:
4.1.
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4.2.
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4.3.
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4.4.
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Chief Executive
To ensure that infection prevention and control is a core part of clinical
governance and patient safety programmes
Promote compliance with infection prevention and control policies in order
to reduce health care associated infections
Awareness of legal responsibilities to identify, assess and control risk of
infection
Appoint Director of Infection Prevention and Control
Director of Infection Prevention Control (DIPC)
Oversee infection prevention and control policies and their implementation
Responsible for infection prevention and control team
Report directly to the Chief Executive and Trust Board
Challenge inappropriate hygiene and infection prevention and control
practice
Assess impact of plans / policies on infection control
Member of clinical governance and patient safety structures
Infection Prevention and Control Team
Review and update this policy
Provide additional advice regarding the application of this policy within
clinical areas.
Include universal/standard precautions in all induction and update training
for clinical staff
Promote good practice and challenge poor practice
Consultants, Managers/Matrons and Senior
Sisters
Must establish a cleanliness culture across their units and promote
compliance with infection control guidelines
Ensure that staff attend infection prevention and control training as per the
training matrix
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4.5.
All staff
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The employee has a responsibility to carry out risk assessments and use
the appropriate equipment provided
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Employees are responsible for ensuring that any breach of this policy is
immediately reported to their manager
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All clinical staff must attend the mandatory Infection Prevention and
Control update at two yearly intervals
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Clinical staff have a responsibility towards the safer working practices of
their colleagues or co-workers such as students or trainees under their
supervision
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Page 6 of 26
5. Universal Standard Infection Control Precautions
5.1.
Risk assessment
Implementation of universal/standard precautions is dependent on an initial risk
assessment of the patient, the task being undertaken and the situation. All body
fluids may pose a risk of transmission of micro-organisms.
Staff must select the appropriate protective equipment. The Risk assessment guide
for selection of protective equipment based on risk of exposure to blood or
body fluid: Appendix 1 will support staff in assessing the risk of contamination to
the healthcare workers clothing and skin by the patient’s blood, body fluids,
secretions and excretions.
Additional precautions
Where a patient is known to have a specific infection or colonisation then reference
to specific Infection Control Policy is recommended for additional precautions:
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Antibiotic resistant micro-organisms
Blood borne viruses
Carbapenemase producing Enterbacteriaceae (CPE)
Chicken pox or shingles
Clostridium difficile
Meningitis
Meticillin resistant Staphylococcus aureus (MRSA)
Influenza
Scabies
Transmissible Spongiform Encephalopathy Agents Including CJD and vCJD
Tuberculosis
Viral diarrhoea and vomiting
5.2.
Hand decontamination
Regular hand hygiene must be highlighted as one of the most critical interventions to
prevent cross infection in healthcare facilities (Damani 2012). All employees must
receive training in the appropriate hand hygiene techniques on induction into the
Trust.
Ongoing assessment and training of the techniques are undertaken as part of the
Trust’s mandatory infection control updates for employees working in clinical settings
at two yearly intervals.
The RUH embraces the ‘Five Moments for Hand Hygiene’ Appendix 2 ( WHO 2009),
aiming to link specific hand hygiene actions to specific infectious outcomes in
patients, by giving clear advice on how to integrate hand hygiene into the complex
task of care Appendix 2.
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Bacteria and viruses cannot penetrate intact skin. It is vital to maintain skin in a good
condition and prevent cracking, chapping and drying of the skin. Moisturiser is
available in all clinical areas to maintain skin moisture. Staff must inform their line
manager if their hands become sore or cracked.
Hand decontamination using liquid soap and water
The following activities are examples of when hands must be washed using
detergent and water:
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Whenever hands are visibly dirty
After removal of gloves
Following any handling of blood or body fluids
After any microbial contamination (e.g. wound examination, wound dressing,
sputum aspiration etc)
Before performing an aseptic procedure
Before preparing, handling or eating food
After visiting the toilet
After patient toileting
After handling laundry
After dealing with patients symptomatic with diarrhoea and vomiting
This is not an exhaustive list.
Hand decontamination using alcohol based gel or solution
The following activities are examples of when alcohol based gel or solution can be
used on socially clean hands:
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Prior to and following examination of a patient
Prior to handling patient equipment
On entering and leaving the clinical environment
Between social patient contact e.g. ward rounds
Before entering and leaving an isolation room or area
Before and after transfer of patients from / bed/ chair/ trolley
This is not an exhaustive list. Refer to Hand Decontamination Policy.
5.3.
Personal protective equipment
Personal Protective Equipment (PPE) is additional to normal clothing and uniforms
and is used to protect both the patient and health care worker from the risk of cross
infection. PPE should be available for all staff and may include aprons and fluid
repellent gowns/suits, gloves (sterile and non-sterile latex free), masks and eye
protection (goggles and face visors).
The use and selection of PPE is based on the assessed risk of the clinical
intervention to be undertaken i.e. identify the likelihood and level of risk associated
with contamination by blood and/or body fluids.
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Under Health and Safety legislation the Trust has a responsibility to ensure that staff
have access to appropriate PPE and staff have a responsibility to use PPE in
appropriate situations (Health & Safety Executive 1999).
5.4.
Gloves
The use of gloves can reduce the risk of acquiring infection through direct skin
contact between HCW and patients. Gloves should not be worn unnecessarily or as
a substitute for hand decontamination as prolonged and indiscriminate use may
cause adverse reactions and skin sensitivity (WHO 2009).
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Gloves are a single use item
Gloves can reduce the likelihood of contact dermatitis in staff exposed to
chemical agents
Gloves must be worn when direct contact with contact with blood, body fluids,
non-intact skin or mucus-membranes is anticipated
Gloves must be changed between patients and different procedures on the
same patient
Gloves must not be worn when using computer keyboards, answering the
phone, writing in patient’s care records or serving meals
Gloves must be disposed of in an orange clinical waste bin
Hands must be decontaminated with soap and water immediately on removal
of gloves
Indications for wearing gloves:
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Venepuncture
Wound inspection
Cannula insertion
Aseptic Non Touch Technique
Emptying urinary catheter bags/stoma bags
Cleaning soiled equipment
Cleaning the clinical environment
IV drug administration
Invasive procedures
Contact with body fluids
Surgical procedures – use sterile gloves
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Sterile gloves
Sterile gloves reduce the likelihood of transmission of microorganisms from the
health care worker’s hands to the patient during sterile and invasive procedures
(Damani 2012). Training on the correct procedure for donning and removing sterile
gloves must be provided for staff to prevent the contamination of the outer surface of
the glove and the hands.
Gloves and latex allergy
The standard gloves in use within the Trust are latex free however some staff may
develop sensitivity to other components within the gloves. If a healthcare worker has
a latex allergy or sensitivity to specific chemicals in gloves, they must report this to
their line manager and seek advice from the Occupational Health Department.
Where a patient is known to be allergic to latex staff must ensure that latex free
gloves are used.
Refer to Skin Management, Protective Gloves and Latex Sensitivity Policy
Storage of gloves
Gloves can be damaged if they are stored in adverse conditions. To ensure that
integrity is not affected they must be stored away from direct sunlight, excessive
heat, humidity and moisture. Gloves can also be affected by x-ray machines, high
intensity fluorescent lights and ultraviolet lights. If a box has been opened and stored
in a room with an infected patient the gloves will be exposed to contamination with
microorganisms so it is vital that unused gloves are disposed of once the patient has
been discharged.
5.5.
Disposable aprons and gowns
Disposable plastic aprons or gowns must be worn to reduce the level of
contamination of uniforms/clothing where direct patient care is given and there is
potential for the dispersal of pathogens. The type of apron or gown to be worn
depends on an assessment of risk of contact with body fluids.
Such activities may include:
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Assisting patients with toileting
Bathing
Changing soiled linen
Procedures causing splashing of body fluids or blood
Aprons:
 Must be worn where there is a risk of blood or body fluid contamination of the
uniform/clothing
 Must be changed between patients and different procedures on the same
patient
 The apron must be disposed in an orange clinical waste bin. as clinical waste
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May be worn for decontamination activities, including cleaning and
disinfection
Non-sterile impermeable water repellent gowns are worn:
 where there is a likelihood of splashing with large amounts of blood or body
fluids
 where there is a likelihood of prolonged contact with patients who have multiresistant microorganisms, e.g. Carbapenemase producing
Enterobacteriaceae (CPE)
 when providing care for a patient with possible viral haemorrhagic fever
Like aprons gowns must be removed and replaced after each episode of care or task
and disposed of as clinical waste.
Sterile water-impervious gowns protect patients from infection where they are
undergoing surgical or aseptic procedures such as insertion of central venous
catheters.
Disposable coveralls
Disposable coveralls may be used if there is a risk of contamination from chemicals
or when providing care for a patient with possible/confirmed viral haemorrhagic
fever. Careful attention must be paid when donning and doffing coveralls as there is
a risk that the clothing beneath the suit may become contaminated. Staff must
consult local procedural documents and have received local training on wearing the
suits before using them.
Eye protection
Mucous membranes of the eyes and mouth must be protected when there is a risk of
splashes, droplets or aerosols of blood or body fluids.
Eye protection may be achieved through the use of goggles, visors or face shields.
They must be comfortable to wear, fit correctly and allow for clear vision.
Where possible single use eye protection should be used and this must be disposed
of as clinical waste. If reusable equipment is used it must be decontaminated
appropriately and stored in a clean environment. Eye protection must be worn for
one episode of care only.
Eye protection must be available in all areas especially those where splashes are
more likely, e.g. Emergency Department, Endoscopy, Theatres, Central Delivery
Suite, Critical Care Unit.
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Masks and respirators
Masks are worn to protect the wearer from potential exposure to micro-organisms via
splashes of blood or body fluid.
The use of a mask must be based on an assessment of risk of body fluid exposure.
Staff may select a face mask or respirator depending on the level of protection
required. Refer to Guidance for the selection of masks: Appendix 3
Masks are rarely worn in general ward environments.
Surgical face masks protect the wearer from expelling droplets (>0.5 microns) into
the environment. If the mask is fluid resistant, the wearer will be protected from
splashes.
Respirators are made to specific standards EN 149 2001, FFP2, FFP3.
Respirators are worn to protect the healthcare worker from airborne particles
(<0.5microns) such as viruses. Staff must receive training in the correct application
of these masks to ensure their efficacy.
Guidance for the selection of masks
Selection of the appropriate mask is required to ensure protection is adequate.
 Where a mask is required it should be applied prior to entering the isolation
room
 Masks must be worn correctly and be close fitting
 Masks must be handled as little as possible
 Masks must be changed between operations or patients
 Masks must be changed if wet
 Discard masks immediately after removal into an orange clinical waste bin
 Hands must be washed on removal of mask
Guidance for the selection of masks: Appendix 3.
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5.6.
Blood/body fluid spillage
Protective clothing, e.g. gloves and apron, must be worn when dealing with
blood/body fluid spillage. The area must be made safe to prevent further
contamination and protect staff and patients.
Blood/body fluid spillage can be divided into groups:
 Soiling of equipment or where it is not practicable to use a hypochlorite
powder e.g. splashes and drips
 Spillage on the floor or a large surface area
Methods to clean up blood spills
Splashes and drips
 Use PPE: gloves and apron
 Wipe the area immediately with a paper towel soaked sodium
hypochlorite solution e.g. Actichlor Plus® 10,000 ppm (10 x 1.7g tablet
in one litre of cold water)
 Discard gloves and paper towel as clinical waste using an orange
waste bag
 Wash hands with soap and water and dry hands immediately
Larger spills
 Use PPE: gloves and apron
 Sprinkle the spill with NaDCC (a solid form of hypochlorite) granules
e.g. Titian Sanitizer™ until the fluid is absorbed. Leave the spill for a
contact period of about 3-5 minutes to allow for disinfection.
 Either scoop up the granules and any paper towels used and discard
into an orange clinical waste bag
 Wipe the area immediately with a paper towel soaked sodium
hypochlorite solution e.g. Actichlor Plus® 10,000 ppm (10 x 1.7g tablet
in one litre of cold water)
 Discard gloves and paper towel as clinical waste using an orange
waste bag
 Wash hands with soap and water and dry hands immediately
Body fluids, eg vomit, urine, faeces
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Use PPE, wear gloves and apron
Clear away spillage with paper roll
Wash area with detergent and water using paper roll
Dispose of used paper roll in an orange clinical waste bin
Dispose of PPE in an orange clinical waste bin
Decontaminate hands using soap and water
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5.7.
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5.8.
Waste disposal
Waste bins/bags must be of the appropriate UN-approved type, colour,
size
Adequate supplies of waste bags/bins must be available to ensure that
waste segregation is able to take place correctly
Waste bag holders are fire-proof, leak-proof, foot pedal operated, secure,
well-maintained and clean
Signs and notices must be displayed to ensure that staff can quickly refer
to correct information about segregation of waste and the correct
container to use
Waste bins and other containers must be kept clean
Segregation of waste
All waste is to be segregated at the point of use.
The most common waste categories are:
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Orange bag: potentially infectious clinical waste
Tiger striped bags: disposal of offensive non-infected waste
Yellow bag: Diagnostic specimens from permitted areas only
Sharps bins: yellow lidded sharps bins take standard clinical sharps including
sharps contaminated with medicines; purple lidded bins take sharps
contaminated with cytotoxic/cytostatic substances
Yellow burn bins: Recognisable anatomical waste, drugs for incineration must
go in separate burn bin (refer to waste policy)
Black bags, General non-recyclable and non-hazardous waste
Clear plastic bags: Waste for recycling i.e. paper, cans, plastic bottles and
containers, separated and put into tied, clear plastic bags & flattened
cardboard, loosely loaded
Hazardous Waste (e.g. solvents and chemicals, aerosols, gas cartridges,
chemicals, oils, batteries, inkjet and toner cartridges, tyres, fluorescent tubes
and compact fluorescent lights (CFLs), mercury, sodium lamps, waste
electrical and electronic equipment (WEEE)
Orange clinical waste bags and ‘tiger striped’ bags must be closed using the ‘swan
necked’ method and tied with a coded zip tie.
Only staff that have been trained and are aware of the correct procedure should be
involved in the handling of clinical waste.
Sharps bins must be kept separate from other clinical waste and MUST NOT be put
into clinical waste bags.
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In order for waste to be traced back to the point of generation:
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Sharps bins must have the front label fully completed and signed
Burn boxes must be have the RUH Department name, date and signature of
the person who closed the box written on the box
Refer to Management and Disposal of Waste policy.
5.9.
Sharps
Sharps can be defined as any object in the healthcare setting that could puncture the
skin and permit the entry of bacteria or viruses into the body.
Sharps include needles, scalpels, suture needles, lancets, scissors, surgical
instruments stitch cutters, glass ampoules, intravenous cannulae, vacuum blood
collecting systems, fragments of bone and patient’s teeth. This is not an exhaustive
list.
Where possible the sharps provided by the Trust will have a safety mechanism built
into their design. The safety mechanism must be used to prevent the risk of
inoculation injuries.
5.10. Inoculation (Sharps) injury
An inoculation injury occurs where a needle or other sharp contaminated with blood
or other high risk body fluid penetrates percutaneously (through the skin). Such
injuries also include cuts, pinches, scratches, bites which break the skin and
splashes of body fluids to the eyes.
Accidents with needles are the most common, so injuries from sharps are often
called needle stick injuries.
5.11. Preventing inoculation injury
The emphasis on preventing contaminated inoculation injury must focus on ensuring
safe handling practices are in place. Staff must:
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Attend the appropriate Infection Prevention and Control training,
Use appropriate PPE,
Always discard used sharps into a sharps container at the point of use,
Ensure that needles are not re-sheathed,
Use a clean plastic tray to carry sharps; never carry loose sharps in your
hands,
Ensure that sharps containers are not filled above the mark indicating they are
full,
Use temporary closure mechanisms when sharps boxes are not in use,
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Locate sharps containers in safe positions, e.g. secured to a wall and away
from children’s reach,
Report all incidents (including near misses) involving contaminated sharps at
the time of occurrence, or as soon as possible afterwards, to the line
manager/Supervisor/Team Leader on duty and Occupational Health.
Refer to Sharps Policy.
5.12. Linen disposal
Used linen is a potential source of infection as it is likely to be contaminated with
potentially pathogenic organisms.
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Gloves and aprons must be worn when dealing with soiled, wet or blood
stained linen
Linen should be bagged by the bedside, never carried through a clinical area
by hand
Linen bags must be half full only. They must not be overfilled
Linen from infected patients or blood stained must be placed in an inner red
alginate bag, and then placed into an outer white plastic bag
When removing soiled linen avoid the production of aerosols
If patient’s clothing is being laundered at home, place soiled laundry in a
water soluble clothing bag, inside an outer plastic bag. Inform visitors that
laundry is awaiting collection in the patient’s locker
Refer to Linen Policy.
5.13. Pathology specimens
All specimens should be handled with care. PPE must be used when handling
specimens.
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All specimens must be safely contained in a leak proof container which is
additionally placed in a sealed polythene bag
Ensure the outside of the container and bag remain free from contamination
with blood or body fluids
Bio-hazard specimens from known or clinically suspected infected
patients
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If there is a risk of spillage of contents then the specimen should be placed
inside a second polythene bag i.e. ‘double bagging’.
The following bio-hazard specimens must not be sent via the vacuum tube
system;
 Classic or variant Creutzfeldt-Jakob disease (CJD)
 Diphtheria
 Hepatitis B or C
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HIV
Paratyphoid
Rabies virus
Tuberculosis
Typhoid
If Viral Haemorrhagic fever is suspected, the microbiologist must be contacted
before any specimens are taken or sent
5.14. Decontamination of equipment
Reusable equipment can be a potential source of infection if not appropriately
decontaminated after each use.
Cleaning is an essential stage in the decontamination process and must always
precede disinfection and /or sterilization. Selection of the appropriate
decontamination method will ensure that the equipment is clean and fit for purpose.
Check manufacturer’s instructions for use of suitable cleaning agents.
The user of the device is responsible for ensuring that it is visibly clean and free
from contamination with blood/body fluids following each procedure and prior to reuse or prior to sending for repair (internally/externally).
The user must sign and date the appropriate labels to confirm that cleaning has
taken place.
During decontamination, the user must check clinical equipment for signs of damage
and send for repair or disposal if appropriate.
A completed label must accompany each piece of equipment sent for repair.
Suitable personal protective equipment must be worn during decontamination
procedures to protect the healthcare worker from exposure to microorganisms or
infectious agents, where the risk of splash is anticipated.
Refer to Decontamination Policy for detailed guidance of suitable methods of
decontamination
5.15. Last offices
When carrying out the last offices the following should be implemented.
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Wear PPE; gloves and apron
Remove all drains, catheters and intravenous lines except where a post
mortem is required
Contain leakage from wounds and line sited by ensuring they are covered
with a waterproof dressing
After carrying out last offices a body bag must be used in the following
circumstances:
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When a body is leaking body fluids or there is gross external contamination
with blood
Staff must ensure that mortuary staff are aware of the reason for using a body
bag
When a patient has or is strongly suspected of having one of the following
biohazard conditions:
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Anthrax
Classic or variant Creutzfeldt-Jakob disease (CJD)
Diphtheria
Hepatitis B, C
HIV
Meningococcal septicaemia / meningitis if death occurs before 48
hours of appropriate antibiotic therapy being completed
Rabies virus
Invasive β-haemolytic Streptococcus Group A disease if death occurs
before 48 hours of appropriate antibiotic therapy being completed
Tuberculosis
Typhoid/ Paratyphoid
Viral Haemorrhagic fever
Any soiled patient’s clothing must be placed in a water soluble clothing bag
which must be secured and placed inside a property bag. Any itemised list of
contents must be attached.
If in doubt contact the Infection Prevention and Control Team - Bleep 7991
5 Monitoring Compliance
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

Infection Prevention and Control Team will audit components of the policy as
part of the annual audit programme with the support of the Audit department.
Audits of compliance with the policy will be undertaken by Ward
managers/Senior Sisters using the ‘Saving lives High Impact Interventions’
audit tools
Results of audits are reported weekly via the HCAI report and at the Infection
Prevention and Control Committee which meets every two months.
Where short falls are identified, Ward managers and Matrons will ensure that
improvement programmes are agreed and put in place to improve
compliance.
Ref.: 622
Status: Final
Page 18 of 26
6 Review
This policy will be subject to a planned review every three years as part of the Trust’s
Policy Review Process. It is recognised however that there may be updates required
in the interim arising from amendments or release of new regulations, Codes of
Practice or statutory provisions or guidance from the Department of Health or
professional bodies. These updates will be made as soon as practicable to reflect
and inform the Trust’s revised policy and practise.
7 Training
Managers are responsible for ensuring all their staff receive the type of initial and
refresher training that is commensurate with their role(s).
Staff must refer to the Mandatory Training Profiles, available on the intranet, to
identify what training in relation to Infection Prevention and Control is relevant for
their role and the required frequency of update. Further information is available on
the statutory and mandatory training web pages about each subject and the
available training opportunities.
The Mandatory Training Policy identifies how training non-attendance will be
followed up and managed and is available on the intranet.
Training statistics for mandatory training subjects are collated by the Learning &
Development team, and are reported to the Strategic Workforce Committee.
Staff must keep a record of all training in their portfolio.
All staff and managers can access their mandatory training compliance records via
the Trust’s mandatory reporting tool (STAR) available on the intranet.
Ref.: 622
Status: Final
Page 19 of 26
8 References
Damani, N (2012) Manual of Infection Prevention and Control Third edition. Oxford
University Press, Oxford.
Department of Health. Saving Lives: reducing infection, delivering clean and safe
care. London: Department of Health. 2007
Department of Health. The Health and Social Care Act 2008 – Code of Practice on
the prevention and control of infections and related guidance. London: Department of
Health. 2010.
Fraise, A and Bradley, Christine (eds) (2009) Alliffe’s Control of Healthcare –
associated Infection. London, Hodder Arnold
Health & Safety Executive, Control of Substance Hazardous to Health (COSHH)
1999
National Audit Office. Reducing Healthcare Associated Infections in Hospitals in
England. London. The Stationary Office. 2009
Loveday H.P. et al (2014) epic3: National Evidence-Based Guidelines for Preventing
Healthcare-Associated Infections in NHS Hospital in England. Journal of Hospital
Infection 86S1 S1-S70
Protective clothing – Principles and Guidance. Infection Control Nurses Association
2002
WHO Guidelines on Hand Hygiene in Health Care (2009). World Health Organisation
Ref.: 622
Status: Final
Page 20 of 26
Appendix 1: Risk assessment Guide for Selection
of Protective Equipment based on risk of
Exposure to Blood or Body Fluid
Assess actual and potential risk of blood or
body fluid exposure in task being
undertaken
No
blood/body
fluid contact
1. Gloves not required
2. Apron if clothing may
be exposed i.e. moving
patient or bed making
3. Eye protection and
mask not required
4. Wash hands before
and after contact
5. Dispose of linen in
white linen bag at
bedside
6. Decontaminate
equipment between
patients
7. Dispose of waste
appropriately
Potential
exposure to
blood/body fluid.
High risk of
splash
1. Wear gloves
2. Wear apron as above
and if splash to clothing
likely
3. Wear mask/eye
protection if appropriate
4. Dispose of soiled
linen as infected i.e. red
alginate bag then red
plastic bag at bedside
5. Dispose of soiled
waste in orange clinical
waste bags
6. Decontaminate
equipment with
appropriate method
7. Wash hands after
contact and removal of
gloves
Potential exposure to
blood/body fluid.
Low risk of splash patient
confirmed as infectious
e.g. Chicken pox, MRSA,
Clostridium difficile, TB
1. Wear gloves
2. Wear apron
3. Wash hands before and
after patient contact and on
removal of gloves
4. Wear mask if
appropriate
5. Wear eye protection if
appropriate
6. Dispose of soiled linen
as infected at bedside
7. Dispose of soiled waste
in orange clinical waste
bags
8. Decontaminate
equipment appropriately
Ref.: 622
Status: Final
Page 21 of 26
Appendix 2: Moments for Hand Hygiene
The RUH embraces the ‘Five Moments for Hand Hygiene’ ( WHO 2009), aiming
to link specific hand hygiene actions to specific infectious outcomes in patients, by
giving clear advice on how to integrate hand hygiene into the complex task of care.
1. Before patient contact
When? Clean your hands before touching a patient when approaching him/her.
Why? To protect the patient against harmful germs carried on your hands
2. Before a clean/aseptic procedure
When? Clean your hands immediately before a clean/aseptic procedure.
Why? To protect the patient from harmful germs, including the patient’s own from
entering his/her body.
3. After body fluid exposure risk
When? Clean your hands immediately after exposure risk to body fluids and after
glove removal.
Why? To protect yourself and the healthcare environment from harmful patient
germs.
4. After patient contact
When? Clean your hands after touching a patient and his/her immediate
surroundings when leaving the patient’s side.
germs.
5. After contact with the patient’s surroundings
When? Clean your hands after touching any object or furniture in the patient’s
immediate surroundings when leaving – even if the patient has not been touched
germs.
Ref.: 622
Status: Final
Page 22 of 26
Appendix 3: Guidance for the Selection of Masks
Type of mask
Standard Surgical mask
Protection provided
 Basic protection
 No fluid repellence
Surgical mask with fluid shield


Direct fluid repellence
No eye protection
Surgical mask with fluid shield
and integral visor


Fluid repellence
Eye protection
High level protection PFR mask

conforming to EN149 (Sometimes 
called ‘Duck bill’)


or FFP3 valved respirator mask

Indication for use
 Immuno-suppressed
patient
 Circulating theatre
staff
 Patients with Group
A Streptococcus
when changing
dressings or
undertaking aerosol
generating
procedures
 Patients with
bacterial meningitis,
Diphtheria, RSV or
bronchiolitis
 Non-immune staff
caring for patients
with mumps,
measles, chickenpox
or rubella.
 Surgical scrub team
 During procedures
that are likely to
generate splashes of
blood or body fluids


Surgical scrub team
Emergency
Department
High standard

Filters 0.2 - .5 microns
Lasts up to 8 hours
Suitable for high risk

procedures
Staff require training
to ensure ‘fit’ is correct 


Tuberculosis – for
aerosol generating
procedures (see TB
policy)
Multi drug resistant
Tuberculosis
Influenza
SARS
Viral haemorrhagic
fevers
Ref.: 622
Status: Final
Page 23 of 26
Document Control Information
Ratification Assurance Statement
Dear
Helen Blanchard
Please review the following information to support the ratification of the below named
document.
Name of document:
Universal/Standard Infection Control Precautions
Name of author:
Yvonne Pritchard
Job Title:
Senior Infection Prevention and Control Nurse
I, the above named author confirm that:

The Policy presented for ratification meets all legislative, best practice and other
guidance issued and known to me at the time of development of the Policy;

I am not aware of any omissions to the Policy, and I will bring to the attention of the
Executive Director any information which may affect the validity of the Policy
presented as soon as this becomes known;

The Policy meets the requirements as outlined in the document entitled Trust-wide
Policy for the Development and Management of Policies (v4.0);

The Policy meets the requirements of the NHSLA Risk Management Standards to
achieve as a minimum level 2 compliance, where applicable;

I have undertaken appropriate and thorough consultation on this Policy and I have
documented the names of those individuals who responded as part of the
consultation within the document. I have also fed back to responders to the
consultation on the changes made to the Policy following consultation;

I will send the Policy and signed ratification checklist to the Policy Coordinator for
publication at my earliest opportunity following ratification;

I will keep this Policy under review and ensure that it is reviewed prior to the review
date.
Signature of Author:
Name of Person
Ratifying this policy:
Helen Blanchard
Job Title:
Director of Nursing and Midwifery
Signature:
Date:
17 December
2014
Date:
19 December
2014
To the person approving this policy:
Please ensure this page has been completed correctly, then print, sign and
post this page only to: The Policy Coordinator, John Apley Building.
The whole policy must be sent electronically to: [email protected]
Ref.: 622
Status: Final
Page 24 of 26
Consultation Schedule
Name and Title of Individual
Dr E Abrishami, Consultant Microbiologist and
Infection Control Doctor
Helen Blanchard, Director of Nursing and
Midwifery/DIPC
Bupe Banda, Occupational Health Nurse
Bronia Charity, Stores Manager
Julia Bloomfield, Infection Prevention and Control
Nurse
Dana Di.Iulio, Infection Prevention and Control Nurse
Katie White, Infection Prevention and Control Nurse
Lucy Butcher, Infection Prevention and Control Nurse
Judy Bull, Sterile Services Manager
Gareth Veal, Estates Compliance Manager
Tim Evans, Portering Manager
Mark Grover, Respiratory Nurse Specialist
Jo Miller, Head of Nursing Medicine
Sharon Bonson, Head of Nursing Surgery
Vicky Tinsley, Head of Nursing and Midwifery Women
and Children’s
Date Consulted
10.11.2014
Amanda Speed, Biomedical Scientist, Haematology
Department, Pathology Laboratory
11.12.2014
Christine Williams, Biomedical Scientist, Haematology
16.12.2014
01.12.2014
10.11.2014
10.11.2014
10.11.2014
10.11.2014
10.11.2014
10.11.2014
10.11.2014
10.11.2014
10.11.2014
10.11.2014
10.11.2014
10.11.2014
10.11.2014
The following people have submitted responses to the consultation process:
Name and Title of Individual
Julia Bloomfield, Infection Prevention and Control
Nurse
Mark Grover, Respiratory Nurse Specialist
Date Responded
14.11.2014
Ref.: 622
Status: Final
Page 25 of 26
08.12.2014
16.12.2014
16.12.2014
Equality Impact: (A) Assessment Screening
To be completed when submitted to the appropriate Executive Director for
consideration and approval.
Person responsible for the assessment:
Name:
Job Title:
Yvonne Pritchard
Senior Infection Prevention and Control Nurse
Does the document/guidance affect one
group less or more favourably than another
on the basis of:
Yes/No
Race
Yes
No
Ethnic origins (including gypsies and travellers)
Yes
No
Nationality
Yes
No
Gender (including gender reassignment)
Yes
No
Culture
Yes
No
Religion or belief
Yes
No
Sexual orientation
Yes
No
Age
Yes
No
Yes
No
Is there any evidence that some groups are affected
differently?
Yes
No
If you have identified potential discrimination, are there
any valid exceptions, legal and/or justifiable?
Yes
No
N/A
Is the impact of the document/guidance likely to be
negative?
Yes
No
N/A
If so, can the impact be avoided?
Yes
No
N/A
What alternative is there to achieving the
document/guidance without the impact?
Yes
No
N/A
Can we reduce the impact by taking different action?
Yes
No
N/A
Disability
(learning disabilities, physical disability, sensory impairment and
mental health problems)
Comments
If you answered NO to all the above questions, the assessment is now complete, and no
further action is required.
If you answered YES to any of the above please complete the
Equality Impact: (B) Full Analysis
Ref.:622
Status: Final
Page 26 of 26

Universal/Standard Infection Control Precautions

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