Section 20 UNIVERSAL (STANDARD) PRECAUTIONS

NHS Eastern and Coastal Kent Community Services Infection Control Manual

Section 20UNIVERSAL (STANDARD) PRECAUTIONS

Note:This manual is as an additional resource supporting the Infection Prevention and otherNHS Eastern and Coastal Kent Community Services Policies.

As such any policy or protocol that has been developed and ratified by CommunityServices will supersede in whole or part all other protocols.

Document Reference No. IPC 0020P

Status Ratified

Version Number Version 1.0

Target audience/applicable to All Staff

Author Health Protection Unit

Acknowledgements

Authorised/Ratified by Clinical Quality & Safety Committee

Authorised/Ratified On 3rd February 2009

Contact Point for Queries [email protected]

Date of Implementation 23rd February 2009 / Circulation

Expiry date End October 2010

Circulation All Clinical Areas via Heads of Service

Review date July 2010

Review criteria This document will be reviewed prior to review date if alegislative change or other event otherwise dictates.

Copyright NHS Eastern and Coastal Kent Community Services2009

1


Infection Prevention and Control Manual

Section 20UNIVERSAL INFECTIONCONTROL PROCEDURES

2


Contents

Page

Title page 1

Contents 2

General Introduction 4

Hand Hygiene - Introduction 5

Procedure for handwashing and hand decontamination 6

When to wash hands 8

Nail brushes 9

Care of hands 9

Broken skin 9

Wearing of jewellery 9

Personal Protective Clothing 10

Gloves 10

Latex allergies 12

Sterile versus non-sterile gloves 12

Disposable aprons 12

Facial protection 13

Waste disposal 14

Action to be taken in the event of needlestick injuries 14or exposure to blood/body fluids

Blood and body fluid spillages 15

Procedure for cleaning of blood spills 15

3


References 17

Appendix A .1 – Handwashing technique 18

Appendix A.2 – Use of alcohol hand gel 19

Appendix B – Uses of Sodium hypochlorite and 20strengths of solution

Policy review page 21

4


Universal (standard) Infection Control Procedures

General introduction

The principles of universal (standard) infection control precautions represent a standardof good hygiene measures that should be applied as normal practice (Wilson 1999) inall clinical settings. These measures are the most important means of protectingpatients and staff from infection.

The guidelines produced by the National Institute for Health and Clinical Excellence(NICE 2003) about the prevention of healthcare-associated infections in primary andcommunity care state the following:“Everyone involved in providing care in the community should be educated aboutstandard principles and trained in hand decontamination, the use of protective clothingand the safe disposal of sharps.”

“Essential steps to safe, clean care” (DH 2006) is the community adaptation of the “DHSaving Lives” document, and describes six steps to managing infection risks andpromoting safe standards in healthcare. Within the document, there are three key areasidentified as risk elements:

o Reducing the risk of microbial contamination in everyday practice and to ensurethere is a managed environment that minimizes the risk of infection to patients,clients, staff and visitors.

o To reduce the occurrence of urinary tract infections relate to indwelling urethralcatheters.

o To reduce the risk of infection associated with enteral feeding.

This document enables organizations to develop a framework to support their own useof best practice to prevent and manage the spread of infection and ultimately improvepatient and service user safety.Hand hygiene, aseptic technique, use of PPE and safe disposal of sharps are one of thekey elements of this document.

Universal (standard)l precautions include:

a. Hand hygiene and care of the hands.

b. Use of personal, protective clothing.

c. Covering of existing cuts or skin lesions and all breaks in the skin on hands andarms with waterproof dressing.

d. Safe handling and disposing of sharps.

e. Cleaning up spillages of blood promptly and decontamination of surfaces.

f. Following safe procedures for disposal of clinical waste.

g. Safe handling of specimens.

5


Hand Hygiene

Introduction

Hand-mediated transmission (spread) of infection is a main contributory factor to theinfection risks for hospital in-patients. These include both methicillin-sensitive andmethicillin-resistant Staphylococcus aureus (MSSA and MRSA), and multi-resistantGram-negative aerobes and enterococci. Microorganisms transmitted on the hands of ahealthcare worker can be spread from one patient to another, or hands can acquiremicroorganisms from the environment, which can then be spread to a patient. This canseriously affect the outcome of patient care.

The following facilities are needed for healthcare staff to carry-out a good standard ofhand hygiene in healthcare settings:

1. Adequate stocks of liquid soap, alcohol handrub and paper towels should beavailable wherever hand hygiene is carried out (NICE 2003). In addition, thefollowing should be in place:

a. Hot and cold running water (wrist, elbow, knee or sensor-operated mixer orthermostatically controlled taps).

b. Liquid soap and disposable paper towels in wall mounted dispensers.

c. A household waste bin with a foot operated lid to dispose of paper towels.

2. The above handwashing facilities should be available in the following areas:

a. All clinical areas.

b. All communal toilets and bathrooms.

c. The sluice and other cleaning areas.

d. All consulting and examination rooms.

e. All kitchen and eating areas.

f. All single rooms (NHS Estates 2002).

g. All laundry areas

6


Procedure for handwashing and hand decontamination

3. The following handwashing technique and guidance are recommended (Pratt et al 2007):a. Before regular hand decontamination begins, remove all wrist and hand jewellery.

b. Cover cuts and abrasions with waterproof dressings.

c. Fingernails should be kept, short, clean and free from nail polish. False nails andnails decorated with nail art should be removed.

4. An effective handwashing technique should involve the following four stages:preparation, washing, rinsing and drying.

5. The Department of Health recommends the following hand washing procedure (seeAppendix A.1):

a. Wet the hands and forearms up to the wrists.

b. Apply one or two squirts of liquid soap to the hands.

c. Rub vigorously to work up a good lather on the surface of the hands.

d. To ensure all the surfaces of the hands are included, do the following actions(3 - 9) six times each:

e. Rub palm to palm.

f. Rub the right palm over the back of the left hand.

g. Rub the left palm over the back of the right hand.

h. Interlace the fingers palm to palm and rub.

i. Rub the backs of the fingers in the back of the opposing palm.

j. Rub the right thumb while rotating in the left hand.

k. Rub the left thumb while rotating in the right hand.

l. Rub the right palm with the backs of the finger tips of the left hand.

m. Rub the left palm with the backs of the finger tips of the right hand.

6. The above procedure should take between 15 – 20 seconds.

7


7. Hands should be dried thoroughly with good quality paper towels. Use at least onepaper towel for each hand and ensure that all surfaces of the hands are dried.

8. A wall chart of how to wash the hands should be displayed in areas where handhygiene takes place (Appendix A.1).

9. An emollient hand cream should be regularly applied to protect skin from thedrying effects of regular hand decontamination. If a member of staff suffers skinirritation as a result of using a particular soap, antimicrobial hand wash or alcoholproduct at work, the occupational health team should be consulted.

10. The rationale for carrying out the above procedures is:

a. Rinsing-off soap from the surface of the hands thoroughly rinses off the microbesloosened from the surface of hands during vigorous hand washing.

b. Using the wrists or elbows to turn-off wrist or elbow-operated taps avoids re-contaminating hands. When turning-off hand-operated taps, use a paper towelto turn off the taps for the same reason.

c. Use one paper hand towel for each hand so that each hand is thoroughly dried.

d. The use of an alcohol hand rub/gel preparation may be advised in somecircumstances to compliment the use of soap and water e.g. before doing anaseptic procedure (Ayliffe et al 1999). Alcohol hand rub can also be used as analternative to hand washing when hands are visibly clean and have not been incontact with blood or body fluids (Pratt et al 2007). Please refer to Appendix A.2for a poster describing the correct use of alcohol hand gel. Alcohol gel can beused several times in succession, after which it will build up a sticky residue onthe surface of the hands; it should then be washed off.

11. Pratt et al (2007) recommend the following when using alcohol hand gel/rub:

a. Hands must be free of dirt and organic matter.

b. The hand rub solution must come into contact with all surfaces of the hands.

8


c. The hands must be rubbed together vigorously, paying particular attention to thetips of the fingers, the thumbs and the areas between the fingers, until thesolution has evaporated and the hands are dry.

d. Alcohol handrubs are a practical and readily acceptable alternative tohandwashing, when the hands are visibly clean and have not come into contactwith body fluids.

e. It is recommended that alcohol handrub dispensers are placed in all appropriateareas in every ward, bay and single room to encourage all staff and visitors tocomply with good hand hygiene. Risk assessments should be done to ensure thatalcohol hand gel is not accessible to unauthorised individuals or to those whomay not understand the implications of its misuse.

When to Wash Hands

12. Pratt et al (2007) states that hands should be decontaminated immediately beforeall episodes of direct patient contact and after any activity or contact thatpotentially results in hands becoming contaminated.

13. If hands are visibly soiled or potentially grossly contaminated with dirt or organicmaterial, they must be washed with liquid soap and water.

14. An alcohol-based hand rub or liquid soap and water should be used todecontaminate hands in between caring for different patients, or in betweendifferent caring activities for the same patient.

15. Hands should be washed/decontaminated (as a minimum standard) at the followingtimes:

a. Before and after each work shift or work break.

b. Before and after food handling or preparation.

c. Before and after caring for a patient.

d. Before and after any clinical procedure.

e. After contact with blood or other body fluid or any other contaminant.

f. After using the toilet.

g. Before and after wearing gloves.

h. If hands are visibly soiled.

9


i. After helping a patient with personal hygiene, taking a patient to the toilet orgiving a bedpan or commode.

j. After smoking.

See Appendix A.1 for a handwashing poster suitable for display in all hand washing areas.See Appendix A.2 for a alcohol hand gel/rub poster suitable for display in clinical areas.

Nail Brushes

16. Nailbrushes are not recommended as they are often contaminated with bacteria(Ayliffe et al 1999) and can damage the skin and allow bacteria to enter. Ifnailbrushes are to be used in clinical areas, they must be single use disposable ones.

Care of Hands

17. Staff should care for their hands to prevent dry cracked skin conditions developing,which are often caused by failure to rinse and dry hands properly. Regular use ofmoisturising hand cream is recommended to help protect the skin (Pratt et al 2007).Hand cream should be presented in individual tubes or pump dispensers.Communal pots and containers must not be used (Gould 1994) because theybecome contaminated and act as a reservoir for potentially harmful microbes.

18. Nails should be kept short and clean. Nail varnish, false nails, nail-art nails or nailextensions should not be worn in clinical settings since they are difficult to cleanthoroughly and can harbour micro-organisms, and have been implicated in anoutbreak of infection (Pratt et al 2007).

Broken Skin

19. Cuts and abrasions on the hands and forearms should be covered with awaterproof plaster. Blue plasters should be used by food handlers or caterers.Gloves may need to be worn if the hands are extensively affected.

20. Healthcare practitioners who have chronic skin lesions on the hands and/orforearms should not perform invasive or exposure prone procedures. Advice shouldbe sought from Occupational Health or the person’s GP.

Wearing of Jewellery

21. Ornate rings and wristwatches/bracelets should not be worn during clinicalprocedures as they can harbour bacteria, may damage patients’ skin (Larson 1985)and prevent thorough hand washing.

10


Personal Protective Clothing22. A risk assessment should be carried out for all clinical tasks when there is exposure

to blood and/or body fluids. Personal protective equipment must be available in allareas when there is expected to be contact with blood or body fluids.

23. Pratt et al (2007) state that protective equipment should be selected according toan assessment of the risk of transmission of microorganisms to the patient orhealthcare staff, and the risk of contamination of the healthcare practitioner’sclothing and skin by patients’ blood, body fluids, secretions or excretions.

Gloves24. Gloves provide a barrier and help protect the skin. However, they are not an

alternative to good handwashing practices. If an activity has been assessed to carrya risk of exposure to blood, body fluids, secretions or excretions, or sharp orcontaminated instruments, disposable gloves should be worn.

25. Pratt et al (2007) state that sterile gloves must be worn for invasive procedures,contact with sterile sites and non-intact skin or mucous membranes.

26. Gloves must be worn for all activities that have been assessed as carrying a risk ofexposure to blood, body fluids, secretions and excretions.

27. Gloves must be worn when handling sharp or contaminated instruments.

28. Gloves must be worn as single-use items. They must be put on immediately beforean episode of patient or treatment and removed as soon as the activity is complete.

29. Gloves must be changed between caring for different patients, and betweendifferent care or treatment activities for the same patient.

30. Gloves must be disposed of as clinical waste and hands must be decontaminatedafter the gloves have been removed, ideally by washing with liquid soap and water(Pratt et al 2007)..

31. The gloves provided in clinical areas should be acceptable to the healthcarepersonnel wearing them and should conform to European Community (CE)standards.

32. Sensitivity to natural rubber latex in patients, carers and healthcare personnel mustbe documented. Alternatives to natural rubber latex gloves must be available sothat neither patient nor health care worker is put at risk by contact with asensitizing agent.

11


33. Powdered gloves, plastic and polythene gloves should not be used in healthcareactivities.

32. Gloves should be single use, disposable, non-powdered latex, nitrile or vinylmaterials; vinyl gloves must be made to European Standards (Pratt et al 2007). Clearpolythene or plastic gloves are highly permeable to bacteria and often split duringuse, therefore must not be used in the clinical area. Hands should be washed afterremoval of gloves; the micro-organisms living naturally on the surface of the handsmay multiply on the warm, moist skin that the wearing of gloves induces. For thisreason, gloves should be worn for the shortest time practicable.

33. Staff should use sterile surgeons’ gloves for surgical or invasive procedures.

34. Sterile examination gloves should be worn for:

a. Direct contact with broken skin.

b. All aseptic procedures.

c. Vaginal examination following ruptured membranes, delivery or surgery.

d. Handling sterile pharmaceutical preparations.

35. Non-sterile latex or nitryl gloves should be worn for direct contact with blood,faeces, vomit, urine and other body fluids, including wounds, e.g. weeping legulcers, and dressings. Gloves must also be worn in the following situations:

a. Intravenous cannulation.

b. Catheter care.

c. Venepuncture.

d. Handling cytotoxic materials.

e. Per rectum procedures including examination, insertion of suppositories or enemas.

f. Performing wound dressings with forceps.g. Direct patient contact or contact with excretions or secretions for patients who

are being barrier nursed using Isolation Precautions.

h. Handling infected or contaminated linen.

i. Handling used or contaminated instruments or equipment.

j. Handling clinical waste.

12


36. Gloves should be disposed of in a clinical waste bag on completion of theprocedure, and hands should ideally be washed with liquid soap and warm water ordecontaminated with alcohol hand gel or rub if hand washing facilities are notavailable.

37. Gloves must be changed between dirty and clean procedures.

Latex Allergies

38. Latex, the sap of the Brazilian rubber tree, contains naturally occurring allergenscausing sensitivity in some people. This sensitivity can be increased due to chemicalsadded to the latex.

39. Staff should be aware that if any signs of irritation develop after glove use, theyshould inform their manager and contact their Occupational Health Department orGeneral Practitioner for advice.

40. Non-powdered/latex free/synthetic gloves must be provided for staff and patientsthat have latex allergies (Pratt et al 2007).

Sterile Vs Non-sterile Gloves

41. Sterile latex gloves, or sterile non-latex gloves if latex allergy, should be worn duringall surgical procedures and during aseptic invasive procedures with potentialexposure to blood or body fluids (Pratt et al 2007).

42. Non-sterile gloves are required during procedures when hands are likely to becomecontaminated with organic matter and micro -organisms (e.g. removing ofdressings, venepuncture, cleaning blood/body fluid spills) or when handling sharp orcontaminated instruments or equipment (Pratt et al 2007.

Disposable Aprons

43. Pratt et al (2007) state that disposable plastic aprons should be worn when there isa risk of clothing becoming exposed potential pathogenic microbes found in blood,body fluids, secretions or excretions, with the exception of perspiration.

13


44. Full-body fluid-repellent gowns should be worn if extensive splashing of blood, bodyfluids, secretions or excretions, (with the exception of sweat), onto the skin orclothing of healthcare personnel is anticipated (e.g. when assisting with childbirth).

45. Plastic aprons should be worn as single-use items for one procedure or episode ofpatient care, and then discarded and disposed of as clinical waste. Non-disposableprotective clothing should be sent for laundering.

46. Disposable plastic aprons provide an effective barrier and should be used in thefollowing situations (Pratt et al 2007):

a. Whenever splashing with body fluids is anticipated.

b. When cleaning contaminated equipment.

c. When handling used linen.

d. When dealing with dressings, a clean apron must be put on immediately beforedoing a dressing.

e. Blue plastic aprons should be worn for food handling.

f. Waterproof gowns should be worn in the delivery suite and in theatre. If notavailable, a full-length plastic apron must be worn under a permeable gown.

g. If doing two procedures on the same patient (e.g. giving a bedpan thenchanging a dressing) aprons and gloves should be changed between the dirtyand clean procedure.

Facial protection

47. Pratt et al (2007) state that face masks and eye protection must be worn wherethere is a risk of blood, body fluids, secretions or excretions splashing into the faceand eyes.

48. Most masks do not confer microbiological protection but they may offer protectionagainst splashing of the face and mouth during certain procedures such as minorsurgery or cleaning equipment.

49. When caring for patients suffering or suspected to be suffering from certainconditions (e.g. certain stages of pulmonary tuberculosis or other respiratoryinfections transmitted by airborne particles), staff may be advised to wear highparticulate filter masks during the initial stages of treatment (Ayliffe et al 1999).

14


50. If masks are used they must be changed after every patient. Hands should bewashed after touching masks. Masks should not be pulled down, worn around theneck, kept in pockets or re-used.

51. Respiratory protective equipment must be correctly fitted to be effective.

52. Wearing glasses is in itself not sufficient eye protection from all splashes.

53. Protective eyewear should be either single–use or decontaminated according to themanufacturer’s instructions.

54. Eyewash should be available in the event of accidental exposure. Contact lensesshould be removed before irrigating eyes after an incident.

Waste Disposal

54. The DH published Health Technical Memorandum 07-01: Safe management ofhealthcare waste (2006) which has replaced all previous legislation regardinghealthcare waste. Please refer to Section 17: Sharps and Clinical Waste Management.

Action to be Taken in the Event of Needlestick Injuries orExposure to Blood/Body Fluids (e.g. splash to eyes, mucousmembranes, broken area of skin)

55. All needlestick injuries or exposures to body fluids should be taken seriously.

56. Immediate action:

a. Encourage bleeding by gentle squeezing under clean, running water.

b. Wash site of the injury thoroughly with soap and water.

c. Cover with a waterproof dressing.

d. For mucous membranes, irrigate the contaminated area thoroughly with 0.9%saline or water.

e. In the event of a splash to the eyes, contact lens wearers should remove theircontact lenses before irrigating the eyes.

57. Follow the “Needlestick” policy for the local Acute NHS Trust hospital. InformOccupational Health of the incident or, if Occupational Health is closed, contact thenearest A+E department immediately for advice on how to manage the injury.

15


Blood and Body Fluid Spillages

58. Blood and body fluids from any individual must be considered a potential hazardbecause of possible contamination with bacterial or viral micro-organisms. Caremust be taken to avoid exposure in order to:

a. Prevent cross infection.

b. Protect the health care worker dealing with the spillage.

59. Personal, protective clothing must be worn when dealing with any body fluidspillage. Staff must be trained in procedures to deal with body fluid spillages.

60. Cuts, abrasions and skin lesions must be covered with a waterproof plaster.

61. Spillages of blood and other body fluids must be dealt with immediately.

62. The personal, protective equipment needed includes:

a. Disposable gloves, plastic apron; eye/face protection if risk of splashing.

b. Paper towels.

c. Sodium dichloroisocyanurate/sodium hypochlorite solution (10,000ppm) granulesor tablets diluted in tepid water (see tub for dilution guidelines and safetyinformation for use and refer to Appendix B for further information).

d. Orange clinical waste bag.

e. Detergent and water.

Procedure for Cleaning of Blood Spills

63. For spillages under 50 mls. of high-risk body fluids (e.g. blood or body fluids containingblood [except urine containing blood]) the following methods should be used:

a. Wearing personal protective clothing, cover the spillage with sodiumdichloroisocyanurate (NaDCC) solution at 10,000 ppm or hypochlorite granules.

b. Leave for at least two minutes. The chlorine released from the solution orgranules will make any potentially harmful viruses or bacteria in the bloodinactive.

c. Scoop up the debris with paper towels and/or a disposable scoop and pusher orcardboard. Discard the debris, paper towels, scoop and pusher or cardboard asclinical waste.

d. Wash the area with detergent and hot water, dry thoroughly.

e. Clean the bucket/bowl with fresh soapy water and dry. Discard protectiveclothing as clinical waste. Wash hands thoroughly (Lawrence and May 2003).

16


64. If the spillage is over 50 mls in size or if the blood spill is dried on and there is still apossibility that viral or bacterial matter may be viable, decontaminate as follows:a. Wear personal protective clothing and cover the blood stained area with paper towels

soaked in sodium dichloroisocyanurate or hypochlorite solution at 10,000 ppm.

b. Leave for at least two minutes.

c. Clear away the paper towels into a clinical waste bag.

d. Wash the area with detergent and water.

e. Clean the bucket with detergent and hot water, then dry. Discard protectiveclothing as clinical waste. Wash hands thoroughly.

65. If equipment is contaminated with blood, refer to the manufacturer’s instructionsfor how to decontaminate.

66. If there is a spillage of urine containing blood, do not put hypochlorite solution orsodium dichloroisocyanurate (NaDCC) granules or solution directly onto the spill(toxic chlorine gas may be released). The spillage may be treated with ahypocholorite solution to neutralize any viral/bacterial matter, if towels are soakedwith the hypochlorite solution before being placed on the spill. Follow this methodto decontaminate the spillage:

a. Wear protective clothing and cover the blood stained area with paper towelssoaked in hypochlorite solution at 10,000 ppm.

b. Leave for at least two minutes.

c. Clear away the paper towels into a clinical waste bag.

d. Wash the area with detergent and water.

e. Clean the bucket with fresh soapy water and dry. Discard protective clothing asclinical waste. Wash hands thoroughly.

67. Spillages of other body fluids not containing blood can be cleaned using detergentand hot water.

68. Spillages of body fluids in clinical and non-clinical areas should be cleaned up bystaff trained in the procedure.

69. All staff cleaning up body fluid spills must be aware of:

a. the risks of cleaning up the spillage

b. the hazards of using disinfectants.

17


References

Ayliffe, G., Babb, J. and Taylor, L. [1999]. Hospital Acquired Infection. 3rd Ed.London: Arnold.

Department of Health (2006). Saving Lives.

Gould, D. [1994]. Making sense of hand hygiene. Nursing Times 90 [47] 63 – 64

Larson E. [1985] Hand washing and skin physiologic and bacteriologic aspectsInfection Control 6 [1] Pp. 14 – 23

Lawrence, J. and May, D. [2003] Infection Control in the Community London:Churchill Livingstone

National Health Service Estates [2002] Infection Control in the Built Environment- design and planning London: The Stationery Office

National Institute for Clinical Excellence [2003] Infection Control Prevention ofhealthcare-associated infection in primary and community care [No.1] Standardprinciples

Pratt, R., Pellowe, C., Wilson, J.A. et al (2007) epic2: National Evidence-BasedGuidelines for preventing Healthcare-Associated Infections in NHS Hospitals in EnglandJournal of Hospital Infection 65 (Supplement 1) Pp. S1 – S64.

Wilson, J. [1999] Infection Control in Clinical Practice London: Ballière Tindall

18


Section 20 - Appendix A.1

Hand-washing technique with soap and water

19


Section 20 - Appendix A.2

Alcohol handrub hand hygiene technique –for visibility clean hands

20


Appendix BUses of Sodium Hypochlorite and Strengths of SolutionGuidance on the use of Sodium Hypochlorite and the recommended strengths areshowing below:

Table 1: Sodium Hypochlorite and the recommended strengths

It is important to follow the manufacturer’s instructions when using chemicaldisinfectants.

Undiluted commercial hypochlorite (bleach) solutions contain approximately 10%(100,000ppm) available chlorine.

USE

Blood SpillsEnvironmental DisinfectionHard surfaces and bathsDisinfection of Clean InstrumentsInfant feeding utensils, catering surfacesand equipment

AVAILABLECHLORINE ppm10,0001,000500

125

DILUTION OF STOCKSOLUTION %1 in 101 in 1001 in 2001 in 800

1.00.10.050.0125

21


Kent Health Protection Unit – Community/Mental Health Hospital Infection Control Manual

Section 20 – Universal Infection Control Procedures

Date of first issue: July 2004

Date to be reviewed Reviewed by – signature and date

July 2005 G Ashford November 2008

November 2010

Documents

Section 20 UNIVERSAL (STANDARD) PRECAUTIONS