HAND HYGIENE 
 
& 
 
STANDARD INFECTION CONTROL            
PRECAUTIONS POLICY 
 
(PPE, WASTE DISPOSAL, SHARPS HANDLING, LINEN 
MANAGEMENT, BODY FLUID SPILLS, SPECIMEN HANDLING) 
 
 
 
 
 
NHT Policy/ Guideline number 
ICP 001   10/05 
 
 
Version Final 
 
Ratified by 
Trust Policy Board 
 
Ratification date 
06/04/09 
 
Name of responsible committee or 
Director for Infection 
 
Individual 
Prevention & Control 
 
Date Issued 
09/04/09 
 
Review date 
April 2011 
 
Freedom of information category 
Policy 
 
 
 
 
 
 
 
 
 

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Table of Content 
1 Document Control Summary 5 
2 Roles and Responsibilities 6 
2.1 Training 7 
2.2 Monitoring Effectiveness 8 
2.3 Dissemination 8 
3.  Hand Hygiene and Standard Infection Control Precautions General Introduction 8 
4 Hand Hygiene 
9 
Table I:  Resident and transient micro-organisms 9 
4.1 Hand Hygiene Principles 10 
4.2  Hand Decontamination Facilities 10 
Table II.  Levels of Hand Decontamination 11 
4.3  Social/Routine Hand Decontamination 11 
4.4 Alcohol Hand Rub 11 
4.5  Surgical Hand Decontamination 12 
4.6  Hand Decontamination Technique 12 
4.7  Hand Drying 13 
4.8 Hand Hygiene in Domestic Care Setting 13 
4.9 Hand hygiene for patients/clients/service users 13 
Figure I    Hand Washing Technique 14 
Appendix I Infection Control Training Needs Analysis 15 
4.11 Hand Hygiene References 16 
Appendix II Hand Hygiene Audit Tool 17 
5 
Personal Protective Equipment (PPE) 
18 
Table I Risk Assessment for use of PPE 18 
5.1  Introduction 19 
5.2  Disposable Plastic Aprons 19 
5.3  Gloves 19 
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5.4  Eye Protection 20 
5.5  Mask 20 
Table II Selection of appropriate gloves 21 
5.6  Personal Protective Equipment References 23 
6 
Disposal of Waste 
24 
6.1  Categories Healthcare Waste 24 
6.2  Segregation of waste 25 
6.3  Storage of Waste 25 
6.4 Clinical Waste from Patients Homes 26 
6.5  Further information and advice from: 27 
Appendix I Waste Categorisation within NHT 28 
Appendix II Securing Clinical Waste Bags 29 
6.6 Disposal of Waste References 30 
7 Safe Use and Disposal of Sharps 
30 
7.1 Introduction 30 
7.2  Sharps Use 30 
Figure I - Action following Sharps Injury and Splash Incidents 32 
Figure II.  Action Following Human Bite Incident 33 
7.3  Safe use and Disposal of Sharps References 34 
8 
Management of Used Linen 
35 
8.1 Introduction 35 
8.2 Definitions of categories of laundry 35 
8.3  General Laundry Principles 35 
Table I Procedures for Handling Used Linen 36 
Table II Patient Own Clothing going out to Sunlight laundry 36 
8.4  On Site Laundry 37 
8.5 Management of Used Linen References 37 
9 
Dealing with Blood and Body Fluid Spillage 
38 
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9.1  Responsibility 38 
9.2  Spillage kit 38 
9.3  Chlorine Releasing Agents 39 
9.4  Blood Spill - Liquid Method of Clearance 39 
9.5  Blood Spill - Granule Method of Clearance 40 
Table I Blood Spills Clearance Methods 41 
9.6  Spillage in Service users own home (Includes Learning Disability homes) 42 
9.7  Other body fluids visibly contaminated with blood 42 
9.8  Spills of body fluids not visibly contaminated with blood 42 
9.9  Blood/ Body Fluids References 43 
10  Collections and Handling of Specimens 
43 
10.1 High Risk specimens 44 
10.2 Transporting Specimens 44 
Table I Specimen/Collection and Storage 45 
10.3 Specimen Collection/Transport References 45 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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1 Document Control Summary 
Policy Title 
 
Hand Hygiene and Standard Infection Control 
Precautions Policy 
Policy aims 
This policy aims to ensure that all Northamptonshire 
Healthcare NHS Trust staff working in hospital or 
community settings are aware of the practices, 
which maintains the highest standards of infection 
prevention and control, thus preventing the spread 
of infection to patient, staff and visitors, largely 
without the need to divulge patient information that 
may be confidential 
Status: - New or Review  
Review 
Trust Policy Board Approved 
07/04/09 
(Date, comments and areas of consideration 
Areas  affected by the policy 
Trustwide 
Policy originators/authors  
Author: Veronica Johnson-Roffey, Infection Control 
Senior Matron on behalf of Infection control 
Committee  
Consultation and communication with stakeholders  Circulated to members of the Infection Control 
including public and patient group involvements (if 
Committee and for wider circulation in their areas as 
necessary) 
necessary. Circulation comprises representation 
 
from:- 
Mental Health & Learning Disability Services 
Sexual Health Service 
Drug and Alcohol Services 
Medical Representative 
Occupational Health,  
Facilities 
Archiving Arrangements 
A central register on the Trust intra-net will hold 
archived copies of this policy.  
Register of Procedural Documents  
A current copy of this policy will be held on a central 
register, on the Trust intra-net.  
Equality Impact Assessment 
Yes  
(Including Mental Capacity Act 2007)  
Training Needs Analysis  
See Appendix 1 
Arrangements for monitoring effectiveness of 
Effectiveness monitored by Infection Control 
policy.  
Committee and by infection control audits.                  
  
Meets National criteria with regard to:  
NHSLA 
Yes:  Standard  1.2.8 & 2.2.8 
NICE  
N/A 
NSF  
N/A 
Mental Health Act  
N/A  
Other 
“The Health and Social Care Act 2008:  Code of 
Practice for the NHS on the prevention and control 
of healthcare associated infections and related 
guidance”  
Further comments to be considered at the time of 
 
ratification for this policy (i.e. National policy, 
Legislation and consultation across SHA). 
If this policy requires Trust Board ratification 
 
please provide specific details of requirements   
 
 
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2 Roles and Responsibilities 
 
Infection control should be seen as everybody’s concern and it is important that all 
healthcare workers observe good infection control practice. 
Healthcare associated infections have an impact on the lives of patients and their 
families, therefore we need to do everything possible to prevent patients acquiring a 
healthcare associated infection. This is particularly true for people who are 
sometimes less aware of the need for personal hygiene because of their age or 
physical/mental disabilities.  It is however important that unnecessary practices are 
avoided such as isolating patients when this may not be necessary.   
The prevention and control of infection should be considered as part of all service 
activity and development.  All managers have responsibility for infection control and 
cleanliness in their area and should ensure that their staff have opportunity to attend 
infection control training as detailed in the training needs analysis. Appendix I 
 
NB: Throughout this policy wherever the term patient occurs, it incorporates 
residents/clients and service users. 
 
Role of the Infection Control Senior Matron 
 
The Infection Control Nurse (ICN) is responsible for providing advice in relation to 
infection control aspects of care delivery to patients in the learning disability, mental 
health, sexual health and addiction services of this Trust.  
The ICN takes the key role in day-to-day infection control activities and serves as a 
specialist source of advice.  S/he is an active member of the Infection Control 
Committee and for example, assists in drawing up infection control policies and 
participates in and initiates infection control audits.  The ICN also provides input in 
identification, prevention, monitoring and control of infection in the Trust and works 
with the Modern Matron, Service leads and the Infection Control Link Nurses and 
others to improve surveillance and reporting of infections to strengthen the 
prevention and control of infection. 
 The ICN is proactive in the provision of infection control education for all levels of 
staff and in particular the development of the Infection Control Link Nurses. 
 
Role of the Infection Control Committee (ICC)  
 
The role of the Infection Control Committee is to advise the Chief Executive and 
Trust Board on matters relating to infection control through the Executive 
Governance Committee. The ICC also commission and approve policies and monitor 
their implementation, endorses the Trust's annual infection prevention and control 
programme, together with all infection control policies, procedures and guidelines. 
Membership of the ICC reflects the services provided by the Trust and includes for 
example, the Infection Control Doctor, Infection Control Matron, Occupational Health, 
Estates, Facilities, Service leads and representatives from the other clinical services. 
 
Role of the Infection Control Link Person (ICLP) 
 
The Infection Control Link Person acts as a link between their own clinical area and 
the infection control team. Supported by the Infection Control Matron and their 
managers, their role is to increase awareness of infection control issues in their 
wards and departments and motivate staff to improve practice.  
 
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Northamptonshire Healthcare NHS Trust Infection Control  
 
Telephone 
Name Designation 
Number 
 
01604 595216 
Trust Infection Control Matron 
Veronica Johnson-Roffey 
PMH Internal: 
NB: First Point Of Contact For All 
 
2716 
Day-To Day Infection Control 
 
Mobile: 
Problems 
07917476475 
 
 
 
Dr Tony Bentley 
Consultant Microbiologist, NGH 
01604 545138 
 
& Infection Control Advisor to NHT 
 
 
 
 
Health Protection Agency East Midlands South 
 
0116 2631400 (Mon-
Fri during office hours) 
The Health Protection Agency provides Urgent infection 
 
control and outbreak advice out of hours, weekends and bank  Out of Hours and 
holidays. 
weekends 
0115 929 6477 
 
 
Northamptonshire TB Services 
 
TB Nurse for Northamptonshire 
01604 615199 
 
 
Microbiology laboratories used by NHT 
(Via main switchboards) 
Northampton General Hospital  
01604 634700 
 
Kettering Hospital  
01536 492000 
 
 
 
2.1 Training  
 
Infection control training is mandatory.  Please refer to the Trust Statutory and 
Mandatory Training Policy HR 25, and Trust Policy for Infection Control ICP000 and 
see Appendix I of this policy 
All clinical staff should receive hand hygiene update at least annually. Managers 
have the responsibility to ensure that their staff have hand hygiene updates and that 
they have the appropriate facilities and resources to facilitate hand hygiene practice. 
 
A record of training delivered and names of attendees is recorded by the Infection 
Control Matron and passed to the Training Department for recording on the training 
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database. Training department will alert managers of non-attenders and it will be the 
manager’s responsibility to follow up. 
Routine infection control training will always include hand hygiene and in addition, the 
other elements of standard infection control precautions as outlined in this policy.  
 
 2.2 Monitoring Effectiveness 
 
Effectiveness of all sections of this policy will be monitored by: 
Audits using the DH/ICNA audit tool which included hand hygiene, sharps handling 
and Personal Protective Equipment.  Audits will be undertaken by Infection Control 
Matron and Link staff annually. However for areas where the audit score is below 
75% this will be repeated six months later.  Results will be collated by Infection 
Control Matron and communicated to Matrons and Managers. 
 
Unresolved infection control issues are entered onto local risk registers for discussion 
at local and directorate risk meetings. 
 
Results of audits will be reported in the Infection Control Matron/ICC quarterly and 
annual reports to the Governance Committee of the Board.  
 
Training record will be kept centrally by training department. Non-attendees for 
training will be reported by training department to individual managers to follow up.  
 
2.3 Dissemination 
 
This policy will be placed on the infection control policies site on the Intranet and a 
hard copy will be included in all ward/department infection control manuals. 
Managers are responsible for ensuring all their staff are aware of this policy.  
                                                                                                    
3. Hand Hygiene and Standard Infection Control Precautions 
General Introduction 
 
There are many people in the health care setting who may be incubating a 
communicable disease such as chickenpox or harbouring a sub-clinical infection 
such as hepatitis B, C virus or HIV.    
However it is not always possible to tell by looking at a person whether or not they 
have an infectious disease.  Therefore, regardless of anyone’s age, ethnicity, gender, 
background or lifestyle, Standard Infection Control Precautions (SICP) must be 
practiced at all times to protect both staff and patients. Each situation should be risk 
assessed to determine the precautions necessary, and all staff should be educated 
as to the use of SICP. 
 
SICP aims to reduce the risk of cross infection between patients, usually via the 
hands of healthcare workers, and to reduce the risk of cross infection from patients to 
healthcare workers.   
 
This policy covers the following SICP principles: 
• Hand 
Hygiene 
•  Personal protective equipment (gloves, aprons, face protection) 
• Waste 
disposal 
•  Sharps disposal and the use of sharps 
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•  Management of used linen 
•  Dealing with blood and body fluid spillage 
•  Collection and handling of specimens 
 
Important Note 
 
The use of alcohol hand preparations is widely recommended as a safe and effective 
means of hand decontamination in most situations.   However it should be noted that 
for religious reasons some ethnic groups might object to the use of alcohol.  However 
in writing these policies I have spoken to Shaykh Ibrahim, Chairman of Mosque and 
Community Affairs Committee, within the Muslim Council of Great Britain.  His advice 
is that, as this is a synthetic preparation, which is not ingested, it does not contravene 
any of the Muslim teachings. However some patients/staff may still prefer not to use 
this hand decontamination preparation, this should be respected and in these 
circumstances thorough hand washing with soap and water is recommended. 
 
 
 
 
 
4 Hand Hygiene 
 
Introduction 
 
Hand decontamination is the single most important activity for preventing infection 
and its transmission to others.  The frequency of hand decontamination is determined 
by assessing the risks of the procedures that have been, and are about to be, 
undertaken.  The aim of routine hand decontamination is to remove dirt, organic 
material and transient micro-organisms, rendering the hands socially clean. Routine 
hand decontamination is sufficient before and after most activities carried out in 
clinical practice.  Prior to minor surgery and invasive procedures, a more intensive 
technique would be required to reduce the number of resident organisms. (Tables 1 
and 2) 
 
The wearing of gloves is not an alternative to hand decontamination.  
 
 
Table I:  Resident and transient micro-organisms 
 
 
 
Transient micro-organisms 
Resident micro-organisms 
 
 
 
Do not normally colonise the skin. They  Deep seated (in skin folds and 
are acquired on hands through contact 
follicles) difficult to remove  
with other sites on the same individual, 
associated with surgical wound 
other people or the environment (cross-
infection, and following invasive 
infection). Easy to remove by hand 
procedures and manipulations, 
washing. 
reduced by a surgical hand wash 
 
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 4.1 Hand Hygiene Principles 
 
The following principles must be adhered to by all staff undertaking clinical 
care- 
 
Maintain intact skin - bacterial counts increase when the skin is damaged. Always 
cover Cuts and abrasions on hands and forearms with impermeable waterproof 
dressing. Report any skin problems to Occupational Health Department. 
 
Keep nails short and clean – pay special attention to nails when decontaminating 
hands, microbial counts are very high beneath the fingernails. 
 
Do not wear false nails, nail art, or nail polish. They harbour micro-organisms.  
 
Stoned rings/rings with ridges should not be worn. Rings interfere with thorough hand 
decontamination and glove use. A wedding band or the equivalent, depending on 
religious beliefs, is the only hand jewellery permitted.   
 
 
Wristwatches or bracelets should not be worn in the clinical area, as wrists should be 
included when undertaking hand decontamination. 
Sleeves must be short or rolled back as per Trust Uniform policy. 
  
Nailbrushes should be avoided however if there is ever a need to use, they should be 
single use and preferably sterile.  
 
 Protect skin by regularly applying hand cream. Pump action or ‘one -shot’ 
dispensers are preferable to communal pots which may become contaminated.   
 
 
4.2  Hand Decontamination Facilities 
 
Hand decontamination can be improved by the provision of adequate and 
conveniently located facilities.  Basins must be provided where hand washing is 
required and in all areas where patient consultations will take place.  Clinical hand 
wash basins should not have a plug or overflow, and ideally should have elbow, or 
foot-operated mixer taps.  A separate sink should be available for other cleaning 
purposes, such as cleaning instruments, crockery and cutlery. 
 
Hand wash basins should have in close proximity: 
Wall mounted liquid soap dispensers with disposable soap cartridges in easy reach.  
They must be kept clean and replenished. 
Disposable paper towels must be conveniently sited next to the basins.  Soft paper 
towels will help to avoid skin abrasions. 
Foot operated pedal bins must also be positioned near the hand wash basin and be 
of appropriate size. 
Ideally also a pump-dispensed alcohol hand preparation after risk assessment and a 
pump dispensed moisturiser 
 
 
 
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 Table II.  Levels of Hand Decontamination 
 
Method 
Solution 
Task 
 
 
 
Social/Routine  
Liquid soap or alcohol gel 
For all routine tasks 
 
(15-30 seconds) 
Hygienic hand 
Social clean (15-30 
In high risk areas and 
disinfection 
seconds) followed by an 
during outbreaks 
antiseptic application e.g. 
Chlorhexidine, povidone 
iodine, or alcohol based 
hand-rub  
 
Antiseptic e.g. 
Prior to surgical and 
Surgical scrub 
Chlorhexidine or povidone 
other invasive 
iodine thorough and careful  procedures 
washing for 2-5 minutes.  
Dry on sterile towels 
 
 
 
 
4.3  Social/Routine Hand Decontamination 
 
The aim of social hand decontamination is to remove the dirt and most transient 
microorganisms found on the hands and should be carried out as often as necessary 
but always: 
•  Before starting work 
•  Before eating and handling food 
•  Before and after giving routine care to each patient 
 
 
• Before 
administering 
medications (other than injections) 
•  After using the toilet 
•  After sneezing/blowing the nose 
•  After cleaning activities 
•  Before going home 
 
Rubbing hands together vigorously for 15-30 seconds using a gentle liquid soap and 
the recommended hand wash technique (fig 1) is adequate for this purpose.  Liquid 
soap is preferable because bar soap can become contaminated.  A disposable, 
cartridge-type system should be used to contain liquid soap; a top-up system should 
not be used as this could harbour micro-organisms. 
 
4.4 Alcohol Hand Rub 
 
Alcohol hand liquids/gels/foams may be used as an alternative to soap and water if 
the hands are visibly clean.  They are particularly useful when hand washing may be 
inconvenient, e.g. opening dressing packs, in the midst of routine care and when in a 
patients’ own home. However, alcohol hand rubs are not effective against spore 
forming bacteria such as Clostridium difficile therefore soap and water should always 
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be used if patient has diarrhoea or other infection caused by a spore forming 
bacteria. 
 
An application of alcohol hand rub, rubbed in until evaporated, will help to remove 
any potential pathogens that might be left after social hand washing and should be 
used on occasions such as:   
•  Before carrying out aseptic technique 
•  Before performing Venepuncture  
•  After contact with known or suspected infected  
•   
• During 
outbreaks 
 
However for the majority of activities either soap and water or alcohol hand 
preparation is sufficient and the use of both will not be necessary. 
Use of a good quality moisturiser will help to protect the skin from dryness.  
Communal pots of cream must not be used because the contents may become 
contaminated; use a pump-action container for communal use or use your own 
individual tubes.  Hand creams must be compatible with the hand-washing agent as 
hand creams with an anionic (A negative ion) emulsifying agent reduce the residual 
antibacterial effect of Chlorhexidine.  Most companies who provide the liquid soap 
will also provide a moisturiser for pump dispensers.  
 
 
4.5 Surgical Hand Decontamination 
 
The aim of surgical hand washing is the destruction of transient organisms and a 
reduction of resident flora before surgical or invasive procedures.  
Surgical hand washing requires the use of an aqueous antiseptic solution applied for 
2-5 minutes.  A more rapid effect can be obtained by applying an alcoholic solution to 
clean hands, rubbed vigorously into the hands and forearms until dry. Two 
applications of 5mls (equivalent to two squirts) of alcohol hand rub are required.  
Alcohol hand rub can also be used between cases if hands are visibly clean. 
 
4.6  Hand Decontamination Technique 
 
The technique is more important than the cleaning solution used.   
 
•  Expose the wrists and forearms (short sleeves to be worn in clinical areas or 
sleeves rolled up (as per “Uniform and Workwear Policy)  
•  Wet hands under running water 
•  Apply soap or aqueous antiseptic solution 
•  Rub all parts of the hands vigorously, without applying more water using the 
recognised technique: (Figure 1) 
         15-30 seconds for Social hand washing 
•  Rinse hands under running water 
•  Dry thoroughly using disposable paper towels  
•  Alternatively, apply 5mls (one squirt) of alcohol hand rub to socially clean 
hands for routine decontamination and rub until dry using the recognised  
technique (Figure 1) 
 
 
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4.7  Hand Drying 
 
This is an essential part of hand hygiene.  Disposable paper towels should be used, 
communal cloth towels have been recognised as a source of cross contamination.  
Paper towels must be stored in a wall-mounted dispenser adjacent to the hand 
washbasin, and disposed of into a foot operated domestic waste bin.  Hands must 
not be used to lift the bin lid or they will be re-contaminated. Hand towels should be 
sterile if used prior to a surgical procedure. Hot air dryers are not recommended in 
clinical settings, because they take too long to dry the hands and may re-circulate 
contaminated air. 
 
4.8 Hand Hygiene in Domestic Care Setting 
 
The potential for cross-infection exists not only in the acute hospital setting but also 
in community care settings. Increasingly healthcare workers such as residential 
home staff undertake a variety of care in community/domestic settings.  Hand 
washing, as an effective means of infection control is no less important in such 
setting. However, it is recognised that sometimes facilities for hand washing in a 
patient’s home may be limited. All clinical community staff in NHT are provided with 
individual hand hygiene kits which contains soap, alcohol gel and moisturiser. 
Community staff should adopt the following strategies for hand decontamination in 
patients’ homes. 
 
•  Assess the infection risk of the procedure you are to undertake 
•  Always decontaminate hands before and after patient care 
 
Use: - 
•  Most appropriate room in the home for hand washing, e.g. bathroom or 
kitchen 
•  Liquid soap and kitchen roll if available 
•  Clean dry bar soap and designated clean cotton towel may be used as a last 
resort unless high-risk procedure  
•  Paper towel/kitchen roll to turn off dirty taps 
•  Paper towel in dressing pack if available for hand drying 
•  Carry alcohol hand rub as an alternative to soap and water.  
•  If possible visit patient with poor facilities at the end of shift. 
 
 
4.9 Hand hygiene for patients/clients/service users 
 
It is important to understand that cultural and religious factors may influence hand 
hygiene practices.   Each individual patient/client/service user must have their belief 
respected but it is also important that as best as possible, appropriate measures are 
in place in order that one person’s practices do not put another at risk of infection.  
Clinical staff must ensure that they afford patients dignity, opportunity and the 
equipment for hand hygiene as often as they wish.  Those who are unable to practice 
adequate hand hygiene themselves should be offered assistance with this, especially 
before eating and after using the toilet.  
Staff should also be aware that patients have a right to request that they, the 
healthcare worker perform hand hygiene before carrying out a procedure or touching 
them and this request should be respected.  
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 Figure I    Hand Washing Technique 
 
 
 
 
7. Finally, don’t forget to wash your Wrists too 
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Appendix I Infection Control Training Needs Analysis  
 
 
Staff Group  
Standard Infection 
Frequency 
Provided by 
 
Control Training 
 
Necessary? 
 
Y or N  
Clinical  
 
Induction then Clinical 
Infection Control 
has patient contact in 
Y 
Update annually 
hospital or community  
 
 
( Nurses, Health Care 
Assistants/ Support 
workers ) 
 
Clinical Bank Staff 
Y 
Induction then annually 
ICN 
(has pt contact in 
hospital or community)  
 
Allied Health 
Y 
Induction then Clinical 
Infection Control 
Professionals 
Update annually   
(has patient contact in 
hospital or community) 
 
Medical Staff 
Y 
Induction  then Clinical 
Infection Control 
(has patient contact in 
Update annually  
hospital or community) 
  
Facilities  
Y 
Induction then Update 
ICN 
(domestics, Porters)  
annually 
 
Non-clinical staff  
Y 
Induction then Update 
Infection Control 
 
on hand hygiene 3 
(e.g. Drivers, estates, 
yearly 
ward clerks,  
 
(No direct patient 
contact but may be 
based in patient 
environment areas and 
may handle specimens) 
 
Standard Infection Control training Includes: 
Hand Hygiene 
Use of Personal Protective Equipment 
Waste Management 
Cleaning and Decontamination 
Sharps handling 
Body fluid spillages 
Sharps/needlestick injury management 
Management of used Linen 
 
 
 
 
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4.11 Hand Hygiene References  
 
•  Ayliffe GAJ et al (2000) Control of Hospital Infection: a practical handbook (4th 
edition).  London:  Arnold. 
 
•  Bissett L (2002) Can alcohol hand rubs increase compliance with hand 
hygiene? British Journal of Nursing 11 (16) 1072, 1074-7 
 
•  Carroll  A (2001) Handwashing for health care workers in domestic care 
settings. British Journal of community Nursing  6(5): 217-223 
 
•  Department of Health (2006) Essential steps to safe, clean care. Reducing 
healthcare-associated infections in Primary care trusts; Mental health trusts; 
Learning disability organisations; Independent healthcare; Care homes; 
Hospices; GP Practices and Ambulance services.  DOH: London 
 
•  Greener M (1997) Why handwashing matters Health and Ageing Oct:  11-13 
 
•  Infection Control Nurses Association (2002) Hand Decontamination 
guidelines.  ICNA 
 
•  Infection Control Nurses Association Audit Tool (2006) 
 
•  Kerr J (1998 Handwashing Nursing standard  12(51) : 35-39, 41-42  
 
•  Larson EL (1995) APIC Guidelines for handwashing and hand   antisepsis in 
health care settings. American Journal Infection Control 23  (4):  251-269 
 
•  National Institute for Clinical Excellence. (June 2003) Prevention of 
healthcare-associated infection in primary and community care. (No. 1) 
Standard principles 
 
•  Pratt RJ, Pellowe CM, Wilson JA et al (2007) epic2: National Evidence- Based 
Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals 
in England.  The Journal of Hospital Infection 655,S1-S64 
 
• RCN 
(2005) 
Good Practice in Infection Control: Guidance for nursing staff. 
London: RCN       
 
•  Roland AJ and Alder VG (1972) Transmission of infection through       towels 
Community Medicine May:  71-73 
 
•  World Health Organisation (October 2005), WHO Guidelines on Hand Hygiene 
in Health Care (Advanced Draft). Part of the WHO Consultation on Hand 
Hygiene in Health Care Global Patient Safety Challenge, 2005-2006: “Clean 
Care is Safer Care.” WHO 
 
 
 
 
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Appendix II Hand Hygiene Audit Tool 
 
 
HAND HYGIENE AUDIT TOOL 
 Standard – hands will be decontaminated correctly and in a timely manner using a cleansing 
 
agent, at the facilities available to reduce the risk of cross infection 
 
 
 
Date ………… Unit/Ward……………………………. Auditor……………........
 
 
Criteria 
Y
N N/A  Comments 
1 
Liquid soap is available at all hand washing sinks 
 
 
 
 
2 
Liquid soap is in single use cartridge  dispensers 
 
 
 
 
3 
Dispenser nozzles are visibly clean 
 
 
 
 
4 
Soft absorbent paper towels are available at  all hand 
 
 
 
 
washing sinks 
5 
Foot pedal bin available near washbasin for towel 
 
 
 
 
disposal 
6 
Hand Moisturiser is available 
 
 
 
 
7 
There are no nail brushes used 
 
 
 
 
8 
Hand washing sinks are free from  inappropriate items – 
 
 
 
 
cups, medicine pots etc 
9 
 Hand wash sinks are dedicated for hand  washing 
 
 
 
 
purpose only 
10 
There are no plugs in the sink 
 
 
 
 
11 
 There are sufficient numbers of hand wash 
 
 
 
 
12 
sinks available in accordance with national  and local 
 
 
 
 
policy (e.g. one sink per six beds  In mental health patient 
settings) 
13   Access to hand wash sinks is Not obstructed 
 
 
 
 
14   Hand washing facilities are clean and intact (check sinks,   
 
 
 
taps, splash backs.) 
15  There is appropriate temperature control to  provide 
 
 
 
 
suitable hand wash water at all  sinks 
16   Elbow operated or automated taps are  available in hand   
 
 
 
wash sinks in clinical  areas 
17   Alcohol hand rub is available for use  either wall 
 
 
 
 
mounted or personal dispenser 
18   Alcohol gel is accessible at point of care 
 
 
 
 
 
 No wrist watches/stoned rings or other wrist  jewellery 
 
 
 
 
are to be worn by staff performing  patient care 
19   Staff nails are short, clean and free from nail  polish 
 
 
 
 
20  No false or acrylic nails are worn by clinical staff 
 
 
 
 
21   Posters promoting hand hygiene are visible 
 
 
 
 
22   Staff have had hand hygiene training in the  last year 
 
 
 
 
23  Patients are offered hand hygiene facilities especially 
 
 
 
 
after using toilet/commode and before eating 
 
Observation  
 
 
 
 
24  staff use the correct procedure for hand decontamination 
 
 
 
 
(Observe practice of those on duty) 
25  All staff available staff can say when to use alcohol hand 
 
 
 
 
rubs 
26  Any signs of dermatitis (check hands of those on duty) 
 
 
 
 
26  If yes has it been checked by Occupational health? 
 
 
 
 
 
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5  Personal Protective Equipment (PPE) 
 
Table I Risk Assessment for use of PPE 
 
 
 
 
Assess risk of Activity to be 
 
Undertaken 
 
 
 
 
 
 
  
 
 
 No risk of blood/body 
Potential risk of 
Potential risk of 
 fluids splashes or 
blood/body fluids 
blood/body fluids 
 dealing with 
splashes or dealing 
splashes or dealing 
 contaminated 
with contaminated 
with contaminated 
 materials or handling 
materials or handling 
materials or handling 
 substances listed 
substances listed 
substances listed 
 under COSHH 
under COSHH 
under COSHH 
 regulations 
regulations 
regulations and a 
 
 
 
HIGH risk of splashing 
 
including into the face
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Disposable gloves 
Gloves, Apron and 
 
No PPE Needed 
and apron to be 
Eye/Face 
 
worn 
protection required
 
 
 
 
 
 
 
 
 
COSHH = Control of Substances Hazardous To Health 
 
 
 
 
 
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5.1 Introduction 
 
Personal protective equipment (PPE) is used to prevent the transfer of 
Microorganisms to or from patients, staff or their uniforms and equipment. 
The use of personal protective clothing, e.g. gloves, aprons and goggles should be 
adhered to for all patient contact when contamination with blood or body fluids or 
dealing with any contaminated material is likely. For routine infection control 
measures disposable gloves and apron and disposable or re-usable visor is normally 
sufficient and these should be readily available.  If it felt that there is frequently a 
need for additional PPE (such as fluid repellent gowns, shoe covers) on a ward/ or 
department then the manager of that ward should ensure that they have a small 
supply of such PPE.  The appropriate level of PPE should be determined according 
to the extent of possible exposure and not speculation about a patient infectious state  
(Table 1) 
 
5.2  Disposable Plastic Aprons 
 
Disposable plastic aprons provide an effective and practical barrier against the 
transfer of microorganisms to or from clothing. They also serve to protect the wearer 
from contamination from blood/body fluids. They are single use and disposable, 
which means that they should be used for one procedure only and then discarded as 
clinical waste.   They should be worn for example: 
 
•  When contamination of the clothing is likely, i.e. during bed-bathing or other 
personal care or handling urine or faeces. 
•  To protect susceptible persons from microorganisms that may be present on 
the wearers clothing. 
•  Between each patient when undertaking aseptic procedures. 
 
Where plastic aprons are used for serving food and drinks this should be a different 
colour (Usually Green) from that used for clinical procedures.  
 
5.3   Gloves 
 
Gloves protect the hands from becoming contaminated with hazardous material and 
help to prevent cross-contamination of the hands. Gloves should not be used as a 
substitute for hand hygiene. Hands should be washed with liquid soap and water and 
dried thoroughly or decontaminated using an alcohol preparation before putting on 
gloves and also on removal. Gloves should be low in allergens, powder-free, 
seamless, well fitting and provided in a range of materials to accommodate 
individuals’ adverse reaction to certain materials. Currently natural latex rubber (NRL) 
gloves are recommended for everyone except in cases of latex allergy.   Anyone who 
suspects they have a latex allergy should report this to the occupational health 
department where this can be investigated and appropriate advice given (see Trust 
Latex Policy in the Health and Safety policies section).  
 
Sterile gloves Protect the patient, and are only required for aseptic procedures or 
when caring for immunocompromised patients. 
 
Non-sterile gloves   Protect health care workers hands from gross contamination 
and should be worn when in contact with blood and body fluids or other potentially 
infected materials or substances listed under COSHH regulations. 
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NB: Because gloves made from nitrile has the same chemical range as latex, 
Persons with suspected sensitivity to latex gloves might also react to nitrile. 
 
 
Gloves should be worn whenever:  
•  Contact with body fluids, mucous membranes or non-intact skin or other 
potentially infected material is anticipated. 
•  Cleaning patient equipment 
•  Handling substances listed under COSHH 
 
And: 
•  They are not an alternative to hand washing. 
•  They should be changed after each procedure and hands must be washed 
following their removal. 
•  Gloves should not be washed because this may be ineffective and affect their 
integrity. 
•  A risk assessment on glove suitability for purpose should be undertaken to reduce 
exposure to latex to the lowest practical level and to ensure gloves are “fit for the 
purpose” of the task (see Table 2). 
•  Latex-free gloves must be provided for anyone who has a latex allergy. 
•  Polythene gloves should not be used in the health care setting. 
•  Dispose of used disposable gloves as clinical waste 
 
5.4  Eye Protection 
 
Goggles, protective glasses or visors are worn when a particular procedure is likely 
to cause splashing of body fluids or substances into the eyes. This would include the 
manual cleaning of instruments, during certain minor surgical procedures, 
administration of cytotoxic agents, or procedures that create aerosols.  If re-usable, 
they should always be washed in warm water and General Purpose Detergent (GPD) 
at the end of each use.  After drying, store in a clean dry place. 
 
 
5.5   Mask 
 
Masks do not need to be worn during routine care / procedures. 
However it may be necessary on certain occasions to wear a mask when caring for 
patients with for example tuberculosis or pandemic influenza as detailed in the 
tuberculosis and pandemic policies.  
The infection control team will advise if the use of mask is necessary when caring for 
a patient/service user with a particular infection.   
 
 
 
 
 
 
 
 
 
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       Table II Selection of appropriate gloves 
Type of Glove 
Example of Use 
Comments 
 
 
 
Rubber household 
General cleaning and 
These Gloves should be 
gloves. (Durable and 
decontamination of 
washed with general-
can be re-used)  
environment. 
purpose GPD and water 
 
 
after each use. 
 
Colour coding should be 
evident when cleaning a 
variety of areas, i.e. 
kitchens, toilets etc. 
If gloves become punctured 
they must be discarded.  
 
 
 
Catering purposes only 
 
Polythene Seamed 
 
Offer very limited protection 
Gloves 
as seams are heat sealed 
(Single use only) 
and may split. Therefore 
 
NOT for use in clinical 
 
areas. 
 
 
Latex/vinyl gloves 
-Non sterile examination  
Should comply with 
(Non-sterile Single use 
-Clinical tactile examination 
European standard EN455 
only) 
-Phlebotomy 
parts 1,2&3 and Medical 
 
-Suitable for handling blood 
Devices Directive 
 
and body fluids.  
93/42/EEC  
 
Vinyl can be used as an 
However, wherever 
alternative in cases of latex 
possible, Vinyl should only 
sensitivity.  
be used for procedures that 
 
do not involve prolonged 
NB: Because gloves made 
contact with blood 
from nitrile has the same 
 
chemical range as latex; 
 
Persons with suspected 
 
sensitivity to latex might also 
react to nitrile.  
Latex procedure gloves 
Basic aseptic procedures 
Should comply with 
(Sterile single use only) 
e.g. sterile dressings, 
European standard EN455 
catheterisation  
parts 1,2&3 and Medical 
 
Devices Directive 
93/42/EEC  
Surgeons Gloves 
For contact with normally 
 
Sterile 
sterile parts of the body, 
Should conform as above 
e.g. during surgical and 
invasive procedures 
 
 
   
 
 
 
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Appendix 1 Correct Order to Don and Remove PPE
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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5.6  Personal Protective Equipment References 
 
•  Ayliffe GAJ et al (2000) Control of Hospital Infection: a practical handbook (4th 
edition).  London:  Arnold. 
 
•  Department of Health (2006) Essential steps to safe, clean care. Reducing 
healthcare-associated infections in Primary care trusts; Mental health trusts; 
Learning disability organisations; Independent healthcare; Care homes; 
Hospices; GP Practices and Ambulance services.  DOH: London 
 
•  Health and Safety Executive (1992) Personal Protective Equipment at Work:  
Guidance on Regulations London:  HMSO 
 
•  Health and Safety Executive (1999) Control of Substances Hazardous to 
Health Regulations.  London:  HSE 
 
•  Health and Safety Executive (1996).  A Guide to Risk Assessment 
Requirements:  Common Provisions in Health and Safety Law.  London:  HSE 
 
•  Infection Control Nurses Association (2002) A comprehensive glove choice. 
Bathgate: ICNA 
 
•  Infection Control Nurses Association (2002).  Protective Clothing – Principles 
and Guidance.  ICNA. 
 
•  Medical Devices Agency (1996) Latex Sensitisation in the Health Care Setting 
(Use of Latex Gloves) MDA DN 9601 
 
•  Pratt RJ, Pellowe CM, Wilson JA et al (2007) epic2: National Evidence- Based 
Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals 
in England.  The Journal of Hospital Infection 655,S1-S64 
 
•  Wilson J (2001) Infection Control in Clinical Practice (2nd edition) London: 
Bailliere Tindall  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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6  Disposal of Waste     
 
Should be read in conjunction with Waste Management Policy: HSC020 
 
The safe management and disposal of all types of hospital and community waste 
should be managed in line with among other guidance, the Environmental Protection 
(Duty of Care) Regulations 1991 and the 2006 Health Technical Memorandum 07-01: 
Safe Management of Healthcare Waste guidance.  
The Health and Social Care Act (2008, Code of Practice for the NHS on the 
prevention and control of healthcare associated infection and related guidance. 
Imposes legal requirement of duty of care and requires Trust to have a Lead person 
to be identified for Waste Management, 
 
 Producers of waste have a duty of care to ensure the safe management of the waste 
at all stages of handling and transportation until its final disposal.   
All staff groups who handle waste must be instructed in the safe handling, 
segregation and disposal of waste and must be familiar with the procedures for 
dealing with spillages.   
 
 
6.1  Categories Healthcare Waste 
 
Safe Management of Healthcare Waste (HTM 07-01, 2006) categories healthcare 
waste and have recommended a colour coding system for segregation and disposal 
of such waste as illustrated below.  
 
 
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Following waste assessment and audit, the categories of waste likely to be produced 
in NHT are:  
 
Waste which Requires Disposal by Incineration 
This is all waste disposed of in yellow sharps container throughout the Trust.  
 
Clinical Waste which may be treated by alternative measure (Orange Bag) 
However this waste may also be destroyed by incineration.  
This is waste arising from all NHT sites except for the Learning Disability Homes.   
 
Offensive Hygiene Waste (Yellow Tiger stripe bag) 
This is the waste generated from the Learning Disability Homes and is waste which 
can be disposed of in a suitably permitted or licensed landfill site 
 
General Waste   (Black bag) 
Waste arising from offices, staff and visitors catering areas, stores, workshops and 
other similar areas where there is no risk of potentially infected materials being 
present. 
 
6.2  Segregation of waste 
 
Waste should be segregated into easily recognisable containers. (Appendix 1) 
Protective clothing should be used when handling any waste 
 
•  Clinical waste (orange or tiger stripe bags) bags should be in foot operated, rigid 
bins.  They   should be removed once ¾ filled.  The “Swan Neck “method of 
securing should be used. (Appendix 2) 
 
•  Sharps boxes should be kept out of public areas and out of the reach of children. 
Ensure correctly assembled and the lids should be closed when not in use.  They 
should only be filled to the Maximum Fill line then container must be sealed and 
labelled indicating department of origin and dated.   
 
•  Domestic waste needs to be visibly in a separate bin from clinical or other waste.   
 
6.3  Storage of Waste 
 
•  All waste must be stored out of the reach of the general public (in a locked, rodent 
and animal proof container) and handled with care. 
•  All waste sacks must be securely tied at the neck when ¾ full 
•  Clinical waste to be segregated from other waste and food preparation area.  
•  Clinical waste must be secured using swan neck technique and tagged, then 
stored in a clean secure locked area, or locked container and protected from 
adverse weather conditions and rodents whilst awaiting collection. 
•  Sharps container should never be placed in a clinical waste bag. 
•  Clinical waste bags must be transported in rigid leak proof containers. 
•  Any leakage/spillage must be dealt with immediately as indicated in spillage 
procedure.  
•  A registered waste carrier must collect clinical waste. 
 
 
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6.4 Clinical Waste from Patients Homes 
 
Where professional staff treats patients at home, employers have a duty to ensure 
that clinical waste generated is disposed of safely.  Arrangements for disposal may 
be made by special arrangement with the local authority, or should be risk assessed 
for disposal as domestic waste. 
Waste generated through a procedure by a nurse in the home of a patient should be 
risk assessed.  In most cases it is safe to deal with in the following manner: 
 
1. Waste generated in a patient’s home (e.g. small dressings, incontinence pads etc.)   
shall be assessed by the nurse. In most cases, it will be appropriate to dispose of the 
waste by double wrapping and depositing it with domestic refuse. However ensure 
the patient is aware of this and check with them that their bin is safe while awaiting 
local authority refuse collection. 
 
2. Where, based on the assessment, a nurse decides that depositing waste with the 
domestic refuse is inappropriate, she may arrange for a clinical waste collection by 
the local authority. 
 
3. Sharps boxes must be brought back by the Community Nurse and dealt with as in 
section 7. 
 
It is not advisable for staff to carry clinical waste bags (Excluding Closed 
sharps boxes) in private vehicle.  
Managers need to ensure that staff has adequate supplies of UN type approved 
sharp boxes if transporting sharps waste.  All such waste carried in private vehicles 
should be kept safely and securely out of sight. 
 
NB:  Within Northamptonshire Healthcare Trust, The ligature audit group have 
discussed the standard within the NIMHE environmental audit tool regarding no 
plastic bags in inpatient areas.   
 
It was agreed that there should be no plastic bags or bags with drawstrings used in 
patient private areas such as bedrooms within in-patient wards.  Therefore clinical 
waste bags should only be kept in locked areas and a bag taken to the patient for 
care and removed to the dirty utility area after use.  
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6.5 Further information and advice from: 
 
•  Northampton Healthcare NHS Trust Estates Manager responsible for waste 
management.  Via St. Mary’s switchboard 01536 410141.   
 
•  Local Authority Districts and Borough councils as below for clinical waste 
collection advice. 
 
 
 
Corby Borough 
Daventry District 
Borough Council of 
Council 
Council 
Wellingborough 
Grosvenor House 
Lodge Road 
Council Offices 
George Street 
Daventry 
Wellingborough 
Corby 
Northamptonshire 
Northamptonshire 
NN17 1QB 
NN11 5AF 
NN8 1BP 
Tel: (01536) 464000 
Tel: (01327) 871100 
Tel: (01933) 229777 
East 
Kettering Borough 
Northampton Borough 
Northamptonshire 
Council 
Council 
Council 
Bowling Green Road 
The Guildhall 
 Cedar Drive 
Kettering 
St Giles Square 
Thrapston 
Northamptonshire 
Northampton 
Northamptonshire 
NN15 7QX 
NN1 1DE 
NN14 4LZ 
Tel: (01536) 410333 
Tel: (01604) 837837 
Tel: (01832) 742000 
South 
 
 
Northamptonshire 
Council 
Springfields 
Towcester 
Northamptonshire 
NN12 6AE 
Tel: (0845) 2300226 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Appendix I Waste Categorisation within NHT  
 
Category of 
Colour Code 
Content of Waste 
Disposal and 
Current 
Waste 
for 
examples 
Storage 
Destruction 
 
Segregation 
Method 
 
(MAY BE 
SUBJECT TO 
CHANGE) 
 
Orange  
Soiled dressings, 
-Secure with tie 
 
Clinical Waste 
Clinical Waste  swabs, used blood 
using “swan neck” 
Alternative 
which may be 
Bag 
bags, materials 
technique 
treatment  
treated.  
(Gauge: 2225)  contaminated with 
-Always label bags 
 
blood and body 
using identification 
(All trust sites 
fluids.  Waste from 
tag 
Except LD 
patients in isolation, 
-Must await 
Homes) 
PPE 
collection in a safe 
secure area  
 
Offensive Waste  Yellow Tiger 
Incontinence pads 
As above 
Landfill 
(LD Homes) 
stripe Bags 
PPE, dressings, 
 
disposable bedpans. 
 
 
 
Waste from offices, 
Tie bags securely 
 
General Waste 
Black Bag 
small amounts of 
and place in 
Landfill 
food paper hand 
designated secure 
towels etc. 
area to await 
 
collection.  
 
Yellow Sharps  Hypodermic 
Once ¾ full secure 
 
Sharps 
Bin with yellow  needles, syringes, 
lid, label container 
Incineration 
lid BS7320 
scalpels, lancets, 
and store in 
approved. 
giving sets, small 
appropriately secure 
amounts of glass, 
area to await 
any sharp 
collection. 
disposable 
 
instruments. 
DO NOT PLACE IN 
 
CLINICAL WASTE 
PLASTIC BAGS 
 
Pharmaceutical Designated 
Out of date 
Contact pharmacy 
 
Pharmacy 
medicines/vaccines 
To discuss. 
By pharmacy 
container 
 
 
Glass, aerosols 
Designated 
Glass and aerosols 
Once ¾ full secure 
Landfill 
cardboard box 
box and store in 
 
designates safe 
collection area 
 
 
 
 
 
 
 
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Appendix II Securing Clinical Waste Bags 
 
 
When clinical waste bags are filled to three quarters (75%) capacity, the “Swan-neck” 
method of sealing should be used as demonstrated below. 
 
 
Source: Environmental Protection Department of Hong Kong 
http://www.info.gov.hk/epd accessed 11th July 2005 
 
Notice on website: 
(“Permission is granted for users to download the materials herein to store them in local computers, 
provided that this is solely for personal or non-commercial internal use, and provided further that this 
copyright notice is downloaded at the same time”.)  
 
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6.6 Disposal of Waste References  
 
•  Ayliffe GAJ et al. (2000) Control of Hospital Infection: a practical   handbook 
(4th edition).  London:  Arnold. 
 
•  DH (2006) HTM 07-01 Health Technical Memorandum (Safe Management of 
Healthcare Waste) 
 
•  Department of the Environment (1991) Environmental Protection Act 1990: 
waste management the duty of care a code of practice. London:  HMSO 
 
•  Health Service Advisory Committee (1999) Safe Disposal of Clinical Waste 
(2nd edition).  Sudbury: HSE Books 
 
•  Health and Safety Commission (2002) The Control of Substances Hazardous 
to Health Regulations (4th edition). Sudbury: HSE Books  
 
•  HMSO (1974) Health and Safety at work Act. HMSO London 
 
 
7 Safe Use and Disposal of Sharps    
 
7.1 Introduction 
 
Please also refer to ICP006 Management of Occupational Exposure to blood-
borne virus Policy. 
 
Sharps frequently cause injury to healthcare workers and may transmit blood-borne 
viruses such as Hepatitis B, C and Human Immunodeficiency Virus (HIV).   
Sharps are defined as anything which may puncture skin and which may be 
contaminated by blood or other body fluids.  This includes cannulae, giving sets, as 
well as hypodermic needles and syringes, suture needles and scalpel blades.  
It is the responsibility of managers and all members of staff to safeguard the health of 
the general public, other members of staff and themselves by complying with the 
Health and Safety at Work act 1974 
 
 
7.2 Sharps  Use 
 
•  Sharps must be handled as little as possible to minimize the risk of injury 
 
•  All sharps including hypodermic needles, suture needles, cannulae, 
scalpel blades etc must be discarded directly and immediately into a sharps disposal 
container, at point of use. Sharps container must comply with BS 7320 and be of the 
appropriate size for its purpose. Must be correctly assembled, signed and dated by 
the assembler.  
 
•  Do not dispose of sharps in anything other than in an approved sharps container.  
 
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•  Never re-sheath needles prior to disposal. Needles must not be bent or broken 
prior to use or disposal. Needle should never be removed from the syringe but 
should be discarded as a single unit,  
•  In general it is the responsibility of the person using the sharp to dispose of it 
properly. Do not leave your sharps for someone else to dispose of. 
 
•  Always follow the manufacturers' instructions when assembling sharps containers 
taking particular care to ensure that the lid is properly fastened into position prior 
to use. 
 
•  When full, write the area, e.g. ward, in which the sharps container has been used, 
the date container was sealed and sign to comply with controlled waste 
regulations 1992 and 1999 guidance. 
 
•  Sharps containers must be readily available in any area where sharps are used. 
For procedures where sharps are used at the bedside, a sharps container must 
be available so that the sharp can be discarded directly and immediately into the 
sharps container after use. 
 
•  Staff who need to transport sharps boxes within the community should ensure 
they are transported safely and securely. 
 
•  Sharps containers must never be placed at floor level. They should always be 
placed out of the reach of children and where unauthorized people cannot gain 
access to them when not in use. 
 
•  It is the duty of the person in charge of the area to carry out a risk assessment to 
determine the safest places for sharps containers to be stored to minimise the risk 
of injury.   
 
•  Sharps containers should ideally be secured using wall brackets or a trolley for 
larger containers. 
 
•  Do not attempt to retrieve any items from sharps containers and do not attempt to 
press down or shake the box to make more room in the sharps container. 
 
•  Do not fill sharps containers above the manufacturers fill line. Check the sharps 
container before use to ensure it is not overfull. 
 
•  Keep temporary closure in place when sharps box not in use. 
 
•  Permanently lock the used sharps container when ready for final disposal (i.e. 3/4 
full)) using the integral locking mechanism. Store in a safe designated place away 
from the public prior to collection. Never put in a clinical waste bag.  
 
•  Change sharps container every 4-6 weeks whether full or not. 
 
 
 
 
 
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Figure I - Action following Sharps Injury and Splash Incidents 
 
 
 Following injury with a used sharp, follow the procedure below immediately.  
 
 
Sharps injury, cuts and bites 
 
 
Encourage bleeding by gentle massage (Do Not Suck) 
 
 
Wash wound under running water, cover with waterproof dressing 
 
 
If body fluids splash into eyes irrigate with cold water 
 
 
If splash into mouth, do not swallow, rinse out mouth with water several times 
 
 
Report incident to senior person on duty 
 
 
                                        Fill in incident form. Then 
 
 
  
                                                
 
If injury from clean unused 
If injury from used needle or 
 
needle or instrument it is 
instrument, seek advice from 
 
likely that no further action is 
Occupational Health. 01536 
 
necessary.  However you 
494009.   If outside of office hours 
 
should still report the incident 
or during the weekend, or Bank 
 
to Occupational Health on 
Holiday contact A+E. However 
 
the needlestick hotline.  
you should still report the incident 
 
Number: 01536 494012 
to Occupational Health on the 
 
next working day or leave a 
 
message on the hotline Number 
 
01536 494012   
 
 
During office hours Occupational Health Department can also be contacted via St 
Mary’s Hospital switchboard: 01536 410141 or direct: 01536 494009 
 
 
Outside of office hours, weekend or bank holidays contact nearest A+E department: 
             Northampton General Hospital: - 01604 634700 
             Kettering General Hospital: -   01536 492350 / 2435 
 
 
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Figure II.  Action Following Human Bite Incident 
 
 
Immediate action 
 
 
 
 
 
 
Skin not broken                                                               Skin is broken 
 
 
 
 
Wash area with soap                                                  Wash wound well under  
and water                                                                   running water, cover with  
                                                                                                   waterproof dressing 
                                                                                
Report incident to                                                                        
senior person on duty                                                                 
Report to senior person 
on duty 
 
Complete incident form 
                                                                    
 
Seek medical advice 
immediately 
 
 
                                                                                                
Complete incident form 
 
 
 
 
Ask yourself why accident happened, what can be done to avoid similar occurrence 
 
Always ensure Occupational Health is informed so that records can be updated and 
advice given as appropriate. 
 
Ensure you are up to date with all vaccination recommended by Occupational Health 
 
 
 
 
 
 
 
 
 
 
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7.3  Safe use and Disposal of Sharps References  
 
•  Ayliffe GAJ et al. (2000) Control of Hospital Infection: a practical   handbook 
(4th edition).  London:  Arnold 
 
•  DH (2006) HTM 07-01 Health Technical Memorandum (Safe Management of 
Healthcare Waste) 
 
•  Department of Health (1999) guidance for clinical health care workers-
protection against infection with blood-borne viruses.  UK Health departments 
 
•  Department of Health (2006) Essential steps to safe, clean care. Reducing 
healthcare-associated infections in Primary care trusts; Mental health trusts; 
Learning disability organisations; Independent healthcare; Care homes; 
Hospices; GP Practices and Ambulance services.  DOH: London 
 
•  MDA (2001) SN2001 (19) Safe Use and Disposal of Sharps 
 
 
•  NHS National Institute for Clinical Excellence (2003)  Infection control: 
Prevention of healthcare associated infections in primary and community care. 
 
•  Pratt RJ, Pellowe CM, Wilson JA et al (2007) epic2: National Evidence- Based 
Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals 
in England.  The Journal of Hospital Infection 655,S1-S64 
 
•  RCN (2005) Good Practice in Infection Control: Guidance for nursing staff.  
London: RCN         
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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8   Management of Used Linen     
 
8.1 Introduction 
The term laundry and linen is used interchangeably.  
 
It is important to ensure that no member of staff is put at risk of infection or any other 
form of injury during the handling or laundering of used linen. In accordance with 
Health and Safety, steps should be taken to avoid the risk of infection during the 
handling of such linen.  
Linen can become contaminated with microorganisms when soiled by blood, excreta 
or other body fluids and from patients with infections.   
The use of a colour coded bag system ensures that used linen is categorised 
appropriately and can be identified on arrival at the laundry, enabling specialised 
laundry processes where necessary. 
 
8.2 Definitions of categories of laundry 
 
The NHS Executive recommends three categories of used laundry: 
 
Used (soiled or foul)  – Used linen includes all linen used by a patient, whether soiled 
with blood, excreta or body fluids or not, except for linen that is infected or heat labile 
 
Infected- Linen from patients with specified infection with potential to infect other 
patients and staff. 
 
Heat-labile – Fabrics that are likely to be damaged by heat disinfection  
 
8.3 General Laundry Principles  
 
•  All linen should be placed in the appropriately colour coded bag (Table1) 
 
•  All linen bags must be securely fastened before being transported to the 
laundry and should not be more than ¾ full. 
 
•  Always ensure an adequate supply of linen bags available. 
 
•  Staff should ensure they wear personal protective equipment (PPE) when 
handling used or infected linen and cover all lesions with a waterproof 
dressing. 
 
•  Always wash hands after handling used linen and removing (PPE) 
 
•  Ensure that there are no foreign objects or sharp instruments placed in linen 
bags 
 
•  Clean linen must be stored separately from used linen in a clean dry area off 
the floor. Excess storage of linen is generally unnecessary. 
 
 
 
 
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      Table I Procedures for Handling Used Linen  
 
 
 
 
Type of Linen  
Type of Inner bag 
Type of Outer Bag 
 
 
 
Used (soiled and foul) linen- 
White plastic bag 
White nylon or polyester 
includes all linen used by a 
 
laundry bag 
patient, whether soiled with 
 
 
blood or body fluids or not. 
 
 
Excludes linen that is infected or   
 
heat labile  
 
 
 
Used  
 
White nylon or polyester 
 Not contaminated with blood, 
Not normally required
laundry bag  
excreta or other body fluids 
 
 
 
Used  
white plastic bag 
White nylon or polyester 
Contaminated with excreta or 
laundry bag 
body fluids 
 
 
 
Infected 
Red water soluble 
Red nylon or polyester 
For example: - 
bag 
laundry bag 
-Diarrhoea of infective cause 
-Blood –borne viruses 
-Other infections as advised by 
ICN 
 
 
Table II Patient Own Clothing going out to Sunlight laundry 
 
 
 
 
Type of Linen/laundry 
Type of Inner bag 
Type of Outer Bag 
 
All infected clothing 
Red plastic bag 
Blue laundry bag 
All soiled clothing  
White plastic bag 
Blue laundry bag  
Non-infected/soiled personal 
 
Place in the patient curtain 
clothing/linen are washed at 
None needed 
bags provided. 
PMH own on site laundry 
 
 
 
Please note this table only relates to patient personal clothing.  An inventory of all 
items placed in the blue bags must be completed on the ward and the white copy 
accompanies the bag and the pink and blue copies are kept for ward and patient 
records.  
 
If you have any queries regarding processing of used laundry/linen to go to Sunlight 
Laundry or about washing of patient’s personal clothing you should contact the Linen 
Supervisor or Hotel Services Manager at Princess Marina or St.Mary’s hospital.  
 
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8.4 On Site Laundry 
 
Where laundering is carried out on site such as in the LD homes and rehabilitation 
units, the following key principles apply:    
 
•  Washing machines must be capable of withstanding recommended 
temperatures (650C for 10 minutes and 710C for 3 minutes) and must have a 
pre-wash/sluice cycle 
•  Laundering area kept separate from kitchen and other clinical rooms 
•  Laundry room should be cleaned daily and kept clean. 
•  Clean laundry should not be left in the laundry room.  
•  Laundering area to allow proper segregation of clean and dirty laundry  
•  Protective clothing available for staff 
• Suitable 
receptacles/containers for clean/dirty linen 
•  Domestic washing machine should only be used for bed linen if the 
temperature can achieve proper heat disinfection as above 
•  Do not overload washing machines. 
•  NO manual sluicing of items should take place. Use pre/wash or sluice cycle 
on the washing machine. 
•  All washing machines and driers should be subjected to a planned programme 
of service and maintenance as part of the quality assurance programme 
 
•  Where patient/residents are encouraged to undertake their own laundering, 
staff should ensure that this is done safely in accordance with this policy. 
Therefore supervision of some patients undertaking laundry process may be 
necessary. Patients with infection should not be allowed to undertake their 
own laundry without supervision to ensure that the machines and laundry 
room is cleaned after their use.  
 
 
 
 
 
8.5 Management of Used Linen References  
 
 
•  Ayliffe GAJ et al. (2000) Control of Hospital Infection: a practical   handbook 
(4th edition).  London:  Arnold  
 
•  Department of Health NHS Executive (1995) Hospital laundry arrangements 
for used and infected linen. HSG (95) 18 London: HMSO 
 
•  Wilson J (2000) Infection Control in Clinical Practice (2nd edition) London: 
Bailliere Tindall  
 
 
 
 
 
 
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9  Dealing with Blood and Body Fluid Spillage  
 
For the purpose of this policy, a spillage, however it occurs, is defined as a leak or 
spill of blood or other body fluid from a patient, equipment, specimen or a container. 
All such spillages present a potential infection hazard so must be dealt with promptly 
to minimise the potential transmission of blood borne viruses and other pathogens.  
 
9.1 Responsibility 
 
It is the responsibility of all clinical nursing staff to deal with any blood or body fluid 
spillage in all wards, clinics and patient care areas.  Spillages that occur outside of 
these areas such as waiting/reception areas, public and staff toilets, public corridors 
etc are the responsibility of the hotel services staff.  Co-operation and communication 
between clinical and hotel services staff is necessary for the safety of everyone. 
Materials for dealing with spillages should be readily available. All managers should 
ensure that their staff attend infection control training and are familiar with the policy 
and procedure for dealing with spillages and know where the materials for dealing 
with spillage are stored.  For most spillages routine PPE (gloves, plastic aprons and 
goggles) is all that will be necessary and managers should ensure that these are 
always available. However if managers feel that in their area there is a need for 
additional PPE, such as waterproof overshoes and overalls then they should ensure 
they have a small central supply of these.  
 
9.2 Spillage  kit 
 
The methods of cleaning up different types of body fluid spillages as detailed below 
should be adhered to. 
Commercial spillage kits containing all the equipment for dealing with a blood spillage 
can be purchased via Purchasing Department and is recommended.  However as an 
alternative, clinical areas can make up their own spills kit, which should contain as a 
minimum the following:  
 
•  Disposable plastic apron 
•  Disposable latex gloves (vinyl gloves should also be available in case of latex 
sensitivity) 
•  Small clinical waste bag 
•  2 strips of rigid cardboard 
•  Chlorine releasing tablets (e.g. Haz-tab or Presept) 
•  Chlorine releasing granules  (e.g. Haz-tab or Presept) 
•  Disposable paper towels 
•  Disposable cleaning cloth 
•  Measuring jug to make up chlorine solution according to manufacturer’s 
instructions on packet 
 
Spillage kits whether commercial or put together in - house should be stored under 
COSHH regulations as they contain chemicals. 
 
 
 
 
 
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9.3 Chlorine Releasing Agents 
 
Chlorine releasing agents fall into two groups: 
1) Sodium dichloroisocyanurates (NaDCC) e.g. Haz-Tab, Sanichlor, Presept 
2) Sodium hypochlorite- e.g. Milton, Domestos 
The use of the NaDCC is primarily recommended for spillages because it is more 
effective in presence of organic matter, less corrosive and has a longer shelf life.  
Spills of blood or body fluid visibly stained with blood should be treated with chlorine 
releasing solution or granules.  The following are important safety measures. 
 
•  To avoid skin contact with chemicals gloves and apron should always be worn 
for preparing and using these agents.   A visor should be worn if there is a risk 
of splashing into face.   
•  Any skin splashes should be washed with cold running water immediately 
•  Chlorine agents must NOT be placed directly onto urine as they can release a 
toxic fume 
•  Any unused solution must be discarded immediately 
•  Dilute to appropriate concentration for use (see below) 
 
 
 
CHLORINE CONCENTRATIONS: 
10,000 parts per million (ppm)   - For use on spillages of blood or body fluids 
visibly stained with blood. 
 
1,000 ppm - For disinfecting surfaces or equipment following contamination 
with body fluids after they have been cleaned.  
 
To make the above concentrations you should follow the manufacturer’s 
instructions depending on the product you are using and strength of the tablet.  
 
Hypochlorite (e.g. Domestos)  
For use in service users home or in LD homes if Haz-tab, Sanichlor or 
Presept tablets not available 
 
Remember that brands of bleach varies, but generally: 
10, 000ppm dilute 1:10 parts water (i.e. 10mls of bleach in 100mls of water).  
Always add the bleach solution to the water and not vice versa. 
 
1, 000ppm dilute 1: 100 parts water.  Always add the bleach solution to the 
water and not vice versa. 
 
 
Following a risk assessment and depending on the products available, blood spillage 
may be dealt with using either of the following methods detailed below: (see also 
Table 1) 
 
9.4  Blood Spill - Liquid Method of Clearance 
 
•  Disposable powder-free gloves and aprons must be worn 
•  Use eye protection if there is a risk of splashing.   
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•  Ensure good ventilation of the area if possible.   
•  Soak up as much of the spill as possible with disposable paper towels then 
gently pour NaDCC chlorine releasing solution or hypochlorite (10,000ppm) 
solution (e.g. Milton, Presept, Haz-Tab or Sanichlor) over fresh paper towels 
and leave for 2 minutes.   
•  After 2 minutes discard the paper towels into clinical waste bag.  
 
•  Clean contaminated area with warm water and general purpose detergent 
(GPD) solution and dry thoroughly.  
 
•  Discard everything used including PPE into a clinical waste sack but if re-
usable i.e. mop heads, should be sent to laundry in red bag and mop buckets 
should be thoroughly cleaned with the chlorine solution followed by detergent 
and water and dried.   
•  Wash hands.   
•  Minor drips or splashes of blood on inanimate surfaces should be wiped up 
using a paper towel soaked with NaDCC or sodium hypochlorite 10,000ppm 
solution (e.g. Milton, Presept, Haz-Tab or Sanichlor). After which the area 
should be washed with warm water and GPD and dried well.   
 
•  Discard everything used including PPE into a clinical waste sack but if re-
usable i.e. mop heads should be sent to laundry in red bag and mop buckets 
should be thoroughly cleaned with chlorine solution followed by detergent and 
water and dried.   
 
•  Wash hands.   
 
9.5  Blood Spill - Granule Method of Clearance  
 
Larger spillages can be treated with absorbent NaDCC chlorine-releasing granules 
e.g. Haz-tabs, Sanichlor or Presept, which will ensure that the active disinfecting 
agent comes into contact with any micro-organisms throughout the spillage and will 
also limit the spread of the blood.  If using one of the commercial spill kits, follow 
instructions on card inside.  But generally: 
 
•  Wear protective clothing  
•  Cover spillage with NaDCC chlorine releasing granules 
•  Leave for 2 minutes 
•  Prepare bucket with warm water and GPD solution 
•  Scoop up the spillage with paper towels or scoop and discard as clinical waste 
•  Clean area with warm water and GPD using disposable cloths, rinse and dry 
•  Clean bucket in fresh water and GPD, rinse and dry 
•  Discard everything used including PPE into a clinical waste sack but if re-
usable i.e. mop heads should be sent to laundry in red bag and mop buckets 
should be thoroughly cleaned and dried.   
• Wash 
hands 
•  Replace spills kit. 
 
If spillage contains glass or other sharps these should be carefully picked up with 
forceps or between two pieces of rigid cardboard and put into sharps box. 
 
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Table I Blood Spills Clearance Methods 
 
 
 
Blood Spill- Hypochlorite Liquid Clearance 
Blood Spill Granule Clearance Method 
 
Method 
 
 
 
 
 
Ensure good ventilation of the area if possible.  
Ensure Good ventilation of area if possible 
 
 
 
 
 
 
Wear Protective Clothing (Gloves, apron and in 
Wear Protective Clothing (Gloves, apron and 
 
addition eye protection if risk of splashing 
in addition eye protection if risk of splashing 
 
 
 
Soak up as much of the spill as possible with 
Cover spillage with NaDCC chlorine 
 
disposable paper towels then place some fresh 
releasing granules and Leave for 2 minutes 
 
towels over spillage area 
 
 
 
Gently pour NaDCC chlorine releasing solution 
After 2 minutes  Scoop up the spillage with 
 
or hypochlorite (10,000ppm) solution (e.g. 
paper towels or plastic scoop in kit and 
 
Milton, Presept, Haz-Tab or Sanichlor) over the 
discard as clinical waste 
 
fresh paper towels and leave for 2 minutes.   
 
 
 
After 2 minutes remove paper towels and 
Clean area with warm water and GPD 
 
discard orange clinical waste bag. 
using disposable cloths, rinse and dry
 
 
 
Clean contaminated area with warm water 
 
Discard everything used including PPE into 
and general purpose detergent (GPD) 
 
a clinical waste sack but if re-usable i.e. 
solution and dry thoroughly.
 
mop heads should be sent to laundry in 
 
red bag and mop buckets should be 
 
thoroughly cleaned and dried.   
Any minor drips or splashes of blood on 
 
surfaces should be wiped up using a paper 
 
towel soaked with NaDCC or sodium 
 
hypochlorite 10,000ppm solution followed 
 
Wash hands 
by washing with warm water and GPD and 
 
dry well
 
 
 
Discard everything used including PPE into a 
clin
 
ical waste sack but if re-usable (i.e. mop 
Replace spills kit. 
 
heads), should be sent to laundry in red bag 
 
and mop buckets should be thoroughly 
 
cleaned with the chlorine solution followed by 
 
detergent and water and dried.   
Wash hands 
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9.6  Spillage in Service users own home (Includes Learning Disability homes) 
 
If you have to deal with a spillage in a patient’s home on carpet or fabric covered 
furniture the use of GPD and water alone is advised to avoid bleaching of carpet or 
furniture by hypochlorite.  Wearing protective clothing, soak up the spill with 
disposable towels then thoroughly clean the area with GPD and warm water using 
disposable cloth.  Make sure the area dried before use.  
 
Dispose of protective clothing and all disposable equipment into a plastic bag 
Which should be double bagged in another plastic bag, securely tied and discarded 
with the household waste.  Ensure any re-usable equipment i.e. mop buckets is 
thoroughly cleaned and dried before storing.   Wash hands.  
If the spill is blood on impervious (liquid does not penetrate it) flooring you can use a 
dilution of 1:10 good quality bleach e.g. Domestos.  Absorb as much of the spill as 
possible then cover the area with absorbent paper and gently pour bleach solution 
and leave for 2 minutes then wipe up with paper towels and discard as above.   
Clean area with GPD and warm water and dry.   Wash hands. 
 
 NB:  In the Learning disability homes waste from such spillage should not be 
put in domestic waste but in clinical waste bags.  
 
 
9.7  Other body fluids visibly contaminated with blood 
 
These include spills of urine, faeces, vomit, and sputum. 
•  Wearing PPE, soak up the urine as thoroughly as possible with paper towels  
•  Clean the area with GPD and water.  (chlorine solution should not be added to 
urine) 
•  The area can then be wiped over with a 10,000ppm chlorine releasing 
solution. However, if for example the spill is on carpet or fabric furniture where 
there is a risk of bleaching, then chlorine releasing solution should not be 
used. Instead, arrange with hotel services for the carpet area to be extractor 
cleaned.  If on furniture the covers should be laundered on hot wash.  
•  Place all waste material and protective clothing into a clinical waste bag. 
•  Discard everything used including PPE into a clinical waste sack but if re-
usable (i.e. mop heads), should be sent to laundry in red bag and mop 
buckets should be thoroughly cleaned with the chlorine solution followed by 
detergent and water and dried.  
•   Wash hands.   
 
 
9.8  Spills of body fluids not visibly contaminated with blood 
 
These include spills of faeces, vomit, urine and sputum. 
•  Wearing PPE, soak up the spill as thoroughly as possible with paper towels. 
•  Discard the paper towels and any other waste from the spillage into a clinical 
waste bag.  
•  Clean the area with GPD and water and dry well.  
•  The above should normally be sufficient; however if it is felt necessary and 
spillage is not on carpet or bleachable fabric, the area can be disinfected with 
a 1 000ppm chlorine solution. 
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•  Discard everything used including PPE into a clinical waste sack but if re-
usable (i.e. mop heads), should be sent to laundry in red bag and mop 
buckets should be thoroughly cleaned and dried.  
•   Wash hands. 
 
 
 
 
 
9.9  Blood/ Body Fluids References  
 
•  Ayliffe GAJ et al. (2000) Control of Hospital Infection: a practical   handbook 
(4th edition).  London:  Arnold  
 
•  Cooper T (1999) Blood spills the evidence. Nursing Times 95:65,68 
 
•  DOH (1998) Clinical Health Care Workers: Protection Against Infection with 
Blood-borne Viruses. Recommendations of the Expert Advisory Group on 
AIDS.  London: HMSO 
 
•  Wilson J (2000) Infection Control in Clinical Practice (2nd edition) London: 
Bailliere Tindall  
 
 
 
 
10 Collections and Handling of Specimens 
 
Clinical specimens include any substance, solid or liquid, (e.g. blood, urine or faeces) 
removed from a patient for the purpose of analysis.  Managers are responsible for 
ensuring that their staff are competent (as guided by this policy) to handle specimens 
safely. Staff are responsible for ensuring that they are up to date with all 
immunisations recommended by Occupational Health.   
 
All specimens must: 
 
•  Be collected in the correct container 
•  Have lids securely fastened on its container 
•  Individually placed into the correct plastic specimen bag 
•  Pins, staples or paper clips must not be used to secure bags, use integral 
sealing strip 
•  For larger specimens such as 24-hour urine containers these can be enclosed in 
individual clear plastic sacks tied at the neck. Request card should be secured to 
outside of the sack and not placed inside. 
•  All specimens should be clearly and correctly labelled with relevant clinical 
details  
•  Request form must be in separate compartment to the specimen 
•  Not be transported in ordinary mail envelopes 
•  Not be stored where food and drinks are stored or consumed 
•  Be stored in a dedicated specimen fridge 
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•  Specimens collected in a patient’s home should be transported safely in a rigid 
watertight container 
• Reach 
the 
laboratory as soon as possible 
•  Spillage must be dealt with immediately (see spillage procedure) 
•  Samples tested on site should be disposed of in a sluice or toilet facility, not in a 
hand wash sink  
 
 
Staff must: 
• Wear 
disposable 
gloves 
and apron when handling blood and body fluids 
•  Should wash hands before obtaining specimen and after handling specimen 
•  Not contaminate the outside of the container 
 
10.1  High Risk specimens 
 
Specimens from patients with known or suspected infections are referred to as high-risk 
specimens, because they are hazardous to lab workers.  These include hazard group 3 
specimens such as, samples from patients with known or suspected hepatitis B, 
hepatitis C, HIV/AIDS, viral haemorrhagic fever, sputum from tuberculosis patients, 
stools from patients with typhoid, paratyphoid, or dysentery. 
You should write clearly in red, “Danger of Infection” on the specimen container and the 
specimen request card, which accompanies specimen from patients thought to be in 
the high-risk group.  To protect patient confidentiality you should ensure the request 
card contains only the necessary information needed to enable laboratory staff 
receiving the specimen to know what special precautions are necessary in the 
laboratory.   
 
Some specimens in hazard group 4 such as Lassa fever and Ebola are not processed 
by the local laboratory but they will need to handle it therefore the clinician should 
discuss with the laboratory how such specimens should be packaged, before the 
specimen is taken.  
 
10.2 Transporting 
Specimens 
 
The Specimen transport carrier used for carrying specimens to the pathology 
laboratory must be secure and conform to guidelines set out in the Health and Safety 
at Work Act (1974).  Other regulations that apply are the Carriage of Dangerous 
Goods (Classification, Packaging and Labelling) and the use of Transportable 
Pressure Receptacles Regulations 1996 
 
In this Trust all specimens should be transported to the pathology laboratory in the 
container provided by facilities. These should be cleaned weekly and whenever 
contaminated. 
Staff working on the community who occasionally need to transport a specimen from 
a patient’s home to the central collection point at Princess Marina or St Mary’s 
hospital or the GP surgery should ensure as a minimum, that these are secured in 
the plastic specimen bag and transported securely in a rigid leak proof container, 
which should be cleaned with detergent and water and dried after every use.  
 
 
 
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Table I Specimen/Collection and Storage 
 
SPECIMEN 
REFRIGERATE? 
CONTAINER 
TO LABORATORY 
 
Wound Swab 
Yes Swab 
containing 
ASAP within 24 
 
transport medium 
hours 
Sputum 
Yes Plain 
universal 
ASAP within 24 
 
container 
hours 
Urine 
Yes Universal 
container 
ASAP within 24 
 
with boric acid 
hours 
Faeces 
Yes Stool 
specimen 
ASAP within 24 
 
container 
hours 
Blood Cultures 
NO – Send direct to 
Specific bottles as 
Immediately 
 
laboratory for 
supplied 
incubation 
Blood for routine 
Send direct to 
Specific bottles as 
Direct to laboratory 
examination 
laboratory or 
supplied 
refrigerate overnight 
CSF 
NO Plain 
universal 
Immediately 
 
container 
 
 
 
 
10.3  Specimen Collection/Transport References  
 
•  Carriage of Dangerous Goods (Classification, Packaging and Labelling) 
(1996) London: HMSO 
 
•  Department of Health (2007) Transport of Infectious Substances: Best 
Practice Guidance for Microbiology Laboratories. London: DOH  
 
•  Health Services Advisory Committee (2003) Safe working and the prevention 
of infection in clinical laboratories and similar facilities. 
•  HSE Books.  
 
•  UK Health Department (1997) guidance for Clinical Health Care Workers: 
Protection Against Infection with Blood-borne Viruses London: HMSO 
 
•  Wilson J (2000) Infection Control in Clinical Practice (2nd edition) London: 
Bailliere Tindall  
 
 
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