INFECTION CONTROL
POLICIES
(Please refer to separate yellow folder)
Assurance Statement
This policy aims to ensure that Suffolk Mental Health Partnership
NHS Trust has in place mechanisms to ensure that the risk of
infection to service users, staff and visitors are minimised.
SMHPT Policy
CL6/07/08
Date approved by Trust Executive July 2008
Date approved by Trust Board
July 2008
Review date
July 2010
Implementation date
July 2008
Governance Committee
Clinical & Service Governance
Director responsible for
Director of Nursing
monitoring and reviewing policy
Freedom of Information category
Policies
SMHPT Infection Control Policy (CL6)
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SUFFOLK MENTAL HEALTH PARTNERSHIP NHS TRUST
INFECTION CONTROL MANUAL
CONTENTS
SECTION 1 – INTRODUCTION
1.1 Introduction
1.2 Scope
1.3 Responsibility
1.4 Notifiable diseases
SECTION 2 – INFECTION, ITS CAUSES AND SPREAD
2.1 The causes of infection
2.2 The spread of infection
SECTION 3 –STANDARD PRINCIPLES (UNIVERSAL PRECAUTIONS)
3.1 Standard Principles (Universal Precautions)
3.2 Hand hygiene and skin care
3.3 Protective clothing
3.4 Safe handling of sharps
3.5 Dealing with spillages
3.6 Waste management
3.7 Laundry management
3.8 Decontamination. A-Z of equipment. Environmental cleaning.
SECTION 4 – MANAGEMENT OF SHARPS INJURIES
SECTION 5 – SPECIFIC ORGANISM RELATED INFORMATION
5.1 Meticillin Resistant Staphylococcus aureus (MRSA)
5.2 Clostridium difficile
5.3 Vancomycin Resistant Enterococci (VRE) and Extended Spectrum Beta-
Lactamase Producers (ESBLs)
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SECTION 6 – OUTBREAK CONTROL
6.1 Specific guidance for outbreaks of diarrhoea and vomiting
6.2 Prevention and control of scabies
6.3 Guidelines for the management of head lice
SECTION 7 – CLINICAL PRACTICE
7.1 Aseptic technique
7.2 Care of clients with known infectious diseases
7.3 Care during enteral feeding (NICE guidelines)
7.4 Care of patients with long-term urinary catheters (NICE guidelines)
7.5 Management of non infectious and infectious deceased clients
7.6 Safe handling of specimens
SECTION 8 – STAFF HEALTH POLICIES
SECTION 9 – QUALITY ISSUES AND AUDIT
APPENDIX 1 -– CONTACTS
APPENDIX 2 – DECONTAMINATION LETTER
APPENDIX 3 – INFECTION CONTROL OUTBREAK SUMMARY REPORT
FORM
APPENDIX 4 – GUIDANCE ON COMMUNICABLE DISEASE (MARCH 2005
ISSUE)
SMHPT Infection Control Policy (CL6)
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SUFFOLK MENTAL HEALTH PARTNERSHIP NHS TRUST
SECTION 1
INTRODUCTION AND CONTACTS
1.1 Introduction
Infection control is an important part of the Trust’s effective risk management
strategy to improve the quality of patient care and the occupational health of
staff.
This manual has been written for Suffolk Mental Health Partnership NHS Trust
(SMHPT) staff and approved by the Trust’s Infection Control Committee.
Its aim is to provide clear, concise policies and guidance on the management of
infection control.
This manual should be read in conjunction with all other relevant current
policies and guidelines including COSHH and Health and Safety regulations.
1.2 Scope
The Manual includes policies and guidance on health and social care as
provided by the Trust.
It is acknowledged that some staff work in premises where they have little or no
control (e.g. client’s own homes). Therefore in some instances staff will have to
use their own judgement in the interpretation of the guidelines. If required,
further advice is available from the Trust’s Infection Control Nurse.
1.3 Responsibility
The philosophy of this manual is to encourage individual responsibility by
every member of staff.
All staff should participate in the prevention and control of infection ensuring a
seamless infection control service between hospitals and the community.
The
Chief Executive is responsible for ensuring that there are effective
arrangements in place for the control of infections.
The designated
Director of Infection Prevention and Control (DIPC) is the
Director of N.S.G.
The
DIPC has delegated responsibility for managing and monitoring the
effectiveness of existing infection control processes.
They will support the Infection Control Team and the Infection Control
Committee in their fulfilment of the annual Infection Control Service Programme
and the production of the Infection Control annual report.
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The Infection Control Committee exists to ensure that Infection Control policies,
procedures and guidance are endorsed.
The role of the Infection Control Nurse is to provide an expert service relating to
Infection Control and associated clinical risk management. It is to ensure that
the service provided matches the needs of the workforce and the local
population, is evidence based and promotes best practice.
1.4
Notifiable Diseases
Statutory Notification. The attending doctor has a statutory duty to notify
infectious diseases listed below, whether confirmed or suspected, to the
local
authority of the patient’s residence.
Prompt notification and reporting of disease is essential
The objectives of notification are:
1. To collect accurate and complete epidemiological information on the disease
2. To ensure prompt and appropriate control measures to prevent the spread
of infection
Any Doctor who considers that a patient is suffering from a Notifiable disease
has a statutory duty to notify the Proper Officer of the local authority using the
standard notification procedure.
It is not necessary to wait for laboratory/microbiological confirmation of a
diagnosis. While laboratories may report, this does not absolve clinicians from their
responsibility to do so.
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List of diseases notifiable under the Public Health (Control of Disease) Act
1984 and the Public Health (Infectious Diseases) Regulations 1988.
Anthrax
Plague
Cholera
Poliomyelitis
Diphtheria
Rabies
Dysentery (Amoebic or Bacillary)
Relapsing Fever
Encephalitis
Rubella
Food Poisoning*
Scarlet Fever
Leprosy
Smallpox
Leptospirosis
Tuberculosis
Malaria
Typhoid Fever
Measles
Typhus
Meningitis (all types)
Viral Haemorrhagic Fever
Meningococcal Septicaemia (without Viral Hepatitis
meningitis)
Mumps
Whooping Cough
Ophthalmia Neonatorum
Yellow Fever
Paratyphoid Fever
*Food poisoning: This category includes any infection which could be
food or water borne e.g. Campylobacter, salmonella, cryptosporidiosis,
Giardia.
Although the following diseases are not Notifiable, the Consultant in
Communicable Disease (contactable at the Suffolk Health Protection Unit)
should be informed of their occurrence:
• Legionnaires’
Disease
• Listeriosis
• Psittacosis
• New variant Creutzfeldt-Jakob disease (vCJD)
• Severe acute respiratory syndrome (SARS)
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SECTION 2
INFECTION, ITS CAUSES AND SPREAD
2.1 The Causes of Infection
Micro organisms that cause infections are known as pathogens. They may be
classified as follows:
Bacteria are minute organisms about one-thousandth to five thousandth of a
millimetre in diameter. They are susceptible to a greater or lesser extent to
antibiotics.
Viruses are much smaller than bacteria and although they may survive outside
the body for a time they can only grow inside cells of the body. Viruses are not
susceptible to antibiotics, but there are a few anti-viral drugs available which are
active against a limited number of viruses.
Pathogenic Fungi can be either moulds or yeasts. For example, a mould which
causes infections in humans is
Trichophtyon rubrum which is one cause of
ringworm and which can also infect nails. A common yeast infection is thrush
caused by
Candida albicans.
Protozoa are microscopic organisms, but larger than bacteria. Free-living and
non-pathogenic protozoa include amoebae and paramecium. Examples of
medical importance include:
Giardia lamblia, which causes enteritis (symptoms
of diarrhoea).
Worms are not always microscopic in size but pathogenic worms do cause
infection and some can spread from person to person. Examples include:
threadworm and tapeworm.
Prions are infectious protein particles. Example: the prion causing (New)
Variant Creutzfeldt - Jakob disease.
2.2 The Spread of Infection
A feature that distinguishes infection from all other disease is that it can be
spread from one person to another.
It is convenient to classify the modes of spread of infection as follows:
Direct Contact: Direct spread of infection occurs when one person infects the
next by direct person to person contact (e.g. chicken pox, tuberculosis, sexually
transmitted infections etc.).
I
ndirect: Indirect spread of infection is said to occur when an intermediate
carrier is involved in the spread of pathogens e.g. fomite or vector.
A fomite is defined as an object, which becomes contaminated with infected
organisms and which subsequently transmits those organisms to another
person.
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Examples of potential fomites are bedpans, urinals, thermometers, oxygen
masks or practically any inanimate article.
Crawling and flying insects are obvious examples of vectors and need to be
controlled. Insect bites may cause infections such as malaria.
Hands: The hands of health and social care workers are probably the most
important vehicles of cross-infection. The hands of patients can also carry
microbes to other body sites, equipment and staff.
Inhalation: Inhalation spread occurs when pathogens exhaled or discharged
into the atmosphere by an infected person are inhaled by and infect another
person. The common cold and influenza are often cited as examples, but it is
likely that hands and fomites (inanimate objects) are also important in the
spread of respiratory viruses.
Ingestion: Infection can occur when organisms capable of infecting the
gastrointestinal tract are ingested. When these organisms are excreted faecally
by an infected person, faecal-oral spread is said to occur. Organisms may be
carried on fomites, hands or in food and drink e.g. Hepatitis A, salmonella,
campylobacter.
Inoculation: Inoculation infection can occur following a “sharps” injury when
blood contaminated with, for example, Hepatitis B virus, is directly inoculated
into the blood stream of the victim, thereby causing an infection. Bites from
humans can also spread infection by the inoculation mode.
Splash Injury: Infection may occur through splashing of blood, body fluids,
secretions or excretions into the face and eyes.
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SECTION 3
STANDARD PRINCIPLES for the Prevention and Control of
Infection (previously known as UNIVERSAL PRECAUTIONS)
3.1 Standard
Principles
It is not always possible to identify people who may spread infection to others,
therefore precautions to prevent the spread of infection must be followed at all
times. These routine procedures are called
Standard Principles.
STANDARD PRINCIPLES include:
Handwashing and skin care
Protective clothing
Safe handling of sharps (including sharps injury management)
Dealing with spillages
Waste and laundry management
Decontamination
All blood and body fluids are potentially infectious and precautions are
necessary to prevent exposure to them.
A disposable apron and latex or
vinyl gloves should always be worn when dealing with excreta, blood and
body fluids.
Everyone involved in providing care in the community should know and
apply the standard principles of hand decontamination, the use of
protective clothing, the safe disposal of sharps and body fluid spillages.
Each member of staff is accountable for his/her actions and must follow
safe practices.
3.2
Hand Hygiene and Skin Care
Hand hygiene is recognised as the single most effective method of controlling
infection.
The ability of transient microorganisms to transfer to, and from, hands with ease
results in hands being extremely efficient vectors of infection. Thorough hand
washing will reduce the risk of cross infection immediately.
Transient organisms are those that are not usually part of the normal flora.
They are picked up during contact with individuals and the immediate
environment, and are located on the surface of the skin and beneath the
superficial cells of the stratum corneum. Any damaged skin, moisture or ring
wearing will increase the possibility of colonization. A social hand wash will
usually remove most of these transient bacteria.
Resident flora are commonly termed commensals. They are bacteria usually
found deep in the epidermis, in skin crevices, hair follicles, sweat glands and
beneath fingernails. The numbers of these organisms are reduced during a
surgical hand wash.
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Hands must be decontaminated:
• Before and after each work shift or work break. Remove jewellery (only plain
band wedding rings are exempt and it must be possible to move and clean
under them).
• Before and after physical contact with each client.
• After handling contaminated items such as dressings, bedpans, urinals and
urine drainage bags.
• Before putting on, and after removing protective clothing, including gloves.
• After using the toilet, blowing your nose or covering a sneeze.
• Whenever hands become visibly soiled.
• Before preparing or serving food.
• Before eating, drinking or handling food and before and after smoking.
Which hand wash solution?
Liquid soap is the preferred option for most care settings and will remove most
transient organisms. Emollients are now standard in the majority of hand wash
agents to reduce skin dryness.
Alcohol gels: Alcohol is an effective decontamination agent but should only be
used on visibly clean hands. It will destroy transient bacteria and is suitable for
use when other facilities are inadequate or when
hand disinfection is required.
Antiseptic solutions are soap solutions with an antiseptic added (eg
chlorhexidine, povidone-iodine). They will remove the resident micro-organisms
as well as the transient. They are harsh on the skin and should be reserved for
surgical hand washing.
How to wash your hands
Hands that are visibly soiled, or potentially grossly contaminated with dirt or
organic material, must be washed with liquid soap and water.
Type of Decontamination
Indication
Agent
Routine / social
When hands are visibly soiled
Soap & water
When hands are visibly clean
Soap & water or
Alcohol gel
Hygienic / antiseptic hand Before an aseptic technique
Alcohol gel
disinfection
Before donning sterile gloves
After providing care to a patient
with a resistant organism
Surgical hand disinfection
Prior to all surgical and other Antiseptic solutions
highly invasive procedures
or alcohol gel
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Preparation
The efficacy of hand decontamination is improved if the following principles are
adhered to:
•
Keep nails short and pay attention to them when washing hands – most
microbes on the hands come from beneath the fingernails
•
Avoid wearing rings with ridges or stones – total bacterial counts,
particularly of Gram negative bacteria, are higher when rings are worn
•
Do not wear artificial nails or nail polish as they discourage vigorous
hand washing. Nail polish can flake and itself become a source of
contamination
•
Remove wrist watches, bracelets and roll-up long sleeves or remove long
sleeved clothing prior to hand washing
•
Cuts or abrasions must be covered with occlusive waterproof dressings.
Cuts can provide a breeding environment for micro-organisms and also
provides an entry site for infective organisms
Hand decontamination technique
Using Soap and Water
• Use
liquid
soap
•
Use running water
• Avoid
splashing
•
Wet the hands under running water
•
Apply the soap and rub hands together vigorously to produce a visible
lather
•
Cover all areas of the hands including fingertips, webs of fingers,
thumbs, palms and backs of hands
•
Wash for at least 20-30 seconds
•
Rinse under running water
•
Dry thoroughly with paper towels using a “blotting” action
•
Do not re contaminate hands on taps or bin lids
Using alcohol gel
•
Apply alcohol to clean dry hands, rub over all surfaces of hands and
wrists
•
Rub hands together covering all surfaces until hands are dry. Pay
particular attention to fingertips and palms of hands.
Surgical Hand Washing
Surgical hand washing destroys transient organisms and reduces resident flora
before surgical or invasive procedures. An aqueous antiseptic solution is
applied for two minutes. Preparations currently available are 4% chlorhexidine-
detergent and 0.75% povidone/iodine solution-detergent.
This is required before minor surgery and invasive procedures.
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Alternative hand preparation for minor surgery and invasive
investigations using alcohol hand rub
For areas where minor surgery or invasive procedures are performed and scrub
sinks are not available, the following hand disinfection technique may be used:
1. Ensure nails are clean. Wash hands and wrists with non-medicated liquid
soap from the dispenser, rinse under running water and dry thoroughly using
paper towels
2. Apply one application of alcohol gel and rub over all surfaces of hands and
wrists paying particular attention to fingertips and palms of hands until the
solution evaporates to dryness. This should take at least 20 seconds but it is
more important that there is enough gel initially to cover all skin surfaces
3. Repeat Step 2
For subsequent procedures in the same session it is only necessary to perform
step 2 unless hands become physically contaminated. The rationale for this
process is that whilst alcohol gel is an excellent bactericidal agent, it only works
on socially clean hands. Washing with soap and water first removes dirt and
transient bacteria.
Notes
Use of hand creams – Communal pots of hand cream should not be used as
these can become contaminated and a source of cross infection. Individual
tubes or lotions with an integral pump dispenser are preferred.
Skin lesions – If staff members have lesions or skin problems on their hands
the Occupational Health
Department should be consulted for advice.
Use of scrub brushes – Scrub brushes should not be used for routine hand
washing as they may abrade the skin and can become reservoirs for bacteria.
Brushes in sterile packs are supplied by HSDU to areas where a surgical scrub
may be necessary.
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Skin care summary
• Wet hands before applying soap
• Use preparations containing emollients
• Always rinse hands and dry thoroughly
• Apply hand cream regularly
• Wear powder-free latex gloves low in extractable proteins and residual
accelerators for protection against blood borne viruses
• Seek professional advice for skin problems
• Wear non-NRL synthetic gloves if sensitised to natural rubber latex proteins
1. Palm to palm
2. Right palm over left
3. Palm to palm fingers
dorsum and left palm
interlaced
over right dorsum
4. Backs of fingers to
5. Rotational rubbing of
6. Rotational rubbing,
opposing palms with
right thumb clasped in
backwards and
forwards
fingers interlocked
left palm and vice versa
with clasped fingers
of
Hand washing facilities
Facilities should be adequate and conveniently located. Hand wash basins must
be placed in areas where needed and where client consultations take place.
They should have elbow-operated or sensor-operated mixer taps. A separate
sink should be available for other cleaning purposes - such as cleaning
instruments.
• Use wall-mounted liquid soap dispensers with disposable soap cartridges -
keep them clean and replenished.
• Place disposable paper towels next to the basins - soft paper towels will help
to avoid skin abrasions.
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• Position foot-operated pedal bins near the hand wash basin – make sure
they are the right size.
• Paper towels may be disposed of as household waste.
Project Managers involved in redesign or new facilities must ensure that the
infection control nurse is consulted about the requirements and relevant
regulations with regard to the
proposed siting and design of handwashing
facilities within all healthcare premises.
Handwashing in patients’ homes
Hands should be washed prior to any procedure in the patient’s home and
before departure.
It is important to do a risk assessment of handwashing facilities available. If
these are not adequate then alcohol gel may be used to disinfect visibly clean
hands. Disposable wipes could be used on soiled hands followed by alcohol
gel.
References
Babb JR (1996). ‘Application of Disinfectants in Hospitals and other Healthcare
Establishments.’ Infection Control. March, p4-12.
Infection Control Nurses Association (ICNA) (2002).Hand Decontamination
Guidelines. London.
NICE Guidelines, Prevention and Control of Healthcare Associated Infection in
Primary and Community Care – June 2003.
RCN (2004). Good practice in infection control – Guidance for nursing staff.
Royal College of Nursing. London.
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3.3 Protective
Clothing
Selection of protective equipment must be based on an assessment of the risk
of transmission of microorganisms to the patient, and the risk of contamination
of the healthcare practitioners’ clothing and skin by patients’ blood, body fluids,
secretions or excretions.
Assessment of Risk
WHAT TO WEAR WHEN
No exposure to
Exposure to blood/body Exposure
to
blood/body fluids
fluids or substances
blood/body fluids or
or substances
listed under COSHH
substances listed
listed under
regulations anticipated,
under COSHH
COSHH
but low risk of splashing
regulations
regulations
anticipated – high risk
anticipated
of splashing to face
Wear gloves, plastic
No protective
Wear gloves and a
apron and
clothing
plastic apron
eye/mouth/nose
protection
Types of Protective Clothing
Gloves
Gloves should not be worn unnecessarily as their prolonged and indiscriminate
use may cause adverse reactions and skin sensitivity.
A risk assessment should be carried out to assess the need for gloves and the
appropriate type.
Gloves must be worn for invasive procedures, contact with sterile sites and non-
intact skin or mucous membranes, and all activities that have been assessed as
carrying a risk of exposure to blood, body fluids, secretions or excretions, or to
sharp or contaminated instruments.
Gloves that are acceptable to healthcare personnel and that conform to
European Community (CE) standards must be available.
DO NOT USE powdered gloves or polythene gloves in healthcare activities.
Gloves must be worn as single-use items. They must be put on immediately
before an episode of patient contact or treatment and removed as soon as the
activity is completed. Gloves must be changed between caring for different
patients, and between different care or treatment activities for the same patient,
and do not substitute for hand washing.
Gloves must be disposed of as clinical waste if contaminated with blood or body
fluid and hands decontaminated after the gloves have been removed.
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Sensitivity to natural rubber latex in patients, carers and healthcare personnel
must be documented. Alternatives to natural rubber latex gloves must be
available. (See Latex Allergy Policy).
Gloves must
not be washed between patients as the gloves may be damaged
by the soap solution and, if punctured unknowingly, may cause body fluid to
remain in direct contact with skin for prolonged periods.
Non sterile gloves
These must be used when hands may come into contact with body fluids or
equipment contaminated with body fluids.
These must be used when the hand is likely to come into contact with normally
sterile areas or during any surgical procedure.
General purpose utility gloves
General purpose utility gloves e.g. rubber household gloves, can be used for
cleaning instruments prior to sterilisation, or when coming into contact with
possible contaminated surfaces or items. Colour coding of such gloves should
be used e.g.
• blue for the kitchen
• yellow for general environmental cleaning
• red for ‘dirty’ clinical duties.
This will help prevent cross-infection from one area of work to another. The
gloves should be washed with general purpose detergent and hot water, and
dried between use. They should be discarded weekly or more frequently if the
gloves become damaged.
Polyurethane/polythene gloves (non sterile and sterile)
Polyurethane/polythene gloves do not act as a barrier to infection. They do not
meet the Health and Safety Commission regulations and they do not have a
place in
clinical application.
DO NOT USE.
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GLOVE USAGE GUIDELINES
TYPE OF GLOVE
Latex
Synthetic alternative
Vinyl
Polythene
Sterile
Non sterile
Sterile
Non sterile
Sterile
Non sterile
Surgeons
Examination
Non aseptic
Aseptic
Tasks with a
Not
Use only for
procedures
procedures
low risk of
recommended
food handling,
with potential
where risk of
contamination
for clinical use.
serving or
exposure to
contamination
with blood/
preparation.
blood/ blood
with blood or
blood stained
stained fluid
blood stained
All surgery
All aseptic
body fluids.
body fluid is
procedures
Cleaning with
minimal.
detergent.
Taks which do
not rquire a
high degree of
dexterity and
REFERENCE ICNA (1999)
will not pull/
twist glove.
All gloves should be powder free and have the lowest possible levels of extractable proteins and chemical accelerators
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Disposable plastic aprons
Must be worn when there is a risk that clothing may be exposed to blood, body
fluids, secretions or excretions, with the exception of sweat. They should also
be worn for giving close physical care and for bed making. Plastic aprons
should be worn as single-use items, for one procedure or episode of patient
care, and then discarded and disposed of as clinical waste.
Face masks and eye protection
Must be worn where there is a risk of blood, body fluids, secretions or
excretions splashing into the face and eyes.
Respiratory protective equipment
There are very few occasions when the wearing of masks is required in the
community.
If a mask is to be worn, a good quality filter type should be used. It must fit the
face closely and be changed if it becomes wet.
References
Infection Control Nurses Association (September 1999) ‘Glove Usage
Guidelines’, London.
Infection Control Nurses Association (2002). Protective Clothing; Principles and
Guidance. London.
Medical Devices Agency (April 1996) ‘Latex Sensitisation in the Health Care
Setting (Use of Latex Gloves)’. London.
NICE Guidelines (June 2003). Prevention & Control of Healthcare Associated
Infections in Primary & Community Care. London
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3.4
Safe Handling of Sharps
All staff should be fully immunised according to national policy. In addition, all
those handling sharps should have had a course of hepatitis B vaccine. A
record of hepatitis B antibody response should be kept by occupation health for
all clinical staff involved in ‘exposure prone procedures’ or where regular
exposure so blood/blood stained body fluids occurs. The Occupational Health
department can advise staff regarding their need for immunisation and any
necessary boosters.
Care should be taken to avoid accidental needlestick injury, as exposure to
contaminated blood may be associated with transmission of Blood Borne
Viruses.
The average risk of transmission of bloodborne viruses following a single
percutaneous exposure with blood known to contain a bloodborne virus has
been estimated to be:
•
Hepatitis
B
(HBV) 33.3%
(1
in
3)
• Hepatitis C virus (HCV)
3.3%
(1 in 30)
• Human Immunodeficiency virus (HIV)
0.31%
(1 in 319)
Sharps include needles, scalpels, stitch cutters, glass ampoules, sharp
instruments and broken crockery and glass. Sharps must be handled and
disposed of safely to reduce the risk of exposure to bloodborne viruses. Always
take extreme care when using and disposing of sharps. Avoid using sharps
whenever possible;
•
clinical sharps should be single use only
•
do not re-sheath a used needle - if this is necessary, a safe method – for
example, a re-sheathing device - must be used
•
discard sharps directly into a sharps container immediately after use and at
the point of use
•
sharps containers should be available at each location where sharps are
used
•
sharps containers must comply with UN 3921 and BS7320 standards
• close the aperture (temporary closure) to the sharps container when
carrying or if left unsupervised to prevent spillage or tampering
•
place sharps containers on a level stable surface in a safe and secure area
•
do not place sharps containers on the floor, window sills or above shoulder
height - use wall or trolley brackets
•
assemble sharps containers by following the manufacturer’s instructions
•
carry sharps containers by the handle - do not hold them close to the body
never leave sharps lying around
•
do not try to retrieve items from a sharps container
•
do not try to press sharps down to make more room
• lock the container when it is three-quarters full using the closure
mechanism
•
label sharps containers with the source details prior to disposal
•
place damaged sharps containers inside a larger container - lock and label
prior to disposal. Do
not place inside a clinical waste bag.
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For community staff carrying sharps boxes in their cars:
• sharps should only be carried by staff if there is no alternative for safe
disposal
• the container should be carried in a secure area of the car to prevent tipping
over whilst driving
• the container should be carried out of sight
• the temporary closure should be used whilst transporting/carrying
• as the volume of sharp clinical waste is small in these circumstances, there
is no requirement for the member of staff to display a ‘Hazard’ notice on their
car
• staff must take sealed sharps boxes to their employer’s lockable clinical
waste storage and collection point as soon as possible to ensure their safe
storage prior to disposal.
Diabetic Sharps
All used diabetic sharps should be disposed of in a regulation sharps container
(this includes lancets and BD needle clippers).
Sharps containers are available for diabetics from all general practice surgeries.
General Practitioners should ensure that the patient is aware of the correct
method of disposal of the filled sharps bin. The Environment Agency (as the
enforcing body) has agreed that, legally, sharps bins can be returned to the
surgery for disposal under exemption 39(2) of the
Waste Management
Licensing Regulations 1994 (as amended). The Local Authority also has a duty
to collect clinical waste including sharps from households. The householder
may be charged by the local authority for this service.
Whichever route is used, the patient must be made aware that it must not be
disposed of in the household waste system under any circumstances.
References
British Medical Association (1990, Reprinted 1993) ‘A Code of Practice for the
Safe Use and Disposal of Sharps’. BMA House, London.
British Standards Institute BS7320 (1990) ‘Specification for Sharps Containers.
London.
Health Service Advisory Committee (1992). ‘Safe Disposal of Clinical Waste’
NICE Guidelines (June 2003). Prevention & Control of Healthcare Associated
Infections in Primary & Community Care. London.
United Nations Standard 3291 (1997). Clinical Waste/Infectious Substances
Unspecified.
SMHPT Infection Control Policy (CL6)
Page 20 of 80 (Section 3)
3.5
Dealing with Spillages
It is vital that any spillage must be attended to as soon as possible. Under the
Control of Substances Hazardous to Health Regulations 1994 (COSHH),
assessment of hazards and associated risks to health must be undertaken to
ensure the health and safety of employees, patients and other visitors to the
Trust’s health care premises.
Responsibilities
Managers are responsible for the implementation of a policy that deals with
spillages. Should exposure occur, they are also required to ensure that any
risks to staff, patients and visitors are minimised.
All staff have responsibility for ensuring that they adhere to any policies and
procedures to minimize the hazards resulting from any spillage.
All staff involved in the clinical care of patients or the safe handling of waste
must be aware of how to deal safely with any spillage should it occur.
Blood/body fluid spillage management guidelines
(not suitable for urine spills) 1.
Hypochlorite / Sodium Dichloroisocyanurates (NaDCC) Method – to
be used ONLY where surface will tolerate chlorine releasing
(bleach) disinfectant i.e. flooring, non-upholstered furniture.
• prevent access to the area containing the spillage until it has been
safely dealt with
•
open the windows to ventilate the area if possible
•
wear protective clothing (disposable gloves and apron)
Either:
cover area with NaDCC absorbent granules or 1% solution (e.g.
Presept™, Actichlor™), leave for 2 minutes, and clean up with
disposable towels
or, for large spills with danger of high fume levels:
mop up organic matter with paper towels or disposable cloths
and/or absorbent powder e.g. Vernagel™ and then wash surface
with a solution containing 10,000 parts per million of available
chlorine (1% hypochlorite solution = 1 part household bleach to 10
parts water) and leave for 2 minutes
•
disposable towels should be disposed of as clinical waste
•
clean area with detergent and hot water, and dry thoroughly
•
clean the bucket/ bowl in fresh soapy water and dry
•
discard protective clothing as clinical waste
•
Wash and dry hands.
SMHPT Infection Control Policy (CL6)
Page 21 of 80 (Section 3)
2.
Detergent and water method – to be used when the surface is
unsuitable for contact with hypochlorite disinfectant i.e. soft
furnishings, carpets.
•
Prevent access to the area until spillage has been safely dealt with
•
wear protective clothing
• mop up organic matter with paper towels or disposable cloths
and/or absorbent powder e.g. vernagel™
•
clean surface thoroughly using a solution of detergent and hot water
and paper towels or disposable cloths
•
rinse the surface and dry thoroughly
•
dispose of materials as clinical waste
•
clean the bucket/ bowl in fresh hot, soapy water and dry
•
remove protective clothing and discard as clinical waste
•
wash and dry hands
•
ideally, once dry; go over area with a mechanical cleaner.
On soiled
carpets, upholstery and soft furnishings, a steam cleaner may be
used after excess fluid has been removed with paper towel.
References
Control of Substances Hazardous to Health regulations 2002
Health and Safety at Work Act (1974)
HSE Environmental Hygiene Guidance Note Number 17
RCN (2004). Good Practice in Infection Control – Guidance for Nursing Staff.
Royal College of Nursing, London.
Substances Hazardous to Health Emergency Spillage Guide – Croner
Publications
SMHPT Infection Control Policy (CL6)
Page 22 of 80 (Section 3)
3.6
Waste Management
Guidelines for the safe handling and management of clinical waste
SMHPT have a legal responsibility to ensure that waste generated by staff
employed by the organisation is disposed of safely, ensuring no harm is caused
either to staff, members of the public or the environment. This responsibility
begins when waste is generated and ends with its final disposal; even where
properly authorised agents are used.
It is essential that persons handling waste exercise care to prevent injury or
transmission of infection to themselves or others. This is to fulfil their
responsibilities under the current legislation (for list see end of this section).
Definition of clinical waste
Clinical waste is:
a)
any waste which consists wholly or partly of human or animal tissue,
blood or other body fluids, excretions, drugs or other pharmaceutical
products, soiled swabs or dressings, or syringes, needles or other sharp
instruments, being waste which, unless rendered safe, may prove to be
hazardous to any person coming into contact with it; and
b)
any other waste arising from medical, nursing, dental, veterinary,
pharmaceutical or similar practice, investigation, treatment, care,
teaching or research, or the collection of blood for transfusion, being
waste which may cause infection to any other person coming into contact
with it.
(Controlled Waste Regulations 1992)
The coding of waste is determined by the List of Wastes (England) Regulations
2005:
18 01 01
Sharps (except 18 01 03)
18 01 02
Body parts and organs including blood bags and blood preserves
(except 18 01 03)
18 01 03 Wastes whose collection and disposal is subject to special
requirements in order to prevent infection
18 01 04
Wastes whose collection and disposal is not subject to special
requirements in order to prevent infection
18 01 06
Chemicals consisting of or containing dangerous substances
18 01 07
Chemicals other than those mentioned in 18 01 06
18 01 08
Cytotoxic and cytostatic medicines
18 01 09
Medicines other than those mentioned in 18 01 08
18 01 10
Amalgam waste from dental care
SMHPT Infection Control Policy (CL6)
Page 23 of 80 (Section 3)
Segregation of waste produced within healthcare premises
The key to the safe disposal of waste is for all staff to conform to the system of
segregation shown in the table below. This system enables clear identification
of the different types of waste encountered and indicates the disposal
procedures that apply to each category.
CATEGORY OF WASTE
RECEPTACLE
General (domestic type) Waste
Black Plastic Bags
Paper, flowers, kitchen waste,
Within solid-sided, pedal-operated,
bottles, aerosols.
lidded bins.
Gloves that have not been in
Never place clinical waste in these
contact with blood or body fluids.
bins
Clinical Waste
Orange Plastic Bags (225 gauge)
All waste that has been in contact Within solid-sided, pedal operated,
with blood or body fluids e.g.
lidded bins.
gloves, dressings, catheter bags,
incontinence aids, nappies.
Empty maceratable products in
event of macerator malfunction
Sharps
BS 7320/UN 3291 Approved Sharps
Needles, blades etc.
Container
Special Clinical /
Advice must be sought from
Pharmaceutical Waste
Pharmacist and/or Facilities Manager
Handling and disposal of waste
• waste should be segregated at the point of origin
• personal protective clothing should be worn when handling waste
Clinical waste should be:
• correctly bagged in orange bags of 225 gauge to prevent spillage
• kept in a rigid-sided holder or container with a foot-operated lid, and so far
as is reasonable practicable, out of the reach of children
• double bagged where:
• the exterior of the bag is contaminated
• the original bag is split, damaged or leaking
• only filled to ¾ full
• securely sealed and labelled with coded tags at the point of use to
identify their source.
•
clinical waste bags should never be:
•
decanted into other bags, regardless of volume
•
contaminated on the outside
SMHPT Infection Control Policy (CL6)
Page 24 of 80 (Section 3)
•
sharps must be disposed of into approved sharps containers that meet
BS7320/UN3291
•
sharps containers should
NEVER be placed into a orange clinical waste
bag. Refer to section 3.4
Disposal of sharps containing medicinal waste
Sharps are items that could cause cuts or puncture wound, including needles,
syringes with needles attached, broken glass ampoules, scalpels and other
blades.
Medicinal waste is classified into two categories:
• cytotoxic and cytostatic medicines = hazardous waste
• medicines other than those classified as cytotoxic or cytostatic
Used Sharps and/or fully discharged syringes may still contain or be
contaminated with medicinal waste.
Sharps and syringes contaminated with residual medicines (other than cytotoxic
or cytostatic medicines) must be disposed of in a
yellow topped UN approved
sharps bin for incineration.
Sharps contaminated with cytotoxic and cytostatic medicines must be disposed
of in
purple lidded sharps bins for incineration.
Storage of clinical waste
Clinical waste should be removed from point of generation as frequently as
circumstances demand, and at least weekly.
Between collections, waste should be:
•
stored in correctly coded bags, with bags of each colour code kept
separate.
•
situated in a centrally designated area of adequate size related to the
frequency of collection.
•
sited on a well-drained, impervious hard standing floor, which is provided
with wash down facilities.
•
kept secure from unauthorised persons, entry by animals and free from
infestations (i.e. lockable bin / area).
•
accessible to collection vehicles.
Management of clinical waste produced in non-healthcare managed
environments i.e. private households.
(this does
NOT include private residential care establishments).
A householder has no legal duty of care to dispose of clinical waste in the way
described above. However. a health or social care worker who provides care in
a private household does e.g. NHS Trust, Social Services, care agency staff.
The assessable health risk of most waste from patient’s homes is very small
SMHPT Infection Control Policy (CL6)
Page 25 of 80 (Section 3)
and in most instances used swabs and dressings can be double wrapped and
placed in the patient’s normal household collection.
A risk assessment should be undertaken to determine whether there is an
increased risk of transmission of infection due to;
• The risk of potential exposure to waste to a third party. For example; waste
placed in the household waste stream is collected and crushed/compacted
in a collection vehicle. If body fluids within the waste are crushed, these
may then spread over an area and possibly contaminate the collection
operative.
• The waste is saturated with body fluids such that if lightly compressed, free-
flowing blood and/or body fluids would result.
• The waste is a used sharp e.g. needle and/or syringe, lancet. Sharps must
be discarded into a sharps container (BS 7320, UN 3291).
In these instances a clinical waste collection should be arranged.
A clinical waste collection can be arranged by ringing the Facilities
Manager for Suffolk Support Services. See Appendix 1 for contact details
The following information will be required:
Client’s name
Full address (including post code)
Telephone number for client
How often the waste needs collecting
What type of waste it is e.g. soft waste in bags, sharps, pharmaceutical.
Contact details of the person making the referral
For waste that does not constitute high risk, but is defined as clinical waste, the
following action should be carried out:
The following table is a guide to help staff to assess the correct disposal route
for clinical waste items.
ITEM ADDITIONAL
INFO
DISPOSAL
Soiled dressings
Less than one 20 litre Double wrapped in
bag per week
plastic bags and
disposed of in household
waste stream (black
bag/bin)
Wound drains and
Empty
collection
tubing – drainable.
reservoir into toilet and
Urinary catheters and
dispose of empty item in
bags.
household waste stream
Stoma bags - drainable
after double wrapping as
above
SMHPT Infection Control Policy (CL6)
Page 26 of 80 (Section 3)
Drainage bags which are Discuss
clinical
waste
not able to be emptied
collection with Facilities
safely
Manager
Large quantities of
More than one 20 litre Discuss clinical waste
heavily soiled dressings bag per week
collection with Facilities
or other waste
Manager
Diabetic sharps
Sharps bin prescribed by Patient to take bin to GP
GP
practice for disposal
Sharps
Clinical waste collection
will need to be arranged
with Facilities Manager
New regulations in force since 01.01.2002 state that all health care risk wastes
(clinical waste) must be contained in UN approved rigid packaging when
transported on the road.
Staff working in the community must not carry clinical waste in their cars (except sharps containers which are already rigid).
Current legislation
• Health & Safety at Work etc Act 1974
• Control of Pollution Act 1974
• Collection and Disposal of Waste Regulations 2005
• Control of Pollution (Amendment) Act 1989
• Environment Protection Act 1990
• Environment Protection (Duty of Care) Regulations 1991
• Controlled Waster Regulations 1992
• The Special Waste Regulations 1996
• The Safe Disposal of Clinical Waste 1999
• Health Care Waste Management and Minimisation 2007
• ADR 2003 (Carriage of Dangerous Goods by Road)
References
Chief Medical Officer 2003. Winning Ways – Working together to reduce Healthcare
Associated Infection in England. Department of Health. London.
DH (2006) Safe Management of healthcare waste – HTM 07-07. Department of Health,
London.
HSC (1999) Safe Disposal of Clinical Waste. London.
IWM (2000) Healthcare Waste Management and Minimisation. London.
Pellowe C et al. 2003. Infection Control – Prevention of healthcare-associated infection
in primary and community care. Infection Control Nurses Association. London.
Phillips G (1999)
Microbiological Aspects of Clinical Waste. Journal of Hospital
Infection 41:1-6.
SMHPT Waste Management policy.
SMHPT Infection Control Policy (CL6)
Page 27 of 80 (Section 3)
3.7
Laundry Management
Linen must be kept to a minimum in community based clinic areas unless
laundry services are contracted. If laundry services are contracted, the service
provider’s guidelines must be followed.
Areas, which do not use a contracted laundry service, should use disposable
pillowcases, sheets and towels as appropriate.
Examination couches
Examination couches and pillows if used, must be covered with a disposable
paper towel, which must be changed between patients
Pillows are not considered essential, as all couches should have head-tilts.
However, if pillows are used, they should be sealed within a plastic
impermeable cover. Disposable pillowcases should then be used. These
should be discarded once weekly or more frequently if they become soiled. If
standard pillowcases are used, they must be washed weekly or more frequently
if they become soiled
Blankets/sheets are not considered essential. For modesty, a length of
disposable paper towel should be used to cover exposed parts of the body.
Curtains
•
At windows, it is recommended that vertical blinds are used
•
Around couches, curtains should only be used if required to protect
patient’s modesty
•
There should be an environmental cleaning schedule which should
include cleaning blinds and bed curtains twice yearly
When linen is used
•
Linen must be changed at least weekly, or more frequently if soiled
•
Place linen soiled with body fluids in a leak-proof, water soluble bag and
arrange prompt laundering
•
Used linen must be laundered at 710C for 3 minutes or 650C for 10
minutes. For staff health reasons and quality control issues (as domestic
washing machines are not generally designed to comply with this
standard), it is not acceptable for linen to be laundered by any member of
staff using their own personal facilities i.e. at home
In the patient’s own home
Staff caring for clients in their own homes or in group homes may be involved in
the laundering of client’s clothes or linen. The following principles should be
noted:
The microorganisms in most soiled and fouled linen are unlikely to cause
infection in healthy workers provided that care is taken. But to further minimize
the risk
SMHPT Infection Control Policy (CL6)
Page 28 of 80 (Section 3)
Wear a waterproof apron and gloves when dealing with used laundry
Ensure that adequate hand washing facilities are available
Remove any protective clothing and wash hands before returning to other
duties
Do not smoke or eat while dealing with laundry
Cover cuts and abrasions with waterproof dressing
In a client’s own home, a domestic washing machine may be used. Soiled and
fouled linen should be pre-washed and then washed at the highest temperature
that the material will withstand. Soiled or fouled linen should not be washed by
hand.
Staff uniforms or work clothes
SMHPT Dress code policy HR26/2/05 must be complied with at all times.
The majority of bacteria and viruses will not survive away from the host and
would not present a high risk of infection on clothing. However, within a mass
of body fluid, organisms would survive longer.
Staff who are at risk of contaminating their clothes by body fluids should always
change into ‘home’ clothes as soon as possible – preferably before leaving the
work place or as soon as home is reached.
Uniforms or work clothes should be washed as soon as possible on as hot a
wash as the fabric will tolerate. This must be at least 40 oC and ideally 60 oC.
Cardigans/jumpers should be washed at least weekly.
Shoes should be cleaned immediately if contaminated with body fluids, using
general purpose detergent and hot water – disposable gloves should be worn.
References
NHS Executive (1995). Hospital Laundry Arrangements for Used and Infected
Linen. HSG(95)18.
DH (2007)
Uniforms and Workwear: an evidence base for developing local
policy.
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd
Guidance/DH_078433
SMHPT Infection Control Policy (CL6)
Page 29 of 80 (Section 3)
3.8
Decontamination of equipment
The aim of decontaminating equipment is to prevent potentially pathogenic
organisms reaching a susceptible host in sufficient numbers to cause infection.
Those involved in the purchase of equipment should consider how it will be
cleaned prior to purchasing.
SINGLE USE EQUIPMENT
Single use means that the manufacturer:
•
Intends the item to be used once, then thrown away.
•
Considers the item unsuitable for use on more than one occasion.
•
Has insufficient evidence to confirm that re-use would be safe.
The Medicines and Healthcare Regulations Authority guidance advises that
reprocessing and re-using such items may pose hazards for patients and staff,
if the reprocessing method has not been validated.
The Consumer Protection Act 1987 will hold a person liable if a single use item
is reused against the manufacturer’s recommendations. Liability under this
legislation continues for 10 years.
Single patient use means that the item can be reused if re-processed using an
appropriate method and is used on the
same patient only. The manufacturer
will provide details of the appropriate method of decontamination of the device
in this instance.
The duration of use is dependant upon undertaking a risk assessment of
individual risk factors.
The Medical and Healthcare products Regulations Agency (MHRA) defines the
following terms:
Cleaning is an essential prerequisite of equipment decontamination to
ensure effective disinfection or sterilisation can subsequently be carried
out.
•
Cleaning is a process which physically removes contamination but does
not necessarily destroy micro-organisms. The reduction of microbial
contamination cannot be defined and will depend upon many factors
including the efficiency of the cleaning process and the initial bio-burden.
•
Disinfection is a process used to reduce the number of viable micro-
organisms, which may not necessarily inactivate some viruses and
bacterial spores. Disinfection will not achieve the same reduction in
microbial contamination levels as sterilisation.
•
Sterilisation is a process used to render the object free from viable micro-
organisms, including spores and viruses.
SMHPT Infection Control Policy (CL6)
Page 30 of 80 (Section 3)
RISK ASSESSMENT
Re-usable equipment should be appropriately decontaminated between each
patient using a risk assessment model. Use only the decontamination method
advised by the manufacturer - using any other process may invalidate
warranties and transfer liability from the manufacturer to the person using or
authorising the process.
Medical equipment is categorised according to the risk that particular
procedures pose to patients - by assessing the microbial status of the body area
being manipulated during the procedure. For example, items that come into
contact with intact mucous membranes are classified as intermediate risk and
require disinfection between each use as a minimum standard. Items that enter
normally sterile body areas, or come into contact with broken mucous
membranes, are classified as high risk and must be sterile before use.
Risk Assessment for Decontamination of Equipment
Risk
Application of Item
Suitable method
Low
• in contact with healthy skin e.g. stethoscopes, Cleaning and
washing bowls,
drying
or
• not in contact with patient
e.g. furniture, mattresses, surfaces,
commodes
Intermediate • in contact with intact mucous membranes
Cleaning followed
or
by disinfection
• contaminated with virulent or readily
transmissible organisms (body fluids)
or single use
or
• prior to use on immuno-compromised patients
e.g. thermometers, auroscope earpieces.
High
• in contact with a break in the skin or mucous
Sterile at point of
membrane
use,
or
• for introduction into sterile body areas for
or single use
example uterine sounds, instruments used for
surgical/ operative procedures
Cleaning methods
Cleaning is the first step in the decontamination process. It must be carried out
before disinfection and sterilisation to make these processes effective.
Thorough cleaning is extremely important in reducing the possible transmission
of all microorganisms, including the abnormal prion protein that causes variant
Creutzfeldt-Jacob Disease (vCJD).
Staff must wear the appropriate personal protective clothing whilst handling and
cleaning used medical devices or equipment. Refer to section 3.3
Thorough cleaning with general purpose detergent (GPD) (i.e. Hospec™) and
warm water - maximum temperature 350C - will remove many micro-organisms.
SMHPT Infection Control Policy (CL6)
Page 31 of 80 (Section 3)
Hot water should not be used as it will coagulate protein making it more difficult
to remove from the equipment.
The concentration of the detergent solution must be as advised by the
manufacturer. This requires that a measured amount of detergent is added to a
known volume of water.
All equipment must be thoroughly rinsed in clean water and dried using a non-
shedding disposable cloth prior to use or further processing.
Manual cleaning of small items and surgical instruments must be undertaken in
a designated sink, which is deep enough to completely immerse the items to be
cleaned.
Scrubbing can generate aerosols, which may convey infective agents.
Therefore if scrubbing is necessary it must be carried out with the brush and
item beneath the surface of the water.
Personal protective equipment, including aprons, gloves and goggles or visors,
must be readily available for staff undertaking the manual cleaning of
equipment.
Cleaning equipment - such as brushes must be stored clean and dry between
uses.
Disinfection methods
Disinfection methods apply to handwashing, pre-operative skin preparation and
the disinfection of medical devices or equipment.
Disinfection of equipment should be limited and, where possible, disposable or
autoclavable equipment used instead. If disinfection is required, use the
method recommended by the manufacturer.
Chemical Advantages
Disadvantages
Uses
Chlorine-based:
• wide range of
• inactivated by
can be used on
Hypochlorites
bacterial,
organic matter
surfaces and for
(e.g. Domestos™,
virucidal,
• corrosive to
body fluid spills –
Milton™)
sporicidal and
metals
minimum contact
NB Undiluted
fungicidal activity • diluted solutions time 2 mins.
commercial
• rapid action
can be unstable
hypochlorite contains • non-toxic in low
• need to be
(0.1% (1000 ppm)
approx. 100,000ppm
concentrations
freshly prepared solution for
available chlorine
• can be used in
• does not
disinfecting
food preparation
penetrate
surfaces and
• cheap
organic matter
equipment,
• bleaches fabrics 1% (10,000 ppm)
• need ventilation solution for
disinfecting blood
spillages)
SMHPT Infection Control Policy (CL6)
Page 32 of 80 (Section 3)
Sodium
• slightly more
• as above
as above
Dichloroisocyanuraes
resistant to
The correct
(NaDCC)
inactivation by
dilutions are better
e.g. Presept,
organic matter
achieved using
Actichlor – available
• slightly less
NaDCC tablets
in liquid, tablet and
corrosive
granule form
• more convenient
• long shelf-life
Alcohol 70%
• good bactericidal, • non-sporicidal
can be used on
e.g. isopropanol
fungicidal and
• flammable
surfaces, or for skin
virucidal activity
• does
not and hand
• rapid action
penetrate
decontamination
• leaves surfaces
organic matter
dry
• requires
• non-corrosive
evaporation
time
Chlorhexidine
• most useful as
• limited activity
for skin and hand
e.g. Hibiscrub™,
disinfectants for
against viruses
decontamination
chlorhexidine wound
skin
• no activity
cleaning sachets
• good fungicidal
against bacterial
activity
spores
• low toxicity and
• inactivated by
irritancy
organic matter
Sterile instruments may be obtained by purchasing pre-sterilised single use
items. These avoid the need for re-sterilisation and are a practical and safe
method. You must store items using a stock rotation system according to
manufacturer’s instructions.
Decontamination of equipment prior to inspection, service, repair or loan.
Do not send contaminated equipment elsewhere without decontaminating first.
All external surfaces must be cleaned using general purpose detergent (GPD),
and dried. If there is visible body fluid contamination the exterior surface should
also be wiped with an alcohol or hypochlorite solution.
Before dispatch, complete and attach a certificate (see Appendix 2), which
states the method of decontamination used, or the reason why it was not
possible (NHS Management Executive 1993). Service and maintenance
engineering contractors may provide identification tags, which must be attached
to the item in addition to the decontamination certificate.
Purchasing equipment
When considering purchasing an item of equipment, consideration should be
given to ease and method of cleaning. Cleaning instructions should be available
with the item and these should be kept and incorporated into local cleaning
guidelines.
SMHPT Infection Control Policy (CL6)
Page 33 of 80 (Section 3)
A-Z OF EQUIPMENT AND THE DECONTAMINATION METHOD
EQUIPMENT CLEANING
METHOD
Babies feeding bottles Disposables preferred.
and teats
Non-disposables – as dummies and feeding equipment (see
Dummies and feeding below).
equipment
Single use preferred.
Communal sterilising tanks must not be used. Single person
use sterilising tanks should be cleaned thoroughly with GPD
solution and rinsed before use. Ensure total immersion of
equipment in Milton (or similar) solution. Tank must be
cleaned daily and fresh solution prepared. Electric steam
steriliser should be used as per manufacturer’s guidance.
Baby changing mats
Cover with paper towel and change between each baby.
Clean between each baby and at end of session with
detergent wipes. Store dry.
Baths,
To be cleaned between users. With gloved hand, clean
Bath hoists
bath surface, grab rails and taps with warm water, GPD and
paper towels. Rinse.
Bath water additives
There are no antiseptic solutions that should be added to
the bath. When antiseptic bathing is prescribed, the agent
should be applied directly to the skin instead of soap.
Bedpans and urinals
Wearing disposable plastic apron and gloves, flush away
(non-disposable)
contents and clean thoroughly using paper towels and GPD
solution. Rinse, dry and store inverted. Disinfection using
sodium hypochlorite solution 1000ppm (0.1%) will be
required if the client has enteric symptoms.
Bedpan washers/
These should be used, cleaned and serviced according to
macerators
manufacturer’s guidance.
Beds, backrests, bed
To be cleaned between users with GPD solution or
cradles and
detergent wipes. If soiling is evident then immediately clean
mattresses
as above and then wipe over with chlorine-releasing
compound.
Bidets
To be cleaned after each use. Clean surface of pan and
taps with GPD solution, using disposable paper towels and
gloved hand and then flush.
Blood pressure cuff
Wipe with detergent wipe.
If heavily contaminated, will need laundering
Bowls, buckets –
Clean between each use with GPD solution, using disposal
patient washing
paper towels. Rinse and store dry.
SMHPT Infection Control Policy (CL6)
Page 34 of 80 (Section 3)
Commode armrests
If no soiling is evident, clean with GPD solution or detergent
and seats
wipes, and dry using paper disposable towels. If soiling is
evident, or there is an outbreak of diarrhoea, or the previous
user had a loose stool, follow by wiping over with a 0.1%
chlorine-releasing solution (eg Presept, Actichlor).
Use
separate wipes for armrests and seats.
Curtains
Wash or dry clean as appropriate if contaminated.
(Normal change every 6 months)
Damp dusting (all
GPD solution or detergent wipe.
surfaces)
If known contamination or resistant organism, follow with
0.1% Hypochlorite solution.
Ear pieces from
Disposable are now available.
auroscopes
Clean thoroughly with GPD solution, using thin brushes to
clean inside. Rinse and dry thoroughly before storage.
ECG/ECT Equipment
• Electrodes
• Use disposable
• Straps
• Wash well with warm water
• Machine
• Wipe over with damp cloth (detergent wipe), keep covered
when not in use
Examination couches
Surface must be in good repair, clean with GPD solution or
detergent wipes at start and finish of each session or if
becomes soiled. Cover with disposable paper roll and
change between each client use.
Nurse’s scissors and Wipe with detergent wipe before and after use
bandage scissors
Razors – safety or
Use disposable or patients own.
electric
Do not allow sharing
Stethoscopes
Clean with detergent wipes.
Suction equipment
Disposable suction units are recommended. After each use
(or 24 hours if in frequent use) the disposable components
should be disposed of as clinical waste.
Non-disposable bottles – ensuring appropriate staff
protection, empty the contents into the toilet, rinse with cold
water. Clean using GPD solution. Store dry.
Tubing should be disposable.
Filters – these should be replaced when wet and at
appropriate intervals in keeping with the manufacturer’s
instructions.
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Thermometers
Disposable or tympanic thermometers are preferred
For traditional thermometers, use disposable sheaths and
wipe between uses with alcohol wipe.
Do not soak in any solution
Tourniquets Wipe
with detergent wipe
Toys
Toys must be cleaned with GPD solution at least weekly.
Soft toys are not recommended.
Urine jugs (non
The use of disposable jugs is advised.
disposable)
Wearing disposable plastic apron and gloves a separate
clean jug should be used for each urine collection. Empty
contents into the toilet and rinse. Clean thoroughly using
GPD solution and paper towels,. Rinse, dry and store
inverted.
Weighing scales
Line with disposable paper towel. Clean with detergent
wipes before next baby is weighted and at the end of each
clinic session. Store dry.
Work surfaces
General Cleaning
Use GPD solution or detergent wipes.
Contaminated Surfaces
Clean with GPD solution or detergent wipes and then wipe
with 0.1% sodium hypochlorite solution.
NB In many instances, detergent wipes may be substituted for GPD
solution. For specialist equipment, refer to manufacturer’s instructions in the first
instance.
ENVIRONMENTAL CLEANING
The environment plays a relatively minor role in transmitting infection, but dust,
dirt and liquid residues will increase the risk and should be kept to a minimum
by regular cleaning and by good design features in buildings, fittings and
fixtures.
A written cleaning schedule should be devised specifying the persons
responsible for cleaning, the frequency of cleaning and methods to be used and
the expected outcomes:
• Work surfaces and floors should be smooth-finished, intact, durable of good
quality, washable and should not allow pooling of liquids and be impervious
to fluids
• Carpets are not recommended in treatment rooms or areas where clinical
procedures will take place because of the risk of body fluid spills
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• Where carpets are in place, there should be procedures or contracts for
regular steam cleaning and dealing with spills
• Keep mops and buckets clean, dry and store inverted
• Mop head should be removable for frequent laundering, or single use if this is
not possible
• Provide single use, non-shedding cloths or paper roll for cleaning
• Colour code cleaning equipment, such as mop heads, gloves and cloths for
toilets, kitchens and clinical areas. Use different colours for each area, see
NHS Estates cleaning manual.
• General purpose detergent is sufficient for most environmental cleaning -
follow the manufacturer’s instructions.
DOMESTIC CLEANING
Bucket (plastic)
Empty contents down toilet or slop hopper.
Wash inside and outside of bucket with detergent solution
(eg Hospec), rinse, and dry prior to storage.
Mop (wet)
Rinse, dry and store head up after use; heat disinfect in
washing machine and dry thoroughly weekly
Mop (dry)
Vacuum after each use
Lavatory brushes
Rinse in flushing water and store dry
Suggested colour
Red:
toilet
bathroom/sluice
coding of cleaning
Blue:
kitchen/pantry
equipment
Yellow: all other areas
Floors
Dust control – dry mop
Wet cleaning – wet mop, wash with GPD solution.
If known contamination follow with hypochlorite 1000ppm
Furniture and
Damp dust with GPD solution.
fittings
If known contamination follow with hypochlorite 1000ppm
(0.1% solution) if fabric will tolerate.
Lavatory seat and
If soiling is evident, or there is an outbreak of diarrhoea, or
handle
the previous user had a loose stool, clean with GPD solution
followed by chlorine-releasing compound (i.e. Prescept,
Actichlor) 1000ppm
Showers
Should be clean and maintained. Launder curtains 3
monthly. Shower heads should be de-scaled when
necessary
Walls and ceilings
When visibly soiled use GPD solution. Splashes of blood
should be cleaned promptly with 1.0% hypochlorite solution.
SMHPT Infection Control Policy (CL6)
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References
Babb JR (1996) ‘Application of Disinfectants in Hospitals and Other Health Care
Establishments’. Infection Control. March 1996 p4-12.
Bassett WH (1992) Clay’s Handbook of Environmental Health. 16th Edition.
London.
Medical Devices Agency (1996) ‘Sterilisation, Disinfection and Cleaning of
Medical Equipment’ MDA part 1
MDA (2000) Guidance on the Purchase, Operation and Maintenance of
Vacuum Bench top Steam Sterilizes. MDA DB 2000(05).
MDA (2000) Single-use Medical Devices: Implications and Consequences of
Reuse. London.
HSC 2000/032 Decontamination of Medical Devices.
MDA (2002) Bench top Steam Sterilisers – Guidance on Purchase, Operation
and Maintenance. MDA DB 2002(06).
National Health Service Executive Health Service Circular HSC 1999/179
‘Controls Assurance in Infection Control: Decontamination of Medical Devices’.
Issue date 13th August 1999
NHS Estates Healthcare Cleaning Manual –
www.dhsspsni.gov.uk/cleaning_manual_section_1_contents_and_introduction.pdf
NHS Estates (1994) Health Technical Memorandum 2010. London
PHLS (1993) Chemical Disinfection in Hospitals. London.
SMHPT Infection Control Policy (CL6)
Page 38 of 80 (Section 3)
SECTION 4
MANAGEMENT OF SHARPS INJURIES
In the event of a sharp injury/contamination incident the following guidelines
should be followed:
A sharp injury/contamination incident includes:
•
inoculation of blood by a needle or other ‘sharp’
• contamination
of
broken skin with blood
•
blood splashes to mucous membrane e.g. eyes or mouth
•
swallowing a person’s blood e.g. after mouth to mouth resuscitation
•
contamination where clothes have been soaked by blood
•
human bites resulting in significant wound
Any staff working in a healthcare facility who handle sharps or clinical waste
should receive a full course of hepatitis B vaccine and have their antibody level
checked on appointment.
Managers should ensure that new staff, or any existing staff who know they are
not already protected, visit their occupational health department to arrange
vaccination without delay.
Blood and body fluids may contain a variety of microorganisms that are
transmissible to healthcare staff. The most important of these are
Hepatitis B,
Hepatitis C, and HIV. Although Hepatitis B and HIV infection are very
uncommon in people who have lived exclusively in this region, they are
increasingly seen in those who have travelled from other parts of the world. For
example, Hepatitis B is particularly common in South East Asia, and HIV in sub-
Saharan Africa. Hepatitis C is known to be common in injecting drug users in
the UK.
The
risk of transmission from a positive source depends on the
nature of the
injury and on
the volume of blood transferred. Thus, splashes to mucous
membranes including the conjunctivae are regarded as being lower risk than
percutaneous injuries such as needlesticks, of which
deep injuries involving
hollow-bore needles removed from a blood vessel represent the greatest
hazard.
For percutaneous injuries, the risk of transmission is thought to be in the order
of:
• 1 in 300 for HIV,
• 1 in 30 for Hepatitis C, and up to
• 1 in 3 for a Hepatitis B e antigen positive source.
However, the risk of transmission may be reduced if appropriate action is taken
without delay.
Healthcare staff must avoid exposure to blood and body fluids wherever
possible by adopting safe handling techniques and correct disposal of needles,
syringes and sharp instruments, and by using gloves and eye protection where
SMHPT Infection Control Policy (CL6)
Page 39 of 80 (Section 4)
appropriate. If an exposure does occur however, the procedures described in
this policy should be followed.
4.1 Summary of actions
First Aid The exposed healthcare worker should thoroughly wash the site of
exposure with soap and water without scrubbing, or irrigate mucous
membranes (including conjunctivae) copiously with water, after removing
contact lenses if present. Puncture wounds should be gently encouraged to
bleed. The wound should then be covered with a waterproof dressing.
Report promptly to line manager, who will ensure that the exposed health
care worker contacts occupational health immediately for further advice and that
the staff member follows this advice. Out of office hours, attend the A&E
department within one hour where the risk assessment will be performed. In
accordance with the Incident Policy the individual must complete an incident
from.
When the source patient is known to be HIV It is helpful if someone telephones
ahead to inform A&E and also alerts Occupational Health so that appropriate
records can be made available.
The exposed healthcare worker will be seen by a practitioner in the A&E
Department as a priority case who will:
• Assess the incident: was it a significant exposure to blood or a high risk body
fluid?
• If so, contact the doctor responsible for the source patient who will find out if
the source patient is known to carry a blood borne virus, and if not known,
make an assessment of the likelihood that the source patient is a carrier.
• Assess the vaccination status of the exposed healthcare worker to Hepatitis
B and give a dose of vaccine (and in some circumstances Hepatitis B
immunoglobulin) if required.
• If the source patient is known or strongly suspected to be HIV positive,
recommend a course of post-exposure prophylaxis to the exposed healthcare
worker. Dispense a starter pack after appropriate discussion and obtaining
consent. Further specialist advice will be obtained from Occupational Health.
• Obtain a serum sample from the exposed healthcare worker (with
permission) for long term storage.
• Arrange follow-up for the exposed healthcare worker with the Occupational
Health Department if required.
Assessment of the source patient
An initial assessment of the source patient will be made by a suitable
professional responsible for the patient (but not the exposed healthcare worker).
The relevant person will ascertain from the medical notes or by direct
questioning whether the patient is known or strongly suspected to be HIV
seropositive, or positive for Hepatitis B or C. This information will be
communicated to the A & E doctor for the immediate management of the
exposed healthcare worker. At this or a later stage, a request will be made of
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the patient, after appropriate discussion and obtaining consent, to be tested for
markers of Hepatitis B, Hepatitis C and HIV infection. The patient will be
informed of the test results, and if required, may receive counselling from the
Department of Sexual Health.
Follow-up by occupational health
The Occupational Health Department will document the nature and
circumstances of the exposure, and will coordinate the follow-up of the exposed
healthcare worker after the incident in the following ways.
• Provide counselling and support as required.
• Ensure that a course of hepatitis B vaccination is completed, if necessary.
• If a course of HIV post-exposure prophylaxis has been started, monitor
compliance and adverse effects. Discontinue the course if further
assessment of the source patient indicates that he or she is unlikely to be
HIV positive.
• Carry out follow-up serological tests (with the healthcare worker’s consent) at
the relevant times for Hepatitis B antibody, Hepatitis C RNA and/or antibody
and HIV antigen/antibody.
• Refer to specialists in other fields, for example sexual health,
gastroenterology, or obstetrics for further advice or treatment if required.
• If the source patient is known to carry a blood borne virus, the exposure and
its outcome should be reported in confidence to the national surveillance
scheme coordinated by the Communicable Disease Surveillance Centre,
Colindale.
References
British Medical Association. A code of Practice for the Safe Use and Disposal of
Sharps. BMA, London. 1990.
ICNA (2003) Reducing Sharps Injury – Prevention and Risk Management.
London
Health Services Advisory Committee. Safe Disposal of Clinical Waste. Sheffield:
HSE 1999
Health and Safety Commission. Control of Substances Hazardous to Health
Regulations 1999. Approved Codes of Practice. HSE Books 1999.
Medical Devices Agency (2001a) MDA SN 2001(19). Safe Use and Disposal of
Sharps. London, Department of Health.
RCN Epinet available from www.needlestickforum.net
RJ Kent, (May 2004). ‘Management of Blood and Body Fluid Exposure
Incidents in Healthcare Staff’
SMHPT Infection Control Policy (CL6)
Page 41 of 80 (Section 4)
SECTION 5
SPECIFIC ORGANISM RELATED INFORMATION
5.1 Guidelines
for
the Management of Meticillin Resistant
Staphylococcus Aureus - MRSA
Staphylococcus aureus is a type of bacterium carried in the nose and on the
skin of about 20-40% of the population, usually without causing any harm.
However, it is the most common cause of simple, uncomplicated skin and
wound infections. It may be responsible for more serious infections and those
most at risk are hospital patients undergoing major surgery or those who require
intensive care.
Some strains of Staphylococcus aureus have become resistant to Meticillin (a
once commonly used antibiotic), as well as to other antibiotics. MRSA behaves
in the same way as ordinary Staphylococcus aureus and does not cause more
severe or different infections. However MRSA is harder to treat as there are
fewer antibiotics with which to treat it, and some of these antibiotics may have
to be given by injection or infusion. They may also have unpleasant side effects.
MRSA rarely causes infection in healthy people, such as healthcare staff and
their families, and does not normally spread easily outside of hospital or other
healthcare settings.
Outside acute hospital units people may carry MRSA without it causing harm to
themselves or others. They are said to be MRSA carriers or to be colonised with
MRSA. Although attempts are made to eradicate colonisation in acute hospitals,
this is not always necessary for patients in low-risk clinical areas of the hospital,
or in the community.
Why is it known as a hospital acquired disease?
MRSA will spread more readily in the acute hospital setting, due to the
increased vulnerability that patients with an acute illness will have to infection.
When an individual suffers an acute illness, their immunity will be vastly
reduced (making them vulnerable to infection). As that individual recovers, so
will their immunity.
If an individual makes a complete recovery, their immune system
generally makes a full recovery.
If an individual goes on to develop a chronic illness, their immune system may
not make a complete recovery. However this deficit in their immune system will
be far less than if they were still suffering from an acute illness.
What is the difference between colonisation and infection?
Colonisation - means the organism (in this case MRSA) is living on the skin
(usually nose, throat, axilla or groin), causing no problem to the individual.
Infection - means that the organism (in this case MRSA) is causing harm i.e.
there are symptoms of an active disease.
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Why is the management of MRSA different in the community?
In the community, there are not the large numbers of acutely ill patients that
there are in the acute hospital. Therefore the increased vulnerability of patients
does not exist to the same extent.
What precautions need to be taken?
No special precautions are necessary.
Standard Principles, especially handwashing, are all that are necessary.
However MRSA does act as an opportunity to remind us of the
good practices that should be in place.
Patients do
not require barrier nursing in the community setting. Ideally they are
in a single room, or share a room with someone who does not have an open
wound or invasive device e.g. urinary catheter, intravenous device.
They can mix with other patients socially and at mealtimes.
Laundry, china and cutlery do
not need to be handled separately. Again, as
long as good practices are already in place, there is no need for additional
precautions.
In patient’s own homes, waste should be handled as with any other patient
(refer to waste section, 3.6).
Screening
Routine screening of patients in the community is not necessary.
Screening swabs may be requested by the hospital prior to a surgical
procedure. The hospital will usually specify the screening required but it is likely
to be nose, groin and any wounds.
Depending on the results, MRSA eradication treatment may be necessary
immediately prior to the patient’s/clients admission to hospital.
The screening of
staff is very rarely required - and should only take place in
consultation with the Infection Control Nurse.
MRSA wound swabbing
Do not swab unless there is clinical evidence to do so.
The state of the wound should be assessed and documented by a registered
nurse with necessary skills in wound assessment:
• size,
depth
•
condition of wound
•
does it look infected (is it red, hot, inflamed or has a discharge?)
The wound should be monitored to assess if it is healing:
•
if the wound is healing - do not swab
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If the patient is colonised with MRSA of the nose and/or groin, do not routinely
swab. Should such a patient then develop any wounds:
•
observe for signs of infection
•
swab if there is any sign of infection in a new wound.
Always treat the wound and not the swab result.
Apply the
dressing that is clinically indicated to promote the correct
environment for wound healing and to control exudate.
Some wounds may benefit from using dressings containing silver or iodine but
when there is significant local cellulitic infection, systemic treatment should be
considered. General Practitioners should refer to the antibiotic policy.
Alternatively, advice may be sought from a microbiologist.
Admission to a care facility,
No inpatient facility or home is allowed to refuse admission of a
patient/resident/client because they happen to have MRSA. However, if a
resident does have MRSA (either colonisation or infection) that resident should:
i.
be in a single room.
OR
ii. be in a shared room, but the other resident must not have an open
wound or a urinary catheter, or any other invasive device.
In addition to the above precautions:
i. environmental
cleaning
should be reinforced to help prevent further
spread
ii.
after patient is discharged the room should be thoroughly cleaned
Further Advice
Please seek further advice from the Infection Control Nurse if required. References
Department of Health (1996). MRSA: What Nursing and Residential Homes
need to know? HMSO, London.
Royal College of Nursing (2000). Meticillin Resistant Staphylococcus aureus
(MRSA); Guidance for Nurses. RCN, London.
Joint BSAC/HIS/ICNA Working Party Report on MRSA (2006). Guidelines for
the Control and prevention of Meticillin resistant Staphylococcus aureus(MRSA)
in healthcare facilities. Journal of Hospital Infection, 63, Supplement 1 May
2006).
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5.2 Guidelines for the management of patients with diarrhoea caused
by Clostridium difficile
Clostridium difficile is a Gram-positive, anaerobic spore forming bacillus which
can be found in the gut. Some strains of the bacterium produce two toxins
which cause fluid loss from the bowel mucosa and cellular damage.
The spores, which are resistant to heat, drying and some disinfectants, can
survive in the environment for several months.
It is the most common cause of antibiotic associated diarrhoea and hospital-
acquired infectious diarrhoea.
Gastrointestinal symptoms may be mild but in extreme cases can lead to
pseudomembranous colitis (PMC), which can be life-threatening.
The symptom is mainly diarrhoea, which usually starts 10-15 days (range from
a few days to 2 months) after commencing antibiotics, in particular the
cephalosporins.
Spread occurs by direct patient to patient contact, the hands of health care
workers and contact with the contaminated environment.
Those at greatest risk of Clostridium difficile infection are the elderly, those on
antibiotic therapy and post surgical patients.
Prevention
The key measure in preventing the development of Clostridium difficile is control
of antibiotic usage:
• Short courses of only 5-7 days are preferable to longer courses
• Narrow spectrum antibiotics are preferable to broad spectrum agents or
combinations
• Avoid high risk antibiotics for patients aged 60 years or more. High risk
antibiotics are clindamycin, cefixime, cefotaxime, ceftriaxone and to a lesser
extent, cefuroxime.
For further information refer to the Suffolk PCT GP Antibiotic Policy.
Rapid improvement from the symptoms usually occurs following stopping the
antibiotic(s) together with fluid replacement. Treatment is with oral
metronidazole. If this is not effective, oral vancomycin should be prescribed.
Infection control precautions
• All staff must
wash their hands after each contact with the patient – alcohol
gel is not effective against Clostridium difficile spores.
• All patients must be able to wash their hands after a bowel motion
• Beds, surfaces, lavatories and commodes must be thoroughly cleaned each
day or after use with detergent and water followed by disinfection with 0.1%
hypochlorite solution.
• All equipment that comes in contact with the patient must be
disinfected/sterilized according to the instructions relating to that item.
Refer to section 3.8
• Disposable equipment should be used whenever possible.
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• Patients’ clothing and linen should be washed according to the section for
dealing with infected linen.
It is important to communicate to any relevant practitioner about previously
infected patients who are being transferred to them in view of the significant
proportion who may relapse and the fact that further antibiotic treatment may
increase the risk of relapse.
NB. Clearance stool samples are not required in any circumstances.
Information leaflets on Clostridium difficile are available for both staff and
patients on SMHPT intranet site under Infection Control
Contact the Infection Control Nurse as soon as there is a suspected case of
Clostridium difficile for discussion and guidance.
All confirmed cases of Clostridium difficile will undergo a local root cause
analysis (RCA) to ascertain the likely cause and to produce an action plan to
address any identified areas of concern.
References
National Clostridium difficile Standards Group (June 2003). Report to the
Department of Health. DoH, London.
Suffolk Primary Care Trust ‘ GP antibiotic Formulary 2008.
www.suffolkpct.nhs.uk/ProfessionalResources/PharmacyMedicinesManagemen
t/MedicinesManagement/tabid/908/Defualt.aspx
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5.3 Guidelines for the management of patients with Vancomycin-
resistant enterococci (VRE) or Organisms producing extended
spectrum beta-lactamase (ESBLs)
• Enterococci are part of the normal flora of the intestinal tract and they are
sometimes also isolated from other non-sterile sites including the vagina, skin
and mouth.
• They are usually organisms of low virulence, but in some situations may
cause infection, including infection of the urinary tract, abdominal wounds,
biliary tract or intravenous catheters. Debilitated and immunocompromised
patients are at a higher risk of infection.
• Enterococci are instrinsically resistant to many antibiotics. Traditionally,
amoxoxillin or glycopeptide antibiotics (Vancomycin and teicoplanin) have
been used to treat significant infections. However, in recent years,
Vancomycin resistance has become more common, especially in
Enterococci faecium. These strains (VRE) are not more likely to cause
disease than susceptible ones, but they are a lot harder to treat when they
do.
• Enterococci are able to survive on environmental surfaces for long periods,
and they are also relatively resistant to heat. VRE are readily transferred
from patient to patient unless a high standard of cleaning and excellent
infection control practice are observed.
Organisms producing extended spectrum beta-lactamase (ESBLs)
• Some strains of ‘coliform’ bacteria, especially
Klebsiella and
Enterobacter,
are known to carry plasmids containing genes for enzymes that break down
a wide variety of antibiotics. These organisms are resistant to all but a few
reserve (and expensive) intravenous antibiotics such as meropenem.
• ESBL-producing organisms may be carried without symptoms in the gut, but
they are also responsible for infection, for example of the urinary tract.
Locally, these are occurring more frequently, even from patients in the
community.
• High standards of infection control practice are required to prevent spread of
these organisms between patients.
Infection control management of these resistant organisms
• Ensure meticulous hand hygiene after contact with patient and/or the
environment.
• Use gloves for handling all body fluids.
• Avoid contaminating the environment when disposing of body fluids.
• Pay particular attention to cleaning the environment, especially wet areas
such as sluices or bathrooms where body fluids are emptied.
• Ensure thorough cleaning of equipment used by the patient.
Contact the Infection Control Nurse to discuss care and treatment of a
patient identified with one of these organisms.
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SECTION 6
OUTBREAK CONTROL
Definition - An outbreak may be defined as two or more linked cases, as
assessed by an Infection Control Nurse (ICN), of an infection or an increase in
the number of infections that would normally be expected.
A single case of some diseases eg Diphtheria, in any setting would also be
considered an outbreak.
It is important to recognize potential outbreaks promptly to enable control
measures to be implemented as soon as possible to prevent further
cases.
All healthcare staff should be aware of possible signs of infection (fever,
diarrhoea, vomiting) and should report these to the manager of the area at the
time. This information should then be reported to ICN immediately for further
management advice. Out of hours, contact the service manager on-call.
The following should always be reported:
• an increased incidence of vomiting and/or diarrhoea occurring either over a
short or extended period amongst patients/clients and/or staff
• several cases of a similar infection (based on clinical diagnosis) in
patients/clients and staff who have had close contact with each other eg
respiratory symptoms
• an unusually high number of absences amongst staff
• an incident involving a member of staff should also be reported to
Occupational Health
If an inpatient day and treatment facility is affected the incident should be
treated as a Serious Untoward Incident and the following guidance should be
followed:
• The person in charge should contact the ICN without delay if they suspect
there may be an outbreak of infection (out of hours, the on call service
manager)
• Senior manager must be informed to ensure adequate staffing to cope with
extra demands of managing an outbreak. Staff working in the area should
not work in other care establishments until the outbreak is declared over
• Senior manager to complete an Infection Control Outbreak Summary Report
Form (see Appendix 3)
• Senior manager to contact Centre for Service Excellence and follow SUI
policy
When
influenza is diagnosed, the ICN or the Director on call should
immediately contact the Health Protection Unit in hours, or the on call Public
Health clinician out of hours, for advice to ensure that the correct procedure is
followed for the administration of prophylaxis/treatment if deemed appropriate.
There is an
Outbreak Control Plan for Suffolk which will be activated by the
Health Protection Unit following criteria defined within the plan.
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6.1
Specific guidance for outbreaks of diarrhoea and/or vomiting
It is important when assessing patient’s symptoms that previous history is taken
into consideration to ensure accurate case-finding and reporting. NB the Bristol
stool chart is attached for reference.
• Inform ICN and complete an incident report form
• Isolate symptomatic patients wherever possible in their own rooms with their
own toilet facilities or a designated commode if en-suite facilities are not
available.
• Environmental cleaning to be increased. Particular attention should be paid
to the toilets, bathrooms, door handles, support hand rails and unit kitchens.
For the duration of the outbreak, environmental cleaning should be
performed using detergent and hot water followed by a chlorine releasing
solution (eg 0.1% Actichlor solution).
• All staff handwashing areas and the rooms of symptomatic patients should
have an alcohol hand rub available for the duration of the outbreak.
NB. Handwashing with soap and water continues to be an effective
procedure in preventing cross-infection.
If norovirus is suspected, soap
and water hand hygiene is essential as soap and water does not
deactivate this virus.
• Patients should be encouraged to wash their hands after using the toilet and
before eating.
• Staff should pay attention to all infection control practices, particularly the
washing of hands and wearing protective clothing.
• Faecal samples should be obtained from patients and staff if they have
symptoms. The microbiology form accompanying the sample should clearly
state it is part of an outbreak, as this will determine which specific tests are
carried out in the laboratory. (Samples of vomit are not required.)
•
On the advice of the Infection Control Nurse and service manager, the
area may need to be closed to admissions until a further risk assessment
deems the area safe for reopening. This action is considered a Serious
untoward Incident and the Centre for Service Excellence should be notified
immediately.
• Symptomatic staff must go off duty, a faecal sample must be taken and they
must remain off work until they have been symptom free for 48 hours (see
Staff Health Policies, Section K).
• Visitors should be informed of the outbreak and unnecessary visits should
be discouraged. Those who choose to visit should wash their hands as they
enter and leave the area and comply with all other hygiene practices in
place.
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• Patients should only be discharged/transferred when/if they are symptom
free (48 hours symptom free is required in those groups with a high risk of
spreading gastro-intestinal infection. For SMHPT purposes these are adults
who may find it difficult to implement good standards of personal hygiene).
Areas receiving discharged/transferred patients should be aware of the
situation.
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6.2 Prevention and Control of Scabies
Introduction
Scabies is an allergic response to an infestation of the skin by the mite
Sarcoptes scabiei. The mites penetrate through the skin and excavate
burrows at the epidermal/dermal junction. The female mite lays eggs which
hatch after 3-4 days. Newly hatched larvae exit the burrows and appear on the
surface of the skin before forming their own tunnels. The burden of mites can
range from 10-20 to several thousand in people who are severely immuno-
compromised. Scabies is distributed world-wide and is endemic in many
developing countries.
Recognition of Symptoms
The most frequent symptom is itching which may affect all parts of the body and
is particularly severe at night.
Occasionally small vesicles may be visible along the areas where the mites
have burrowed. A papular rash may be visible in areas such as around the
waist, inside the thighs, lower buttocks, lower legs, ankles and wrists. Firm
nodules may develop on the front folds of the axillae and around the naval and
in males around the groin. Pale burrows described as a “greyish line
resembling a pencil mark” may be present in the skin between the fingers, but
are less commonly seen than text books suggest.
Failure to find burrows does
not exclude scabies as a diagnosis.
It should be emphasised that scabies may be difficult to recognise particularly if
scratching, inflammation or infection have obscured the presentation. Also
scabies can look atypical in anyone with immature or impaired immunity such
as very young children, those with Down’s Syndrome, alcoholics or the very
elderly. In immunosuppressed people, such as those with AIDS or those on
immunosuppressive therapy, a more severe hyperkeratotic form may develop
known as Norwegian or crusted scabies
Mode of Transmission
Scabies mites are generally not capable of surviving off the host long enough to
establish a new infection as they quickly become too dehydrated and weak.
Mites are passed directly from the skin of one person to another. The likelihood
of transmission increases with the duration and frequency of skin to skin
contact.
Fomites and animals are not implicated in transmission.
Incubation
The incubation period is up to 8 weeks after contact with an affected person.
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Diagnosis
The definitive diagnosis of scabies is made by microscopic identification of the
mites, eggs or mite faeces from skin scrapings.
Outbreaks
Outbreaks occur particularly in long-stay healthcare establishments.
Advice
For NHS establishments advice will be given on the need to treat and the
treatment programme by the Community Infection Control Nurse following
confirmed diagnosis by a competent practitioner. The Scabies outbreak policy
(separate document) will be followed and all information required by staff,
patients, relatives etc will be supplied to the area manager at the time.
References
Applying treatment for scabies. Leaflet produced by North West (Liverpool)
Regional Drug Information Centre.
British National Formulary BNF 43, March 2002.
Burgess I, Cohen J. Treating Lice and Scabies. Prescriber, pages 99 –105, 19
November 2000
Roberts DT (Editor). Lice & Scabies - A Health Professionals Guide to
Epidemiology and Treatment. Public Health Laboratory Service, London 2000.
The Management of Scabies and Threadworms. National Prescribing Centre -
Prescribing Nurses Bulletin Volume 1, November 3, 1999.
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6.3 Guidelines for the Management of Head lice
Head lice are flat greyish-brown insects about the size of a grain of rice, which
live in the hair. They like to stay close to the scalp for warmth and feed by biting
the scalp. The female louse lays eggs each night and glues them on to the base
of individual hairs.
Lice are spread from head to head. The lice crawl over from one person to
another when heads are touching. They are not spread by using someone
else’s hat, scarf etc.
Lice are common in both adults and children and as such are a family problem.
People may have head lice and not know that they have. It is important that
everyone checks their hair regularly for lice and if they find them, treat them
correctly and tell all their contacts.
The best way to control head lice is by detection, treatment and contact-
tracing.
Detection involves looking for live lice by combing with a lice detection comb on
wet and conditioned hair:
Part the hair into small sections and comb through with the lice detection
comb, from scalp to the ends of the hair, section by section.
After each stroke, wipe the comb on a tissue and check for live lice.
The whole head needs to be checked. If lice cannot be found, treatment is
not necessary.
If live lice are found,
treatment and contact tracing should be undertaken.
Lyclear is currently the recommended treatment. Alternatively, Derbac M or
Quellada M may be used. The manufacturer’s instructions should be carefully
followed.
Alternatively, head lice may be cleared over a period of 2 weeks by
‘wet
combing’. Between 15 and 30 minutes are needed to undertake this procedure
and it needs to be repeated every 3 days for 2 weeks:
Wash hair as normal and rub in some conditioner. Comb with the conditioner
still in the hair.
Divide into sections.
Put comb into the hair as flat as possible and comb each section of hair
down to the ends.
Do this for every part of the hair.
After each stroke, wash comb under the tap to remove lice.
Contact tracing is a vital part of head lice treatment. If infected individuals are
not identified they may pass head lice on. Examples of contacts include
household members, grandparents, cousins, best friends, school friends and
social contacts.
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Reference
Aston R, Duggal H, Simpson J. Head lice. Report for Consultants in
Communicable Disease Control, Public Health Medicine Environmental Group
1998.
Burgess I, Cohen J. Treating Lice and Scabies. Prescriber, pages 99 –105, 19
November 2000
Roberts DT (Editor). Lice & Scabies - A Health Professionals Guide to
Epidemiology and Treatment. Public Health Laboratory Service, London 2000.
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SECTION 7
CLINICAL PRACTICE
7.1 Aseptic Technique
Aseptic technique is the term used to describe the methods used to prevent
contamination of wounds and other susceptible sites by organisms that could
cause infection (Marsden Manual of Clinical Nursing Procedures).
The aims of aseptic technique are:
• To prevent the introduction of pathogens to the site.
• To prevent the transfer of pathogens from one patient to another.
An aseptic technique should be implemented during any invasive
procedure that bypasses the body’s natural defences.
An aseptic technique should also be adopted when undertaking the following
procedures:
• Dressing
wounds
• Endotracheal
suction
• Dressing tracheostomy site
Hands should be washed before and after the technique. A clean pair of latex
gloves should be donned prior to commencing the technique.
Many aseptic techniques include a ritualistic practice of cleaning trolleys with
alcohol between patients. It is now felt that this serves no useful purpose, and
that an area cleaned by detergent and hot water is sufficient, as the sterile field
will be created by the sterile towel contained within the dressing pack.
Bacteria acquired on the clothing during the procedure may be transferred into
the wound of another patient, therefore a clean disposable apron should be
used for each dressing procedure.
Management of Chronic Wounds
If dressings are removed by soaking, a plastic impermeable liner/bag should be
placed in the bucket/bowl before filling with water.
After the wound has been washed then water should be disposed of in a sluice
or a sink which is separate from the handwash sink.
The plastic liner should be disposed of and the bath or bowl should be
thoroughly cleaned with detergent solution and then dried to ensure that
pathogens are removed.
This process should be undertaken after each separate patient episode.
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7.2
Care of Clients with Known Infectious Diseases
It should be recognised that staff caring for clients in their own homes do not
have to fully implement the traditionally recognised methods of barrier nursing.
This is because there are generally no other vulnerable clients who need to be
protected from cross infection, apart from staff and other people who live in the
house, for whom the practice of universal precautions will suffice.
However it is important for staff to appreciate that when they are caring for
someone with a known or suspected infectious disease, there is the potential for
cross-infection if basic infection control principles are not followed.
DISEASES
More detailed information about certain organisms can be found in section 5 of
this manual.
Refer to Appendix 4 for a table of communicable diseases.
Precautions should also be taken with clients suffering from the following
symptoms, until a diagnosis is confirmed:
(a)
Diarrhoea of unexplained origin
(b)
Pyrexia of unknown origin
(c) Excessive
bleeding
(d)
Rashes of unknown aetiology
(e) Excessive
vomiting
PROCEDURES
Standard Principles should be strictly adhered to at all times refer to
Section 3
Once a diagnosis has been made, the client (and family) must have their
infectious disease carefully explained, the mode of spread and its significance if
any, for the patient’s condition.
Hand Hygiene
Alcohol hand rub should be used after normal handwashing, or an antibacterial
soap should be used to wash hands.
Disposal of Potentially Infected Items
Contaminated dressings and all disposable items should be disposed of as
clinical waste. A designated collection from the client’s home may be necessary
if there is a large quantity (see section on Waste Management – refer to section
3.6).
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Urinals and Bedpans
It is recommended that disposable products are used. If these are not available,
following the safe disposal of the contents, care should be taken when cleaning
the urinal or bedpan to avoid splashing. A plastic apron and non-sterile latex or
vinyl gloves should be worn. The item should be cleaned with General Purpose
Detergent and hot water prior to disinfection with a sodium hypochlorite solution
(strength 10,000 ppm, (1 part household bleach to 10 parts water) and left for
10 minutes). The bedpan/urinal should be dried and stored inverted.
Linen
Linen should be washed on as hot a wash as the fabric will tolerate, as promptly
as possible.
Crockery and Cutlery
Disposable items are not required. General purpose detergent and water as hot
as can be tolerated is sufficient. A dishwasher may be used if available.
Transporting Clients
Clients should only be sent to other department/premises (i.e. care homes,
hospital Out-patient or In-patient departments) when it is essential. Staff
involved in the direct care of the client should be informed of the risk, so that
relevant control measures can be implemented.
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7.3
Care during Enteral Feeding (NICE Guidelines)
These guidelines apply to adults and children and should be used in conjunction
with the guidance on Universal Precautions (Standard Principles).
They should be considered when developing related policies.
The recommendations are divided into four distinct interventions:
• Education of patients, their carers and healthcare personnel
• Preparation and storage of feeds
• Administration of feeds
• Care of insertion site and enteral feeding tube
Education of patients, their carers and healthcare personnel
Patients and carers should be educated about and trained in the techniques of
hand decontamination, enteral feeding and the management of the
administration system before being discharged from hospital.
Community staff should be trained in enteral feeding and management of the
administration system.
Follow-up training and ongoing support of patients and carers should be
available for the duration of home enteral tube feeding.
Preparation and storage of feeds
Wherever possible pre-packaged, ready-to-use feeds should be used in
preference to feeds requiring decanting, reconstitution or dilution.
The system selected should require minimal handling to assemble, and be
compatible with the patient’s enteral feeding tube.
Effective hand decontamination must be carried out before starting feed
preparation.
When decanting, reconstituting or diluting feeds, a clean working area should
be prepared and equipment dedicated for enteral feed use only should be used.
Feeds should be mixed using cooled boiled water or freshly opened sterile
water and a no-touch technique.
Feeds should be stored according to the manufacturer’s instructions and, where
applicable, food hygiene legislation.
Where ready-to-use feeds are not available, feeds may be prepared in advance,
stored in a refrigerator, and used within 24 hours.
Administration of feeds
Minimal handling and an asceptic no-touch technique should be used to
connect the administration system to the enteral feeding tube.
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Ready-to-use feeds may be given for a whole administration session, up to a
maximum of 24 hours. Reconstituted feeds should be administered over a
maximum 4-hour period.
Administration sets and feed containers are for single use and must be
discarded after each feeding session.
Care of insertion site and enteral feeding tube
The stoma should be washed daily with water and dried thoroughly.
To prevent blockage, the enteral feeding tube should be flushed with water
before and after feeding or administering medications. Enteral feeding tubes for
patients who are immunosuppressed should be flushed with either cooled
freshly boiled water or sterile water from a freshly opened container.
Reference
National Institute of Clinical Excellence (NICE), (2003). Prevention of healthcare
associated infection in primary and community care. Care during enteral
feeding. London.
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7.4
Care of patients with long-term urinary catheters (NICE Guidelines)
These guidelines apply to the care in the community of all adults and children
and should be used in conjunction with the recommendations on universal
precautions (standard principles). These guidelines focus on preventing
infection. However, because infection has a complex interrelationship with
encrustation and blockage, these aspects of catheter management are also
addressed.
The recommendations are divided into five distinct interventions:
• Education of patients, their carers and healthcare personnel
• Assessing the need for catheterisation
• Selection of catheter drainage options
• Catheter
insertion
• Catheter
maintenance
Education of patients, their carers and healthcare personnel
Patients and carers should be educated about and trained in techniques of
hand decontamination, insertion of intermittent catheters where applicable, and
catheter management before discharge from hospital.
Employees must be trained in catheter insertion. Follow-up training and ongoing
support of patients should be available for the duration of long-term
catheterisation.
Assessing the need for catheterisation
Indwelling urinary catheter should be used only after alternative methods of
management have been considered.
The patient’s clinical need for catheterisation should be reviewed regularly and
the urinary catheter removed as soon as possible. Catheter insertion, changes
and care should be documented.
Selection of catheter drainage options
Following assessment, the best approach to catheterisation that takes account
of clinical need, anticipated duration of catheterisation, patient preference and
risk of infection should be selected.
Intermittent catheterisation should be used in preference to an indwelling
catheter if it is clinically appropriate and a practical option for the patient.
For urethral and suprapubic catheters, the choice of catheter material will
depend on an assessment of the patient’s individual characteristics and
predisposition to blockage.
In general, the catheter balloon should be inflated with 10ml of sterile water in
adults and 3-5ml in children.
In patients for whom it is appropriate, a catheter valve may be used as an
alternative to a drainage bag.
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Catheter insertion
All catheterisations carried out by healthcare personnel should be aseptic
procedures. After training, healthcare personnel should be assessed for their
competence to carry out these types of procedures.
Intermittent self-catheterisation is a clean procedure. A lubricant for single-
patient use is required for non-lubricated catheters.
For urethral catheterisation, the meatus should be cleaned before insertion of
the catheter, in accordance with Trusts/policy.
An appropriate lubricant from a single-use container should be used during
catheter insertion to minimize urethral trauma and infection.
Catheter maintenance
Indwelling catheters should be connected to a sterile closed urinary drainage
system or catheter valve.
Healthcare personnel should ensure that the connection between the catheter
and the urinary drainage system is not broken except for good clinical reasons,
(for example changing the bag in line with the manufacturer’s
recommendations).
Healthcare personnel must decontaminate their hands and wear a new pair of
clean, non-sterile gloves before manipulating a patient’s catheter, and must
decontaminate their hands after removing gloves.
Carers and patients managing their own catheters must wash their hands
before and after manipulation of the catheter, in accordance with the
recommendations in the universal precautions (standard principles) section.
Urine samples must be obtained from a sampling port using an asceptic
technique.
Urinary drainage bags should be positioned below the level of the bladder, and
should not be in contact with the floor.
A link system should be used to facilitate overnight drainage, to keep the
original system intact.
The urinary drainage bag should be emptied frequently enough to maintain
urine flow and prevent reflux, and should be changed when clinically indicated.
The meatus should be washed daily with soap and water.
Each patient should have an individual care regimen designed to minimize the
problems of blockage and encrustation. The tendency for catheter blockage
should be documented in each newly catheterised patient.
Bladder instillations or washouts must not be used to prevent catheter-
associated infection.
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Catheters should only be changed when clinically necessary or according to the
manufacturer’s current recommendations.
Antibiotic prophylaxis when changing catheters should only be used for patients
with a history of catheter-associated urinary tract infection following catheter
change, or for patients who have a heart valve lesion, septal defect, patent
ductus or prosthetic valve.
Reusable intermittent catheters should be cleaned with water and stored dry in
accordance with the manufacturer’s instructions.
Reference
National Institute of Clinical Excellence (NICE), (2003). Prevention of healthcare
associated infection in primary and community care. Care of patients with long-term
urinary catheters. London.
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7.5
Management of Non Infectious and Infectious Deceased Clients
This guideline sets out the procedures for staff to follow for the management of
non infectious and infectious deceased clients.
MANAGEMENT OF DECEASED CLIENTS
The deceased should be treated with the due respect and dignity appropriate to
their religious and cultural background. Last Offices, which vary according to
religious and cultural practices, may be compromised by the need for specific
measures if an infectious disease was associated with the death, or co-existed
at the time of death. Any problems should be discussed with the Consultant in
Communicable Disease Control who may wish to consult the appropriate priest
or religious authority.
Most bodies are not infectious, however through the natural process of
decomposition the body may become a source of potential infection whether
previously infected or not, therefore sensible precautions should be taken
routinely.
a. Disposable gloves and aprons should be worn when washing and preparing
the body.
b. Washing the body with soap and water is adequate.
c. Dressings, drainage tubes, etc. should be removed unless the death
occurred within 24 hours of an operation or was unexpected in which cases
a post-mortem is likely.
d. Clean dressings should be applied to any wounds.
e. Profusely leaking orifices may be packed with gauze or cotton wool.
ADDITIONAL LAST OFFICES FOR A KNOWN INFECTED BODY
The body of a person who has been suffering from an infectious disease may
remain infectious to those who handle it.
Body bags are available from either the undertaker or the stores centre where
all other care equipment is requested from.
The mortuary/funeral director staff should be informed of the potential infectious
risk.
If the deceased has died from one of the following infectious diseases listed
below, the body will need to be placed in a cadaver bag.
Anthrax Plague
Brucellosis Acute
poliomyelitis
Chickenpox/shingles Psittacosis
Cholera
Pyrexia of unknown origin
Diphtheria Q
Fever
Food Poisoning (if faeces is present)
Rabies
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Hepatitis B
Tuberculosis (infective)
Hepatitis C
Viral Haemorrhagic Fever
HIV/AIDS Yellow
Fever
Leprosy
Meningococcal Septicaemia (without
meningitis)
or if there are large quantities of body fluids present.
A ‘Notification of Death’ label and a ‘Danger of Infection’ label should be
attached discreetly to the outside of the bag. Neither label should state the
diagnosis, which is confidential information. It is the responsibility of the
certifying clinician to ensure the funeral directors have sufficient information
about the level of risk of infection and stating the type of precautions required.
Once the body is sealed in the body bag, protective clothing will no longer be
necessary.
Relatives and friends who wish to view the body should do so as soon after
death as possible. The bag can be opened by a member of staff wearing gloves
and plastic apron, but relatives should be told that there is a risk of infection and
should be advised to refrain from kissing or hugging the body. In some rare
instances the bag could not be opened e.g. if the patient suffered from Anthrax,
Plague, Rabies or Viral Haemorrhagic Fever.
Further advice on specific infectious diseases can be found in the Infection
Control Guidelines for Funeral Directors
(www.ehpt.nhs.uk/publications/FuneralPolicy.pdf), or advice can be sought from
the Infection Control Nurse.
Reference
Infection Control Guidelines for Funeral Directors. Essex Health Protection Unit.
July 2004. (www.ehpt.nhs.uk/publications/funeralpolicy.pdf)
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7.6
Safe Handling of Specimens
Clinical specimens include any substance, solid or liquid, removed from the
patient for the purpose of analysis.
Staff should be trained to handle specimens safely and receive regularly
updated immunisation cover.
General Principles
• All specimens should be collected using
Standard Principles – refer to
section 3.1 (i.e. wearing of appropriate gloves, disposable plastic apron and
washing and drying of hands before and after the procedure).
• When a patient is asked to provide a specimen, they should be provided with
the appropriate container and given instructions as to how to collect the
specimen.
• Should a patient bring a specimen in an inappropriate container (i.e. pickle
jars, old medicine pots), they should be given the correct container and
asked to take their incorrectly presented specimen back home for disposal,
as the facility is unlikely to have any safe means of disposal. It may be
possible to provide the specimen at the facility to save an extra journey.
• Laboratory approved containers must be labelled with patient identification
details, date of specimen and specimen details. The lids should be screwed
on tightly. The container with the specimen must be placed in an individual
transparent plastic transport bag as soon as it has been labelled.
• The transport bag must be sealed. The request form must always
accompany the specimen but should not be put inside the bag with the
specimen. If a wound swab, state type of wound, where on the body, whether
deep or superficial and if antibiotics have been used either topical or
systemic.
• Specimens must be sent to the laboratory as soon as possible after
collection. This will mean planning work load carefully. Whilst awaiting
transport, specimens should be stored securely, for as short a time as
possible i.e. not overnight and away from food and medicines.
• If specimens have to be stored awaiting transport for more than 4 hours,
specimens should be stored in an air tight container in a designated fridge -
not a food fridge.
• Sputum specimens must be received by the laboratory within 24 hours.
NB. In the event of a suspected outbreak of infection it is important for
specimens to be collected promptly and for the request form to be
marked as ‘Possible Outbreak’. Stool specimens should be sent as
soon as an outbreak is suspected e.g. the second loose stool.
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SECTION 8
STAFF HEALTH
This section of the Manual gives an overview of the guidance for managers and
for staff. Each section contains information about the transmission of the
disease followed, where applicable, by recommendations about prevention,
acute infection, return to work and advice for contacts.
Where advice refers to “health care workers” this applies to all staff in clinical
roles or who have routine contact with patients.
Pregnant staff should seek individual advice from Occupational Health about
infectious hazards in their work area e.g. chickenpox.
Cross references are made within this manual to other national and local
Policies and Guidelines.
The Occupational Health Department will have local operational policies
Blood borne viruses:
For further information on exposure to blood borne viruses, see section 3.4.
•
Hepatitis B
This viral infection is transmitted by percutaneous and permucosal
exposure to infected blood or body fluids for example at work by sharps
injury, bites or blood splashes. Transmission rates may be up to 30% in
certain circumstances. Immunisation against hepatitis B is recommended
for all staff in patient contact or handling blood or body fluids and tissue
samples, including domestic and portering staff. Since 1987 the vaccine
has been genetically engineered and not made from blood products.
Only a proportion of acute hepatitis B infections may be clinically
recognised, the remainder being asymptomatic therefore the diagnosis
must be confirmed by blood tests. In accordance with Department of
Health Guidelines (HSG 93 (40) and Addendum EL(96)77) carriers of the
hepatitis B virus who are known to be e antigen positive, i.e. highly
infectious, must not carry out procedures where there is a risk that injury
to themselves will result in their blood contaminating a patient’s open
tissues (“Exposure Prone Procedures”-EPP's). Therefore all staff
expected to perform EPP’s must demonstrate satisfactory immunity or
absence of infectivity.
•
Hepatitis C
This virus has a similar epidemiology to hepatitis B, with a transmission
rate of between 3% and 10% following percutaneous exposure. There is
no vaccine available and staff exposed to or infected with hepatitis C
should seek individual advice from the Occupational Health Department.
•
HIV
The virus that causes AIDS (Acquired Immuno Deficiency Syndrome) is
transmitted in a similar way to hepatitis B virus but the rate of
transmission appears to be much lower. Current evidence suggests 0.3%
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transmission following percutaneous exposure. There is currently no
vaccine available.
Health care workers who are HIV positive must not undertake exposure
prone procedures, in accordance with Department of Health Guidance. In
the event of an exposure to
known HIV infected blood, visit the acute
hospital A&E department within 1 hour where drug treatment will be
made available as post exposure prophylaxis.
Gastro Intestinal Infections
No employee who has symptoms of food poisoning or viral gastro-enteritis, that
is diarrhoea and/or vomiting, should be at work.
A single stool sample should be submitted wherever possible. For most
common gastro-enteritis (including most Salmonellas) no further samples are
necessary. Health care workers and food handlers may return to work 48 hours
after they have become symptom free, with emphasis on the importance of
hand-washing. (See section 6.1)
For certain unusual infections (Salmonella typhi/paratyphi, Vibrio cholera, Vero
toxin producing E coli (VTEC) and Shigella dysenteriae) please consult
Occupational Health for advice re return to work. Where there is an outbreak of
gastro-intestinal infection which is likely to affect a number of staff, the Infection
Control Nurse will alert Occupational Health.
Group A Streptococci
Group A Streptococci cause a variety of diseases most commonly
Streptococcal sore throat and skin infections (impetigo, pyoderma). Staff with
Group A Streptococcal infection should remain off work until clinically well or
until 48 hours after commencement of an appropriate antibiotic.
Hepatitis A
This viral infection is transmitted person to person by the faecal-oral route. A
vaccine is available, but is not routinely recommended as prophylaxis for health
care workers.
Estate staff whose work involves dealing with raw sewage are offered the
vaccine.
Following acute hepatitis A infection, staff should be excluded from work until 7
days after the onset of jaundice or until clinical recovery. Stool samples are
unnecessary but wherever possible the diagnosis should be confirmed by a
salivary or blood test.
Influenza and Other Respiratory Viruses
This group of viral infections is transmitted by airborne route and direct contact
(e.g. from hand to mucus membrane). The common cold is probably infectious
from 24 hours before onset of symptoms and for 5 days afterwards. Influenza is
probably infectious for 3 - 5 days from clinical onset in adults.
Immunisation against the currently circulating strain of influenza is available for
vulnerable individuals and is recommended for key health care workers.
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Meningococcal meningitis: prophylaxis for contacts
Prophylaxis for health care workers is only recommended where:
a) Mouth-to-mouth resuscitation has been undertaken.
b) Blood or vomit has been splashed on the worker’s face.
MRSA
This is a strain of Staphylococcus aureus which is resistant to methicillin and
often other anti-staphylococcal antibiotics. Hands are the most important source
of transmission either directly or indirectly by contact with contaminated
surfaces and equipment. Airborne spread may occur via contaminated skin
scales.
Transmission and colonisation/infection are similar to other strains of S. aureus
but treatment of significant infections may be more difficult. MRSA is not, in
general, a risk to the health of staff or their families or the pregnant worker.
Screening of staff for MRSA colonisation will only be undertaken on the
recommendation of the infection control nurse.
Any staff member found to be colonised with MRSA should be managed directly
by the Occupational Health Department (rather than the GP) who will be able to
carry out a specialist assessment which will identify the need for any restriction
from clinical duties.
Rubella
Rubella is important because of its effects on the developing foetus. To protect
pregnant patients and staff all new Health Care Workers should be screened for
Rubella antibodies unless they are known to be immune. Those without
antibodies should be immunised by Occupational Health.
Tetanus & Polio
Tetanus and Polio immunisation should be kept up-to-date for all staff in patient
contact and for all maintenance staff (either by Occupational Health or via the
individual’s own General Practitioner). Once a member of staff has received 5
doses of tetanus and polio vaccine they are considered immune. Further
boosters are not required (unless for a specific injury in the case of Tetanus).
Tuberculosis
Tuberculosis in health care workers may result from occupational exposure and
infected workers pose a potential infection risk to susceptible patients. The
disease is transmitted by exposure to airborne droplets produced during
coughing or sneezing from infectious pulmonary or laryngeal TB cases. In most
circumstances extra-pulmonary TB is not infectious.
All staff in contact with patients should have had BCG immunisation. New staff
who do not have a characteristic BCG scar are screened by Mantoux testing in
the Occupational Health Department, in accordance with NICE guidelines, 2006
(Ref: CG033).
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Multiple drug resistant TB (MDRTB) is now appearing in the UK and poses a
particular problem. Staff involved with the care of patients with MDRTB must be
adequately protected i.e. have a scar or documented positive Heaf/Mantoux
test.
Any member of staff with active pulmonary TB should be excluded from work
until they have been adequately treated by a respiratory physician to render
them non infectious.
Varicella-Zoster Virus (VZV)
VZV is highly infectious by direct and indirect contact with vesicle fluid and
respiratory secretions. However, most adults brought up in the United Kingdom
will already be immune. All health care workers should be aware of whether or
not they are immune i.e. have ever had either Chicken Pox or Shingles. Staff
working with immuno-compromised patients who do not have a positive history
should have a blood test for Varicella-Zoster antibody to confirm their status.
Any member of staff who develops Chicken Pox, or Shingles on exposed areas
of skin, should go off work immediately and inform Occupational Health as soon
as possible. They should not return to work for at least 5 days after the rash first
appears or until all the skin lesions are fully scabbed.
Non immune contacts of VZV cases should seek advice as soon as possible
regarding the use of VZ Immuno Globulin prophylaxis especially if pregnant,
taking oral steroids or immuno-compromised.
Further guidance on other common communicable diseases can be found on
the ‘Guidance on Communicable Diseases’ sheet produced by the Health
Protection agency. This is attached as Appendix 4.
References
Benenson AS (Ed). Control of Communicable Disease Manual 16th Edition.
American Public Health Association, Florida. 1995.
Department of Health. Food Handlers Fitness to Work. DOH, London. 1995.
DH (1996) Immunisations against Infectious Disease – ‘The Green Book’. New
February 2006, Chapter 35 – Varicella.
www.dh.gov.uk/assetRoot/04/12/86/09/04128609.pdf
Drug and Therapeutic Bulletin. Preventing Meningococcal Infection. 1990. 28
(9) 34-6
NICE (2006). Tuberculosis (Ref CG003)
www.nice.org.uk/page.aspx?o=CG033NICEguideline
PHLS. Communicable Disease Report. 1993. Vol. 3 No 10.
UK Health Departments. Guidance for Clinical Health Care Workers: Protection
against Infection with Bloodborne Viruses. DOH, London. 1998.
SMHPT Infection Control Policy (CL6)
Page 69 of 80 (Section 8)
SECTION 9
QUALITY ISSUES AND AUDIT
The effective control of preventable infections has always been seen as an
indicator of the quality of care a patient may receive. Activities such as standard
setting and audit programmes have become essential components of an
infection control programme. Clinical governance is as an umbrella term of
these programmes. Its broad aim is to reassure people that quality is the
essence of healthcare at all levels of the organisation.
Accountability and responsibility for risk assessment and quality of care will be
an issue for all health professionals. All staff have a clear responsibility for their
risk assessments and the quality of the service they provide.
All practitioners will be expected to follow practices that are clinically safe,
effective and evidence based. Particular commitment will be given to following
the guidelines and recommended practices introduced by the National Institute
for Clinical Excellence (NICE).
Infection control in all healthcare settings is gaining a higher profile. It is
essential to maintain public confidence in the services offered by the production,
implementation and audit of robust policies and the documentation of activities
such as decontamination of equipment.
All action plans should commence with the setting of standards for infection
control. An audit tool can be used to monitor infection control practices and
provide data on compliance with policies. This data has other uses including the
planning of educational needs or evaluating the overall effectiveness of infection
control programmes.
Following an audit it is important that all relevant staff are given the opportunity
to discuss the findings. Urgent problems identified in the audit would have to be
addressed at that time.
A report should be written that recognises and highlights areas of good practice
as well as those of concern. There should be an action plan, recommendations
and time scales for their adoption.
Re-audit of the area will ensure that recommendations have been accepted.
A wide range of audit tools are available covering all aspects of infection control
practice and the environment. The ICNA audit tools can be accessed via the
Infection Control section of SMHPT intranet site.
The infection control nurse, members of the Infection Control Link group and the
audit team will be able to assist in the selection of an appropriate audit tool
where areas wish to initiate their own audit.
Audit will also be carried out as part of an annual programme endorsed by the
SMHPT Infection Control Committee.
SMHPT Infection Control Policy (CL6)
Page 70 of 80 (Section 9)
APPENDIX 1
CONTACTS
Infection Control advice can be obtained from:-
For urgent enquiries please contact the Director of Nursing –
mobile number 07534 901923.
Advice on microbiological sampling, results of microbiological investigations and
therapeutic guidance should be requested from the investigating laboratory’s
Consultant Microbiologists. Contact details will be given on the investigation
request form or on the microbiological report form.
Information is also available on the Health Protection Agency website
www.hpa.org.uk
This site has advice and information on a wide range of infection control issues
and links to a number of other useful organisations.
Local infection control advice for non-NHS community organisations can be
obtained from the Suffolk Health Protection Unit.
Telephone: 01473 329583
Email:
[email address]
Contact details for Occupational Health:
Occupational Health
Direct Line: 01473 329343
A clinical waste collection can be arranged by contacting
Carole Clarke,
Facilities Manager for Suffolk Support Services
Telephone number: 01473 329766
Mobile phone number: 07973156755
e-Email address: [email address]
SMHPT Infection Control Policy (CL6)
Page 71 of 80 (Appendix 1)
APPENDIX 2
DECONTAMINATION CERTIFICATE
From:
----------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------
To:
----------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------
Make and description of equipment item:__________________________
Model/Serial/Batch Number: __________________________
Other distinguishing marks: __________________________
•
This equipment/ item has not been in contact with blood or other body
fluids. It has been cleaned in preparation for inspection, servicing or
repair.
•
This equipment has been decontaminated. The method used was :
_______________________________________________________________
•
This equipment could not be decontaminated. The nature of risk, and
safety precautions to be adopted are:
_______________________________________________________________
Signed
Date
Position
Address
SMHPT Infection Control Policy (CL6)
Page 72 of 80 (Appendix 2)
APPENDIX 3
Infection Control Outbreak Summary Report Form
Facility
Ward/Dept:
Description of
illness:
Start
End
Date:
Date:
Total no. of patients
affected:
No. of patients of
ward/unit:
Total no. of
specimens obtained:
Results:
(both
positive & negative)
Total no. of staff
affected:
Occupational Health
Yes No
involvement:
(delete as necessary)
Infection Control
Yes No
involved
(delete as necessary)
Brief description of
advice given:
Action
taken:
Details of bed closures or restrictions on admission/discharges and transfers:
Name:
Job
Title:
Signature:________________________________________________________
1 copy to be sent to Infection
Control Nurse
Date completed:
SMHPT Infection Control Policy (CL6)
Page 73 of 80 (Appendix 3)
SMHPT Infection Control Policy (CL6)
Page 74 of 80 (Appendix 3)
APPENDIX 4
Guidance on Communicable
Diseases
(March 2005 Issue)
Produced by: Suffolk Health Protection Unit
PO Box 170, St Clements Hospital, South Building, Foxhall Road, Ipswich IP3 8LS
Tel: 01473-329583; Fax: 01473-329090
SMHPT Infection Control Policy (CL6)
Page 75 of 80 (Appendix 4)
GUIDANCE ON COMMUNICABLE DISEASES (MARCH 2005 ISSUE)
DISEASE INCUBATI
INFECTIOUS
ADVICE ON
SCHOOL
NOTES
ON
PERIOD
RESTRICTIONS
CONTACTS
PERIOD
MODE OF
& EXCLUSIONS
TRANSMISSION
Athletes’ foot
Unknown
Infectious while
No exclusion
No action
Treatment is by
lesions are present. required as
required
drying between
Spread by direct
transmission
toes after
contact or via
requires
bathing and
contaminated
prolonged
applying
floors, showers etc. contact
fungicidal
dusting powder
to feet
Chicken pox
2-3 weeks
Infectious from 5
Exclude for at
Pregnant non-
A highly
days before to 5
least 5 days after immune
contagious
days after
spots first appear women in the
disease which
appearance of
or until they
first 20 weeks
appears to be
spots.
become dry
of gestation or
most
Transmission is
in the last
infectious
mainly respiratory
weeks of
around the
but blisters contain
gestation need
onset of the
some virus
to see their GP
rash.
as this disease
Infection
can affect them confers long
and their fetus
immunity and
severely
second attacks
are rare.
N.B. Shingles
is a reactivation
of the
chickenpox
virus and, in
general, adults
do not require
exclusion. For
advice on
individual
cases,
however,
please consult
the Suffolk
Health
Protection Unit
(SHPU) –
contact details
overleaf
Cold sores
2-12 days
Usually spread by
No exclusion
No Action
Once acquired,
(Herpes
direct contact or
required – or
this virus
Simplex)
saliva. Up to 20%
feasible as virus
remains in the
of healthy children
is shed for up to
body,
are shedding
8 weeks following
awakening at
herpes simplex
development of a
intervals to
virus at any one
cold sore
cause recurring
time
cold sores
Conjunctivitis
24-72
Can be infectious
Exclusion not
No Action
Good personal
“Pink eye”
hours
while eye is
usually
hygiene can
inflamed. Spread
necessary after
reduce the risk
by contact, sharing
medical advice
of transmission
flannels etc.
given or
treatment started
SMHPT Infection Control Policy (CL6)
Page 76 of 80 (Appendix 4)
Gastro-
Varies
Multiple linked cases should be reported at the earliest opportunity to the
enteritis
according
local environmental health department. Under usual circumstances, all
(Diarrhoea
to cause
individual cases of gastroenteritis should be excluded until well and free from
&/or
symptoms for 48 hours.
vomiting)
Glandular
4-6 weeks
Virus may be
Exclusion is not
No Action
fever
carried for up to a
routine as most
year after the
transmission is
illness. Spread is
from
usually via kissing
asymptomatic
carriers of the
virus.
Hand foot &
3-5 days
Respiratory and
No exclusion
No Action
Usually a mild
mouth
faecal-oral spread
required
illness causing
during illness.
blisters on
Faecal-oral spread
palms, soles &
alone for some
mouth.
weeks thereafter
Virus in faeces
for some weeks
Headlice
Headlice can only move from one There is no need to exclude a child
All
infested
head to another during head to
from school who has headlice but
members of an
head contact of at least 1 minute
advice should be given to families
affected
about checking and treating all
person's family
infested people. For further
must be treated
guidance please see information
sheet on the Health Protection
Agency website at www.hpa.org.uk
Hepatitis A
2-6 weeks
Faecal-oral
Exclusion
Advice should
Scrupulous
(“Yellow
transmission,
mandatory until 1 be sought from
hygiene after
Jaundice”)
mostly in the week
week after
SHPU at an
using the
before and the
jaundice appears. early stage
lavatory is
week after jaundice Person may be
(contact details essential for
appears
ill, but non-
overleaf)
limiting spread
infectious, for
weeks
Influenza 1-5
days
Infectious up to one Exclusion for 1
No Action
Immunisation is
week after onset
week
available for
certain
vulnerable
groups
Impetigo
1 – 4 days
Infectious usually
Exclusion for 48
No Action
The three
depending until lesions healed. hours after
important
on
The bacteria are
treatment
measures are
organism
usually spread by
commenced
medical
pus on fingers
unless lesions
treatment,
can be covered
covering the
lesion and
personal
hygiene
Measles
7-18 days
Infectious from just
Transmission is
No Action
Unimmunised
before illness starts unusual after the
(Most children
persons can
until 3 days after
third day of the
immunised)
usually be
the appearance of
rash, so 5 days
vaccinated
the rash
exclusion is
successfully if
sufficient
within 3 days of
contact
Meningitis
Varies
Advice should be sought at an early stage from SHPU (contact details
according
overleaf)
to cause
SMHPT Infection Control Policy (CL6)
Page 77 of 80 (Appendix 4)
Molluscum
7days – 6
Spread by direct
No exclusion
No action
Most
contagiosum
months
contact or by
required
transmission is
contaminated
within families
materials. Lesions
can persist for 2
years
Mumps
12-25 days Infectious for 1
Exclusion until 1
No Action
week either side of
week after the
the onset of facial
onset of swelling
swelling
Ringworm 10-14
days
Spread by direct
Exclusion not
No Action
Pets and farm
contact skin to skin
necessary after
animals
may be
or indirect contact
treatment has
a source of
via combs, clothing
started. Scalp
infection - but
etc.
ringworm needs
this is not
oral treatment
usually so
Roseola
Most transmission
No exclusion
No Action
Prolonged
infantum
is within families
required. Most
asymptomatic
children immune
shedding
by school age
common in
children and
adults
Rubella
14-23 days Infectious for about
Exclusion for 5
Non-immune
Virus shedding,
“German
1 week before, and
days after onset
pregnant
and thus
Measles”
for 5 days after, the of rash
women should
transmission,
onset of the rash.
be made aware wanes from 2
so that they
days after the
can consult
rash appears
their doctor for
advice
Scabies 2-6
weeks
Infectious until
Exclusion until
Household
The mites
(1-4 days
treated. Mites are
the day after the
members and
make tiny
if
transferred during
first treatment
those who have burrows in the
previously skin-to-skin
had prolonged
skin which itch
infected)
contact.
skin-to-skin
intensely
Transmission via
contact should
especially at
bed linen is
have
night. Sites
unusual.
simultaneous
include
treatment
between
fingers, wrists,
elbows.
Scarlet fever
1-3 days
Infectious until
Exclusion until 48 No Action
(Scarlatina)
treated with
hours after
appropriate
treatment started
antibiotic for 48
hours
Slapped cheek
4-20 days
Infectious before
Exclusion until
Pregnant
Rash has a
disease
onset of rash but
clinically well. As
women should
“slapped
(Fifth disease)
probably not after
not all children
be made aware cheek”
rash appears
are ill, this may
so that they
appearance
mean no
can consult
followed a day
exclusion at all
their doctor for
or so later by a
advice.
lace-like body
rash
Threadworms A
few Infectious until
None Contacts
and
Good hygiene
days (the
treatment. Eggs
family
and adequate
time taken
can be transferred
members
treatment are
for the
to mouth on fingers
should be
essential
worms to
if the anus is
treated
transit the
scratched
simultaneously
gut)
SMHPT Infection Control Policy (CL6)
Page 78 of 80 (Appendix 4)
Tuberculosis Highly Only infectious if
Smear-positive
variable.
many germs in the
cases will be
Minimum
sputum.
excluded for two
6 weeks
weeks from the
start of treatment.
Verrucae and
2-3
Infectious while
Neither
No Action
Usually
Warts
months
visible lesions
exclusions nor
disappear
persist
'verucca socks'
spontaneously.
have proved
If there is pain
useful in limiting
on walking,
spread
medical advice
can be sought
Whooping
7-10 days
If untreated,
Exclusion for 3
Unimmunised
During an
Cough
infectious from
weeks from onset household
outbreak
(Pertussis)
onset until about 3
if untreated. If
contacts under
children under
weeks later. If
treated with
7 years should
5 years should
antibiotics are used antibiotic can
be excluded
not be admitted
very early, this
return after 5
until on
to school
period is reduced to days
antibiotic
unless known
5 days
treatment
to be
immunised.
SMHPT Infection Control Policy (CL6)
Page 79 of 80 (Appendix 4)
Contacts
Environmental Health Departments
Babergh District Council
St. Edmundsbury Borough Council
Environmental Health Department
Environmental Health & Housing Services
Corks Lane
Borough Offices, Angel Hill
Hadleigh, IP7 6SJ
Bury St. Edmunds, IP33 1XB
Tel: 01473-825890
Tel: 01284-757054
Fax: 01473-825738
Fax: 01284-757039
Forest Heath District Council
Suffolk Coastal District Council
Environmental Health Department
Environmental Health Department
College Heath Road
Melton Hill
Mildenhall, IP28 7EY
Woodbridge, IP12 1AU
Tel: 01638-719284
Tel: 01394-444358
Fax: 01638-716493
Fax: 01394-444359
Ipswich Borough Council
Waveney District Council
Environmental Health Department
Environmental Health Department
Civic Centre
Town Hall
Civic Drive
High Street
Ipswich IP1 2EE
Lowestoft, NR32 1HS
Tel: 01473-432000
Tel: 01502-562111
Fax: 01473 433062
Fax: 01502-523150
Mid-Suffolk District Council
Environmental Health Department
131 High Street
Needham Market, IP6 8DL
Tel: 01449-720711
Fax: 01449-727237
Primary Care Trusts
Suffolk PCT
Rushbrook House
Paper Mill Lane, Bramford
Ipswich, IP8 4DE
Tel. 01473 770000
Waveney PCT
6 Regent Road
Lowestoft, NR32 1PA
Tel: 01502-533733
Fax: 01502-512772
Education Departments
Northern area:
Southern area:
Suffolk County Council
Suffolk County Council
Education Department
St Andrew House
Adrian House
County Hall
Alexandra Road
Ipswich, IP4 1LJ
Lowestoft, NR32 1PL
Tel: 01473-583000
Tel: 01502-405000 Fax: 01502-519956
Western area:
Suffolk County Council
Education Department
Shire Hall
Bury St Edmunds, IP33 1RX
Tel: 01284-352000 Fax: 01284-352106
SMHPT Infection Control Policy (CL6)
Page 80 of 80 (Appendix 4)
Document Outline
