STANDARD INFECTION CONTROL
DOCUMENT CHANGE HISTORY
Comments (i.e. viewed, or reviewed, amended,
approved by person or committee)
Infection Control Committee
Reviewed by Lead Infection Control Nurse group
Infection Control Committee
Infection Control Committee
Judy Potter on behalf of Devon Primary Care Trust - Infection Control
Available via InfoPoint
Review Date of
Devon PCT has made every effort to ensure this policy does not have the
effect of discriminating, directly or indirectly, against employees, patients,
contractors or visitors on grounds of race, colour, age, nationality, ethnic
(or national) origin, sex, sexual orientation, marital status, religious belief
or disability. This policy will apply equally to full and part time employees.
All Devon PCT policies can be provided in large print or Braille formats if
requested, and language line interpreter services are available to
individuals of different nationalities who require them.
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Standard Infection Control
Standard precautions underpin safe practice, offering protection to both staff
and patients from healthcare related infections. Since examination and medical
history alone cannot reliably identify all patients with infections, standard
precautions represent a standard of care to be used routinely for all patients
regardless of perceived or known infection risk factors.
Standard infection control precautions include:
• effective hand hygiene practices (Refer Section 2.5)
• maintenance of skin integrity (Refer Section 3.3)
• protection of open wounds/skin lesions (Refer Section 3.3)
• use of appropriate personal protective clothing (Refer Section 5)
• avoidance of sharps injury through safe use and disposal of sharps (Refer
• appropriate decontamination of instruments and equipment, including safe
management of blood spillage (Refer Decontamination Policy)
• maintaining a clean hospital environment (Refer Source Isolation Policy and
• safe disposal of waste (refer Trust Waste Management Policy)
• safe handling and laundering of used linen (Refer Section 8)
2. Hand Hygiene Policy and Guidelines
Hands are the principle route by which cross infection occurs in health care
settings. Hand hygiene is, therefore, the single most important means of
reducing the spread of infection. All healthcare workers are required to comply
with this policy.
Compliance will be encouraged by:
• ensuring easy access to appropriate hand hygiene products at the point of
care, (wherever this is safe to do so)
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• increasing awareness of the importance of hand hygiene amongst
healthcare workers using a variety of strategies such as training, posters
and positive role modelling
• wearing uniforms and other clothing worn for direct contact with patients or
the clinical environment that are short sleeved, leaving the arm naked below
• providing information for patients about the importance of hand hygiene
• inviting patients to prompt staff to clean their hands if they think they have
Microbes on the hands can be classified as either transient or resident.
2.3.1 Transient micro-organisms are found on the surface of the skin. Direct
contact with other people or equipment can result in the transfer of
'transients' to or from the hands with ease. As such they are an
important cause of cross infection. However, they are also easily
removed by routine hand hygiene practice (Refer 1.1.3a).
2.3.2 Resident micro-organisms are more deeply seated in the epidermis. As
a result they are difficult to remove and are not usually implicated in
cross infection. However, during surgery and other major invasive
procedures they may enter deep tissues and cause infection. Thus there
is a need for more extensive hand hygiene prior to such procedures
When decontaminating hands, the critical point for hand hygiene to occur
immediately prior to every episode of direct patient contact (even if gloves
after every episode of direct patient contact (even if gloves have been worn)
after contact with a patient’s immediate environment and the equipment
In addition, hands must be decontaminated:
• after any contact that may result in the hands becoming visibly dirty
handling potentially contaminated equipment
• prior to an aseptic procedure, including the manipulation of IV systems
• after going to the toilet
• prior to eating/preparing food or drink
Levels and Methods of Hand Hygiene
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2.6.1 Routine Hand Hygiene
Handwashing: hand washing will remove transient micro-organisms
and visible dirt/soiling.
Method: liquid soap and running water is required for this level of
NB: Bar soap is not permitted for staff handwashing in health care
Wet hands thoroughly under running water
Apply liquid soap for 10-15 seconds using an effective technique
(Refer Figure 1).
Rinse thoroughly under running water.
Dry thoroughly with paper towels.
Use of alcohol handrub
Generally, alcohol handrub is an effective alternative to routine
handwashing if the hands are visibly clean
. It is useful when
handwashing facilities are not readily available +/or when speed is of
the essence. It facilitates timely hand hygiene i.e. immediately
before and after direct patient contact and, therefore, must be readily
available in dispensers at the bedside or carried by staff. However,
there are some microbes that are resistant to alcohol e.g. Clostridium difficile
spores and Norovirus. It is essential to wash
your hands with soap and water when dealing with patients known or
suspected to have these infections. As the diagnosis is not always
obvious, a pragmatic approach is to use soap and water whenever
dealing with a patient with diarrhoea.
Method: apply enough of the product to thoroughly cover your
hands, using an effective technique (Refer Figure 1). Rub hands
together briskly until completely dry.
Surgical Handwashing: pre-operative surgical handwashing will
remove or destroy transient micro-organisms and significantly reduce
detachable resident micro-organisms.
Method: antiseptic detergent solutions are required for this level of
hand hygiene eg povidone iodine detergent or 4% chlorhexidine
Wet hands and forearms under running water.
Apply antiseptic detergent to the hands and forearms for two
A sterile nailbrush may be used at the start of a list to clean nails.
Repeated scrubbing is not recommended as it may damage the skin
and result in an increase in the numbers of micro-organisms
colonising the skin.
Rinse thoroughly under running water
Dry thoroughly with towel.
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Use of alcohol handrub/gel
This method can be used between cases if the hands are physically
clean. A surgical hand wash must be undertaken at start of list.
Ensure that the alcohol hand rub/gel purchased is suitable for
preoperative hand disinfection - check manufacturers
Method: two separate applications of alcohol handrub/gel rubbed
onto hands and forearms until dry.
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3. Other aspects of hand hygiene for clinical staff
3.1 Finger Nails: finger nails must be kept clean and short ie not visible beyond the
finger tip, when viewed from the palm side. Nail varnish and false finger
nails/tips must not be worn.
3.2 Jewellery: staff must remove rings (other than a plain band), bracelets and
wristwatches prior to clinical patient contact to facilitate effective hand washing.
Staff have ongoing clinical contact e.g. doctors, nurses, physiotherapists should
remove such jewellery at the start of their shift as it is impractical to do this prior to
every patient contact.
Although a plain band ring is permitted during most clinical practice but it should
be removed prior to surgical procedures.
• Bacterial counts increase when the skin is damaged therefore care must be
taken to maintain skin integrity:-
− Always wet hands thoroughly prior to application of liquid soap or
− Rinse hands thoroughly to remove soap or antiseptic detergent.
− Dry hands carefully.
− Apply good quality non ionic hand cream at the end of a shift (avoid
communal pots of hand cream).
• Any staff who develop eczema, dermatitis or any other skin condition must
seek advice from the Occupational Health Department as soon as possible.
• Any member of staff unable to use the recommended hand cleansing agents
due to a skin condition/allergy must seek advice from the Occupational
• Cuts and abrasions must be covered with a waterproof dressing.
• Always cleanse hands after removing gloves.
4. Patient hand hygiene
Patients should be offered hand hygiene facilities and encouraged to wash their
hands particularly after using toilet/commode/bedpan and prior to meals. Hand
cleansing wipes can be obtained from NHS Supply Chain and must be offered
to patients who are unable to access hand washing facilities.
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5. Personal protective clothing
Selection of appropriate protective clothing should follow a risk assessment of
the procedure to be performed. The following factors should be considered:
• risk of contamination to Health Care Workers clothing and skin
• risk of transmission to the patient
Patient/user latex allergy must also be considered in relation to gloves.
The use of protective clothing does not negate the need to wear a freshly
laundered uniform/clothing for each shift. Furthermore, uniforms/clothing must
be changed if contaminated during the course of a shift.
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Gloves do not replace the need
for hand hygiene.
Surgery and other major invasive Double gloving is recommended for
procedures where comfort,
orthopaedic implant surgery.
dexterity and sensitivity is
The Expert Advisory Group on AIDS
and HIV also recommends double
gloving as a method of reducing
percutaneous exposure during
surgical procedures on patients with
blood borne pathogens.
• Non surgical aseptic
Non sterile, vinyl
• Non sterile procedures with
Gloves must be manufactured to BS
potential exposure to
blood/blood stained body
involving used sharps
Non sterile, nitrile
• An alternative to vinyl gloves
when vinyl deemed
unsuitable by Occupational
• For domestic and ancillary
Reusable. Gloves should be
staff for cleaning duties.
washed in detergent and warm water
• For unavoidable manual
cleaning of surgical
Offers protection to/from clothing
Must be changed between clean and
at site of greatest
exposure/contact during routine
patient care activities
To protect eyes from aerosol or
splash contamination of body
fluids eg from surgery,
• Offers protection to clothing
Use mainly restricted to:
and skin during procedures
where there is the potential
sterile or non
for gross exposure to blood
and other body fluids.
• Reduces skin scale dispersal Aseptic drug preparation units
from the wearer thus reducing
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risk of infection for the patient
Sterile gowns must be used for
during invasive procedures.
(than aprons) to staff during
the care of certain infectious
conditions eg Norwegian
• Limited reduction of
If masks are worn they must cover
transmission of micro-
the nose and mouth
organisms expelled from the
mouth and nose of the
Do not handle the mask whilst in
• Protects the wearer from
blood and other body fluid
To remove mask, handle by tapes
splashes/aerosols to the
only and then wash hands.
lower face and mouth eg
Staff should be fit tested to ensure
Dust & Mist Filter
the brand of mask used is
appropriate for their use. If it is not,
nd other infections
alternatives must be provided.
transmitted by droplet nucleii.
Use indicated in:
• Protects feet from body fluids. Theatres if blood spill likely to be
• Use not recommended.
6. Safe handling and disposal of sharps
6.1 Sharps injury should be avoided by safe handling and correct disposal
6.2 It is the responsibility of the person using the Sharp to dispose of it safely as
• avoid resheathing needles. If resheathing is unavoidable use a resheathing
device or one handed technique
• discard needle and syringe as one unit, whenever possible. If disassembly is
necessary it must not be done by hand
• dispose of sharps into a sharps container (conforming to UN3291 & BS7320)
immediately after use
• Sharps bins must be easily accessible to staff but at the same time must not
be a hazard to patients or visitors. Sharps bins must be placed out of easy
reach of unauthorised persons, especially children
• avoid carrying used sharps to a sharps bin. A small sharps bin should be
taken to the patient
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• ensure sharps bins are correctly assembled, according to manufacturer's
instructions, before use
• avoid passing used sharps from person to person by hand eg from surgeon to
scrub nurse - use a receiver or similar container
• Sharps disposal devices, such as adhesive pads, must be available in areas
such as theatres
• consider the use of needlestick prevention devices when there is clear
indication that they will provide safer systems of work
• use a vacuum system for venepuncture whenever possible
• if using syringe and needle for venepuncture avoid filling blood tubes using
the needle. Remove used needles using needle removing device on the
sharps bin. Unscrew tops of bottles to fill
• never overfill sharps bins. When 3/4 full sharps bins must be properly closed
and sealed. Do not place in a yellow bag
• Sharps bins must be labelled with the source department/unit
• staff moving sharps bins must check that the seal remains closed during and
• always carry sharps containers by the handle and away from the body
6.3 If you sustain an inoculation injury, the risk of infection is likely to be very low.
However, it is important to report it immediately so that appropriate action
can be taken
6.4 Procedure following Inoculation Injury: exposure to blood or body fluid, from a
sharps injury, bite or from splashing into the eyes, mouth or broken skin must always
be reported and followed up because of the potential risk of infection with blood
Inoculation injury/Spillage on damaged skin/Bite:
Encourage bleeding of injury (but not by sucking).
Wash site immediately and thoroughly with soap and water.
Splashes in the eye/mouth
Irrigate the eye with copious amounts of water using eye wash equipment,
rinse mouth with water and spit out.
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Where the source patient has sepsis eg Group A Streptococcus,
antibiotic prophylaxis may be indicated for the victim. This should be
mentioned when seeking advice.
6.5.1 IMMEDIATE ADVICE: injured Staff - phone the relevant Occupational
Royal Devon and Exeter Hospital
24 hour - Inoculation Injury Hotline –
Torbay District Hospital
Mon-Fri Daytime - 01803 653489
Out of hours 01803 653488
Anytime - Contact A&E.
North Devon District Hospital
Mon-Fri Daytime 01271 341520
Out of hours 01271 341529
6.5.2 Injured members of the public – Contact the nearest Accident and
An assessment will be then be made as to the appropriate action,
e.g. need for prophylaxis.
Refer local Inoculation Injury Policy for further advice
Member of Public
A&E/Minor injury unit
7. Segregation of waste
Waste must be segregated in accordance with local Waste Management
8. Management of used linen
It is the responsibility of all staff involved to comply with the agreed colour coded
segregation system identified on laundry segregation posters, using water
soluble inner bags where linen is contaminated with blood and other body fluids
or for linen from a source isolation room . This will ensure appropriate
laundering procedures are used and provides for the protection of laundry
Great care must be taken to prevent extraneous and hazardous items eg
sharps, gloves, incontinence pads, disposable gowns being sent to the laundry.
Such items can injure staff and/or can damage washing/drying machines.
Failure to prevent such incidents may be regarded as a disciplinary offence.
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: Water soluble bags used for hospital laundry cannot be used in domestic
washing machines such as those in patients' own homes or in small community
units. Staff working in such units will therefore have to handle fouled or infected
laundry when doing the laundry and must ensure they wear gloves and aprons
for protection. Alternatively, water soluble bags designed for use in domestic
machines should be purchased. These are available through NHS Supply Chain
– catalogue code MVF010.
Patients’ personal clothing: wherever possible, patients’ relatives should be
encouraged to take personal clothing home for laundering. If the clothing that is
soiled with blood or other body fluids or poses an infection risk it should be
placed in a water soluble bag designed for use in domestic machines. These are
available through NHS Supply Chain – catalogue code MVF010.
If home laundry is not possible then personal clothing may be laundered within
the community hospital/residential unit. Procedures vary depending on the
provider of such services e.g. in-house or commercial contract. Local
procedures must be in place to ensure that staff are aware of correct procedure.
When changing the provider of such services infection control advice must be
sought to determine whether proposed arrangements are appropriate.
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Standard Infection Control Precautions
Infection Control Policy
Major Outbreak Plan
Source Isolation Policy
Protective Isolation Policy
Ward Closure due to a Suspected or Confirmed Outbreak of
Guidelines for the Management and Control of MRSA
Clostridium Difficile and Antibiotic Associated Colitis
Extended Spectrum Beta Lactamases (EBLSs) and Resistant
Amp C Type Beta Lactamases (AMP Cs)
Vancomycin/Glycopeptide Resistant Enterococci (VRE/GRE)
IC 12g Herpes Simplex Guidance
IC 12h Tuberculosis Management in a Hospital Setting
Guidance on Animals and Pets in Healthcare Facilities
Inoculation Injury Policy
Staff Immunisation and Vaccination
H:\Jackie Crang\infection control\infection control policies\approved policies 08\IC01 Standard Infection Control
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