This is an HTML version of an attachment to the Freedom of Information request 'Hand Hygiene'.


 
 
 
IC 01                            
 
STANDARD INFECTION CONTROL                
PRECAUTIONS 
 
 
Document Status
Approved 
Version:  
V3 
 
DOCUMENT CHANGE HISTORY 
Version 
Date 
Comments (i.e. viewed, or reviewed, amended, 
approved by person or committee) 

V1 Draft  
21.06.07  
Infection Control Committee 
V1 Reviewed 
23.07.07 
Reviewed by Lead Infection Control Nurse group 
V2 Approved  
31.07.07 
Infection Control Committee 
V3 Approved 
21.01.09 
Infection Control Committee 
 
 
 
 
 
 
 
Authors: 
Judy Potter on behalf of Devon Primary Care Trust - Infection Control 
Committee 
 
Document 
Available via InfoPoint 
Reference: 
 
 
 
Review Date of 
November 2011 
approved 
document: 
 
 
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. 
 
 
 
 

 
Page 1 of 12 


 
 
Standard Infection Control 
Precautions 
 
 
1.     Introduction 
 
1.1 
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 
Section 6) 
 
•  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 
Decontamination Policy) 
 
•  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 
 
2.1 
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. 
 
2.2 
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) 
 
Page 2 of 12 

 
•  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 
the elbow 
 
•  providing information for patients about the importance of hand hygiene 
 
•  inviting patients to prompt staff to clean their hands if they think they have 
forgotten 
 
2.3 
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 
(Refer 1.1.3b). 
 
2.4 
When decontaminating hands, the critical point for hand hygiene to occur  
is: 
 
  immediately prior to every episode of direct patient contact (even if gloves 
are worn) 
 
  after every episode of direct patient contact (even if gloves have been worn) 
 
  after contact with a patient’s immediate environment and the equipment 
within it 
 
2.5 
In addition, hands must be decontaminated: 
 
• after any contact that may result in the hands becoming visibly dirty 
 
• after 
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 
 
2.6 
Levels and Methods of Hand Hygiene 
 
 
Page 3 of 12 

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 
hand hygiene. 
 
NB: Bar soap is not permitted for staff handwashing in health care 
premises. 
 
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. 
 
 2.6.2 
Surgical 
Hand 
Hygiene 
 
  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 
detergent. 
 
Wet hands and forearms under running water. 
Apply antiseptic detergent to the hands and forearms for two 
minutes. 
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. 
 
Page 4 of 12 








 
  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 
recommendations. 
 
 
 
Method:  two separate applications of alcohol handrub/gel rubbed 
onto hands and forearms until dry.  
 
Figure 1
 
 
 
 
 

 
Page 5 of 12 

 
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. 
 
 
3.3 Skin 
Care 
 
•  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 
antiseptic detergent. 
−  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 
Health Department. 
 
•  Cuts and abrasions must be covered with a waterproof dressing. 
 
•  Always cleanse hands after removing gloves. 
 
 
4.     Patient hand hygiene 
 
4.1 
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. 
 
 
 
 
 
 

 
Page 6 of 12 

 
5.     Personal protective clothing 
 
5.1 
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. 
 
5.2 
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. 
 
Page 7 of 12 

 
 
 
 
ITEM OF 
PURPOSE/USE 
COMMENTS 
CLOTHING 
 
GLOVES 
 
Gloves do not replace the need 
for hand hygiene.
 
Sterile, surgeons 
Surgery and other major invasive  Double gloving is recommended for 
gloves 
procedures where comfort, 
orthopaedic implant surgery. 
dexterity and sensitivity is 
The Expert Advisory Group on AIDS 
required. 
and HIV also recommends double 
gloving as a method of reducing 
percutaneous exposure during 
surgical procedures on patients with 
blood borne pathogens. 
Sterile, 
•  Non surgical aseptic 
 
examination 
procedures 
gloves 
• Sterile 
pharmaceutical 
preparations 
Non sterile, vinyl 
•  Non sterile procedures with 
Gloves must be manufactured to BS 
examination 
potential exposure to 
EN 455 
gloves 
blood/blood stained body 
fluids 
• Non 
sterile 
procedures 
involving used sharps 
• Handling 
disinfectants 
(excluding aldehydes) 
Non sterile, nitrile 
• Handling 
aldehydes 
 
examination 
• Handling 
cytotoxic 
material 
gloves 
•  An alternative to vinyl gloves 
when vinyl deemed 
unsuitable by Occupational 
Health 
 
Rubber household  •  For domestic and ancillary 
Reusable.  Gloves should be 
gloves 
staff for cleaning duties. 
washed in detergent and warm water 
•  For unavoidable manual 
after use 
cleaning of surgical 
instruments 
 
PLASTIC APRONS  Offers protection to/from clothing 
Must be changed between clean and 
at site of greatest 
dirty tasks 
exposure/contact during routine 
patient care activities 
EYE PROTECTION  To protect eyes from aerosol or 
 
Glasses, goggles, 
splash contamination of body 
visors 
fluids eg from surgery, 
endoscopy, suctioning 
GOWNS 
•  Offers protection to clothing 
Use mainly restricted to: 
Waterproof or 
and skin during procedures 
 
water repellent, 
where there is the potential 
Theatres 
sterile or non 
for gross exposure to blood 
Endoscopy units 
sterile 
and other body fluids. 
Delivery suite 
•  Reduces skin scale dispersal  Aseptic drug preparation units 
from the wearer thus reducing   
 
Page 8 of 12 

risk of infection for the patient 
Sterile gowns must be used for 
during invasive procedures. 
sterile procedures. 
• Offers 
greater 
protection 
(than aprons) to staff during 
the care of certain infectious 
conditions eg Norwegian 
Scabies 
MASKS 
•  Limited reduction of 
If masks are worn they must cover 
Surgical Masks 
transmission of micro-
the nose and mouth 
 
organisms expelled from the 
 
 
mouth and nose of the 
Do not handle the mask whilst in 
 
wearer. 
place. 
 
•  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 
 
 
surgery, endoscopy, 
 
 
suctioning. 
 
 
 
Staff should be fit tested to ensure 
Dust & Mist Filter 
• Protection 
against 
the brand of mask used is 
respirators 
Mycobacterium tuberculosis 
appropriate for their use.  If it is not, 
(FFP3) 
and other infections 
alternatives must be provided. 
transmitted by droplet nucleii. 
 
 
FOOTWEAR 
 
Use indicated in: 
Rubber boots 
•  Protects feet from body fluids.  Theatres if blood spill likely to be 
 
 
profuse. 
 
•  Use not recommended. 
Overshoes 
 
 
6.     Safe handling and disposal of sharps 
 
6.1  Sharps injury should be avoided by safe handling and correct disposal 
procedures. 
 
6.2  It is the responsibility of the person using the Sharp to dispose of it safely as 
follows: 
 
•  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 
 
Page 9 of 12 

 
•  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 
after transportation 
 
•  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 
borne viruses.  
 
 
6.5 First 
Aid:   
 
 
a) 
Inoculation injury/Spillage on damaged skin/Bite: 
 
 
i) 
Encourage bleeding of injury (but not by sucking). 
 
ii) 
Wash site immediately and thoroughly with soap and water. 
 
iii) Cover 
with 
waterproof 
dressing. 
 
b) 
Splashes in the eye/mouth 
 
 
Irrigate the eye with copious amounts of water using eye wash equipment, 
rinse mouth with water and spit out. 
 
c) Sepsis 
 
Page 10 of 12 

 
 

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 
Health Department: 
 
Royal Devon and Exeter Hospital 
24 hour - Inoculation Injury Hotline –  
01392 405500  
 
Torbay District Hospital 
Mon-Fri Daytime - 01803 653489 
Out of hours 01803 653488  
Derriford Hospital 
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 
Emergency Department. 
 
 
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 
 
Management Responsibility 
 
             Staff   
 
     Patient 
 
 
Member of Public 
 
 
 
      Occ Health 
 
Clinical Team   
     
A&E/Minor injury unit 
 
 
7.     Segregation of waste 
 
7.1 
Waste must be segregated in accordance with local Waste Management  
Policy. 
 
 
8.     Management of used linen 
 
8.1 
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 
workers. 
 
8.2 
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. 
 
Page 11 of 12 

 
NB: 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. 
 
8.3 
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.   
 
8.4 
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. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Page 12 of 12 

 
POLICY  INDEX 
 
IC 01   
Standard Infection Control Precautions 
 
IC01a  
Infection Control Policy 
 
IC 02   
Aseptic Technique 
 
IC 03   
Major Outbreak Plan 
 
IC 04   
Source Isolation Policy 
 
IC 04a 
Protective Isolation Policy 
 
IC 08   
Ward Closure due to a Suspected or Confirmed Outbreak of  
  Infection 
 
IC 12   
Guidelines for the Management and Control of MRSA 
 
IC 12a 
Clostridium Difficile and Antibiotic Associated Colitis 
 
IC 12b  
Extended Spectrum Beta Lactamases (EBLSs) and Resistant  
 
 
Amp C Type Beta Lactamases (AMP Cs) 
 
IC 12c 
Vancomycin/Glycopeptide Resistant Enterococci (VRE/GRE)  
  Guidelines 
 
IC 12d  
Viral Gastroenteritis 
 
IC 12e  
Scabies Guidance 
 
IC 12f  
Measles Guidance 
 
IC 12g            Herpes Simplex Guidance 
 
IC 12h           Tuberculosis Management in a Hospital Setting 
 
IC 12i   
Guidance on Animals and Pets in Healthcare Facilities 
 
IC 12j   
Inoculation Injury Policy 
 
HR 11 
Staff Immunisation and Vaccination 
 
 
 
 
 
H:\Jackie Crang\infection control\infection control policies\approved policies 08\IC01 Standard Infection Control 
Precautions.doc 
 
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