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

Part of the 


Issued November 2003,  
Reviewed April 2005, and July 2007 


SECTION A – INTRODUCTION AND CONTACTS .................................................... 1 
1.  Introduction .......................................................................................................... 1 
2.  Scope .................................................................................................................... 1 
3.  Responsibility ...................................................................................................... 1 
4.  Contacts................................................................................................................ 2 
SECTION B – INFECTION, ITS CAUSES AND SPREAD.......................................... 3 
1.  The Causes of Infection....................................................................................... 3 
2.  The Spread of Infection ....................................................................................... 4 
1.  Standard Principles of Infection Control ........................................................... 5 
2.  Hand Hygiene and Skin Care .............................................................................. 6 
Preparation .................................................................................................... 7 
Washing and Rinsing ..................................................................................... 7 
Drying............................................................................................................. 8 
Handrubs/Alcohol Gels .................................................................................. 8 
     Hand Decontamination Facilities ......................................................................... 8 
3.  Protective Clothing .............................................................................................. 9 
Types of Protective Clothing ..................................................................................... 9 
Disposable Gloves.................................................................................................... 9 
4.  Safe Handling of Sharps.................................................................................... 11 
SECTION D – NOTIFICATION OF INFECTIOUS DISEASES .................................. 13 
1.  Introduction ........................................................................................................ 13 
2.  Accountability .................................................................................................... 13 
3.  Notification Procedures..................................................................................... 13 
4.  Reporting & Documentation of Illness for a Suspected/Confirmed Outbreak
............................................................................................................................ 16 
SECTION E – MANAGEMENT OF SHARPS INJURIES .......................................... 23 
1.  Occupational Injuries......................................................................................... 23 
2.  Control Measures............................................................................................... 24 
3.  Sharps Injuries in Members of the Public........................................................ 29 
SECTION F – SPILLAGE MANAGEMENT............................................................... 31 
1.  Spillage Management ........................................................................................ 31 
SECTION G – MANAGEMENT OF INFECTIOUS DISEASES ................................. 33 
1.  Introduction ........................................................................................................ 33 
2.  Factsheets .......................................................................................................... 33 
3.  Meningococcal and Hib Disease ...................................................................... 34 
4.  Guidelines for the Management of MRSA in the Community......................... 37 
5.  Specific Guidance for Residents with Clostridium difficile ........................... 40 
SECTION H – INFESTATIONS................................................................................. 42 
1.  Prevention and Control of Headlice in the Community .................................. 42 
2.  Some Facts about Headlice and Nits (Pediculus humanus capitis) .............. 42 
3.  Treatment - for when Lice are Found ............................................................... 42 
6.  Prevention and Control of Scabies in the Community ................................... 49 

SECTION I – CLINICAL PRACTICE......................................................................... 56 
1.  Aseptic Technique ............................................................................................. 57 
2.  Care of Patients with known Infectious Diseases –........................................ 59 
Source Isolation (Barrier Nursing) ................................................................... 59 
3.  Decontamination ................................................................................................ 65 
4.  Enteral Feeding .................................................................................................. 86 
5.  Intravenous Therapy.......................................................................................... 87 
6.  Laundry Management ........................................................................................ 91 
7.  Management of Non-Infectious and Infectious Deceased Clients ................. 94 
8.  Guidelines for Community Sector Performing Minor Surgery....................... 96 
9.  Prevention and Control of Infection in Urinary Catheter Care ..................... 103 
10. Safe Handling of Specimens........................................................................... 106 
11. Vaccine Control................................................................................................ 107 
12. Waste Management.......................................................................................... 109 
SECTION J – VACCINATIONS .............................................................................. 122 
1.  Where can I Refer Patients for Advice? ......................................................... 123 
2.  Where can I Obtain Advice on Travel Vaccinations?.................................... 123 
SECTION K – FOOD HYGIENE.............................................................................. 127 
1.  Introduction ...................................................................................................... 127 
2.  Legislation ........................................................................................................ 127 
3.  Basic Requirements for Food Safety ............................................................. 127 
SECTION L – PETS and PESTS ............................................................................ 129 
1.  Introduction ...................................................................................................... 129 
2.  Pets ................................................................................................................... 129 
3.  Litter Box Care ................................................................................................. 129 
4.  Pests ................................................................................................................. 130 
SECTION M – AUDIT TOOL................................................................................... 131 
SECTION N – REFERENCES................................................................................. 133 

1. Introduction   
These guidelines have been written for ………………………………………………. 
Infection control is an important part of an effective risk management programme to 
improve the quality of patient care and the Occupational Health (OH) of staff. 
This guidance should assist organisations and individuals to adhere to the Health Act 
2006: Code of Practice for the Prevention and Control of Healthcare Associated 
2. Scope 
The manual includes guidance on care given in General Medical Practices, individual 
homes, clinics, day care facilities, and covers all areas of health and social care 
provision as provided by the organisation. The manual is available in its entirety, or in 
individual sections on our website. 
For chiropody and dental, refer to specific Essex Health Protection Unit (EHPU) 
guidance available on the EHPU website 
It is acknowledged that some users of these guidelines work in premises over which 
they have little or no control (e.g. clients' own homes).  Therefore in some instances 
users will have to use their own judgement in the interpretation of the guidelines.  
However further advice is available from the Essex Health Protection Unit. 
3. Responsibility 
The purpose of this manual is to encourage individual responsibility by every member 
of staff. All should participate in the prevention and control of infection ensuring a 
seamless infection control service between hospitals and the community. 
The Chief Executive/owner of the organisation is responsible for ensuring that there 
are effective arrangements in place for the control of infections. 

4. Contacts 
Infection Control advice can be obtained from the Essex Health Protection Unit, 8 
Collingwood Road, Witham, Essex CM8 2TT.  
The main office telephone number is: 0845 1550069. Please note that this is a 
new telephone number.
 The CsCDC and Communicable Disease Control Nurses 
are contactable via this number. 
Advice is also available on the Essex Health Protection Unit website: 
Users are encouraged to ensure they have access to this site as it has advice and 
information on a wide range of local communicable disease issues, and during 
incidents will be updated at least daily with the current state of affairs. 
Out of working hours – for URGENT communicable disease enquiries:   
Contact 01245 444417, and ask them to page the on-call Public Health Person. 


The Causes of Infection 
Micro-organisms are integral to infections, and a basic insight into the characteristics 
of commonly encountered micro-organisms is essential for good infection control 
practice.  Micro-organisms that cause disease are referred to as pathogenic 
organisms.  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 an enteritis (symptoms of 
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 
Prions are infectious protein particles.  For example the prion causing (New) Variant 
Creutzfeldt-Jakob Disease (vCJD). 


The Spread of Infection 
There are various means by which micro-organisms can be transferred from their 
place of reservoir to susceptible individuals.  These are: 
Direct Contact.  Direct spread of infection occurs when one person infects the next 
by direct person-to-person contact (e.g. chickenpox, tuberculosis, sexually transmitted 
infections etc.).   
Indirect.  Indirect spread of infection is said to occur when an intermediate carrier is 
involved in the spread of pathogens e.g. fomite or vector. 
fomite is defined as an object, which becomes contaminated with infected 
organisms and which subsequently transmits those organisms to another 
person.  Examples of potential fomites are instruments, impression trays and 
suction tips 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 in areas where 
malaria carrying mosquitoes live. 
Hands.  The hands of healthcare 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 gastro-
intestinal 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. 

Standard Principles of Infection Control 
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 of Infection Control (or 
Universal Precautions).  
The recommendations on standard principles provide guidance on infection control 
precautions that should be applied by all healthcare personnel, and other carers, to 
the care of patients in community and primary care settings. 
Standard Principles of Infection Control include: 
Hand Hygiene and Skin Care  
Safe Handling of Sharps (including Sharps Injury Management). 
All blood and body fluids are potentially infectious and precautions are necessary to 
prevent exposure to them.  
Everyone involved in providing health and social care should know, and have a duty to 
apply the standard principles of hand decontamination, the use of protective clothing 
and the safe disposal of sharps. Each member of staff is accountable for his/her 
actions and must follow safe practices. 


Hand Hygiene and Skin Care 
There are two methods of hand decontamination which are handwashing and 
handrubs, both alcohol and non-alcohol based. 
Hand decontamination is recognised as the single most effective method of controlling 
Hands must be decontaminated: 
Before and after each work shift or work break.  Remove jewellery 
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 
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. 
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. 
Liquid soap 
For all routine tasks 
(15-30 seconds) 
Hygienic hand 
Antiseptics, e.g. chlorhexidine, 
In high-risk areas and 
povidone-iodine or alcohol 
during outbreaks 
(15-30 seconds) 
handrub after social clean 
Surgical scrub 
Antiseptics, e.g. chlorhexidine, 
Prior to surgical and other 
(3 minutes) 
povidone-iodine, thorough and 
invasive procedures.  Bars 
careful.  Dry on sterile towels 
of soap not recommended 

An effective handwashing technique involves four stages:   
(a) Preparation 
Before washing hands, all wrist and, ideally, hand jewellery should be removed.  Cuts 
and abrasions must be covered with waterproof dressings.  Fingernails should be kept 
short, clear and free from nail polish.  Hands should be wet under tepid running water 
before applying liquid soap or an antimicrobial preparation. 
Washing and Rinsing 
The handwash solution must come into contact with all of the surfaces of the hand.  
The hands must be rubbed together vigorously for a minimum of 15-30 seconds, 
paying particular attention to the tips of the fingers, the thumbs and the areas between 
the fingers.  Hands should be rinsed thoroughly.  
Hygienic Hand Disinfection for Outbreak Control 
This can either be achieved by using antiseptic liquid soap, or by routine 
handwashing, followed by 5mls of an alcohol handrub.  
Surgical Handwashing 
Surgical handwashing 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. 

(c) Drying 
This is an essential part of hand hygiene.  Dry hands thoroughly using good quality 
paper towels.  In clinical settings, disposable paper towels are the method of choice 
because communal towels are a source of cross-contamination.  Store paper towels in 
a wall-mounted dispenser next to the washbasin, and throw them away in a pedal 
operated fire-retardant domestic waste bin.  Do not use your hands to lift the lid or 
they will become re-contaminated. 
Hot air dryers are not recommended in clinical settings.  However if they are used in 
other areas, they must be regularly serviced and users must dry hands completely 
before moving away. 
(d) Handrubs/Alcohol 
Hands should be free from dirt and organic material.  The handrub solution must come 
into contact with all surfaces of the hand.  The hands must be rubbed together 
vigorously, paying particular attention to the tips of the fingers, the thumbs and the 
areas between the fingers, until the solution has evaporated and the hands are dry. 
Hand Creams 
An emollient hand cream should be applied regularly to protect skin from the drying 
effects of regular hand decontamination.  If a particular soap, antimicrobial handwash 
or alcohol product causes skin irritation, an Occupational Health (OH) team should be 
Hand Decontamination Facilities 
Facilities should be adequate and conveniently located.  Hand washbasins must be 
placed in areas where needed and where client consultations take place.  They should 
have elbow- or foot-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 
Dispensers should be dismantled and washed regularly with particular 
attention to the nozzle 
Place disposable paper towels next to the basins - soft towels will help to 
avoid skin abrasions 
Position foot-operated pedal bins near the hand washbasin - make sure 
they are the right size. 
Handwashing in Individuals Homes 
Hands should be washed prior to any procedure in the patient’s home and before 
departure.  If handwashing facilities are inadequate (e.g. no warm water, no soap, no 
hand towel), the healthcare worker should carry either liquid soap and paper hand 
towels, baby/detergent wipes or alcohol handrub.  However alcohol handrub should 
only be used if the hands are visibly clean.   

Protective Clothing 
Selection of protective equipment must be based on an assessment 
of the risk of transmission of infection between the patient and the 
risk of contamination of the healthcare workers’ clothing and skin by 
patient blood and body fluids. 
Assessment of Risk 
What to Wear When 
No exposure to 
Exposure to blood/body 
Exposure to blood/body 
blood/ body fluids 
fluids anticipated, but low 
fluids anticipated - high-
risk of splashing 
risk of splashing to face 
Wear gloves, plastic 
No protective 
Wear gloves and a plastic 
apron and 
Types of Protective Clothing 
Disposable Gloves 
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. Gloves do not 
substitute for handwashing. 
Following risk assessment for infectious hazard, gloves should be disposed of via the 
offensive, non hazard route, or infectious hazard route, (Refer Waste Management 
Section I -12
) and hands must be decontaminated after the gloves have been 
Sensitivity to natural rubber latex must be documented and alternatives to natural 
rubber latex gloves must be available. 

To prevent transmission of infection, gloves must be discarded after each procedure.  
Gloves should 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 
Should be used when hands may come into contact with blood and body fluids, 
or equipment contaminated with blood and body fluids. 
2. Sterile 
Should 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 should be used 
when coming into contact with possible contaminated surfaces or items. 
Colour-coding of such gloves should be used e.g. green for the kitchen, blue for 
general environmental cleaning, and red for ‘dirty’ clinical duties.  This will help 
prevent cross-infection from one area of work to another.  The gloves should be 
washed with GPD and hot water, and dried between uses.  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. 
Disposable Plastic Aprons 
Should be worn when there is a risk that clothing may be exposed to blood, body 
fluids, secretions or excretions, with the exception of sweat. 
Plastic aprons should be worn as single-use items, for one procedure or episode of 
patient care, and then discarded and disposed of by the appropriate waste route 
(Refer Waste Management Section I -12).  
Face Masks and Eye Protection 
Must be worn where there is a risk of blood, body fluids, secretions or excretions 
splashing into the face, mouth and eyes. Full face visors are appropriate for protection 
against splashes into the face and eyes. 

Respiratory Protective Equipment 
For example, a particulate filter mask, must be used when clinically indicated for 
pulmonary tuberculosis. 
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 for all clinical staff involved in ‘exposure 
prone procedures’ or where regular exposure to blood/blood-stained body fluids 
Care should be taken to avoid accidental needlestick injury, as exposure to 
contaminated blood may be associated with transmission of blood-borne viruses 
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 blood-borne 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, i.e. 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 to the sharps container when carrying or if left unsupervised 
to prevent spillage or tampering 
•  Place sharps containers on a level stable surface 
•  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 waste bag. 
Giving Injections 
Always wash hands thoroughly prior to giving an injection. 
If the patient’s skin is visibly dirty, it should be cleaned with an individually packed 
swab soaked in 70% isopropyl alcohol and left to dry.  If skin is clean, this step is not 
Venepuncture and injections should be carried out only by staff who are adequately 
trained and experienced. 
For occupationally acquired sharps injuries refer to Section E

1. Introduction 
This guideline sets out the procedures for staff to follow in respect of communicable 
disease control.  It includes the reporting, documentation and notification procedures. 
2. Accountability 
Operational Directors 

Should ensure the application of recommendations within their Directorates. 
To support the Operation Directors in the implementation of the guidelines within their 
directorate.  Managers of residential establishments owned by the PCTs should report 
outbreaks to the PCT infection control team.  Managers of independent residential 
establishment to report outbreaks to the EHPU. 
Clinical and Support Staff 
•  All staff have an important role in the prevention and control of infection which 
is an integral quality issue in the care and management of patients/residents 
and the health and safety of staff 
•  All staff need to follow all guidelines 
•  All staff need to bring infection control issues to the attention of Senior 
•  All staff need to maintain a high standard of infection prevention and control as 
a matter of good practice. 
3. Notification 

Explanatory note 
Any registered medical practitioner who becomes aware or suspects that a 
patient/resident (s)he is attending is suffering from a notifiable disease is required by 
law (Public Health Control of Disease Act 1984) to send a notification form to the local 
authority Proper Officer forthwith.  
It is not necessary to wait for laboratory/microbiological confirmation of a 


While laboratories may report, this does not absolve clinicians from their responsibility 
to do so. 
Which diseases are notifiable? 
List of Notifiable Diseases 
Paratyphoid Fever 
Dysentery (Amoebic or Bacillary) 
Relapsing Fever 
Food Poisoning* 
Scarlet Fever 
Typhoid Fever 
Meningitis (all types) 
Meningococcal Septicaemia (without 
Viral Haemorrhagic Fever 
Viral Hepatitis 
Whooping Cough 
Ophthalmia Neonatorum 
Yellow Fever 
* This category includes any infection which could be food or water-borne e.g. 
campylobactersalmonella, cryptosporidiosis, giardia. 
How quickly should I notify? 
The law specifies that notification should be “forthwith” i.e. without any delay.  Please 
send out notification forms on the same day the patient is seen and make sure they 
are not being “batched”. 
The aim of notification is to ensure public health action is taken promptly.  The EHPU 
should be telephoned on the day of diagnosis on Tel: 0845 1550069 on strong clinical 
suspicion for all except: 
•  Isolated cases and household contacts with dysentery 
•  Isolated cases and household contacts with food poisoning (we would like to be 
telephoned about any E coli 0157,  Listeria and Hepatitis A) 
•  Chronic Hepatitis B and C 

• Leptospirosis 
• Malaria 
• Ophthalmia 
• Scarlet 
•  Cases of tuberculosis already under the care of a chest physician. 
These may be notified by post utilising the usual notification forms. 
Where do I obtain notification forms? 
These are available on application to the EHPU, who supply them on behalf of the 
Essex Local Authorities; we can post or email a blank template. 
We would also like to know about cases of: 
• Legionella 
•  Suspected outbreaks of any infection i.e. D&V 
•  One or more cases of scabies in a residential setting 
•  Sudden increase of chest infections in care homes. 


Reporting & Documentation of Illness for a 
Suspected/Confirmed Outbreak  

Recognising Outbreaks of Infection 

Any suspicion of an outbreak of communicable disease in the community should be 
reported to the EHPU immediately for further investigation, and management as 
The EHPU should be contacted if: 
•  There are two or more individuals with vomiting and/or diarrhoea (amongst 
patients/residents or staff) 
•  There are two or more individuals suffering from the same infectious illness 
i.e. chest infections 
•  There is a high sickness rate amongst staff, who appear to be suffering from 
the same infectious disease. 
If a residential establishment is affected (whether the member of staff is directly 
employed by the establishment or not) the following guidance should be followed: 
•  Care home managers should contact the EHPU without delay if they 
suspect there may be an outbreak of infection in a home (PCT owned 
establishments should report directly to the PCT Infection Control Team) 
•  They must also inform their local Environmental Health Department if food 
poisoning is suspected and the Commission for Social Care Inspection 
•  Senior management must be informed and requested to ensure adequate 
staffing to cope with the extra demands of managing an outbreak.  Staff 
working in the home should not work in other care establishments until the 
outbreak is declared over by the Essex Health Protection Unit 
•  List all residents and staff affected, including age, area/unit where resident/ 
working, onset of symptoms, symptoms suffered, duration of illness, GP 
and whether a sample has been taken (blank forms on following pages). 

Please use the Bristol stool chart to indicate the frequency and type of stool during an 
outbreak of D&V, diarrhoea is defined as watery or liquefied stools comparable with 
types 6 and 7. 

Specific Guidance for Outbreaks of Diarrhoea and/or Vomiting 
•  Isolate symptomatic residents 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 kitchen units.  
For the duration of the outbreak, environmental cleaning should be 
performed using detergent and hot water followed by a 1 in 1000 parts per 
million available chlorine-releasing solution that is 0.1% hypochlorite 
solution, 1 part household bleach in 10 parts of water or Sodium 
Dichloroisocyanurate (NaDCC) e.g. Precept, Haztabs diluted as per 
manufacturer’s guidance, or a proprietary brand that combines detergent 
and chlorine agent i.e. Antichlor Plus  
NB Alcohol Gel alone will not destroy Norovirus or Cl. Difficile. 
•  All staff handwashing areas and the rooms of symptomatic residents should 
have an antibacterial liquid dispensed soap (or an alcohol handrub following 
handwashing with a regular liquid soap) for the duration of the outbreak, 
then normal liquid dispensed soap should be used 
•  Residents 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.  A new pair of disposable 
gloves and a plastic apron should be worn for each resident 
•  Faecal samples should be obtained from residents and staff if they have 
symptoms.  The microbiology form accompanying the sample should clearly 
state it is part of an outbreak, and additionally please request virology 
screening. as these will determine which specific tests are carried out in the 
laboratory (samples of vomit are not required) 
•  The home should be closed to admissions until 48 hours after the last 
symptomatic patient has recovered 
•  Symptomatic staff must go off duty, a faecal sample must be taken and they 
must remain off work until 48 hours symptom free 
•  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 home and comply with all other hygiene practices in 
•  Residents should only be discharged 48 hours after their last symptom and 
with the full consent of anyone who may be required to care for them in the 

Type: Diarrhoea/Vomiting/Chest Infection/…………………….. 
Name of Home:    ______________________  
Record started by: ___________________ 

Reported to:   EHPU/EHO/CSCI/PCT 

Total number of residents in home: _________ 

Total number of residents affected: _________ 
Name of 
DOB Area/Unit 
Duration of GP 
 Name     Seen 
 Sent            Result 

Type: Diarrhoea/Vomiting/Chest Infection/……………….   
Name of Home:    ______________________  
Record started by: ___________________ 

Reported to:   EHPU/EHO/CSCI/PCT 

Total number of staff in home: _________ 

Total number of staff affected: _________ 
Name of  
DOB Area/Unit 
Duration of GP 
Name Date Seen
 Sent            Result 

Name of Home:    ______________________  
Record started by: ___________________ 
Date:  ________________  

Reported to:   EHPU/EHO/CSCI/PCT 

Total number of residents in home: _________ 

Total number of residents affected: _________ 
Name of Resident 
DOB  Area/Unit 
Diagnosed  by 
Treatment Date 
where resident  Symptoms 
         GP                  EHPU 
            1st                     2nd  


Name of Home:    ______________________  
Record started by: ___________________ 

Reported to:   EHPU/EHO/CSCI/PCT 

Total number of members of staff in home: _________ 

Total number of members of staff affected: _________ 
Name of Staff 
DOB Area/Unit 
Diagnosed  by 
Treatment Date 
where resident  Symptoms 
         GP                  EHPU 
            1st                     2nd  


1. Occupational 
In the event of a sharp injury/contamination incident these guidelines should be 
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 the individual has an open wound, and clothes have been 
soaked by blood 
•  Bites (where the skin is broken). 
When a sharp injury/contamination incident occurs: 
1.  Encourage bleeding from the wound 
2.  Wash the wound in soap and warm running water (do not scrub) 
3.  Cover the wound with a dressing 
4.  Skin, eyes or mouth, wash in plenty of water 
5.  Ensure the sharp is disposed of safely i.e. using a non-touch method into a 
sharps container 
6.  Report the incident to immediate supervisor.  An incident form should be 
completed as soon as the recipient of the injury is able 
7.  The incident should be reported to the Occupational Health department and GP 
(Refer to Sharps Injury poster
8.  Attempt to identify source of the needle/sharp.  Depending on the degree of 
exposure and the knowledge of the source patient/client it may be necessary to 
take further immediate action, see below. 

2. Control 
Any staff working in a healthcare facility who handle sharps or hazard infectious waste 
should receive a full course of Hepatitis B vaccine and have their antibody level 
checked to establish immunity.  
New staff or any existing staff who know they are not already protected should contact 
their occupational health department to arrange vaccination without delay. 
Generally staff in the community do not perform Exposure Prone Procedures (EPPs) 
with the exception of dental and some podiatrist practices. EPPs are invasive 
procedures where there is a risk that injury to the worker may result in the exposure of 
the patient’s open tissues to the blood of the healthcare worker. 
However, all staff who do perform EPPs need to be aware of their obligations (see 
statements by the General Medical Council in Serious Communicable Diseases, 1997; 
[General Dental Council in Maintaining Standards Guidance 1997;] United Kingdom 
Central Council for Nursing, Midwifery and Health Visiting Registrar’s letter 4/1994 
Annex 1) i.e. to declare it if they know themselves to have been at risk of exposure to 
a blood-borne virus infection (Hepatitis B, C or HIV). 
Existing staff that undertake EPPs should be screened for Hepatitis B. 
New employees must be screened for both Hepatitis B and Hepatitis C prior to 
commencing work. 
Testing the Source Patient 

In some instances it will not be possible to identify the source patient.  However, if the 
source is identifiable and available for testing, a blood specimen should be obtained 
(with counselling and consent) and sent to the microbiology laboratory (an 
appropriately trained person should discuss the implication of the blood test and 
results, prior to obtaining consent from the source patient).  This can be done on an 
urgent basis, in consultation with the laboratory.  All donors should be tested for 
Hepatitis B and C, and HIV if appropriate.  Additional advice on risk assessment can 
be obtained from your occupational health department. 
Investigation of the Person Receiving the Injury 

Baseline serum should be obtained from the exposed person and stored in a secure 
archive at 20°c or below for at least two years. 

The following table summarises the action to be taken following any sharp 
injury/contamination incident in relation to protection against Hepatitis B. 
If the source is unknown, follow the advice in table 1 (Immunisation Against infectious 
Disease, 2006 – The Green Book).  

Significant exposure 
Non-significant exposure 

HBV status of person  HBsAg positive source  Unknown source 
HBsAg negative 
Continued risk 
No further risk 
≤1 dose HB vaccine 
Accelerated course of 
Initiate course of 
Initiate course of 
No HBV prophylaxis 
HB vaccine* 
course of HB 
HB vaccine 
HB vaccine 
HBIG x 1 
≥ 2 doses HB vaccine  One dose of HB 
One dose of HB 
Finish course of 
Finish course of 
No HBV prophylaxis 
vaccine followed by 
HB vaccine 
HB vaccine 
(anti-HBs not known)  second dose one 
month later 
Known responder to 
Consider booster dose  Consider booster 
Consider booster 
Consider booster 
No HBV prophylaxis 
HB vaccine (anti-
of HB vaccine 
dose of HB 
dose of HB 
dose of HB 
HBs> 10mlU/ml) 
Known non-
HBIG x 1 
HBIG x 1 
No HBV prophylaxis 
responder to HB 
Consider booster dose  Consider booster 
Consider booster 
Consider booster 
vaccine (anti-HBs < 
of HB vaccine 
dose of HB 
dose of HB 
dose of HB 
10mlU/ml 2-4 months   
A second dose of 
A second dose of 
HBIG should be given 
HBIG should be 
at one month 
given at one month
* An accelerated course of vaccine consists of doses spaced at zero, one and two months. A booster dose may be given at 12 months to 
those at continuing risk of exposure to HBV. 
Source PHLS Hepatitis Subcommittee (1992)  

There is no post exposure prophylaxis for Hepatitis C. 
In the event that the source patient cannot be tested, management of the healthcare 
worker should be based upon a risk assessment.  Clinical information about the 
incident and/or the source patient should be reviewed.  If the source patient is 
considered to be ‘high-risk’ then the healthcare worker may be managed as if exposed 
to a source known to be positive. (Such exposures would normally be limited to 
sharps injuries contaminated with fresh blood from a known high-risk population such 
as IV drug users.) 
Summary of Investigation and Follow-up of Healthcare Workers 
Known HCV infected source 
Obtain serum/EDTA for genome detection at 6 and 12 weeks 
Obtain serum for anti-HCV at 12 and 24 weeks. 
Source not known to be infected with HCV 
Obtain follow up serum if symptoms or signs of liver disease develop. 
HCV status of source unknown 
Perform risk assessment. 
Source Considered High-risk 
Manage as known infected source. 
Source Considered Low Risk 
Obtain serum for anti-HCV at 24 weeks. 
Genotyping of source and healthcare worker will help to confirm whether transmission 
from patient to the worker has occurred


The risk of acquiring HIV from a single percutaneous exposure is small and on 
average is estimated to be 0.3%. 
The risk of acquiring HIV through mucous membranes exposure is less than 
Post exposure prophylaxis should be considered only when there has been exposure 
to blood or other high-risk body fluids known to be or strongly suspected to be 
infected with HIV.  (These fluids include: amniotic fluid, vaginal secretions, semen, 
human breast milk, CSF, peritoneal fluid, pericardial fluid, pleural fluid, synovial fluid, 
saliva in association with dentistry, unfixed organs and tissues.) 
Strongly suspected” includes individuals with clinical symptoms highly 
suggestive of HIV disease or individuals from countries where HIV is highly 
prevalent who may not yet have had a blood test. 
Strongly suspected does not include an injury from an unknown source i.e. an 
inappropriately discarded needle in the healthcare setting or in a public place, nor an 
individual with a single lifestyle factor e.g. intravenous drug abuser. 
Post-exposure prophylaxis should not be considered following contact through any 
route with low risk materials e.g. urine, vomit, saliva, faeces, unless they are visibly 
If post-exposure prophylaxis is indicated it should be started as soon as possible 
after the incident and ideally within the hour.  (However Department of Health 
recommends it may be worth considering PEP even if 1-2 weeks have elapsed since 
the incident.) 
The individual should attend the nearest A&E department without delay.  

Sharps Injuries in Members of the Public  
Assess whether a significant injury has occurred.  If not, reassure. 
The source is rarely known (i.e. discarded needle) and members of the public are 
usually managed as for an unknown source.  
A rapid course of Hepatitis B vaccine should be offered and serum taken for a serum 
Testing for Hepatitis B antibodies should be undertaken at 6 months, and if the patient 
requests it, Hepatitis C and HIV as well.  

What to do after a…… 
Directions for the management of needlestick injuries, 
and cuts and penetrating wounds, contaminated with blood or blood-stained 
body fluids 
Wash cuts thoroughly with soap and warm water, 
then gently encourage to bleed. 
Apply a dressing if necessary. 
Splashes to the eyes or mouth 
should be thoroughly rinsed with running water 
Report incident to your manager immediately (if applicable) 
Your medical advisor should: - 
a)  Take a history and make a risk assessment 
b)  Review your Hepatitis B vaccine status 
c)  Take 10ml clotted blood from the recipient and, 
if possible, the ‘source’ (with informed consent) 
d)  Send the samples to the microbiology department marked 
‘needlestick Injury’ 
e) Ensure appropriate follow-up 
Complete an accident form 
Insert your local arrangements 
Please Note 
If the source is known or a risk of having HIV the injured person should contact  
Accident & Emergency, and attend if possible within the hour 
Be prepared – If you are at risk of exposure – 
get immunised against Hepatitis B Virus 
Tel:  In hours:- Your GP or Occupational Health Dept 
Tel:  Out of Hours:- Your local A&E Department 

1. Spillage 
Deal with blood and body fluid spills quickly and effectively.   
Commercial spillage kits are available to deal with blood and body fluid spillages, and 
should be used. 
The kits should be kept in a designated place (depending on the size of the 
establishment more than one kit should be available). 
Ensure that kits remain in date and that kits are replaced immediately after use. 
For staff working in a private household the following guidance should be adhered 
to as closely as possible: 
For spillage of high-risk body fluids such as blood, method 1 is recommended.  For 
spillage of low-risk body fluids (non-blood containing excreta) such as faeces, vomit 
etc., use method 2. 
Hypochlorite/Sodium Dichloroisocyanurates (NaDCC) Method 

•  Prevent access to the area containing the spillage until it has been safely 
dealt with 
•  Open the windows to ventilate the room if possible 
•  Wear protective clothing  
•  Soak up excess fluid using disposable paper towels and/or absorbent 
powder e.g. vernagel 
•  Cover area with NaDCC granules (e.g. Presept, Sanichlor) 
•  Cover area with towels soaked in 10,000 parts per million of available 
chlorine (1% hypochlorite solution = 1 part household bleach to 10 parts 
water) e.g. household bleach, Milton, and leave for at least two minutes  
•  Remove organic matter using the towels and discard as hazardous 
infectious 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 hazardous infectious waste 

• Wash 
This method is suitable for carpets, and spills of low-risk body fluids. 
Detergent and Water Method 
•  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 area with cold water 
•  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 
•  Discard protective clothing in the appropriate waste bag 
• Wash 
•  Ideally, once dry, go over area with a mechanical cleaner 
•  Wash hands again 



1. Introduction 
The EHPU produce a series of factsheets, which are available from the EHPU 
website,, or the main HPA website, under Topics 
A-Z, factsheets. 
The factsheets include information on incubation periods, method of spread, period of 
infectivity, exclusion periods and where appropriate the management of contacts. 
The factsheets can be photocopied and passed to members of the public. 
In addition, there is extended text in this document on Meningococcal Disease, MRSA 
and PVL, Clostridium Difficile and CJD. (Refer to Section H - Infestations, for 
further information on Scabies and Headlice.) 
2. Factsheets 
Blood-Borne Viruses 
Bugs, Fleas and Ticks 
MMR and Immunisations 
Conjunctivitis Molluscum 
Diarrhoea and Vomiting 
ESBLs Mumps 
Glandular Fever 
Parvovirus (Slapped Cheek) 
Group A Streptococci 
Pertussis (Whooping Cough) 
Hand, Foot and Mouth  
Headlice Rabies 
Hepatitis A 
Rashes in Childhood 
Hepatitis B 
Hepatitis C 
Rubella (German Measles) 
Herpes Scabies 
Immunisation – General Information 
Impetigo Tuberculosis 
Influenza Verrucas 
Lyme Disease 


Meningococcal and Hib Disease 
Patients showing symptoms suggestive of meningococcal disease should be 
immediately referred to hospital.  Usually the admitting hospital will notify the EHPU or 
Public Health doctor on call at the time of the case. 
Prophylaxis will be arranged for contacts identified by the EHPU.  Giving antibiotics 
inappropriately may do more harm than good as it can result in eliminating carriage of 
non-pathogenic organisms, such as Neisseria lactamica, which boost immunity.  It 
also undermines efforts to give consistent advice to the public. 
The working definition of a ‘contact’ according to national guidelines is: 
Those who have had close personal and prolonged contact with a 
confirmed or probable case during the seven days before the onset of 

This includes: 
•  Household or household equivalent contacts: 
Those sleeping in the same household/overnight stays 
Close social contacts 
Intimate ‘kissing contacts’ i.e. girlfriends/boyfriends 
It does not include casual contacts such as: 
o Cheek 

Attendance at birthday parties and other social events 

Presence in same office or classroom 

Sharing cans of drink or cigarettes. 
•  Healthcare Workers (HCWs) who have been in contact during 
resuscitation.  In general this applies to staff who: 
Have inserted an endotracheal tube 
Have given mouth-to-mouth resuscitation

Rationale for Prophylaxis 
People who live in the same household are at a higher risk of developing disease than 
other members of the community – the attack rate is increased by about 500-1200 
times.  The risk is highest in the first seven days after a case and falls rapidly 
The aim of chemoprophylaxis is to eliminate carriage from the network of close 
contacts.  Although there is evidence that chemoprophylaxis at least delays the onset 
of further cases in a family, it is not known whether the total number of further cases is 
reduced due to a lack of comparative studies. 
Choice of Antibiotic 
The drug of choice is Rifampicin and, in the absence of contraindications, may be 
used in all age groups. 
Adults and Children over 12 years of age should be prescribed 600 mg bd for 
48 hours 
Children 1-12 years 10 mg/kg bd for 48 hours 
Infants (under 12 months of age) 5 mg/kg bd for 48 hours. 
Approximate doses in children based on average weight for age are: 
0-2 months 20 mg (1 ml syrup)    ) 
3-11 months 40 mg (2 ml syrup)  )    bd for 48 hours   
1-5 years 150 mg (7.5 ml syrup  ) 
6-12 years 300 mg (one tablet)  ) 
N.B.   Information on dosage should also be checked in the BNF prior to 
Current guidelines suggest that prophylaxis is recommended for pregnant women, 
Rifampicin 600mgs, every 12 hours for 2days, or intramuscular ceftriaxone 250mg. 
Drug Interactions Should Be Considered 

Patients must be informed of possible side effects of rifampicin including: 
•  Orange staining of urine and other body fluids 
•  Orange staining of soft contact lenses 
•  Possible interaction with oral contraceptives.  Women should be advised to take 
additional contraceptive precautions for at least four weeks post-prophylaxis. 

PATIENT INFORMATION (factsheet available on EHPU website) 
Contacts receiving prophylaxis should be advised: 
•  The purpose of prophylaxis is to eliminate carriage of organism from the close 
social network 
•  It will not prevent infection in someone currently incubating the disease 
•  98% of cases of meningococcal disease are sporadic i.e. not linked to any other 
•  The risk to contacts is actually very low – one in several thousand 
•  The risk is greatest in the first seven days post exposure 
•  They will only be offered vaccine if the strain is confirmed as either C, A, Y or 
W135.  The protective effect of antibiotic prophylaxis lasts for several weeks and 
so the vaccine can be given later e.g. up to a month post antibiotics and 
sometimes longer 
•  The most important thing is to have a high index of suspicion for any unusual 
symptoms and to contact a doctor without delay 
•  How to recognise the early symptoms and signs of meningococcal disease 
•  Contacts of ‘contacts’ are not at risk. 
Numbers of helplines for further information: 
•  Meningitis Trust – Telephone: 01453 768000 
24 hour helpline: 0800 028 1828 
•  Meningitis Research Foundation – 24 hour helpline: 0808 800 3344 

Guidelines for the Management of MRSA in the Community 
What is MRSA? 
MRSA stands for Meticillin Resistant Staphylococcus aureus. 
It occurs when some strains of the common bacterium of Staphylococcus aureus 
become resistant to treatment with meticillin.  This is not used for treatment, but a very 
similar antibiotic, Flucloxacillin. 
The most common scenario for an individual with MRSA in the community 
environment is that they have an infection in a wound, which is then slow to heal. 
Why is it known as a hospital-acquired disease? 
MRSA will spread more readily in the acute hospital setting, owing to the increased 
vulnerability that patients with an acute illness will have to infection. 
When an individual suffers an acute illness, their immunity may be greatly reduced 
(making them vulnerable to infection).  As that individual recovers, so will their 
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. 
This is why patients who were hospitalised with an acute illness, and then acquire 
MRSA, are discharged as soon as they have recovered from their acute episode - 
meaning they do not stay in a vulnerable environment for longer than necessary. 
What is the difference between colonisation and infection? 
 - means the MRSA is living on the skin (usually nose, throat, axilla or 
groin), causing no problem to the individual. 
 - means that the MRSA is causing an active infection i.e. the wound is red, 
hot, inflamed, there may be a discharge and pain. 
What precautions do you need to take in the residential care/intermediate care 
No special precautions are necessary. 
Standard principles of infection control (especially handwashing) are all that are 
However MRSA does act as an opportunity to remind us of the good practices that 
should already be in place. 

Resident/patients are not barrier nursed in the residential case/intermediate care 
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 or china and cutlery does NOT need to be handled separately.  Again, as 
long as they have good practices already in place, there is no need for additional 
Waste should be handled as with any other patient - if the patient is known to have an 
infection, and that infection is producing a discharge, then arrangements should be 
made for a clinical waste collection.  Otherwise the waste should be well wrapped and 
placed in the household waste. (Refer to Waste Management Section I -12). 
Maintaining a clean environment will help to reduce the transmission of the bacteria.  
The daily removal of dust and body substances is crucial.  Cleaning protocols should 
also include regular cleaning of high surfaces, curtains, carpets, extractor fans and the 
removal of radiator covers to clean radiators. 
Protocol for Treatment and Screening 
Do not screen unless there is clinical evidence to do so. 
The state of the wound should be assessed and documented: 
• Size, 
•  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 
•  If the wound does not appear to be healing, re-swab after 4 weeks and at 4 
weekly intervals thereafter until there is evidence of healing, to check whether 
antibiotic treatment is indicated. 
If the patient is colonised with MRSA of the nose, throat, axilla 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. 
The screening of staff is very rarely required - and should only take place in 
consultation with the CDCN/ICN. 

Admission and care to Residential/Nursing Home 
No home is allowed to refuse admission of a patient/resident because they happen to 
have MRSA.  However, if a resident does have MRSA (either colonisation or infection) 
that resident should: 
•  Be in a single room, or 
•  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 precautions on previous page: 
a) Environmental cleaning should be reinforced to help prevent further spread 
b) After patient is discharged the room should be thoroughly cleaned and curtains 
removed for laundering. 
Suggested Treatment Protocol for Patients with MRSA infected wounds 
General Information on this organism can be found on the factsheet available at 
Please refer to PCT Wound Management Policy, or consult with Tissue Viability 
Specialist where access to the above is not available the protocol below can be 
•  Clean infected sit with sterile water for 4 weeks 
•  If there is no improvement, seek further advice from the Tissue Viability nurse. 
Environmental Decontamination Post-Infectious Patient in Clinical Premises e.g. 
GP Surgeries, Health Centres clinical rooms 

Treatment rooms should be kept clean and dust-free with items stored in cupboards 
and as little equipment on surfaces as possible. Clutter will attract dust and prevent 
appropriate cleaning. Unnecessary equipment should be removed from the room prior 
to the procedure. 
In addition to changing of paper roll from couch, the couch and all horizontal surfaces 
should be decontaminated by wiping with a solution of detergent and hot water, or 
detergent/hard surface wipes. 
The use of linen is not advised in clinical rooms.  If used, all linen must be changed 
daily and washed in a machine that will thermally disinfect linen. 
The use of body fluid spillage kits should be dealt with as described in Section F – 
Spillage Management.  


Pre-Hospital Screening/Treatment of Colonisation prior to Hospital Admission 
If this is required the admitting hospital’s infection control team/hospital microbiologist 
should provide guidance for their requirements. 
Additional advice: 

Please seek further advice from the EHPU or Infection Control team, if required. 
Newly identified MRSA in clinical specimens should be managed as above. 
No routine MRSA screening should be undertaken


Specific Guidance for Residents with Clostridium difficile 

What is Clostridium difficile?  
Clostridium difficile is a bacterium of the intestine, which can be found in both healthy 
and ill people. There are millions of different types of bacteria in the body which are 
important for health. These protective bacteria help to break down and digest food and 
also help to ward off many harmful or foreign bacteria. In a healthy person all the 
bacteria live in a state of balance with one another.  
What is Clostridium difficile colitis?  
When there is an imbalance of bacteria and Clostridium difficile takes over, it 
produces two toxins that affect the body and give the symptoms of the disease. The 
symptoms may include diarrhoea and cramping pain at first, and, in the later stages, 
flu-like symptoms, nausea, vomiting and blood in the stool/faeces. 
How is Clostridium difficile
 colitis diagnosed?  
The disease is suspected if a person has been taking, or is currently taking, antibiotics 
and is suffering with abdominal cramps and diarrhoea. A diagnosis is made by a 
laboratory test using a stool sample to confirm whether or not the toxin is present in 
the intestine. The results are usually available within 24 hours. Some patients may 
have Clostridium difficile in their stool but without the symptoms of diarrhoea.  It is 
unlikely that they have Clostridium difficile colitis.  
Hospital Transfer
•  Symptomatic patients (with diarrhoea) should not be accepted from Acute 
hospitals. Ideally they should be 48 hours free from symptoms. Seek advice 
from an EHPU nurse 
•  Patient should be isolated in their own room for a further 48 hours until bowel 
habit is established – if diarrhoea returns inform the doctors. The patient must 
remain in isolation until 48 hours free from symptoms, and normal bowel action 
has been established 

•  Faecal samples are not required for clearance 
•  If symptoms persist, seek advice from GP – further antibiotic treatment may be 
Newly diagnosed cases 
• Isolate 
•  On lab confirmation of a case of Clostridium difficile inform the GP – if the 
patient is still symptomatic commence antibiotics 
•  Ensure completion of antibiotics 
•  If symptoms cease – no further treatment is required. Once diarrhoeal 
symptoms have ceased for 48 hours the room and toilet facilities should be 
thoroughly cleaned using the guidance in ‘ Specific Guidance for Outbreaks 
of Diarrhoea and/or Vomiting’  

•  If symptoms persist, seek advice from GP. 



Prevention and Control of Headlice in the Community 
These guidelines are written to enable healthcare staff and staff working in schools, 
nurseries, pharmacies and care homes to promote a co-ordinated approach to the 
prevention and treatment of headlice.   
Headlice are found on adults and children. They are transferred from person to person 
wherever head-to-head contact occurs.  This is generally at social gatherings or within 
a household environment. 
Parent/carer are encouraged to check their child’s head regularly, and to treat when 
headlice are found.  The School Health Advisor, Health Visitor, Practice Nurse, 
Pharmacist or GP should offer advice and assistance to parents/carers when required.  
Information on headlice can be found on the HPA website. 
Some Facts about Headlice and Nits (Pediculus humanus 

Headlice can be more efficiently found by combing through (preferably wet) hair with a 
detection comb. Divide the hair into sections and hold the comb at angle of 450.  If lice 
are found, that person should be treated. Weekly combing to detect headlice is 
advised for households with primary age children. 
When one member of the household has been found to have headlice, all other 
members of the household must be carefully checked using the detection comb. 
Headlice lotions (or shampoos) should not be used as a preventative measure. 
Treatment - for when Lice are Found 
Only treat those with a proven headlice infection. 

There are three options for the treatment of headlice: 
1. Wet 
This method does require perseverance but some parents may find it more preferable 
than using a chemical product on their child’s head.  However, if this treatment 
appears to continually fail, treatment with insecticides may still be required. 
Wash the hair in the normal way with an ordinary shampoo 
Make sure the teeth of the comb slot into the hair at the roots with every 
stroke.  This should be done over a pale surface, such as a paper towel 
or the bath 
Clear the comb of lice between each stroke 
Wet lice find it difficult to escape, so removal with the comb is easier 
This routine should be repeated every day for 2 weeks, so that any lice 
emerging from the eggs are removed before they can mature, mate and 
lay more eggs. 
Insecticides (pesticides) 
There are three chemical insecticides available. However, there is evidence that some 
headlice have become resistant to particular insecticides. This may lead to problems 
of eradicating headlice from an individual's head. 
Insecticides should ONLY be used if live lice are found. 
The insecticides are Malathion, Pyrethroids (Phenothrin and Permethrin) and 
Carbaryl. Carbaryl can only be prescribed by a healthcare professional (e.g. GP and 
some nurses), the other two chemicals can be purchased from a pharmacy. 
All products must be used according to manufacturer’s guidance.  Insecticides are not 
effective on eggs therefore a second application is required a week later to kill the 
newly hatched lice. Fine comb the hair every 3-4 days between applications and for at 
least a further 2 weeks after the final application is recommended 
Insecticides are available in alcohol and aqueous-based preparations. Individuals that 
suffer from asthma, eczema etc should avoid alcohol based products.  Please check 
the suitability of the product with the pharmacist. 
Babies under the age of 6 months should only be treated under medical supervision. 
Insecticides must not be used more than once a week, and not for more than 3 
consecutive weeks. 
Chlorine may weaken the effect of insecticides. It is recommended that if the person 
has been swimming in a chlorinated pool in the 72 hours before treatment, their hair 

should be washed and dried before the lotion is applied.  The patient should not swim 
in a chlorinated pool for 48 hours after application.   
There is no reason to keep children away from school. 
Non-pesticide Lotion 
Non pesticide lotion – Dimeticone compound (proprietary name Hedrin)- coats 
headlice and smothers them. There is no resistance to this lotion. However careful 
application is required for effective killing of the lice.  It is important to follow the 
instructions on the pack, ensuring that the lotion is applied evenly and is combed 
throughout the length of the hair. 
Two applications, one week apart, is required to kill hatching lice. To check 
effectiveness use a detector comb 24 hours after the second treatment. Further 
applications can be used if headlice remain present after the 2nd course of treatment. 
Contact Tracing 
Contact tracing is an important part of the control of headlice infestation. 
Contacts will be other individuals who have had head-to-head contact lasting 
approximately one minute or more in the past month.  
These social contacts outside of the household may include grandparents, friends 
from playgroup, school and other social groups. 
A contact list should be formulated by each person with headlice.  This list will be fairly 
short. Every person on the list should then be told that they have been in contact with 
a person who has had headlice and that they should have their own hair checked
Alternative Therapies - Aromatherapy/Essential Oils 

Many products are now available on the market.  Advice from the Insect Research 
Centre is that these products should not be recommended as a method of treatment 
and/or prevention of headlice as: 
There is no scientific evidence to support its effectiveness against headlice 
Misuse in the application of such oils can easily occur and there have been 
reports of children acquiring superficial burns as a result of oils not being 
correctly diluted 
Some of the oils used in “headlice preparations” may aggravate medical 
conditions, for example eucalyptus oil should be avoided by people who suffer 
from epilepsy and asthma.  To date no such warnings have appeared on these 

It is the physical act of combing that actually removes lice from the hair. 

Non-Compliant Public 
In the event of an individual failing to treat themselves or their child, a multi-
disciplinary approach may be required.  The attached checklist can be used to assist. 

The aim of the checklist is to guide you through the process and to aid documentation. 
It is not intended that details of all potential and actual cases of headlice should 
be documented in the checklist format. 
It is anticipated that the checklist will rarely need to be completed.  It will act as an 
aide-memoire to assist health and education professionals to direct the individual to 
the most appropriate place for assistance e.g. if the parent did not receive an 
information leaflet any professional could photocopy one for them and ensure they 
understand what they need to do. 
Any health or education professional can start using the checklist as the basis for their 
documentation, and it can be passed on to the next professional group as an onward 
referral is made. 

Comb wet hair using 
a fine-toothed detector comb 
at least once a week 

eck family and
If NO liv
e lice 
for headlice 
Treatment Option One: 

Treatment Option Two/Three: 

Wash the hair in the normal way with an 
•  Check with your pharmacist, GP or School 
ordinary shampoo 
Nurse which preparations are 

While the hair is very wet, comb through 
•  Follow the manufacturer’s instructions 
the hair from the roots with a fine-
toothed comb 
Make sure the teeth of the comb slot 
•  After treatment and whilst the hair is still 
into the hair at the roots with every 
wet, a fine-toothed comb may be used to 
remove dead lice 
This should be done over a pale surface, 
•  It could take up to 24 hours for lice to die, 
such as a paper towel or the bath 
so do not assume the treatment has not 

Repeat this routine every day for two 
•  To ensure treatment has been successful, 
weeks, so that any lice emerging from 
detection combing on wet hair should be 
the eggs are removed they can be 
carried out on all treated persons three 
times over the next seven days 
•  REPEAT treatment on the SEVENTH DAY 
whether or not lice are found 
•  Small lice means that the eggs were not 
affected by the first treatment.  A repeat 
treatment will kill the baby lice before they 
can lay more eggs 

•  Large lice means that the head has been re-
infested – so contact tracing and the 
treatment cycle will have to be restarted 

Comb wet hair using a  

FOUND: fine-toothed comb at least 
Check family and friends 
Use Treatment  

ACTION: Repeat treatments 
If treatment Option 1   
If treatment Option 2   
If treatment Option 3 
used previously, use   
used previously, use   
used previously, use 
Treatment Option 2 or 3 
Treatment Option 1 or 3 
Treatment Option 3  


Name of child: 
Did parent receive the headlice information leaflet?  
Has child attended child targeted education programme? 
If attended, did parent also attend? 
Has parent attended a parents meeting? 
If parent is having persistent problems check the following: 
•  do they have instructions? 
•  do they understand the instructions?  
•  have they followed the instructions? 
•  have they done any contact tracing? 
•  have they approached their identified contacts? 
•  has the school consulted the LEA? 
Do they require further intervention from the school nurse? 
Name of school 
If a parent expresses concerns of another family’s failure to control headlice, check the 

•  are you already aware of persistent problems? 
•  is the school nurse already involved? 
Name of school nurse: 
Has the school approached the relevant family to confirm other parents 
Has a date been set with school nurse and family to meet? 

taken: Telephone   Home visit       
Have other agencies been involved? 
Has a referral been made to social services if there is a suspicion of greater 
‘social’ problems? 
Name of social 
services worker: 
Has problem been reported to LEA? 

Prevention and Control of Scabies in the Community 

Scabies is an allergic response to an infestation of the skin by the mite Sarcoptes 
.  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 (Norwegian Scabies).  
Scabies is distributed worldwide 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.  There may be no sign of infection for 2-6 weeks after 
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 textbooks 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 (Norwegian 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 with prolonged 
contact.  The likelihood of transmission increases with the duration and frequency of 
skin to skin contact. 
Fomites and animals are not implicated in transmission. 
The incubation period is 2–6 weeks before onset of symptoms in those infected for the 
first time. Symptoms may occur 1–4 days after re-exposure. 

Outbreaks occur particularly in residential/nursing homes, mental healthcare 
establishments, long-stay hospital wards and pre-school nurseries. 
Advice will be given on the need to treat and the treatment programme by the EHPU. 
Treatment in a Residential Establishment (Care Home) (Intermediate Care) 
When a single suspected case of Scabies occurs in a residential establishment the 
EHPU (or Infection Control Team if the residential setting is owned by the PCT) 
should be alerted promptly to investigate.  It may be necessary to treat all residents 
and anyone with whom they have had close contact. 
If this action is required, it is important that all staff who have come into direct contact 
with residents also treat themselves because they may be incubating the disease 
without showing any symptoms.  Family members of symptomatic staff will require 
one application of treatment.  If family members are symptomatic they will require 2 
applications of treatment.  Family members of asymptomatic staff need not be treated 
routinely but asked to report any later symptoms. 
As far as possible all staff members should receive the treatment on the same day 
that their unit is treated.  Staff should not work in any other area until treatments have 
been completed throughout the home. 
Symptomatic people should be treated using 2 applications of insecticidal cream at 7-
day intervals.  The EHPU will make an individual assessment and advice. 
Following Treatment 

It is not uncommon for a person to have itching for up to 4 weeks after successful 
treatment.  Antihistamines may be helpful.  In residents with dry skin conditions 
emollient cream will moisturise the skin. 
Treatment in a Household 

Scabies is easily treated but the treatment must be done thoroughly and 
conscientiously otherwise failure will occur. 
Symptomatic cases in the community should be treated using 2 applications of 
scabicidal cream at 7-day intervals.  Their asymptomatic household contacts 
should be given a single course of treatment at the same time as the index case’s 
initial application of cream. 
People should be regarded as infectious until one application of scabicidal cream has 
been applied. 
Once treatment has commenced the person cannot transmit the mite. 
Children need not be excluded from school or nursery having commenced treatment. 

Infected staff do not need to be excluded from work. 
If Scabies is left untreated for a long period of time it can have an immunodepressive 
effect and cause a more severe form to develop. 
Treatment of babies, young children under 2 years and pregnant women 
should be supervised by a GP.  The recommended treatment is Lyclear 
dermal cream for which there are no contraindications in these groups. 


Lyclear dermal cream is suitable for use by adults, including the elderly and children 
over 2 months old.  Children between 2 months and 2 years should be treated under 
medical supervision.  Pregnant women should seek medical advice. 
Ensure that the entire surface of the body is covered from the hairline on the 
head to the soles of the feet.  This should include the area behind the ears 
and the face, avoiding the area around the eyes, otherwise the treatment 
may not
 be effective.  If the person to be treated has little or no hair the scalp 
should also be included 
Areas of skin normally covered by extensive dressings should be exposed, and 
Lyclear cream applied onto the intact skin up to and around the wound.  The 
dressing may then be replaced 
Apply the cream to clean, dry and cool skin.  Do not apply following a bath or 
Pay particular attention to the areas behind the ears, between the fingers and 
toes, wrists, under the arms, external genitalia, buttocks and under finger and 
toe nails 
The whole body should be washed thoroughly 8 - 12 hours after treatment, with 
warm water 
Be sure to reapply any lotion washed off during the treatment period e.g. after 
handwashing, or cleaning of the skin 
Directly after treatment, change bed linen and wear freshly laundered clothes 
Lyclear Dermal Cream disappears when rubbed gently into the skin.  It is not 
necessary to apply the cream until it remains detectable on the surface 
Where possible, the cream is best applied by someone other than the person 
receiving treatment.  This makes it easier to get to difficult to reach parts of the 

It may be necessary to prescribe two tubes of cream to ensure all areas of the body 
are covered thoroughly bearing in mind very dry areas of skin will absorb more of the 
The following table shows the approximate amount of cream to be used as a single 
Adults and children over 12 years 
1 tube, but large people may 
require up to 2 tubes but no more 
than 2 tubes 
Children aged 5 to 12 years 
Up to half a tube 
Children aged 1 to 5 years 
Up to one quarter of a tube 
Children aged 2 months to 1 year 
Up to one eighth of a tube 
Following discussions with the Medical Entomology in Cambridge, it is 
now recommended to apply scabicidal lotions/creams to the face 
avoiding the area around the eyes. 

This may conflict with some manufacturers’ guidance.  However, there is 
increasing evidence that scabies may also affect the face and failure to 
treat this area could result in an incomplete and therefore unsuccessful 

Benzyl Benzoate has been shown to have reduced effectivity compared to 
other scabicides.  BNF caution that it is an irritant to skin therefore not 
recommended for elderly and sensitive skins. 


Single case of scabies reported to EHPU 
EHPU will liaise with you and the home to confirm diagnosis, establish whether others are 
affected, liaise with all relevant GPs regarding treatment 
2 or more symptomatic cases in a home 
Symptomatic Resident / Staff
Non-symptomatic Resident / Staff
Treat with scabicidal& repeat in 7 days
Treat with scabicidal 
Treat with Scabicidal, if contacts are 
Follow the same instructions for staff 
repeat in 7 days 
Action for Essex Health Protection Unit 

     - Arrange staff education sessions on treatment and 

Inform residents’ GPs and request treatments 
  - Provide 
- Inform 
     - Establish surveillance procedure post mass treatment 

Name of Home:    ______________________  
Record started by: ___________________ 
Date:  ________________  

Reported to:   EHPU/EHO/CSCI/PCT 

Total number of residents in home: _________ 

Total number of residents affected: _________ 
Name of Resident 
DOB  Area/Unit 
Diagnosed  by 
Treatment Date 
where resident  Symptoms 
         GP                  EHPU 
            1st                     2nd  



Name of Home:    ______________________  
Record started by: ___________________ 

Reported to:   EHPU/EHO/CSCI/PCT 

Total number of members of staff in home: _________ 

Total number of members of staff affected: _________ 
Name of Staff 
DOB Area/Unit 
Diagnosed  by 
Treatment Date 
where resident  Symptoms 
         GP                  EHPU 
            1st                     2nd  




The Clinical Practices included in the section are
• Aseptic 
Care of Patients with known Infectious Disease - Source Isolation (Barrier 
• Decontamination 
• Enteral 
• Intravenous 
• Laundry 
Management of Non-Infectious and Infectious Deceased Clients 
Guidelines for Community Sector Performing Minor Surgery 
Prevention and Control of Infection Associated with Urinary Catheter Care 
Safe Handling of Specimens 
• Vaccine 
• Waste 

1. Aseptic 
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 the patient to staff or other 
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 (this list is not exhaustive): 
• Dressing 
•  Removal of sutures or clips 
•  Dressing peripheral or centrally sited intravenous lines 
•  Removal of drains 
• Endotracheal 
•  Dressing tracheostomy site. 
However the procedure is undertaken either with forceps or sterile gloved hands. The 
important principles are that the susceptible site should not come into contact with any 
item that is not sterile. 
Any items that have been in contact with the wound will be contaminated and should 
be disposed of safely, or decontaminated. 
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 and hot water, and then dried to ensure that pathogens are 
This process should be undertaken after each separate patient episode. 
Wound Swabbing 
Swabbing should only be undertaken if wound/site of invasive device exhibits signs of 
infection. They should not be taken routinely, or if wound/site is healing. 

Care of Patients with known Infectious Diseases –  
Source Isolation (Barrier Nursing) 
In Residential Settings 
Within the home setting, traditional barrier nursing is not often recommended.  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. 
More detailed information about diseases can be found in the relevant Section of 
these guidelines, and on the HPA website 
The following communicable diseases may require isolation nursing precautions to be 
Infectious until: 
Group A 
(a) Clearance of organism is demonstrated 
(b) 24 hours after the start of appropriate  
      antibiotic therapy 
Infectious until vesicles are dry (usually about 5 days) 
Clostridium difficile 
Infectious until diarrhoea has ceased for 48 hours 
Infectious until symptom free for 48 hours 
Hepatitis A 
Infectious until 7 days after the onset of jaundice 
Hepatitis B + C 
Blood and body fluids should be assumed to be infectious 
As above – Hepatitis B and C 

Infectious until: 
a) lesions are crusted or healed 
b) however infectivity will be reduced following 24 hours of         
appropriate antibiotics 
Infectious for 24 hours after start of appropriate antibiotic 
Infectious for 9 days after onset of swelling in salivary glands 
Infectious for 4 days from onset of rash.  Non-immune 
pregnant staff should not nurse these patients 
Infectious until one application of a scabicidal treatment has 
been completed 
Infectious until diarrhoea has ceased for 48 hours 
Infectious to a person who has not had chickenpox by direct 
contact with vesicles.  The contact will develop chickenpox 
Pulmonary Tuberculosis  
Infectious until the first two weeks of appropriate antibiotic 
therapy have been given. The infectious period may be 
prolonged for Multi-Drug Resistant TB (MDRTB) 
Precautions should also be taken with residents suffering from the following symptoms 
until a diagnosis is confirmed: 
Diarrhoea of unexplained origin 
Temperature of unknown origin 
Excessive bleeding 
Rashes of unknown aetiology 
Excessive vomiting. 

Standard Principles of Infection Control should be strictly adhered to at all 
times (Refer to Section C) 

Once a diagnosis has been made, the patient (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 handrub 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 hazardous 
waste (Refer to Waste Management Section I – 12). 
Urinals and Bedpans 
Automated washer/disinfectors are recommended, but are unlikely to be available in 
private individuals' homes.  
In which case the following procedure should be followed: 
The contents should be emptied down the toilet and flushed away.  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 
GPD and hot water prior to disinfection with a sodium hypochlorite solution (strength 
1,000 p.p.m. (1 part household bleach to 100 parts water) and left for 10 minutes).  
The bedpan/urinal should be dried and stored inverted. 
Should be washed on as hot a wash as the fabric will tolerate, as promptly as 
Crockery and Cutlery 
Disposable items are not required.  GPD and water as hot as can be tolerated is 
sufficient, to be washed in the usual kitchen sink or dishwasher. 
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. Ambulance control should be unformed when booking transport. 

Deceased Clients 
Standard Principles of Infection Control should be maintained when a patient dies. 
Body bags are not necessary in most cases (only used in highly infectious cases i.e. 
Viral Haemorrhagic Fever). However if there is excessive risk of body fluids from the 
body, body bags should be used. 
Body bags are available from the stores centre from where all other care equipment is 
The mortuary/funeral director staff should be informed of the potential infectious risk. 
For Community Hospitals and Intermediate Care Units 
Barrier nursing is the term used to describe the methods used in the inpatient setting, 
to minimise the risk of transmission of a potential pathogen from one patient to 
Barrier Nursing - Practice 
The main diseases requiring isolation are diarrhoeal infections and untreated 
pulmonary tuberculosis.  The Infection Control Team may also advise that patients 
identified as having an infection caused by any antibiotic resistant organism are 
barrier nursed (see management of patients with MRSA).  
The patient requiring barrier nursing should be accommodated in a single room 
equipped with a handwash basin and, ideally, a separate en-suite cloakroom or 
shower room facility.  If en-suite facilities are not available, precautions must be taken 
to prevent contact between patients using the ward facilities, and to ensure that 
shared facilities are appropriately cleaned and disinfected between uses. 
The isolation room must not contain unnecessary furniture, and all surfaces must be 
easily cleaned. 
The door of the room must be kept closed at all times. 
The possibility of adverse psychological effects of isolation on the patient must be 
considered and addressed within the Care Plan. 
Standard Principles of Infection Control should be adhered to at all 
times (Refer to Section C). 
Once a diagnosis has been made, the patient (and family) must have their infectious 
disease carefully explained, the mode of spread and its significance if any, for the 
patient’s condition. 
Personal Protective Equipment (PPE) 
A risk assessment must be made for each patient contact episode in order that the 
correct protective clothing is worn.  If the staff member is not planning to have any 
direct contact with the patient or the immediate surroundings, protective clothing may 
not need to be worn. 

Supplies of disposable gloves, aprons and masks (if necessary) should be accessible 
outside the isolation room and donned prior to entering the room.  Hands must be 
sanitised prior to the wearing of protective clothing. 
Hand Hygiene 
Alcohol handrub 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 and protective clothing should be 
disposed of as infectious hazardous waste.  The orange bag must be situated inside 
the isolation room, and hands must always be washed inside the room after protective 
clothing is removed.  Hands should also be sanitised immediately after leaving the 
Medical Equipment 
Disposable equipment should be used whenever possible.  Non-disposable equipment 
such as sphygmomanometers, stethoscopes etc. should remain in the room and be 
terminally cleaned once the patient is discharged. 
Urinals and Bedpans 
Contents should be emptied down the toilet and flushed away.  In the community 
hospital setting an automated process achieving a temperature of at least 80oC for 1 
minute should be used for the decontamination of these items.  A service contract for 
these machines must be in place, and provision made for the prompt replacement or 
repair in the event of malfunction. 
If the automated system is temporarily unavailable the following process may be used: 
•  Care should be taken when cleaning the urinal or bedpan to avoid splashing. 
•  A plastic apron, and face protection should be worn 
•  The item should be cleaned with General Purpose Detergent (GPD) and hot 
water prior to disinfection with a sodium hypochlorite solution (strength 10,000 
p.p.m. (1 part household bleach to 10 parts water) and left for 10 minutes). 
•  The bedpan/urinal should be dried and stored inverted. 
Should be segregated into dissolvable laundry bags thereby minimising any risk to 
portering or laundry staff. 
Crockery and Cutlery 
Disposable items are not required.  A dishwasher capable of achieving a temperature 
of at least 80oC for at least 1 minute should be used.  A service contract for these 
machines must be in place, and provision made for the prompt replacement or repair 
of the machine in the event of malfunction.  

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. 
Daily Cleaning of Isolation Rooms 
All rooms must be cleaned at least daily using freshly prepared GPD solution.  
Horizontal surfaces should be kept dust free and any spillages cleaned immediately.  
Isolation rooms should be cleaned after the other areas of the ward and all equipment 
such as cloths and mops should be disposable or laundered after each use. 
Terminal Cleaning of Isolation Rooms 
Disinfection is not generally required although the Infection Control Team for specific 
situations may recommend it. 
It is unnecessary to wash walls and ceilings unless they are visibly contaminated. 
All horizontal surfaces and equipment inside the room, including bedframes, 
mattresses, other furniture and equipment, must be cleaned using disposable cloths 
and freshly prepared GPD solution. All items and surfaces must then be dried.  
Equipment, which is to be returned to a central equipment store, must be returned 
promptly and accompanied by a decontamination notice. 
Please contact the Infection Control Team if further advice is required. 

3. Decontamination 
Although primary care minor surgery has a low incidence of complication, it is 
important that practices providing minor surgery operate to the highest possible 
Practices should be aware of current documents and legislation pertaining to design 
and build of facilities for surgery and decontamination of equipment. 
Key features of Hospital Building note 13 (see below) should be used in any primary 
care centres. 
Washroom must be segregated from the clean area, with a pass-through 
Automatic washer/disinfector, which complies with HTM 2030 and is fully 
validated, is desirable 
Dedicated handwash basin 
Clean area for packing/sterilising, with a controlled environment 
All staff involved in decontamination trained and training records kept 
Tracking and traceability systems implemented that are suitable for the level 
of procedures being undertaken, i.e. for invasive procedures, details of 
specific cycles on washer/disinfector and sterilisers must be kept  
Ongoing costs of maintaining a compliant decontamination service 
To fully comply with the National Decontamination Strategy, a ‘mini’ Sterile 
Services Department within the premises is to be used. All decontamination 
must be done away from the patient treatment areas. 
The aim of decontaminating equipment is to prevent potentially pathogenic organisms 
reaching a susceptible host in sufficient numbers to cause infection. 
Items that are classified as single-use only must never be re-used.  If in doubt, refer to 
the manufacturer’s recommendations. 
After use these items should be disposed of as clinical waste. Where there is a choice 
of single-use or re-usable items, the single-use item is recommended. The single-use 
logo is usually displayed on the item. 
Guidance from the NHS Estates and Medical and Healthcare Products Regulatory 
Agency (MHRA) strongly recommends that surgical instruments are single-use, or if 
reusable that decontamination takes place in a Sterile Services Department (SSD). 
The Consumer Protection Act (1987) (6), in particular ‘product liability’, has 
implications for the reprocessing of devices used in patient care. 

Re-usable equipment should be appropriately decontaminated between each patient 
using a risk assessment model.  Use only the 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.  If you have any doubts 
about the manufacturer’s recommendations, seek further advice. 
The Medical and Healthcare Products Regulatory Agency (MHRA) defines the 
following terms: 
Cleaning ‘is a process which physically removes contamination but does not 
necessarily destroy microorganisms’.  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 
Cleaning is an essential prerequisite of equipment decontamination to ensure 
effective disinfection or sterilisation can subsequently be carried out 
Disinfection ‘is a process used to reduce the number of viable 
microorganisms, 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’. 
HTM 2030 and HTM 2010 are to be replaced by HTM 01-01 Decontamination of 
Reusable Medical Devices, Part A, and Part B 2007-08. 
Risk Assessment 
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 skin or mucous membranes, are classified as high-risk and 
must be sterile before use. 
Some high-risk devices cannot tolerate high temperatures, and must either be single-
use or disinfected between each use - for example fibre-optic endoscopes. It is 
recommended that items used in the vagina or cervix must be single-use.  (Vaginal 
speculae – MHRA recommend single-use disposable.)  If reusable items are used 
sterilise between each use. 

Classification of Infection Risk Associated with the Decontamination of Medical 

Application of Item 
Minimum Standard 

•  In close contact with broken skin or 
Cleaning followed by sterlisation 
broken skin or broken mucous 
•  Introduced into sterile body areas 
Medium  •  In contact with mucous membranes 
Cleaning followed by sterilisation 
•  Contaminated with particularly virulent 
or disinfection 
or readily transmissible organisms 
NB: Where sterlisation will 
•  Before use on immunocompromised 
damage equipment, cleaning 
followed by high level disinfection 
may be used as an alternative 
•  In contact with healthy skin 
•  Not in contact with patient 
MHRA DB2006 (05) November 2006 
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 vCJD. 
Mechanical cleaning using a washer/disinfector is recommended as the process can 
be validated, and records kept. Certain items may also require additional cleaning in 
an ultrasonic bath. 
Thorough cleaning with detergent and warm water - maximum temperature 350C - will 
remove many microorganisms.  Hot water should not be used as it will coagulate 
protein making it more difficult to remove from the equipment. 
Manual cleaning is not advised.  Mechanical cleaning reduces the risk of infection to 
the healthcare worker. 
Washer Disinfectors 
Guidance from HTM 2030 should be followed: 
Use a detergent solution as recommended by manufacturer 
Operate and load as recommended by manufacturer 
Inspect instruments for residual debris after cleaning, and repeat process if 

Ensure daily, weekly, quarterly and annul testing is undertaken and results 
recorded and retained. 
Most instruments will be cleaned in the washer/disinfector, however there may be a 
few devices that are complex in design or excessively soiled that may require 
additional cleaning in an ultrasonic cleaning bath. 
Ultrasonic cleaning baths: 
Use a detergent enzymatic solution as recommended by the manufacturer 
Empty at least twice daily before the solution becomes heavily contaminated 
depending on work load 
Empty, clean and dry at the end of the session/day 
Staff must record the results of periodic testing in accordance with HTM2030 
and manufacturer’s instructions 
Service frequently - include checking the power output of the transducer 
Inspect instruments for residual debris after cleaning, and repeat if necessary 
Document all servicing and repairs. 

Compatibility of all materials and items to be processed should be 
established by reference to the manufacturer’s instructions.   



Disinfection methods apply to handwashing, skin preparation and 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 
•  wide range of 
• inactivated by 
•  can be used on 
organic matter 
surfaces and for 
(e.g. Domestos, 
•  corrosive to metals 
body fluid spills 
sporicidal and 
• diluted solutions 
NB Undiluted 
fungicidal activity 
can be unstable 
• rapid action 
•  needs to be freshly 
hypochlorite contains 
•  non-toxic in low 
approx. 100,000ppm 
•  does not penetrate 
available chlorine 
•  can be used in 
organic matter 
food preparation 
• bleaches fabrics 
• cheap 
• need ventilation 
• slightly more 
• as above 
• as above 
resistant to 
inactivation by 
e.g. Presept, Haz-Tab, 
organic matter 
• slightly less 
• more convenient 
• long shelf-life 
Alcohol 70% 
• good bactericidal,  • non-sporicidal 
•  can be used on 
e.g. isopropanol 
fungicidal and 
• flammable 
surfaces, or for 
virucidal activity 
•  does not penetrate 
skin and hand 
• rapid action 
organic matter 
• leaves surfaces  • requires 
evaporation time 
• non-corrosive 
•  most useful as 
•   limited activity 
•  For skin and 
e.g. hibiscrub, 
disinfectants for 
against viruses 
chlorhexidine wound 
•  no activity against   decontamination 
cleaning sachets 
• good fungicidal 
bacterial spores 
• inactivated by 
•  low toxicity and 
organic matter 


You can obtain sterile instruments 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 
Using a sterile supplies department (SSD) 
SSDs may provide a cost-effective and efficient service.  There should be a 
contract specifying the responsibilities of both parties.  Since June 1998 SSDs 
have been bound by the Medical Devices Directive 93/42/EEC, which requires 
the department to have a quality system of audit and to have been assessed 
and validated as CE compliant.  The PCT or GP practice should seek legal and 
risk management advice if the contracted SSD has not been assessed as being 
CE compliant 
•  Clinics may sterilise their own equipment using a benchtop steam 
steriliser/ vacuum steam steriliser 
Increasingly healthcare providers are required to comply with a number of 
quality assurance standards, outlined in the following pages of this document. 
Sterilisation of Instruments – Responsibilities 
If sterilisation is to be carried out, then management and other personnel are required 
to ensure that the sterilisers are operated safely and effectively and in compliance with 
legislation and standards. This is dependent on training and a sound general 
knowledge of the principles of sterilisation
The key responsibilities of management can be summarised as follows: 
•  To ensure that sterilisation is carried out in compliance with the law and with 
the policy of the UK health departments 
•  To ensure all personnel connected with sterilisation, including any contractors, 
are suitably qualified and trained for their responsibilities 
•  To ensure that purchased sterilisers conform to legal requirements, the 
minimum specifications set out in British and European standards and any 
additional requirements of the UK health departments 
•  To ensure that sterilisers are installed correctly and safely with regard to proper 
functioning, safety of personnel and environmental protection 
•  To ensure that newly installed sterilisers are subject to a documented scheme 
of validation comprising installation checks and tests, commissioning and 
performance qualification tests before they are put into service 

•  To ensure that sterilisers are subject to a documented scheme of prevention 
•  To ensure that sterilisers are subject to a documented scheme of periodic tests 
at yearly, quarterly, weekly and daily intervals 
•  To ensure that procedures for production, quality control and safe working are 
documented and adhered to in the light of statutory requirements and accepted 
best practice 
•  To ensure that procedures for dealing with malfunctions, accidents and 
dangerous occurrences are documented and adhered to 
•  To ensure that there is a procedure for the de-commissioning of unsafe units 
and removing from service. 
Installation and Validation 
HTM 2010 contains detailed DoH advice on installation, maintenance and operation. 
After installation the steriliser must be validated prior to use.  
Validation is a documented procedure for obtaining, recording and interpreting data 
required to show that a process will consistently comply with predetermined 
specifications. The process of validation consists of performance qualification. All 
records of the validation process should be retained by the owner for inspection. 
Following validation a schedule for periodic testing and planned preventative 
maintenance should be drawn up. 
Validation of the steriliser should be carried out by an appropriately qualified person. 
This will probably be the person who also conducts the required periodic testing and 
maintenance.  The manufacturer’s programme of planned maintenance should be 
used. If no manufacturer’s programme is available then advice should be sought from 
an appropriately qualified maintenance engineer. 
Periodic Testing of Benchtop High Temperature Steam Sterilisers 
Failure to carry out periodic tests and maintenance tasks could 
compromise safety and may have legal and insurance implications for the 
user or owner of the steriliser. 

Sterilisation is a process whose efficiency cannot be verified retrospectively by 
inspection or testing of the product.  Routine monitoring of the process, combined with 
periodic testing of the steriliser’s performance is therefore needed to give assurance 
that sterilising conditions are consistently being achieved. 
Appropriate training should be undertaken by staff undertaking testing of sterilisers.  
A daily, weekly, quarterly and yearly testing schedule is required. 
Each steriliser should have a log book in which details of maintenance, tests, faults 
and modifications are recorded. The log book should be stored in the same location 
as the steriliser, accessible for inspection. 

Daily Testing 
The owner/user is responsible for daily testing.  These tests are designed to show that 
the operating cycle functions are correctly shown by the values of the cycle variables 
indicated and recorded by the instruments fitted to the steriliser
Procedures for Daily Testing 

•  A normal cycle is operated with the chamber empty except for the usual chamber 
“furniture” (e.g. trays, shelves, etc.) 
•  A record should be made in the log book of the elapsed time and indicated 
temperature and pressure (the values shown on the dials or other visual displays 
fitted to the steriliser) at all significant points of the operating cycle – the beginning 
and end of each stage or sub-stage, and the maximum temperature and pressure 
values attained during the holding time 
•  If the steriliser is fitted with a temperature and pressure recorder, the printout 
should be compared with the records in the steriliser log book and retained for 
future inspection. 
•  The test can be considered satisfactory if all the following apply: 
o  A visual display of “cycle complete” is indicated 
o  The value of the cycle variables are within the limits established by the 
manufacturer as giving satisfactory results 
o  The steriliser hold time is not less than that specified in Table 1 
o  The temperatures during the hold time are within the appropriate 
temperature range specified in Table 1 
o  The door cannot be opened until the cycle is complete 
o  No mechanical or other anomaly is observed. 
•  If the steriliser is fitted with a temperature and pressure recorder, then during the 
plateau period: 
o  the indicated and recorded chamber temperatures are within the 
appropriate sterilisation temperature range 
o  the difference between the indicated and recorded temperatures does 
not exceed 2°C 
o  the difference between the indicated and recorded pressure does not 
exceed 0.1 bar. 

Table 1 
Sterilisation temperature ranges, holding times and pressure for 
sterilisers with high temperature steam 
Sterilisation Temperature  
Range (°C) 

B 127.5 
C 122.5 
Weekly Testing 
Examine the door seal, check security and performance of door safety devices 
Check that safety valves, or other pressure limiting devices are free to operate. 
Quarterly and Annual Checks 
These tests should be conducted by a suitably qualified person as they require the 
use of specialised equipment and will probably be conducted by the person who 
undertakes the maintenance. Guidance on these tests are contained in HTM 2010. 
Examples of log book pages, and daily, weekly test sheets are available in HAD 
(2002) Benchtop Steam Steriliser – Guidance Purchase, Operation & Maintenance 
MDA DB 2002 (6). 
These records should be kept for 11 years. 
In the event of a malfunction notify the engineer at once 
Technical Aspects and Safety Considerations 
Steam sterilisation is dependent on direct contact between the load material 
and saturated steam under pressure, at one of the temperatures shown in 
Table 1, in the absence of air. 
Benchtop steam sterilisers achieve the above conditions by electrically heating 
water (usually sterile water for irrigation, but manufacturers may recommend 
purified) within the chamber to produce steam at the required pressure and 
temperature, with air being passively displaced from the chamber by steam. 
During the sterilising cycle the steriliser door must prevent access to the 
chamber whilst it is under pressure.  The door should not be able to be opened 
until the “cycle complete” signal is indicated. 

Maintenance of Sterilisers 
Record sheet 
Unwrapped Instrument Steriliser 
Daily weekly record 
Week Commencing: 
Machine reference number: 
Warm up cycle completed? 
Daily test results 
Cycle counter number 
Cycle start time 
Time to attain temp 
Pressure gauge reading 
Temp. gauge reading 
Time at 134°C (min 3mins) 
Total Cycle time 
Initial of authorised user 
Note: in the event of a malfunction notify the engineer at once 

Use of Displacement Bench-Top Steam Autoclaves 
British Standard 3970 
Autoclaves vary in sophistication, and it is essential that the displacement bench-top 
steriliser is to an acceptable standard, such as British Standard 3970.  Autoclaves 
must comply with BS and EC standards.  Check with MHRA prior to purchase. 
Regular maintenance is advised to ensure the monitoring equipment is functioning 
correctly (refer to previous pages). 
Temperatures and Pressures 
Each autoclave should include temperature and pressure indicating equipment, a 
cycle stage indicator, and a fault and cycle complete indicator.  Temperatures and 
pressures achieved should be observed each time it is used, and documented at least 
once for each day that it is used (refer to previous pages).  Retain records for 11 
Protective Clothing 
The use of protective clothing is recommended when handling or dealing with blood 
and/ or body fluids.  As these instruments will have been contaminated with blood and 
body fluids, and whilst the action of cleaning such instruments may give rise to 
splashing with these fluids, disposable latex gloves, disposable aprons and eye 
protection should be worn
The physical cleaning of instruments is a pre-requisite to sterilisation, as this will 
ensure all surfaces are free of debris and able to be completely sterilised.  It is 
recommended that an automated washer-disinfector is used.  This process can be 
validated and prevents the need for manual cleaning of contaminated instruments. 
Scrubbing Brushes 
The use of an automated washer-disinfector will negate this process. 
Prior to sterilisation, items should be checked for both cleanliness and operation i.e. 
that forceps align, the handle grip is firm, joints move freely - but are not loose, 
instruments are not rusted, etc. 
Loading the Autoclave 
When loading instruments into the steriliser, ensure they are dry and not touching.  
Place bowls and receivers on edge and leave hinged instruments open.  Do not 
overload machine. 

Unwrapped Instruments 
It is advised to use a downward displacement steam autoclave, for use with 
unwrapped instruments. 
Lumen and Wrapped Instruments 
These items should be processed in a vacuum steriliser. 
If instruments are wrapped prior to sterilisation in the bench-top downward 
displacement steam autoclave, there is no guarantee that the instruments inside the 
wrapping will be sterilised. (Hollow-lumen items will not be effectively sterilised in 
a downward displacement autoclave.)  
Use of Instruments 
Instruments should be used immediately (up to 3 hours after the cycle is finished 
when the door remains shut) after sterilisation, as no adequate method exists to store 
and also maintain sterility when instruments have been sterilised unwrapped. 
For non-invasive procedures store instruments in a clean, dry and dust-free place, 
preferably a drawer or covered box. 
Training of personnel to use the equipment correctly is an essential part of ensuring a 
safe procedure.  No staff should be expected to use such equipment, or be involved in 
the sterilisation procedure unless a clear understanding is first ensured. 
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. 
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 duration of use is 
dependent upon undertaking a risk assessment of individual risk factors. 
The MDA (1995) guidance suggests that reprocessing and re-using such items may 
pose hazards for patients and staff, if the reprocessing method has not been 
validated.  Therefore re-use of single-use products is not advisable unless the 
outcomes have been taken into account.  The Consumer Protection Act 1987 will hold 
a person liable if a single-use item is reused against the manufacturer’s 

Ensure that manufacturers’ instructions are followed to obtain correct concentration of 

Babies feeding 
Use single-use pre-sterilised bottles and teats 
bottles and teats 
Baby changing 
Cover with paper towel and change between each baby.  
Clean at end of session or when the mat is soiled, with GPD 
and water, or GPD wipes 
To be cleaned between users.  With gloved hand, clean bath 
surface, grab rails and taps with hot water, GPD and paper 
towels, or GPD wipes.  Rinse 
Bath water 
Bath emollients should be added to the bath water.  Dome 
preparations can be applied to wet skin and rinsed off. Follow 
manufacturers' instructions 
Disposable pans are recommended and disposed off in a 
Macerator. Reusable Pans to be decontaminated in Washer 
Disinfector. Manual cleaning is not advised. 
Non-disposable bedpans in an individual’s own home - 
wearing disposable plastic apron and gloves, empty urine into 
the toilet, clean thoroughly using paper towels, hot water and 
GPD.  Rinse, dry and store inverted 
Beds, backrests, 
To be included in the regular cleaning regime, but to be 
bed cradles and 
cleaned between users with hot water and GPD, or GPD 
wipes.  If soiling is evident then immediately clean as above 
and then wipe over with chlorine-releasing compound 
To be cleaned after each use.  Clean surface of pan and taps 
with hot water and GPD, or GPD wipes, using disposable 
paper towels and gloved hand and then flush 
Bowls - patient 
Clean between each use with hot water and GPD, or GPD 
wipes, using disposal paper towels.  Rinse and store dry on 
the shelf of a cupboard 

If no soiling is evident, clean with hot water and GPD, and dry 
armrests and 
using paper disposable towels.  If soiling is evident, or there is 
an outbreak of diarrhoea, or the previous user had a loose 
stool, clean with hot water and GPD, or GPD wipes.  Wipe 
over with a chlorine-releasing compound (e.g. Presept, 
Chlortabs).  Use separate wipes for armrests and seats 
Dummies and 
Single-use advised. 
feeding equipment   
Infants  12 months and over  decontaminate in a dishwasher 
or wash in  water and detergent  
Under 12 months  decontaminate in a dishwasher or wash in 
water  and detergent followed by total immersion in a Milton 
(or similar ) solution  
Ear pieces from 
Single-use recommended.  
Clean thoroughly with GPD and hot water, using thin brushes 
to clean inside.  Rinse and dry thoroughly before storage 
Ear syringe 
Single-use disposable equipment is preferred. 
Propulse tips are single-use   
Stage 1 – Each day before use, the Propulse must be 
disinfected using a solution of Sodium Dichloroisocyanurate 
0.1% (NaDCC). This may be Presept, or similar, use 
according to manufacturer’s instructions to get a solution 
which provides 1,000 parts (NaDCC) per million (0.1%). 
Fill the water tank with NaDCC solution. 
Run the Propulse for a few seconds to allow the solution to fill 
the pump and flexible tubing 
ECG Equipment 
-  Electrodes 
Use disposable 
-  Leads 
Wipe well with hot water and GPD, or general-purpose     
-  Machine 
Wipe over with damp cloth, keep covered when not in 
          Follow manufacturers’ guidance 
Surface must be in intact and in good repair, clean with hot 
water and GPD, or general-purpose wipes, at start and finish 
of each session or if becomes soiled.  Cover with disposable 
paper roll and change between each client use. 
Family Planning 
All reusable items entering the vagina must be 
adequately decontaminated between use.  This can only 
be achieved by a heat method of sterilisation, not by 
disinfectant or boiling water. 
Vaginal specula 
Single-use recommended.  For re-usable, either return to 
CSSD, or pre-clean and sterilise in a downward replacement 

Trial size caps and  Single-use recommended.  Following Department of Health 
IUCD instruments 
instructions, all articles inserted into the vagina should be 
Hoists and slings 
Residents/patients  slings should be allocated to each 
individual, and kept at their side ready for use.  On discharge, 
or if the sling becomes soiled, the sling should be washed in 
an industrial washing machine on as hot a wash as the fabric 
will tolerate as per manufacturers guidance.  The slings 
should be dried and then stored in a designated area.  
Alternatively, single patient slings can be used and disposed 
of once the patient no longer requires it 
Nail brushes 
Single-use only 
Single patient use nebuliser and tubing recommended. 
Clients should have their own nebuliser units, which should 
be washed with hot water and GPD, or GPD wipes between 
use.  Store dry.  On completion of treatment, dispose of 
nebuliser.  Follower manufacturer’s instructions. 
Nebulisers which are used in the surgery or loaned to clients 
must be thoroughly decontaminated between patient uses. All 
tubing, mask, and filters should be disposed of after use, and 
replaced with new, disposable components before the item is 
used by another client.  
Staff must maintain a register of use (giving patient details 
and date of use) for each nebuliser including a record of the 
decontamination process detailing the date, time, cleaning 
method used, items replaced, and the signature and name of 
the member of staff responsible 
Clean with GPD wipe after each use 
Suction equipment  Disposable suction units are recommended. After each use 
(or 24 hours if in frequent use) the disposable components 
should be disposed of in the appropriate waste.(See waste 
Section I,12) 
Non-disposable bottles – recommend change to disposable. 
Tubing should be disposable. 
Filters - these should be replaced when wet and at 
appropriate intervals in keeping with the manufacturer’s 
Single-use recommended 

Trolleys (dressing 
Clean top and all surfaces with hot water and GPD, or GPD 
wipes daily.  Dry thoroughly.  If trolley becomes contaminated 
between patient use, wash with GPD and hot water again 
Soft toys should be washable via an industrial washing 
machine. Plastic toys to be washed in hot water and GPD.  
Wooden toys are not suitable 
Single-use recommended.  Non disposable urinals 
mechanically cleaned as described in bedpans. 
Non-disposable urinals an individual’s own home -wear 
disposable plastic apron and gloves, empty urine into the 
toilet, clean thoroughly using paper towels, hot water and 
GPD.  Rinse, dry and store inverted 
Urine jugs 
Single-use recommended.  
Reusable - Wearing gloves and apron, a separate clean jug 
should be used for each urine collection.  Empty the contents 
into the toilet and rinse.  Clean thoroughly with hot water and 
GPD using disposable paper towels.  Rinse and dry.  Store 
inverted. Allocate a jug per individual resident/patient 
Walking frames, 
Clean with GPD and hot water, or GPD wipes  and dry 
wheelchairs etc.  
In residential environment clean weekly , daily during 
outbreaks and immediately after contamination with body 
Weighing scales 
Line with disposable paper towel.  Wash bowl of scales with 
GPD and hot water, or GPD wipes if they become soiled 
before next baby is weighed and at the end of each clinic 
Work surfaces 
General Cleaning 
Use GPD and hot water, or GPD wipes. 
Contaminated Surfaces 
Clean with GPD and hot water, or GPD wipes, and then wipe 
with 1% sodium hypochlorite solution 
Environmental Cleaning 
The environment plays a relatively minor role in transmitting infection, but dust, dirt 
and liquid residues will increase the risk.  They should be kept to a minimum by 
regular cleaning and by good design features in buildings, fittings and fixtures.   
National initiatives such as The Health Act 2006, Essential steps to Safe Clean Care 
(2006), Towards cleaner hospitals and lower rates of infection (2004), and NHS 
Estates Healthcare Facilities Cleaning Manual (2004) all promote the importance of 
cleanliness in the healthcare environment, to assist in tackling the problem of 
healthcare acquired infections.  

•  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. All surfaces should be kept clear of unnecessary equipment or clutter to 
ensure regular and thorough cleaning can occur. The most important 
component of an effective cleaning programme is the regular removal of dust 
from all horizontal surfaces. 
•  GPD and water should be used for all environmental cleaning – follow the 
manufacturer’s instructions. Disinfectant such as a chlorine releasing solution, 
should only be used to decontaminate spills of body fluids, or for “terminal” 
cleaning of an area after a known case or outbreak of infection 
•  Carpets are not recommended in treatment rooms or areas where clinical 
procedures will take place because of the risk of body fluid spills. Where 
carpets are in place, should be cleaned with vacuum cleaner with filters daily  
or contracts for regular steam cleaning  and dealing with spills (suggested 
frequency of steam cleaning in waiting rooms yearly) 
•  Walls require spot cleaning to remove splashes/marks 
•  Difficult to reach/clean areas should have contracts arranged for regular 
planned preventive maintenance and cleaning e.g. behind radiator guards, 
fans, ventilation units/grills etc 
•  All cleaning equipment should be colour-coded for different areas of use, as per 
National colour-coding guide (see below). E.g. buckets, mop handles, aprons, 
gloves and disposable cloths etc.  
•  The water used for cleaning, in buckets, must be changed frequently and 
disposed in a sluice sink/hopper. Clean the mop handle and bucket after use. 
Dry and store bucket inverted.  
•  Mop heads should be removed after each use for laundering in a hot wash and 
then stored dry but if heavily soiled to be discarded.  Single-use mop heads 
should be used if industrial washing machine laundering facilities are not 
•  Single-use, non-shedding cloths or paper roll should be used for cleaning and 
•  Equipment and materials used for general cleaning should be kept separate 
from those used for dealing with body fluids. 
•  All equipment used for cleaning including vacuums and floor polishers should 
be clean and maintained properly 


Colour-Code for Hygiene 
Based on the Safer Practice Notice – Colour-coding hospital cleaning materials and 
equipment, published by the National Patient Safety Agency. 
1.   The aim of a colour-coding system is to prevent cross-contamination 
2.  It is vital that such a system forms part of any employee induction or continuous 
training programme 
3.  A minority of people are colour-blind in one or more colours. Some individuals 
may not know this and colour identification testing should form part of any 
induction training 
4.  Always use two colours within the washroom/sanitary area 
5.  The colour-coding system must relate to all cleaning equipment, cloths and 
Monitoring of the system and control of colour-coded disposable items against new 
stock release is extremely important. 

Bucket (plastic) 
Empty contents down toilet or slop hopper.  Wash with GPD and 
Launder 6 monthly or at once if visibly soiled or after an outbreak 
of infection as part of the terminal clean 
Disposable curtains are available and are recommended where 
a laundry service is not available 
Mop (wet) 
Disposable recommended.  Dispose after single task or for 
periods not exceeding three hours.  Reusable, heat disinfect in 
washing machine and dry thoroughly daily, or more frequently if 
necessary.  Store dry 
Mop (dry) 
Single-use covers – dispose of after use 
Lavatory brushes 
Rinse in flushing water and store dry 
Suggested colour - Red:    
toilet bathroom/sluice 
coding of cleaning 
General areas 
Green;           kitchen/pantry 
Yellow:         isolation 
Dust control - dry mop. 
Wet cleaning - wet mop, wash with hot water and GPD. 
If known contamination - follow with hypochlorite 1000 ppm  
Furniture and 
Damp dust with hot water and detergent. 
If known contamination - follow with hypochlorite 1000 ppm 
Lavatory seat and 
If soiling is evident, or there is an outbreak of diarrhoea, or the 
previous user had a loose stool, clean with hot water and GPD 
followed by chlorine-releasing compound (i.e. Presept, 
Chlortabs) 1000 ppm 
Should be clean and maintained.  Launder curtains 3 monthly.  
Shower heads should be de-scaled when necessary. 
If not in use – shower should be run for 5 mins weekly (potential 
Legionella risk) 
Walls and ceilings 
Not an infection problem.  When visibly soiled use hot water and 
detergent.  Splashes of blood, urine or known contaminated 
material should be cleaned promptly with hypochlorite solution of 
1:1000 ppm 


MHRA DB2006(05) 

4. Enteral 

Preparation and Storage of Feeds 
Effective hand hygiene must be carried out before starting feed preparation. 
Wherever possible pre-packed, 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 
to the enteral feeding tube. 
When decanting, reconstituting or diluting feeds, a clean working area should be 
prepared and equipment dedicated for enteral feed use only should be used. 
Where ready-to-use feeds are not available, feeds may be prepared in advance, 
stored in a refrigerator, and used within 24 hours. 
The system selected should require minimal handling to assemble, and be compatible 
with the patient’s enteral feeding tube. 
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.  
Administration of Feeds 
Minimal handling and an aseptic no-touch technique should be used to connect the 
administration system to the enteral feeding tube. 
Ready-to-use feeds may be given for a whole administration session, up to a 
maximum of 24 hours.  Reconstituted feeds should be administrated over a maximum 
4 hour period. 
Administration sets and feed containers are for single-use and must be discarded after 
each feeding session. 
In some areas, single patient use syringes are used to administer drugs. Check the 
packaging to ensure it is single patient use, and, if it is, follow the manufacturer’s 
instructions on decontamination between uses. 
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 fresh tap 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. 

5. Intravenous 
Community Control of Infection in Intravenous Therapy is of paramount importance.  
Catheter-related sepsis causes significant morbidity and mortality. 
The incidence of Central Venous catheter related infections is 4-20%.  Staphylococci 
is implicated in 50% of episodes.  Other micro-organisms include: 
Intravenous therapy may be accessed via a peripheral vein or a central line.  A central 
line catheter is inserted into the superior vena cava and is often tunnelled under the 
skin in the chest wall e.g. a ‘Hickman’ Line.  Another access point into a central line is 
through an entry port in the arm or chest wall e.g. Porta Cath, Peripherally inserted 
long lines. 
Different types of catheters are available, the correct type and insertion site is critical 
in reducing the risk of infection. Specialist advice must be sought and followed for 
each patient.  
These various devices may be left in situ for different lengths of time.  Individual 
instructions on care of specific lines can be obtained either from the healthcare 
premises that the patient attended, community nurses that specialise in intravenous 
therapy, or from the manufacturer. 
Intravenous Cannulation and Therapy 
Factors influencing development of sepsis include: 
Initial skin preparation 
Care of the insertion site 
Type of connector 
Skin microflora and type of dressing 
Care of entry port. 
Type of connector – use single-lumen catheter unless multiple ports are essential for 
the management of the patient.  When multi-lumen catheter is used, identify and 
designate one port to administer parental nutrition. 

Recognising Catheter Associated Infections 
 effects may occur at the insertion site or along the track of a tunnelled 
device.  These include: 
• Thrombophlebitis 
• Exudate 
Heat at site 
• Oedema 
• Pain 
• Irritation 
• Erythema. 
Systemic effects include: 
• Pyrexia 
White cell count elevated. 
Action To Take in the Event of an Infection Occurring 
Do not inject via the catheter or use the intravenous line 
Contact the Doctor in charge of the patient’s care – and follow his/her guidance 
Take swab for Microbiology culture and sensitivity 
May need blood cultures whilst still in-situ from: 
Peripheral Line 
Central Line 
Mid-stream specimen of urine (MSU), chest X-ray, throat swabs. 
Occurs when a cannula pulls out of a vein and the fluid accumulates around the 
cannula site in the surrounding tissues. 
Possible signs are: 
• Swelling 
• Discomfort 
• Burning 
• Pain. 

Ensure line is turned off 
Do not use intravenous line 
Inform Doctor in charge of the patient’s care 
Elevate the limb to promote venous drainage 
Monitor vital signs. 
General Principles for the Control of Infection in Central Lines 
Insertion - sterile procedure, it is recommended that this is performed in a 
theatre environment 
• Hand 
A clean procedure for all manipulations 
Wear appropriate gloves 
Keep handling to a minimum 
General principles for catheter management 
The injection port or catheter hub should be decontaminated using either alcohol or a 
non-alcoholic solution of chlorhexidine gluconate before and after it has been used to 
access the system.  Check with manufacturer for compatibility with catheter.  
Chlorhexidine 2% in 70% isopropyl alcohol is first choice of product.  
In-line filters should not be used routinely for infection prevention. 
Antibiotic lock solutions should not be used routinely to prevent catheter-related 
bloodstream infections (CRBSI). 
Preferably, a sterile 0.9% sodium chloride injection should be used to flush and lock 
catheter lumens. 
Systemic anticoagulants should not be used routinely to prevent CRBSI. 
In general, administration sets in continuous use need not be replaced more 
frequently than at 72-hour intervals unless they become disconnected or a catheter-
related infection is suspected or documented. 
Administration sets for blood and blood components should be changed every 12 
hours, or according to the manufacturer’s recommendations. 
Administration sets used for total parenteral nutrition infusions should generally be 
changed every 24 hours. If the solution contains only glucose and amino acids, 
administration sets in continuous use do not need to be replaced more frequently than 
every 72 hours.  
Systemic antimicrobial prophylaxis should not be used routinely to prevent catheter 
colonisation or CRBSI either before insertion or during the use of a central venous 
When recommended by the manufacturer, implanted ports or open-ended catheter 
lumens should be flushed and locked with heparin sodium flush solutions. 

When needle-less devices are used, healthcare personnel should ensure that all 
components of the system are compatible and secured, to minimise leaks and breaks 
in the system. 
Preferably, a single lumen catheter should be used to administer parenteral nutrition. 
If a multilumen catheter is used, one port must be used exclusively dedicated for total 
parental nutrition and all lumens must be handled with the same meticulous attention 
to aseptic technique. 
When needle-less devices are used, the risk of contamination should be minimised by 
decontaminating the access port with either alcohol or an alcoholic solution of 
chlorhexidine gluconate before and after using it to access the system. 
If needle-less devices are used, the manufacturer’s recommendations for changing 
the needle-less components should be followed. 
Catheter Site care 
Preferably, a sterile transparent, semi-permeable polyurethane dressing should be 
used to cover the catheter site. 
If a patient has profuse perspiration, or if the insertion site is bleeding or oozing, a 
sterile gauze dressing is preferable to a transparent, semi-permeable dressing. 
Gauze dressings should be changed when they become damp, loosened or soiled, 
and the need for a gauze dressing should be assessed daily. A gauze dressing should 
be replaced by a transparent dressing as soon as possible. 
Dressings used on tunnelled or implanted CVC sites should be replaced every 7 days 
until the insertion site has healed, unless there is an indication to change them 
An alcoholic chlorhexidine gluconate solution should be used to clean the catheter site 
during dressing changes, and allowed to dry. An aqueous solution of chlorhexidine 
gluconate should be used if the manufacturer’s recommendations prohibit the use of 
alcohol with the product. 
Healthcare personnel should ensure that catheter-site care is compatible with catheter 
materials (tubing, hubs, injection ports, luer connectors and extensions) and carefully 
check compatibility with the manufacturer’s recommendations. 
Transparent dressings should be changed every 7 days, or sooner if they are no 
longer intact or moisture collects under the dressing. 
Individual sachets of antiseptic solution or individual packages of antiseptic-
impregnated swabs or wipes should be used to disinfect the dressing site. 
Total Parental Nutrition 
Parenteral nutrition (PN) is the administration of nutrient solutions via a central 
or peripheral vein.  It is most commonly administered through a peripherally 
inserted central venous catheter into the superior vena cava and it is only used 
when the patient’s gastro-intestinal tract is not functional. 
Preferably a single lumen catheter should be used to administer parenteral 
Strict asepsis is required when dealing with parenteral nutrition procedures. 
Administration sets should be changed every 24 hours. 

All clients are self-caring with advice and support from the Nutrition Support 
The Nutrition Nurse Specialist team are available 24 hours a day via your local 
6. Laundry 
In Clinical Treatment Areas 
It is strongly recommended that linen is kept to a minimum. 
The surface of all couches must be of a washable impermeable fabric 
The condition of the surface of all couches should be regularly checked 
(minimum once monthly) to ensure the fabric remains intact   
The couch should be covered with a disposable paper towel, which must be 
changed between patients 
If the paper towel becomes soiled and the soiling seeps through to the surface 
of the couch, the couch must be decontaminated before use by another patient. 
If contaminated with blood clean with detergent wipes, followed by a sodium 
dichloroisocyanurate compound (NaDCC) (e.g. Acti Chlor) 
If the contaminate is another body fluid, GPD and warm water, or detergent 
wipe is sufficient to decontaminate the surface of the couch 
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 pillow cases are used, they must be washed weekly or more 
frequently if they become soiled. Linen that is washed must be thermally 
disinfected in an industrial washing machine 
Blankets/sheets are not considered essential.  For modesty, a length of 
disposable paper towel should be used to cover exposed parts of the body. 
At windows, it is recommended that washable blinds are used.  Obscured 
glazing is advised where this is not available 
Around couches, curtains should only be used if required to protect patient’s 
There should be an environmental cleaning schedule which should include 
blinds and bed curtains to be washed twice yearly, or when contaminated
Terry Towels 
Terry towels should not be used in healthcare premises.  Hands should be 
dried on disposable paper towels 

If used to protect the patient whilst performing ear syringing (instead of the 
correctly designed receptacle), each patient should be provided with a clean 
towel (or disposable paper towel)
When Linen is Used: 
All 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 general practice 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 may be involved in the laundering of client’s 
clothes or linen. The following principles should be noted: 
The germs in most soiled and fouled linen are unlikely to cause infection in 
healthy workers provided that care is taken.  But to further minimise the risk: 
Wear a waterproof apron and gloves when dealing with used laundry 
Ensure that adequate handwashing 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 the client’s own home, a domestic washing machine may be used. Soiled and foul 
linen should be pre-washed in the washing machine, and then washed at the highest 
temperature that the material will withstand. Healthcare workers are not advised to 
manually wash a patient's linen. 
Sending Laundry to a Commercial Laundry 
If clients’ laundry is sent to a commercial laundry, by collection or delivery, it should be 
checked whether they have any special instructions, e.g. a colour-coding system. 
Usually laundry bags are colour-coded in the following way: 
Used linen - a white bag 
Foul linen and/or 
Infected linen – placed in a red water-soluble bag. 
NB: If the foul or infected linen is excessively wet it may be necessary to place the 
soluble bag within a clear polythene/plastic bag within a blue or red bag. 

Staff Uniforms or Work Clothes 
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.  
Under no circumstances should staff go out socialising in clothes that may have been 
in contact with body fluids.  
Uniforms or work clothes should be washed as soon as possible on as hot a wash as 
the fabric will tolerate.  Cardigans/jumpers should be washed at least weekly. 
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. 
Shoes should be cleaned immediately if contaminated with body fluids, using GPD 
and hot water - disposable gloves should be worn. 

Management of Non-Infectious and Infectious Deceased 

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: 
Disposable gloves and aprons should be worn when washing and preparing the 
Washing the body with soap and water is adequate 
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. 
Clean dressings should be applied to any wounds 
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 from where all 
other care equipment is requested. 
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: 
Acute poliomyelitis  
Pyrexia of unknown origin  
Food Poisoning (if faecal matter is leaking)  Q fever 
Hepatitis B 
Hepatitis C 
Tuberculosis (infective) 
Viral Haemorrhagic fever 
Meningococcal Septicaemia (with or 
Yellow fever. 
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 
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, Smallpox or Viral Haemorrhagic Fever. 
Further advice on specific infectious diseases can be found in the Infection 
Control Guidelines for Funeral Directors, or advice can be sought from the 

8.  Guidelines for Community Sector Performing Minor Surgery 
This specification describes the working practices, standards and procedures that 
Essex Health Protection Unit recommends Practitioners who have registered with the 
Healthcare Commission or Primary Care Trust to follow when performing minor 
surgery.  For the purposes of this document minor surgical procedures are considered 
under three different groups so as to reflect the need for a higher standard of infection 
control as the procedures become more invasive. 
Group One:
These minor surgical procedures require a standard of good basic infection control 
procedures, and can be found in Appendix One. 
Group Two:
Incisions *   

Group Three: 
Lumps and bumps 
HSG (96) 31 
Other services or procedures under HSG(96)31 
*at the discretion of the practitioner, some incisions and excisions 
(e.g. warts and removal of toe nails) may fall into Group One, as 
they could be seen as very minor 
Please note that there may be additional requirements for specialised 
Infection control is an important part of an effective risk management programme to 
improve the quality of patients’ care and the occupational health of staff. 
Patients undergoing invasive procedures such as minor surgery will have an 
increased susceptibility to infection.  There is evidence that adherence to good 
infection control principles can significantly reduce the risk of infection post procedure. 
The Primary Care Trust, as a purchaser of healthcare services for its population, and 
the Healthcare Commission have concerns for the general standards of quality of 
these services. 

Aims and Objectives 
To ensure an adequate infection control programme is in place for the 
protection of patients undergoing minor surgical procedures within healthcare 
To ensure practitioners involved in minor surgery are protected against 
infectious hazards by maximising occupational and procedural safety. 
Action Required by Healthcare Practitioners Performing Minor Surgical 
Procedures that fall under Groups Two and Three 
Each Practitioner should comply with the following: 
Environment - Designated* room where minor surgery is performed 
Ceiling and walls should have an intact, washable surface and be visibly clean.
A suitable covering should be used i.e. washable emulsion paint. 
Flooring should be intact, impervious, washable, and visibly clean. 
Windows should be in a good condition and state of repair, and be visibly 
clean. Frosted glass should be used if the inside of the room is visible from the 
exterior unless blinds are always used.  All window coverings should be blinds 
that are washable. 
Cupboards must be structurally sound and in a good state of repair, washable 
and visibly clean. There should be sufficient storage space, to aid cleaning and 
prevent accumulation of dust.  Open shelving is not recommended. 
Work surfaces should be intact, seamless and easily washable.  They should 
be kept clear of unnecessary items. 
The lighting in the room should allow good visibility to perform the procedure. 
The light fitting should be easy to clean.  All fluorescent tubes should be 
covered with a diffuser. 
The couch material should be impervious to body fluids. Disposable paper 
towelling should be used for each individual patient, not linen. 
Instruments are recommended to be processed by SSD or disposable.  If not, a 
dirty utility area should be available for the decontamination of equipment and it 
should be within easy access to the procedure room.  In the absence of such 
facilities, there should be a designated area, with a   designated sink for the 
pre-cleaning of contaminated equipment, within the room itself.  The workload 
should be managed in such a way to allow for decontamination of equipment to 
take place after each case, once the patient has left the room. 
There should be a designated hand washbasin with elbow operated taps, which 
is not used for the decontamination of equipment.  Access should be clear and 
sinks should be visibly clean. 

Designated room - these procedures should be performed in a controlled 
environment i.e. the fabric of the room should be intact and clean. 


Wall-mounted liquid soap dispensers should be available at all sinks in 
clinical/treatment areas. Bar soap should not be present in these areas. 
The practitioner should ensure his/her hands are effectively cleaned to prevent 
cross-infection.  Anti-bacterial soap (e.g. hibiscrub, betadine) should be 
available for minor surgical procedures. 
Wall-mounted dispensers for paper towels for drying hands should be available 
at all sinks. 
Single-use sterile surgeons gloves should be available and worn by the 
person/s performing minor surgical procedures. 
Single-use unsterile, unpowdered and low protein, latex gloves should only be 
worn by those not directly involved in the minor surgical procedure, for all 
contact with body fluids. 
Single-use disposable plastic aprons should be available.  These must be worn 
by all personnel if they are likely to come into contact with body fluids. 
Plastic goggles and masks/visors should be available for use if it is anticipated 
that there may be splashing of body fluids. 
Single-use items must never be re-used. 
Sterile products should be stored above floor level. 
2.10  Where sterile equipment is obtained from Sterile Services Department (SSD): 
a.  the equipment should be rotated to ensure products are used  
within expiry times 
b.  clean equipment should be stored in cupboards 
c.  used equipment should be stored separately in a designated safe area   
prior to collection 
d.  equipment must be collected within a 7 day period. 
2.11  Where practices sterilise their own equipment, a steam autoclave meeting BS 
and EC regulations should be used, and operated according to standards laid 
out in Health Technical Memorandum 2010 part 1 (HTM 2010). 
2.12  A stainless steel, free-standing dressing trolley, designated for use in minor 
surgical procedures, should be structurally sound and in a good state of repair. 
2.13  Sharps containers used should conform to BS 7320 and EC regulations. They 
should be correctly assembled and stored off the floor. 
2.14  Orange clinical waste bags should be supported in a lidded, foot operated, rigid 
2.15  A spillage kit for body fluids should be available. 

3. Procedures 
The workload should be managed to assure adequate time for infection control 
procedures to be effectively carried out between patients.  This may require 
varying intervals of time between cases to allow decontamination and re-
sterilisation of equipment. 
Protective clothing should be used whenever handling body fluids and changed 
between each patient. 
Hands should be washed between each patient activity with liquid soap using 
the social handwashing method, and with anti-bacterial soap (e.g. Hibiscrub) 
before minor surgical procedures. 
Only sterile, single-use nail-brushes should be used. 
Staff must only operate autoclaves when they have been fully trained in their 
Equipment for minor surgical procedures should be autoclaved and used 
directly from the autoclave within 3 hours.  It is essential that instruments are 
sterilised unwrapped (unless a specific porous load autoclave is used). 

Staff should be fully aware of the requirements of HTM 2010 with regard to 
checks and monitoring of the autoclave. 
All staff must follow the protocol for removing spillages of body fluids. 
Specimens should be collected using universal precautions.  The specimen 
container should be clearly labelled and secured in a clear plastic bag.  
3.10  Specimens should be stored in a designated safe area (refrigerators used for 
foods and vaccines must not be used).  They should be transferred to the 
laboratory under controlled conditions. 
3.11  All hazardous infected healthcare/household waste should be identified and 
segregated at source into colour-coded bags. 
3.12  Waste bags should be no more than 3/4 full.  The bag must be sealed and 
labelled to identify source once in transit.  All waste should be collected on a 
regular basis, at least once weekly. 
3.13  There should be a designated area to store all waste prior to collection.  It 
should be kept secure from unauthorised persons, entry by animals and free 
from infestations. 

3.14  Sharps containers should be positioned near to the operator and disposed  
of when ¾ full.  
3.15   All staff must observe the sharps injury protocol. 
3.16  If the couch becomes contaminated with body fluids it should be cleaned with 
detergent and hot water and the disposable sheet should be changed between 
each patient.  If contaminated with blood, a sodium hypochlorite solution should 
be used. 
3.17  Dressing trolleys must be washed down with detergent and hot water before 
each session commences, or if the trolley becomes contaminated with body 
fluids.  The trolley should be wiped down with 70% alcohol between each 
3.18  There should be a programme for environmental cleaning that includes the 
walls, ceiling, lighting, flooring, cupboards and work surfaces. 
3.19  The infection control policy should be readily accessible to all staff. 
4. Occupational 

All staff involved in minor surgical procedures should be vaccinated against 
Hepatitis B and have documented proof of immunity. 
Staff carrying out Exposure Prone Procedures must follow current guidelines 
regarding testing for Hepatitis C and HIV.  This should be monitored and 
supervised by the Occupational Health provider. 
All staff should adhere to “Health and Safety at Work” - Guidance for GPs.
General Medical Services Committee, BMA.  April 1995. 
Note: Guidance within HTM2010, 2030 and 2040 is under review. The Department of 
Health will be replacing the documents with Health Technical memorandum 01 Part A 
(Decontamination of reusable medical devices) and HTM 01 Part B, due to be 
published in Autumn 2007. 

Appendix One 
Action required by general practitioners performing minor surgical procedures 
that fall under Group One 
1. Equipment 
Liquid soap should be available at all sinks in clinical/treatment areas.  Bar 
soap should not be present in these areas. 
Paper towels for drying hands should be available at all sinks. 
Single-use unsterile, unpowdered and low protein latex gloves should be worn. 
Single-use disposable plastic aprons should be available.  These must be worn 
by all personnel involved in the minor surgical procedure. 
Single-use items must never be re-used. 
Sterile products should be stored above floor level. 
Where sterile equipment is obtained from Sterile Services Department (SSD): 
stock rotation must be implemented to ensure products are used within 
expiry times 

clean equipment should be stored in cupboards 

used equipment should be stored separately in a designated safe area 
prior to collection 

contaminated equipment must be collected within a 7 day period. 
Where practices sterilise their own sterile equipment, a steam autoclave 
meeting BS3970 should be used and operated according to standards laid out 
in HTM 2010. 
A stainless steel, free-standing dressing trolley, designated for use in minor 
surgical procedures, should be structurally sound and in a good state of repair. 
1.10  Sharps containers used should conform to BS 7320.  They should be correctly 
assembled and stored off the floor. 
1.11  Orange clinical waste bags should be supported in a foot operated, rigid bin. 
1.12  A spillage kit for body fluids should be available. 

2. Procedures 
Protective clothing should be used whenever handling body fluids and changed 
between each patient. 
Hands should be washed between each patient activity with liquid soap using 
the social handwashing method. 
For re-usable equipment such as curettes, these should be decontaminated 
after use as per specification 3.5 - 3.8. 
All staff must follow the protocol for removing spillages of body fluids. 
Specimens should be collected using universal precautions.  The specimen 
container should be clearly labelled and secured in a clear plastic bag.  Where 
a specimen carries a likely “Infectious Risk” this should be indicated on the 
container and request form. 
Specimens should be stored in a designated safe area (refrigerators used for 
food or vaccines must not be used).  They should be transferred to the 
laboratory under controlled conditions. 
Waste should be handled as per specification 3.12 - 3.15. 
All staff must observe the sharps injury protocol. 
Dressing trolleys must be washed down with detergent and hot water before 
each session commences, or if the trolley becomes contaminated with body 
fluids.  The trolley should be wiped down with 70% alcohol between each 
2.10  The infection control policy should be readily accessible to all staff.  

Prevention and Control of Infection in Urinary Catheter Care 
Routes of Entry for Infection 
Urinary catheters are inserted to provide urinary drainage.  They may be introduced 
via the urethra or into the bladder through a supra-pubic procedure. 
Comprehensive information, advice and support is available from the continence 
Bacteria may enter the bladder of the catheterised patient in one of four ways: 
Introduced with the catheter at the time of insertion 
Travel along the outside of the catheter 
Travel along the inside lumen of the catheter 
Through a break in the closed system. 
Assessment for Catheter Equipment 
Indwelling urinary catheters should be used only after alternative methods of 
management have been considered.  
The patient’s clinical need for catheterisation should be documented and reviewed 
regularly, and the urinary catheter to be removed as soon as possible. 
Catheter insertion, changes and care should be documented. 
Catheter drainage options 
Following assessment, the best approach to catheterisation that takes account of the 
clinical need, anticipated duration of the 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 supra-pubic catheters, the choice of catheter material and gauge 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. 
There are a variety of types of urinary catheters. When the assessment for the need 
for catheterisation is made the catheter material and expected usage should be 
recorded. In the community medium (up to 28 days) or long-term (up to 12 weeks) 
catheters are recommended. 

The retaining balloon should be filled with sterile water to the volume indicated by the 
manufacturer (usually 10mls for adults). 
Catheter Insertion 
Catheterisation is an aseptic technique. 
Ensure that healthcare workers are trained and competent to carry out catheter 
Intermittent self-catheterisation is a clean procedure. A lubricant for single patient use 
is required for non-lubricated catheters. 
The urethral meatus should be cleaned before insertion of the catheter, with sterile 
normal saline prior to insertion. 
An appropriate lubricant from a single-use container should be used during catheter 
insertion to minimise urethral trauma and infection. 
The following details must be documented in the patient records e.g. amount of urine 
drained, problems encountered, patient discomfort, reason for catheterisation, date of 
insertion, catheter size, type, length, balloon size, batch number, expiry date.  
Catheter Maintenance 
Indwelling catheters should be connected to a sterile closed urinary drainage system 
or catheter valve. 
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 their gloves. 
Urine samples must be obtained from a sampling port using aseptic technique. 
A link system should be used to facilitate overnight drainage, to keep the original 
system intact. Drainage bag should be single-use
The meatus should be washed daily with soap and water. 
Reusable intermittent catheters should be cleaned with water, and stored dry in 
accordance with the manufacturer’s instructions. 
Catheters should be changed only when clinically necessary or according to the 
manufacturer’s current recommendations. 
Healthcare personnel should ensure that the connection between the catheter and the 
urinary system is not broken except for good clinical reasons, (for example changing 
the bag in line with the manufacturer’s recommendations). 

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 
standard principles of infection control. 
Urinary drainage bags should be positioned below the level of the bladder, and should 
not be in contact with the floor. 
The urinary drainage bag should be emptied frequently enough to maintain urine flow 
and prevent reflux, and should be changed when clinically indicated. 
Each patient should have an individual care regimen designed to minimise 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 
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 

10.  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 of Infection 
 (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 
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 clinic 
is unlikely to have any safe means of disposal.  It may be possible to provide 
the specimen at the clinic 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 or a drug 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. 


11. Vaccine 

Vaccines are biological products that need to be stored under controlled conditions to 
maintain their potency and efficacy. They should be stored under conditions 
recommended by the manufacturer in product literature.  
On arrival, vaccines should be checked to ensure the cold chain has not been 
broken and for signs of damage or leakage 
A nominated person, who has received specific training in this practice, should 
make sure vaccines are correctly stored and handled by staff 
Store vaccines in a fridge designed for vaccine storage 
Ensure strict stock rotation with new vaccines being placed behind older stock 
Discard expired vaccines safely 
Prevent overstocking and allow air to circulate around all stock 
Do not store in fridge door or in separate drawers in the bottom of the fridge as 
air cannot circulate 
Ensure systems are in place to prevent accidental disconnection of the 
Do not store items other than vaccines in the same fridge 
Defrost and clean regularly, storing vaccines in an alternative fridge during the 
Temperature Control 
Vaccines must be kept between 20C and 80C during transportation and 
delivery, and must not directly touch ice packs 
Store vaccines between 20C and 80C and not below freezing.  Monitor fridge 
temperature using a minimum/ maximum thermometer, and record results 

Use reconstituted vaccine according to the manufacturer’s recommendations, 
usually within one to four hours 
Remove vaccines from the fridge for the minimum length of time before 
administration - discard any opened in error 
Vaccines which are liquid suspension, or are reconstituted before use should 
be adequately mixed to ensure uniformity of the material to be injected 
Do not prepare vaccine in advance of immunisation, as this increases the risk 
of administering the wrong vaccine and may affect the temperature.  Prepare 
each vaccine for the individual who is to receive it 
Cleanse skin only when it is visibly dirty.  If alcohol or other antiseptics are 
used, they must be completely dry otherwise the live vaccines may be 
Multi-dose vials may be used for one session only - discard any remaining at 
the end of the session 
Dispose by heat inactivation or incineration. 

12. Waste 
The management of Healthcare Waste has changed in line with the new 
Hazardous Waste Regulations.  
The new document is entitled: The Department of Health Environment and 
Sustainability – Health Technical Memorandum 07-01: Safe Management of 
Healthcare Waste
 guidance has been produced to provide a framework for best 
practice in waste disposal. The guidance is designed to help healthcare organisations 
and other producers of waste to meet their legislative requirements. 
HTM 07-01 is available from the Stationary Office or it may be electronically 
downloaded from DH website or
The following advice has been developed from the above publication. However it is 
strongly recommended that the organisation/healthcare business also consult the 
HTM 07-01 and discuss waste disposal with the management/advisors of the waste 
collection contractor. 
All healthcare organisations should have a waste policy that provides clearly written 
instructions on the way waste should be managed. The roles and responsibility of the 
waste management chain from “cradle to grave” still applies. Producers of waste are 
advised to carry out regular audit of their waste management systems to ensure that 
they complying with best practice. 
The new regulations encompass all waste produced in healthcare. Examples are 
illustrated in the following table 

All healthcare organisations have a legal responsibility to dispose of waste 
safely, ensuring no harm is caused either to staff, members of the public or the 
environment.  The healthcare organisations' 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). 
The definition of clinical waste remains the same. 
Clinical waste is: 
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 
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 regulations subdivide healthcare clinical waste into: 
Waste that poses a risk of infection 
2. Medicinal 
Infectious Waste 
The Hazardous Waste Regulations define as: 
H9 Infection: Substances containing viable micro-organisms or their toxins which are 
known or reliably believed to cause disease in man or other living organisms. 
(Traditionally known as “clinical waste”.) 
Medicinal Waste 
Classified into two categories: 
Cytotoxic and cytostatic medicines (Classified as Hazardous Waste) 
(b) Medicines 

Failure to segregate cytotoxic and/or cytostatic medicines from other medicines will 
mean that the entire medicinal waste stream will need to be classified as hazardous. 
Cytotoxic and cytostatic classifications can be found in the NIOSH Alert or the BNF. 
Offensive/Hygiene Waste 
Non-infectious (human waste and sanpro (sanitary protection) waste such as nappies, 
incontinence pads etc), which does not require specialist treatment or disposal, but 
which may cause offence to those coming into contact with it. 
The new regulations focus on the correct segregation at the point of generation, 
correct identification of the waste and the safe disposal via the appropriate route. 
The European Waste Code (EWC) coding for correct labelling is illustrated in the 
following table 
A national colour-coding system has been developed. Most infectious clinical waste 
generated in community settings will be disposed of in the orange package stream.  
Non-infectious waste and incontinence waste is considered to be offensive. It can be 
disposed of in yellow bags with black strips. Refer to figures 4 and 5 on the following 
The assessment for whether waste is hazardous because of infection will be made at 
the point of generation i.e. The site of healthcare provision.  

An assessment is required to ascertain the correct type of packaging i.e. if there is a 
risk of an item piercing a waste bag a rigid container should be used. 
Colour-coding key to segregation system 

Waste Packaging and Colour-coding 

Assessment of Hazard  
Generally in primary healthcare the waste generated is less of an infectious hazard.  
Infectious waste is waste that has been generated from a person with signs and 
symptoms of infection and will be considered infectious or potentially infectious and 
should be disposed of in orange waste streams. Non-infectious but offensive waste 
should be disposed off in yellow bag with black stripe. There will be occasions when 
offensive/hygiene waste is potentially infectious e.g. patients/residents with 
gastroenteritis, in which case the correct waste-stream is orange.  
Healthcare workers working in the community and in the household environment need 
to assess the waste they are producing for the hazardous properties it may contain, 
most notably 'infectious'. 

Waste should be segregated at the point of origin 
Personal protective clothing should be worn when handling waste 
Waste should be: 

correctly bagged in the appropriate coloured bag of 225 gauge to 

double bagged where: 
-  the exterior of the bag is contaminated 
-  the original bag is split, damaged or leaking 


kept in a rigid-sided holder or container with a foot operated lid, 
and, so far as is reasonably practicable, out of the reach of 

only filled to ¾ full 

securely sealed and labelled with coded tags at the point of use to 
identify their source. 
Waste should not :  

Be decanted into other bags, regardless of volume 

Be contaminated on the outside 

Sharps must be disposed of into appropriate colour-coded sharps 
containers that meet BS7320/UN3291 

Sharps container should NEVER be placed into a waste bag. 
All staff handling waste should receive appropriate training to carry out the procedure 
The bag should be removed and securely fastened at least once a day or when ¾ full, 
labelled with its place of origin (e.g. surgery details) and placed in the designated 
waste collection point. 
Disposal of Sharps 
A risk assessment is required to identify the correct waste stream required. 
Syringes, needles, razors, ampoules and other sharps should always be placed in the 
correct sharps container (See Waste-packaging and colour-coding).  These items 
should never be placed in a waste bag of any kind. 
Care should be taken to ensure that sharps containers are correctly assembled 
according to the manufacturer’s instructions. 
Use the appropriately sized sharps container to prevent used sharps being stored for 
long periods of time. 
It is the responsibility of the person who uses a sharp to dispose of it safely. 
Always place sharps in the sharps container as soon as possible. 
Sharps containers must be sealed, labelled with the point of origin and placed in the 
designated clinical waste collection point when ¾ full. 
Sharps containers should conform to BS 7230/UN 3291. 
Sharps containers should be kept in a safe location (on a flat surface, below eye level 
but not on the floor).  This will reduce the risk of injury to patients, visitors and staff.   

For community staff carrying sharps boxes in their cars: 
Sharps should only be carried by staff if there is no alternative for safe disposal 
Sharps should be placed in the sharps container at the point of use 
The container should be carried in a secure area of the car, to prevent tipping 
over whilst driving 
The container carried should be out of sight 
Diabetic Sharps 
All diabetic sharps should go into a sharps container (this includes lancets).  
General Practitioners/healthcare prescribers will prescribe sharps boxes on FP10.  
General Practitioners should ensure that the patient is aware of the correct method for 
disposal of the filled sharps bin.  Disposal points may include: returning it to the 
General Practice, returning it to a local clinic, or returning it to a local pharmacy. 
Disposal of Aerosol Cans/Glass/Bottles/Broken Crockery/Dry Cell Batteries 
These must never be placed in any waste bag, especially a waste bag which is 
destined to be incinerated. 
These items should always be placed in a designated cardboard box, lined with a 
plastic bag to render it leak-proof.  The box should be labelled to indicate its contents 
and method of disposal. 
Disposal of Pharmaceutical Waste - Medicinal Waste 
Pharmaceutical waste includes all part-used and out of date medicines, cream and 
ointment tubes and aerosols.  Other associated waste e.g. empty blister packs and 
alcohol wipe containers can be disposed of in the domestic waste stream (black bag). 
All pharmaceutical waste should be placed directly into the pharmaceutical waste 
container, or returned to the local chemist for them to place into their pharmaceutical 
waste container. 
Ensure that the container is clearly labelled, and that all associated 
documentation is signed off at the time of collection. 

Infectious waste should be removed from the 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 
Accessible to collection vehicles. 

The above guidance should be followed in full. 
Each health and social care employer is responsible for ensuring that contracts are in 
place to collect clinical waste from their premises.  They are also responsible for 
monitoring the performance of their staff and waste contractors.  
Community healthcare workers generating waste in health and social care 
establishments are responsible for ensuring the waste that they generate is managed 
correctly, this is part of their duty of care. 
(this does NOT include private residential care establishments) 
Although a householder has no legal duty of care to dispose of Healthcare waste in 
the way described above, any health or social care worker who provides care in a 
private household does, e.g. NHS Trust, Social services, care agency staff. This duty 
of care includes the safe storage of waste in the household whilst awaiting collection 
by the approved collection contractor. 
The waste should be stored in a suitable place to which children, pets, pests etc. do 
not have access. 
This 'cradle to grave' responsibility will include the correct storage of waste whilst 
awaiting collection by an authorised collector. 
Risk Assessment for Care in Private Households 
A risk assessment should be undertaken to determine whether the waste generated 
by the healthcare worker is a hazard because it has a known or potential risk of 
infection. This should be a professional assessment based on clinical signs and 
symptoms and prior knowledge of the patient. 
Infectious Waste 
The table below is based on the Delphi process for identifying wound infection 
(European Wound Management Association 2005) and can be used to assist in the 
risk assessment. 

However the healthcare worker may have further information that would indicate that 
the waste is potentially infectious. Infectious waste must be disposed of in an orange 
Non-infectious waste 
Legally, non-infectious healthcare waste generated by a healthcare worker should not 
be disposed of in the black bag stream but be disposed of via the offensive waste 
stream (yellow with black strip waste bag).  However it is recognised that household 
waste may contain plasters, dressings and incontinence waste.  Where similar waste 
is generated by a healthcare worker, with the householder's permission, such waste 
when securely wrapped may be disposed of in the domestic refuse, provided the 
volume is low. 
The following should be considered for disposal via the domestic route: 
•  Small dressings, dressing pad not larger than 130mm x 220mm 
•  Specialised antimicrobial types of dressings (however some medicinal 
dressings will require disposal via the medical waste route seek advice from 
•  The quantity should not exceed the amount that would be consistent with that 
likely to be found in a household waste stream. 
The above waste should be wrapped in plastic sacks but those sacks must not be 
orange or yellow. It is suggested that plastic bags such as sandwich bags are 
Sharps Disposal  
Sharps such as syringes, needles, lancets etc should be disposed of via the correct 
colour lidded sharps box. 
HTM 07-01 advises that in order to reduce the quantity of waste streams in the 
community, sharps or medicinal residues that are contaminated with cytogenic 
medicines to be discarded in purple lidded boxes.  Fully discharged or partially 

discharged sharps with medicinal residues to be discarded in yellow lidded boxes. 
However a PCT should do its own risk assessment and may adopt the orange lidded 
sharps box for non-medicinally contaminated sharps. Leak-proof boxes should be 
considered where there is a likelihood of liquids escaping from boxes. 
Waste Carriage regulations state that all healthcare hazardous waste must be 
contained in UN approved rigid packaging when transported on the road.   
Additional Waste guidance: 
Stoma and urinary catheter bags 

1.  The healthcare worker or the householder should carefully empty the contents 
down the toilet (taking care not to create a splash-back) and flush away. The 
empty bag should then be double wrapped in plastic bags before being placed 
in the household waste. 
2.  If large amounts of offensive/hygiene waste is generated, the yellow bag with 
black strip route of disposal must be used 
3.  If the person develops gastroenteritis or wound infection, waste must be 
disposed of via the infectious orange bag stream. 
Wound vacuum drains  
Treat as infectious waste and dispose via the orange bag stream. 
Dispose in a secure airtight rigid yellow container (UN3291). Do not use a yellow 
sharps box. 
Incontinence sheets/pads 
If the contaminate is solid and can be easily and safely emptied down the 
toilet and flushed away, it should be 
The sheet should be double wrapped in plastic bags before being placed in 
the household waste. If incontinence pads are produced in bulk an 
offensive waste collection should be arranged. 
Dialysis equipment 
When a programme of home dialysis is commenced it should include a 
collection service of used items.  Usually as new equipment is delivered, 
used items are collected. 


Health & Safety at Work etc Act 1974 
Control of Pollution Act 1974 
Collection and Disposal of Waste Regulations 1988 
Control of Pollution (Amendment) Act 1989 
Environmental Protection Act 1990 
Environmental Protection (Duty of Care) Regulations 1991 
Controlled Waste Regulations 1992 
The Special Waste Regulations 1996 
HTM Environment and Sustainability 07-01 Safe Management of 
Healthcare Waste Department of Health 2006 
Health Care Waste Management and Minimisation 2000. 

Where can I get Advice on Childhood Immunisations? 
The Department of Health’s reference manual on childhood immunisation is currently, 
"Immunisation Against Infectious Disease 2006" available from the HMSO 
Publications Centre 0207-873-9090. 
The full text is also available on the web
7254 , or search for ‘The Green Book’ where you can download the full document in 
pdf format. 
If you have a specific issue or query not covered by the Green Book you can contact 
your District Immunisation Co-ordinator: 
(covering the Brentwood area) 
Dr F Fernandez 
01708 465495 
The Willows, St George’s Hospital 
117 Suttons Lane 
Hornchurch, RM12 6RS 
Mid Essex           
Child Health Department    
01376 302612 
Unit 12, Atlantic Square 
Fax: 01376 302618 
Station Road, Witham, CM8 2TL 
North East Essex 
659-662 The Crescent 
Dr A Dominquez 
01206 286625 
Severalls Business Park 
Fax: 01206 286600 
CO4 9YG 

Southend Child Health Dept 
Harcourt House 
Dr M Rahman 
01702 224902 
Harcourt Avenue 
Southend on Sea 
SS2 6HE 
Child Development Centre 
Dr S Myint 
01375 390044 
Gifford House 
Ext: 5544 
Thurrock Hospital 
Long Lane, 
Grays, RM15 2PX 
West Essex 
Child Development Centre 
Dr V Amadi 
01279 827178 
Hamstel House, Hamstel Road 
Fax: 01279 444298 
Harlow, CM20 1QZ 
You can also contact the Essex Health Protection Unit on 0845 1550069. 
Where can I Refer Patients for Advice? 
Useful websites for patients where they can obtain additional information on the 
vaccines are: and 
Each District Immunisation Co-ordinator runs a regular vaccine 
advice/contraindications clinic.  If you are unfamiliar with the arrangements for booking 
appointments you can contact the relevant office number. 
Where can I Obtain Advice on Travel Vaccinations? 
The Department of Health has a reference manual “Health Information for Overseas 
 2001 edition HMSO which can be ordered on 0870-600-5522 or via 
‘On-line’ advice is available for health professionals via and , and for the public on 
There are advice paylines available to the public:   
Hospital for Tropical Diseases 09061-337733  
MASTA Travellers Health Line 0906-8224100. 

Further information 
Copies of the current vaccination schedule and the algorithm “Vaccination of 
Individuals with Uncertain or Incomplete Immunisation Status” is available on Select “Immunisation” in the A- Z of topics. 

Firstly check whether there is any single practical way of corroborating 
their prior vaccination history e.g: 

Can they check with a relative? 
Can they confirm with their previous doctor in their country of origin? 
Can you compare their history with the normal vaccination schedule for their 
National vaccine schedules are available on the WHO website  Select the relevant document entitled “WHO 
vaccine preventable diseases: monitoring system”.  However bear in mind the 
national programme may have broken down in countries with political problems or 
civil unrest. 
If it is a child who will be returning abroad within one year, it is best to keep to the 
schedule of that country (if possible) including vaccines such as Hib or Men C that 
may not be provided abroad. 
If the vaccination history remains unknown you should start a complete 
vaccination programme according to age. 

An algorithm for ‘Vaccination of Individuals with Uncertain or Incomplete 
Immunisation Status’ is available on the website, under the 
section Vaccination/ Vaccination guidelines. 
Other Things to Consider 
BCG Vaccine 
Should be considered to children born to immigrants from countries with a high 
prevalence of tuberculosis if not already given.  This also applies to children who will 
be returning to “high-risk” countries for stays longer than one month/visiting relatives 
Hepatitis B Vaccine 
Hepatitis B screening and vaccine should be considered for families with a higher 
prevalence of Hepatitis B.  (Refer to section Hepatitis B in the Green Book 
“Immunisation against Infectious Disease.) 

Patients without a Functioning Spleen 
After splenectomy patients are at major long-term risk of serious infections. 
Splenic macrophages have an important filtering and phagocytic 
role in removing bacteria and parasitised red blood cells from the 
circulation.  Though the liver can perform this function in the 
absence of a spleen higher levels of specific antibody and an intact 
complement system are probably required. 
Other categories of patient may be functionally asplenic.  These include patients with: 
Sickle cell anaemia 
• Thalassaemia 
• Thrombocytopaenia 
Some lympho proliferative diseases 

Patients without a functioning spleen should be identified and should 

Pneumococcal vaccine (with a booster at 5 yearly intervals). 
Haemophilus influenzae type b vaccine. 
Influenza vaccine (yearly). 
Conjugated meningococcal C vaccine. 
Antibiotic Prophylaxis 

Adult dose:   
Penicillin V 500mg bd 
This should be given lifelong but at least for 2 years post-splenectomy if patients 
refuse to take it long-term. 
Where a patient is no longer taking antibiotic prophylaxis they should be given a short 
course of Amoxil to keep at home which they should start taking at the start of any 
febrile illness. 
NB.   Patients allergic to penicillin should receive erythromycin 500mg bd. 

Asplenic patients should be strongly advised of the increased risk of severe 
falciparum malaria and should be discouraged from travelling to areas where 
malaria is endemic.  Where travel is undertaken patients should be advised 

about chemoprophylaxis relevant to local patterns of resistance and measures 
to reduce exposure to malaria parasites. 
Tick bites - Babesiosis - is a rare tick-borne illness endemic in certain parts of 
the USA, China, Taiwan, South Africa and Egypt.  Some species have caused 
human infections in Europe.  Clinical presentation is with fever, fatigue and 
haemolytic anaemia.  Patients (particularly those in contact with animals) 
should be warned about the danger of tick bites spreading the disease.  
Protective clothing may be beneficial. 
Quadrivalent ACYWVAX (SKB) is recommended for all those travelling to some 
sub-Saharan African countries and for pilgrims to Mecca.  Consult the ‘Yellow 
Book’ - Health Information for Overseas Travel 1995 (now slightly out-of-date) 
or the WHO or CDC Altanta travel websites for up to date information (refer to 
travel health advice section). 
Patients who are not otherwise taking antibiotic prophylaxis should do so during 
periods of travel and should keep a therapeutic course of antibiotics with them 
for the duration of the holiday. 
Animal Bites 
Asplenic patients are especially vulnerable to invasive infection following dog and 
other animal bites from the organism Capnocytophaga canimorsus.  They should 
receive a 5 day course of co-amoxiclav (erythromycin in allergic patients). 
Patients should be encouraged to carry a Medic-Alert disc and carry a card with 
information about their lack of spleen. 
I have no functioning spleen cards’ are available from the Department of Health, 
PO Box 410, Wetherby LS23 7LL, fax 01937 845381.  They are currently being 
updated to include new advice regarding Men C vaccine. 

1. Introduction 
This guideline sets out the procedures for staff to follow for food hygiene in client’s 
own homes. 
2. Legislation 
All individuals who handle food should follow basic food hygiene practices to ensure 
contamination and subsequent disease does not occur.  
All staff involved in the handling of food should be aware of the legislation relevant to 
food management.  The main legislation is the Food Safety Act 1990 (amended 
Regulations 2004) and its related regulations (General Food Hygiene Regulations 
(1995) and The Food Safety (Temperature Control) Regulations (1995). 
Basic Requirements for Food Safety 
It is recognised that when preparing food for clients in their own homes, adequate 
kitchen equipment, crockery and cutlery, facilities for the handling and distribution, 
preparation and storage of food may not be readily available. 
However basic principles should be observed: 
•  It should be ensured that the food purchased is of good and wholesome 
quality and is subsequently stored, prepared, cooked and served in hygienic 
•  Check “use by” dates.  Use food within recommended times 
•  Do not eat food containing uncooked eggs.  Keep eggs in the fridge 
•  Food Preparation Areas.  All food preparation surfaces should be cleaned 
before, and after use with hot water and GPD, and dried with disposable 
paper towels 
•  Pets.  Keep pets away from food, dishes and worktops 
•  Cross Contamination.  Care is taken not to contaminate cooked foods with 
raw foods. There should be a separate chopping board and utensils for each 
type of food (e.g. raw meat, cooked meat and raw and cooked perishables) 
•  Hands and Hand-washing.  Hands must be washed thoroughly following 
any cleaning session, after toilet visits, before handling food and between 
handling different food types e.g. raw and cooked meats 

•  Refrigerators.  All fridges should be defrosted and cleaned regularly.  
Should a spillage occur or food become stale the whole interior of the fridge 
should be cleaned with hot water and GPD and dried thoroughly 
•  Food.  Food should be stored at the correct temperature.  The fridge should 
be kept at 5oc or lower.  The freezer should be kept at minus 18oc or below.  
Bacteria will grow in temperatures between 10-65oc.  It is recommended that 
a record of daily temperature recordings is kept 
•  Storage.   Store raw meat and fish at the bottom of the fridge ensuring 
juices do not drip on to salads and vegetables.  Raw meat and defrosting 
foods should be stored in covered dishes, or boxes which can catch drips 
Dry foods should be stored in sealed containers on shelves or in cupboards.  Food 
should not be stored on the floor to inhibit the entry of animals.  Open bottles, such as 
squash, sauces and jams may require storage in the refrigerator.  Follow 
manufacturer’s guidelines 
•  Defrosting.  All foods should be defrosted in the fridge or microwave, not at 
room temperature (unless specified on the packaging).  Do not re-freeze 
uncooked food.  Cook before you freeze again 
•  Cooking.  Always follow cooking times on the labels and in cook books.  
Cook food thoroughly so that the temperature reaches 70oc for at least 2 
minutes.  Ideally food should be eaten as soon as it is cooked or prepared.  
Never re-heat food more than once 
•  Leftovers.  These should not be left out unnecessarily.  Cold food should be 
covered and put directly into the fridge.  Hot food should be cooled for one 
hour at room temperature and then placed in the fridge.  All leftovers should 
be eaten within 2 days 
•  Crockery and Cutlery.  If a dishwashing machine is not available, hot water 
and GPD should be used for washing. Dry with disposable heavy-duty paper 
•  Dishcloths.  Disposable cloths should be used. 

1. Introduction 
This guideline sets out the procedures for staff to follow for pets. 
Whilst staff caring for clients in their own homes have no direct responsibility for 
clients’ pets, there may be occasions when staff do become involved in their care.  
However, with regard to the management of pets, staff may be the only individuals in 
a position to instigate the control and management of them, by referring the problem 
to the local Environmental Health Department. 
2. Pets 
Many types of animal are often kept as pets can be the source of human infection, 
including exotic species such as reptiles, fish or birds. Sensible precautions can 
reduce any infection risk to an acceptable level. 
All animals should be regularly groomed and checked for signs of infection, flea 
infestation, or other illness.  If pets become ill, diagnosis and treatment by a vet should 
be sought.  All animals should have received relevant inoculations.  Dogs and cats 
should be wormed regularly, as directed by a vet and be subject to a regular 
programme of flea prevention. 
Hands should be washed following any contact with animals, their bedding or litter. 
Pets should not be fed in the kitchen or other food preparation areas and their dishes 
and utensils should be washed separately from other household articles. 
Once opened, pet food containers should be kept separate from food for human 
Food not consumed in one hour should be taken away or covered to prevent attracting 
Litter Box Care 
Never deal with a cat’s litter box if you are pregnant. 
Always wear a protective apron and gloves when cleaning the litter box. 
Always wash hands immediately after removing protective clothing. 

If possible, fit a disposable liner to the box for easy cleaning. 
Soiled litter should be changed daily. 
Litter should be sealed in a plastic bag and disposed of in household waste. 
The litter box should not be sited near food preparation, storage or eating areas. 
The litter box should be disinfected whenever the litter is changed by being filled with 
boiling water which is allowed to stand for at least 5 minutes in order to kill 
toxoplasmosis eggs and other organisms. 
4. Pests 
Pests may be found in any property but with sensible precautions will not present an 
infection risk to residents and staff. 
These include: 
Insects      - ants, flies, cockroaches, fleas, silverfish 
Rodents    - rats and mice 
Birds          - pigeons, magpies, sparrows, etc. 
Feral cats and foxes 
Kitchen and food stores provide ideal conditions for pests.  Not only do they eat the 
food but also they contaminate and spoil a lot more. 
Control measures should include the following: 
•  Stop pests getting in by fly screens, well-fitting doors, covered drains and bird 
•  Look out for droppings, nests, chew-marks on wood or cables 
•  Discard any foodstuffs or other articles affected by pests, including milk from 
bottles, the tops of which have been pecked by birds 
•  Clean up any spillage and decaying food immediately.  Carry out regular 
inspection and rotate any stock.  Use rodent-proof containers with well-fitting lids.  
Store food off the ground. 
If any pests are found the local Environmental Health Office or Pest Control 
Contractor should be contacted. 


Refer to ICNA audit tools for the community, which are available from the ICNA. or contact the EHPU for advice and examples of audit tools. 


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