Standard (Infection Control) Precautions Policy

STANDARD (INFECTION CONTROL) PRECAUTIONS POLICY

Version / 6
Name of responsible (ratifying) committee / Infection Prevention Management Committee
Date ratified / 02 August 2017
Document Manager (job title) / Infection Prevention Management Committee
Date issued / 31 August 2017
Review date / 30 August 2020
Electronic location / Infection Control Policies
Related Procedural Documents / Infection Control Policies / Occupational Health
Key Words (to aid with searching) / Risk Assessment; Standard Precautions; Universal precautions potentially contaminated; HIV infections; Staff; Visitor; Patient; Locum; Personal protection equipment; (PPE): Risk assessment; Body fluids; Occupational health and safety; Gloves; Aprons; Clinical waste; Training; Infection control; Waste disposal; Clinical guidelines; blood borne viruses

Version Tracking

Version / Date Ratified / Brief Summary of Changes / Author
6 / 02/08/2017 / Minor revision (no change to process) / IPT
5 / 13/05/2015 / Update to standard infection control precautions to include decontamination of medical devices, cough and respiratory hygiene / IPT

CONTENTS

QUICK REFERENCE GUIDE 3

1. INTRODUCTION 4

2. PURPOSE 4

3. SCOPE 4

4. DEFINITIONS 4

5. DUTIES AND RESPONSIBILITIES 4

6. PROCESS 5

7. TRAINING REQUIREMENTS 14

8. REFERENCES AND ASSOCIATED DOCUMENTATION 15

9. EQUALITY IMPACT STATEMENT 15

10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS 16

EQUALITY IMPACT SCREENING TOOL 17

QUICK REFERENCE GUIDE

1. Standard Infection Control Precautions are the basic infection prevention and control measures necessary to reduce the risk of transmission of infectious agents from both recognised and unrecognised sources of infection.

2. Standard Infection Control Precautions are to be used by all staff, in all care settings, at all times, for all patients whether infection is known to be present or not.

3. The main elements of SICP’s are:

·  Hand Hygiene – refer to Hand Hygiene Policy

·  Personal Protective Equipment & Risk Assessment

·  Respiratory and Cough Hygiene

·  Occupational Safety: Prevention and Exposure Management including Sharps - refer to NSI and contamination incidents policy

·  Management of blood and body fluid spillage

·  Safe use of Medical Devices (inc. Decontamination) - refer to Decontamination policy

·  Aseptic technique – refer to Asepsis policy

·  Management of Linen – refer to Linen Handling and Laundry policy

·  Management of Healthcare Waste – refer to Waste Handling policy

4. The type of PPE worn is based on the assessed risk of the clinical intervention to be undertaken.

5. All PPE should be:

·  single-use only items unless specified by the manufacturer

·  single patient use (only be used for one patient episode)

·  donned and removed in an order that minimises the potential for cross-contamination

1.  INTRODUCTION

Standard Infection Control Precautions (SICP) (previously known as Universal Precautions) are the basic infection prevention and control measures necessary to reduce the risk of transmission of infectious agents from both recognised and unrecognised sources of infection. Sources of (potential) infection include blood and other body fluids secretions or excretions (excluding sweat), non-intact skin or mucous membranes and any equipment or items in the care environment that could have become contaminated.

2.  PURPOSE

The purpose of this policy is to provide guidance for staff within Portsmouth Hospitals NHS Trust about the requirements and processes for implementing Standard Infection Control Precautions.

3.  SCOPE

Standard Infection Control Precautions are to be used by all staff, in all care settings, at all times, for all patients whether infection is known to be present or not to ensure the safety of those being cared for, staff and visitors in the care environment.

This Policy applies to all staff employed by Portsmouth Hospitals NHS Trust (the Trust) or Carillion, and also to all visiting staff including staff from external agencies (e.g. CCG or other Trusts), tutors, students, agency/locum staff and contractors.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

4.  DEFINITIONS

Standard Infection Control Precautions (SICP) (previously known as Universal Precautions) are the basic infection prevention and control measures necessary to reduce the risk of transmission of infectious agents from both recognised and unrecognised sources of infection.

5.  DUTIES AND RESPONSIBILITIES

Chief Executive

·  Ensure that infection prevention and control is a core part of clinical governance and patient safety programmes

·  Promote compliance with infection prevention and control policies in order to reduce health care associated infections

·  Awareness of legal responsibilities to identify, assess and control risk of infection

Director of Infection Prevention Control (DIPC)

·  Oversee infection prevention and control policies and their implementation

·  Responsible for infection prevention and control team

·  Report directly to the Chief Executive and Trust Board

·  Challenge inappropriate hygiene and infection prevention and control practice

Infection Prevention Team:

·  Review and update he Standard Infection Control Precautions policy

·  Give additional advice regarding SICP’s and risk assessments

·  Include SICP’s in all induction and update training for clinical staff

·  Promote good practice and challenge poor practice

·  Conduct audit and inspection of SICP with feedback to clinical staff

Matrons / Ward Managers:

·  Must establish a cleanliness culture across their units and promote compliance with infection prevention guidelines, including SICP

·  Promote good practice and challenge poor practice

All Healthcare Staff:

·  Must be familiar with and adhere to the relevant infection prevention policies to reduce the risk of cross infection of patients

·  Must adhere to the full terms and conditions of SICP’s documented in this policy

·  Must use the risk assessment process to identify the appropriate level of SICP for each situation

·  Promote good practice and challenge poor practice

·  Refer to the infection prevention team if unable to follow the policy guidelines

6.  PROCESS

6.1 To be effective in protecting against infection risks, SICPs must be used continuously by all staff.

The application of SICPs during care delivery is determined by an assessment of risk to and from individuals and includes:

·  the task;

·  level of interaction;

·  and/or the anticipated level of exposure to blood and/or other body fluids.

The main elements of SICP’s are:

·  Hand Hygiene – refer to Hand Hygiene Policy

·  Personal Protective Equipment & Risk Assessment

·  Respiratory and Cough Hygiene

·  Occupational Safety: Prevention and Exposure Management including Sharps - refer to NSI and contamination incidents policy

·  Management of blood and body fluid spillage

·  Safe use of Medical Devices (inc. Decontamination) - refer to Decontamination policy

·  Aseptic technique – refer to Asepsis policy

·  Management of Linen – refer to Linen Handling and Laundry policy

·  Management of Healthcare Waste – refer to Waste Handling policy

·  Last Offices – refer to When an Adult Dies Policy

6.2 Hand Hygiene

The decontamination of hands is shown to significantly reduce the carriage of potential pathogens and decrease the risk and occurrence of Healthcare Associated Infections.

Hands must be decontaminated when visibly dirty / contaminated, at the 5 key moments and immediately after the removal of gloves:

All staff must be ‘naked below the elbow’ before entering a clinical area and for the duration of their work.

The two main products for hand decontamination are:

·  alcohol-based hand rub for clean hands, or

·  liquid soap and water for visibly dirty hands or when caring for patients with vomiting or diarrhoeal illness.

All clinical staff must use a seven-step technique to systematically decontaminate hands and aseptic hand hygiene must be performed prior to invasive procedures e.g. central line insertion, dressing etc.

Staff should follow recommended hand hygiene techniques to prevent damage or cracking to hands and regularly use emollient hand cream to maintain skin patency when hands are at rest.

All clinical staff are responsible for completing, and remaining up to date with annual hand hygiene training.

Refer to the Hand Hygiene Policy.

6.3 Personal Protective Equipment & Risk Assessment.

Personal Protective Equipment (PPE) is additional to normal clothing and uniforms and is used to protect both the patient and health care worker from the risk of cross infection. PPE should be available for all staff and may include aprons and fluid repellent gowns/suits, gloves (sterile and non-sterile latex free), masks and eye protection (goggles and face visors).

Before undertaking any procedure staff should assess any likely exposure and ensure PPE is worn that provides adequate protection against the risks associated with the procedure or task being undertaken.

All PPE should be:

·  located close to the point of use

·  stored to prevent contamination in a clean/dry area until required for use (expiry dates must be adhered to)

·  single-use only items unless specified by the manufacturer

·  disposed of after use into the correct waste stream i.e. offensive or infectious waste.

Gloves must be:

·  Worn when exposure to blood and/or other body fluids is anticipated/likely

·  Changed immediately after each patient and/or following completion of a procedure or task on the same patient

·  Changed if a perforation or puncture is suspected

·  Well-fitting to avoid excessive sweating and interference with dexterity (sized sterile gloves may be used for clinical procedures if required).

·  Gloves are not impervious to infection but reduce penetration of blood and body fluids on to the hands

·  Gloves should not be worn unnecessarily as their prolonged and indiscriminate use may cause adverse reactions and skin sensitivity. The gloves themselves also become a source of infection/contamination

·  Gloves should be non-powdered and not made of latex

·  Gloves should not be washed or sanitised with alcohol gel

·  Gloves are not a replacement for hand hygiene

·  Sized sterile gloves should be available and used for all aseptic procedures.

Double gloving is recommended during some Exposure Prone Procedures (EPPs) or when attending major trauma incidents.

Aprons must be:

·  Worn to protect uniform or clothes when contamination is anticipated/likely e.g. when in direct care contact with a patient

·  Changed between patients and/or following completion of a procedure or task.

Staff are to wear a YELLOW (or colour coded) apron when caring for infectious patients nursed in isolation or with transmission precautions.

Full body gowns/Fluid repellent coveralls must be:

·  Worn where there is a risk of extensive splashing of blood, body fluids, secretions and excretions, with the exceptions of sweat, onto the skin of health care workers. These may be sterile or non-sterile in nature depending on the intended use

·  Changed between patients and/or following completion of a procedure or task.

Eye/face protection (including full face visors) must be:

·  Worn if blood and/or body fluid contamination to the eyes/face is anticipated/likely.

If reusable equipment is used it should be decontaminated appropriately (refer to the Decontamination policy)

·  Single use / single patient use items should be disposed of immediately

·  Goggles and visors should fit the wearer well

·  Hands should be washed with soap and water on removal.

Fluid repellent surgical face masks must be:

·  Worn if splashing or spraying of blood, body fluids, secretions or excretions onto the respiratory mucosa (nose and mouth) is anticipated/likely e.g. for influenza cases, bacterial meningitis, diphtheria

·  Worn to help prevent particles being expelled into the environment or onto the sterile field by the wearer in order protect patients from the operator as a source of infection e.g. during surgery

·  Well fitting and fit for purpose (fully covering the mouth and nose) (recognizing that such masks are not necessarily designed for filtration efficiency, or to seal tightly to the face)

·  Be handled as little as possible and changed between patients or operations.

·  Removed or changed;

·  at the end of a procedure/task;

·  if the integrity of the mask is breached, e.g. from moisture build-up after extended use or from gross contamination with blood or body fluids; and

·  in accordance with specific manufacturers instructions (including disposal).

Respirator FFP3 masks must be:

·  Worn to provide protection from exposure to airborne particles

·  Made to defined national European standard EN149:2001+A1:2009 FFP3 respirator

·  Fit tested to ensure that an adequate seal is achievable

·  Worn correctly to seal firmly to the face, thus reducing the risk of leakage

·  Only be used when clinically indicated and should be disposed of by the wearer on leaving the infected environment. Indications include airborne respiratory pathogens e.g. Open Pulmonary Tuberculosis, where high level protection is needed e.g. Viral Haemorrhagic Fevers or during potentially infectious Aerosol Generating Procedures in patients with specific pathogens e.g. influenza, SARS

Aerosol Generating Procedures are defined as:

·  Intubation, extubation and related procedures, e.g. manual ventilation/open suctioning

·  Cardiopulmonary resuscitation

·  Bronchoscopy

·  Surgery and post mortem procedures in which high-speed devices are used

·  Non Invasive Ventilation (NIV) e.g. Bilevel Positive Airway Pressure Ventilation (BiPAP) and Continuous Positive Airway Pressure Ventilation (CPAP)

·  High Frequency Oscillatory Ventilation (HFOV)

·  Induction of sputum.

Removal of Personal Protective Equipment must be:

Performed in an order that minimises the potential for cross-contamination. On completion of a task/procedure, gloves, gown and eye goggles should be removed (in that order) and disposed of as clinical waste. If wearing a mask, this should be removed last, to minimise contamination of the face.

1. Gloves

·  Grasp the outside of the glove with the opposite gloved hand; peel off

·  Hold the removed glove in gloved hand