appendix a infection prevention specification for ... · infection prevention specification for...

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Appendix A

Infection Prevention Specification for Community Extended Minor Surgery Services

Introduction Minor surgery in the community is an important service, is popular with patients, cost-effective and in line with Government initiatives. Sandwell and West Birmingham CCG (SWBCCG) must ensure that the range of surgical procedures offered to patients is performed safely within high environmental standards. To minimize infection, firstly, the surgical technique adhering to aseptic practice is crucial. Secondly, practitioners carrying out minor procedures should be competent to do so, appropriately trained and able to demonstrate evidence of appropriate educational activities every 5 years, with a continuing sustained level of clinical activity1. It is expected by the RPNST that all clinical staff in general practice will attend infection control training annually and adhere to the regulations regarding immunisations and should have documented evidence of their Hepatitis B status. Finally, the design and layout of facilities in primary care and community settings is appropriate and comply with infection prevention guidance and standards2,3,4. The guidance draws upon best practice, available evidence, other guidelines where appropriate, and expert consensus to provide sensible and feasible advice. Surgical procedures in secondary care are performed in compliance with strict environmental standards5,6,7 to minimise the risk of post-operative infection. These environments are controlled and monitored. As services are decommissioned from secondary care to primary care there will be an increase in the range of surgical procedures offered to patients by their GPs. SWB CCG must be assured that the practice provides a safe, clean environment to perform minor surgical procedures. The range of premises where minor surgical procedures are performed within the local area varies considerably. Provision of a compliant service with HBN 26 is extremely expensive, not feasible and unnecessary for the majority of minor surgery procedures. The information obtained from audits undertaken question not only whether the rooms are ‘fit for purpose’ to perform minor surgery but whether treatment rooms where procedures are performed (that breach the skin’s integrity e.g. phlebotomy, wound dressing) reach an appropriate standard for the delivery of safe, clean care. A risk category approach to determine the appropriate facilities for minor surgery is required. The level of risk of procedure is dependant on the room required (appendix B). It is recognized that the risk of infection will vary according to the procedure and the patient. Consequently, such factors should be considered in deciding where a procedure should be carried out and under what conditions, i.e. conventional operating theatre standards or those outlined below.

1 BMA (2001) Minor Surgery in General Practice

2 Department of Health (2010) The Health Act : Code of practice for the prevention and control of healthcare associated infections Department of Health London 3 HIS (2011) Guidelines on the facilities required for minor surgical procedures and minimal access interventions 4 AfPP (2008) Standards and Recommendations for Surgery in Primary Care 5 Department of Health (2007) Heating and ventilation systems HTM 03-01: Specialised ventilation for healthcare premises 6 NHS Estates (2007) Facilities for surgical procedures HBN 26 Leeds 7 Journal of Hospital Infection (2002) 52:1-28 Microbiological commissioning and monitoring of operating theatre suites http://www.idealibrary.com on

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Low risk procedure require Clean room standards Medium risk procedure require Treatment room standards High risk procedure require Operating room standards

High risk procedures are not currently undertaken and standards are not included in this document. Low and medium risk surgical procedures should be performed preferably in a dedicated room. If this is not possible dedicated time should be allocated and the procedures should not be performed in between patient consultations. This area must be free from sources of contamination e.g. dust blown from open windows, fans, incorrect storage of sterile packs. This document attempts to provide guidance particularly focusing on facilities to provide assurance to SWCCG that the quality standards can be met by the providers of the service to cover the full range of minor surgical procedures commissioned by the CCG. Compliance with the standards (appendix B) should be monitored annually and the report available during inspection. Cryotherapy, curettage and cauterisation will continue to be provided by general practitioners as an Additional Service and practices wishing to opt out of providing these treatments will be obliged to apply to do so in the prescribed manner. Joint aspiration will not be funded under this agreement as there is a lack of evidence of joint aspiration alone as a treatment. Environmental hygiene and clinical practice in healthcare facilities will be covered briefly as they have an important role to play in the prevention and control of infection and providers must comply with the registration requirements of The Health and Social Care Act 20082. Clinical Practice

1. Providers must have all infection prevention and control policies stated in the Health Act2 (see appendix C), particularly and adhere to national guidelines8,9. All procedures should be performed using aseptic technique and all instruments and materials used for surgical procedures must be sterile.

2. Skin cleansing is essential and appropriate skin disinfectants must be used. Alcohol based solutions are preferred to aqueous solutions but it is important to allow the skin to dry following application and before the use of electrocautery. Solutions should be available in single-use sachets and not multi-use bottles as they can become contaminated on repeated opening. If multi-use bottles of skin disinfectants are used they should be used by the ‘use by date’ and not refilled.

3. No other multi-use bottles should be used this includes local anesthetic.

4. Pre-operative hair removal is only necessary if it interferes with surgery. The length of time

from shaving prior to surgery impacts on the risk of infection. The longer the time in advance, the higher the risk of infection. If hair removal is necessary then depilatory cream should be used the day before operation. If this is not possible (e.g. skin reaction from depilatory creams) shaving should be performed as close to surgery as possible immediately pre-operatively using

8 Department of Health Health BuildingNote 00-09(2013): Infection control in the built environment 9 Department of Health Decontamination Health Technical Memorandum 01-01: Decontamination of reusable medical devices

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clippers rather than a razor. Clipper heads should be single-use or decontaminated adequately prior to re-use.

5. Surgical hand decontamination is an important contributor to reducing infections. A two minute

hand wash using an aqueous disinfectant is required before any procedure regarded as ‘sterile’. Alcohol hand rubs are an acceptable alternative to repeated decontamination. Enough hand rub should be dispensed into cupped hands to allow vigorous rubbing over hands and forearms using an effective technique in between cases. Hands must be dried on a sterile towel for invasive techniques.

6. The use of sterile gloves and plastic apron or disposable gown is the minimum requirement for

performing surgical procedures and is essential as a barrier for personal protection from patient’s blood and exudates, and to prevent contamination of the surgical site from bacteria on the operator’s hands and clothing. A fresh pair of sterile gloves should be worn for each procedure. For joint injections non-sterile gloves may be used if a non-touch technique is performed. Alternatives to natural rubber latex gloves are readily available. e.g. nitrile and should be the glove of choice. If latex gloves are worn sensitivity to natural rubber latex in patients and healthcare personnel must be assessed and documented.

Equipment

1. It has also been previously agreed local decontamination of re-usable medical instruments is unacceptable. The preferred methods for safe instrumentation are re-usable instruments that are transferred to an accredited central sterile service department or the use of single-use instruments as it will be difficult for local decontamination to comply with national guidance.

2. Containers to transport used surgical instruments for decontamination must be compliant with

UN337310. All single-use items, including electrocautery probes must be used within the use by date and disposed of immediately following use.

Ventilation

1. Where mechanical ventilation is in use these must be maintained, monitored and comply with HTM 03-03, HBN 03-0111,12

Environment

1. Providers must adhere to the approved set of standards set out in appendix B.

2. A separate fully equipped cleaner’s room is required. 3. Waste is to be stored in a secure area, away from the public.

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Department of Health (2007) Decontamination of re-usable medical devices in the primary, secondary and tertiary care sectors 11 Department of Health (2007) Heating and ventilation systems HTM 03-01: Specialised ventilation for healthcare premises 12 Department of Health (2013) Health Building Note 00-03:Clinical and clinical support spaces

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4. All other rooms in the surgery must meet infection control standards. Cleaning Providers must provide and maintain a clean, clutter free and appropriate environment in managed premises that facilitates the prevention and control of infections. Surgeries must follow guidance13 to comply with Criterion 2 of the Code of Practice:

1. Clear definition of specific roles and responsibilities for cleaning;

2. Clear, agreed and well-publicised cleaning routines;

3. Consultation with ICTs on cleaning protocols when internal or external contracts are being prepared;

4. Sufficient resources dedicated to keeping the environment clean and fit for purpose; and

5. Details of how nurses can request additional cleaning, both urgently and routinely

6. The room is cleaned at least daily with a freshly prepared detergent and water solution used. If a known healthcare infection is present, the individual is to be left till the end of the list where possible. The room is then to be cleaned with 1000ppm chlorine-solution, paying particular attention of horizontal surfaces.

7. Colour coding systems must be in place to ensure there is no cross contamination. It is suggested that yellow mops, buckets and cloths are used for minor surgery rooms. Cloths must be disposable and mops used are for minor surgery only.

8. Providers must ensure that there are audit and inspection policies in place which ensure cleaning services are regularly monitored, any shortcomings identified, remedial actions taken, and that there is a clear and robust audit trail in place.

9. External annual infection prevention audit required.

Surveillance The tariff for each procedure performed, does not take into account the additional costs incurred by treatment of a healthcare associated infection (HCAI). The risk of wound infection is dependant on risk category of patient, classification of surgical procedure, environmental standards, contamination from surgical instruments and staff, skin disinfection, pre-op shaving, length of procedure and surgeons technique. Surveillance is a key component to measure clinical practice and associated outcomes. General practitioners will be expected to undertake prospective surveillance to accurately determine the any complications arising from the surgical procedure, post procedure infection rate and clinical outcomes. MRSA screening is required from high risk patients these include patients who are; immunocompromised, from care homes; previously MRSA. Audit and Records: Full records of all procedures should be maintained in such a way that aggregated data and details of individual patients are readily accessible for lawful purposes. Providers should regularly audit and peer review minor surgery work. Possible topics for audit include:

13 National Patient Safety (2010) The national specifications for cleanliness in the NHS: Guidance on setting and measuring performance outcomes in primary care medical and dental premises

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1. clinical outcomes 2. rates of infection 3. unexpected or incomplete excision of basal cell tumours or pigmented lesions which following

histological examination are found to be malignant. Advice should be requested from the Infection Prevention and Control Lead on infection control issues, specific requirements for decontamination and for the commissioning of new and refurbishment of old builds. This document has been produced to assist providers to assess their ability to meet the quality standards set down in the new contract. The overall requirements around infection control and health and safety are common to all of these services and others routinely provided in primary care. If standards are unacceptable information will be communicated with the SWBCCG Quality and Safety Committee who will review the action required and suspend the service if risks are identified. Minor surgery will resume following re-audit to confirm the appropriate standards have been achieved to ensure the environment is safe to perform minor surgery.

Appendix B

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Appendix B - FACILITIES REQUIRED FOR CATEGORY OF RISK

PROCEDURE SITE RISK CATEGORY Minimal FACILITIES REQUIRED

Aspirations Abscesses Medium Treatment

Bursae Low Clean

Cysts Low Clean

Hydrocele Low Clean

Joints Medium Treatment

Curretage, cautery and cryocautery

Warts,verrucae, nasal, molluscum contagiosum

Low Clean

Excisions Ganglia Low Clean

Intradermal naevi, papilloma Medium Treatment

Lipoma Low/medium depending on size Clean/Treatment depending on risk

Removal of toenail (partial) Low Clean

Sebaceous cysts Medium Treatment

Skin lesion for histology Medium Treatment

Superficial orthopaedic metalwork

Medium treatment

Warts Medium Treatment

Wedge resection Medium Modified Treatment

Incisions Abscesses Medium Treatment

Cysts Medium Treatment

Marsupialisation Medium/High Treatment/Operating

Thrombosed haemarrhoids Medium Treatment

Appendix B

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PROCEDURE SITE RISK CATEGORY Minimal FACILITIES REQUIRED

Other Arthroscopy High Operating

Avulsion of varicose veins Medium Treatment

Carpal tunnel Medium/High (depending on complexity and patient risk factors)

Modified Treatment/Operating

Circumcision Medium Treatment

Colposcopy Low Clean

Dupuytren’s contracture Medium Modified Treatment

Fissure Low Clean

Hammer toe surgery High Operating

Herniorraphy High Operating

Hormone implants Low Clean

Removal of foreign body Dependant on site Dependant on risk

Vasectomy High Modified Treatment/Operating

Zadeks procedure (wedge osteotomy)

High Operating

Appendix B

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Incision None Epidermis Muscle Fat Sterile Organ / Cavity

Duration of Exposure

Short Long

Mix of Dirty & Clean Procedures

No Yes LOW risk procedure Clean room standards MEDIUM risk procedures Treatment room standards HIGH risk procedures operating room standards

Risk Assessment

Facilities Required for Minor surgery

Low High

Appendix B

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ENVIRONMENTAL STANDARDS FOR MINOR SURGERY

Room Comments Compliant Yes/No

If no Action required

Scheduled date for completion

The room is at a minimum of 12m2 (New Builds – 16m2 –

20m2)

Room of adequate size to perform minor surgery – Less than 12m2 is not acceptable

The room is dedicated for minor surgery room/or dedicated sessions

Dedicated sessions must be performed prior to commencing consultations am or pm

The room is free from clutter. Contains the minimum amount of equipment to clean adequately.

The room is clean and free from dust

The room is cleaned daily. Cleaning schedules to be available

The ceiling should preferably be made from non-porous material that can be easily cleaned.

No artex. Suspended ceilings should not be installed in new facilities

The walls are smooth, continuous

The walls are clean, in a good state of repair, no tiles and no plaster damage. On cleaning schedule

The walls can withstand a chemical disinfectant

Walls to be painted with egg shell or satin paint. No ceramic tiles

The flooring is impervious, durable, easy to clean and non-slip

Appendix B

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The flooring forms a coved skirting with welded seams

Coved flooring to 20cm. No visible dust in corners.

Door must be self closing with an vision panel

Must be balanced with the necessity for patient privacy-opaque panel.

Pipework is contained in a smooth-surfaced washable box

Central heating radiators should have covers

Radiator covers must be removed for cleaning at least quarterly or when visible dust is apparent.

Windows should be unable to be opened, where mechanical ventilation is provided. Where there is natural ventilation windows must be closed during surgical procedures or a fly screen to prevent ingress of insects.

To be stated in operational policy - Must be standard in new build. Where windows are present, these must not compromise patient privacy.

Electric fans are not in use Fans will disperse micro-organisms carried on dust and skin scales

Mechanical ventilation maintenance and filter change

10 air changes per hour supply and extract as a minimum

Air vents are on a 6 monthly maintenance programme

Dust and organisms will be dispersed back into the room if vents not cleaned

Appendix B

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An adjustable easy to clean examination lamp and fitted with a heat filter

Naked bulbs and heat will attract dust

Overhead lighting is clean and bulbs enclosed

Naked bulbs and heat will attract dust

Fixtures and fittings are well maintained, able to be cleaned

in a good state of repair

All furniture are impermeable made from washable material, clean and in a good state of repair

There is an adjustable, mobile, treatment couch, in a central position and accessible from both sides

Washable impervious material surface. Non-textured.

Work surfaces are free from clutter

Work surfaces are smooth, impervious, easily cleaned with coved edges and can withstand chemical disinfectants

All edges to be heat sealed

A range of built-in storage cupboards

Not surrounding sink-any leakage from u-bends will damage the integrity of items

Appendix B

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There is designated secure storage for sterile supplies

There are no items on shelves

No bookcases

Blinds are vertical or absent

Blinds are made of wipeable material

There is a cleaning programme for material blinds/curtains

Curtain tracks do not hinder good infection control practice

Curtains are on tracks which when drawn allow sufficient movement without contact with couch, staff and immediate facilities

There is a paper roll holder attachment incorporated at the head of couch

To avoid contamination of roll

Pillows are impervious if used

There is a dedicated clinical procedure hand wash basin complying to HTM 64/ Overflow

No sinks with drainers Splash back no tiles 100mm either side

Hand wash basin has no plug

Appendix B

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Elbow operated or automated mixer taps are available

No faucets. Provision with suitable hand wash water Appropriately positioned

An approved hand disinfectant is available

Must be pump action In date

Alcohol gel dispenser is available

In date

Wall mounted cartridge soap dispenser in close proximity to sink

Not sited over work surfaces. No ‘top-up’ system

Wall mounted paper towel dispenser in close proximity to sink

Sterile gloves are available for invasive procedures

Wall mounted apron dispenser

Aprons on a roll available

Gowns are available

For high risk procedures

Face masks and goggles are available when splashing of body fluids is anticipated

Solidifying pouches are available for absorbing bodily fluids

Access to clean and dirty room. New builds

Appendix B

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Suction canisters to be fitted with disposable liners

An approved skin disinfectant is available

Must be alcohol based chlorhexidine or iodine for intact skin. Sterile saline or chlorhexidine for non intact skin or mucous membranes. 500ml bottles acceptable if dated when opened

No multi use products are used

e.g. Local anesthetics

A designated clean free standing procedure trolley is available for minor surgery

No items stored on the trolley. Waste bags are not attached to cupboard/trolley etc.

A sharps container is available to dispose sharps at point of use

At a height out of reach for children but low enough to allow visual disposal of sharp

There is a foot operated household waste bin

There is a foot operated clinical waste

Instruments to be laid up as required not in advance of procedures where there is no laying-up area

Appendix B

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Re-usable medical instruments are not in use

There is no evident of re-use of single use items

There is evidence of MRSA screening for high risk patients

Infection prevention policies are available

There is evidence of annual infection prevention training

There is evidence of ongoing audit

Monthly hand hygiene Quarterly environmental Quarterly aseptic technique

There is evidence of annual external agency infection prevention audit

There is a fully equipped cleaners room

Hand wash basin Low disposal sink Appropriate colour coded equipment

There is evidence of surveillance of wound infection

To early identification of clusters of infection

All rooms in the surgery comply with infection prevention standards

Appendix C

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Appendix C - Guidance for compliance with criterion 9

Have and adhere to policies, designed for the individual’s care and provider organisations, that will help

to prevent and control infections. The following guidance indicates the policies that may be relevant to

providers.

a. Standard infection prevention and control precautions

b. Aseptic technique

c. Outbreaks of communicable infection

d. Isolation of service users with an infection

e. Safe handling and disposal of sharps

f. Prevention of occupational exposure to blood-borne viruses (BBVs), including prevention

of sharps injuries

g. Management of occupational exposure to BBVs and post-exposure prophylaxis

h. Disinfection

i. Decontamination of reusable medical devices

j. Single-use medical devices

k. Antimicrobial prescribing

l. Reporting of infection to the Health Protection Agency or local authority

m. Control of outbreaks and infections associated with specific alert organisms-MRSA,

Clostridium difficile

n. CJD/vCJD – handling of instruments and devices

o. Safe handling and disposal of waste

p. Packaging, handling and delivery of laboratory specimens

q. Care of deceased persons

r. Purchase, cleaning, decontamination, maintenance and disposal of equipment

s. Uniform and dress code

t. Immunisation of service user

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