good practice in infection prevention and control: guidance for

Good practice in infectionprevention and control

Guidance for nursing staff

Note about languageThe term ‘patient’ has been used throughout this textbut this can also be understood to mean client orresident.

This publication contains information, advice and guidance tohelp members of the RCN. It is intended for use within the UKbut readers are advised that practices may vary in each countryand outside the UK.

The information in this booklet has been compiled fromprofessional sources, but its accuracy is not guaranteed. Whilstevery effort has been made to ensure the RCN provides accurateand expert information and guidance, it is impossible to predictall the circumstances in which it may be used. Accordingly, theRCN shall not be liable to any person or entity with respect toany loss or damage caused or alleged to be caused directly orindirectly by what is contained in or left out of this websiteinformation and guidance.

Published by the Royal College of Nursing, 20 Cavendish Square,London, W1G 0RN

© 2005 Royal College of Nursing. All rights reserved. No part ofthis publication may be reproduced, stored in a retrieval system,or transmitted in any form or by any means electronic,mechanical, photocopying, recording or otherwise, withoutprior permission of the Publishers or a licence permittingrestricted copying issued by the Copyright Licensing Agency, 90Tottenham Court Road, London W1T 4LP. This publication maynot be lent, resold, hired out or otherwise disposed of by ways oftrade in any form of binding or cover other than that in which itis published, without the prior consent of the Publishers.

…effects [fromhospital acquired infection]vary from discomfort forthe patient to prolonged orpermanent disability and asmall proportion of patientdeaths each year areprimarily attributable tohospital acquiredinfections. (National Audit Office, 2000)

R O Y A L C O L L E G E O F N U R S I N G

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Good practice in infectionprevention and controlGuidance for nursing staff

Contents

Foreword 2

Introduction 3

The general principles of infection prevention and control 3

1. Hand hygiene 4

2. Using personal protective equipment 4

3. Safe handling and disposal of sharps 5

4. Safe handling and disposal of chemical waste 6

5. Managing blood and bodily fluids 6

� Spillages 6

� Collecting, handling and labelling of specimens 6

6. Decontaminating equipment 7

� Cleaning 7

� Disinfection 8

� Sterilisation 8

7. Achieving and maintaining a clean clinical environment 9

8. Appropriate use of indwelling devices 9

9. Managing accidental exposure to blood-borne virus 10

10. Good communication 11

11. Training 11

Variant Creutzfeldt Jakob Disease (vCJD) 12

Methicillin-resistant Staphylococcus aureus (MRSA) 12

References 12

Useful reading 13

Useful websites 15

Glossary 15

Appendix 1 Infection control checklist 16

10-Step handwashing guide Inside Back Cover

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G O O D P R A C T I C E I N I N F E C T I O N P R E V E N T I O N A N D C O N T R O L

Foreword

Infection prevention and control is deservedly high on the agendafor patients, nurses and decision makers. The RCN Wipe it Outcampaign is part of our mission to promote excellence in practice.

This updated guidance will be a valuable tool to help you and yourteam reduce the prevalence of health care associated infections(HCAIs). Use it together with the other Wipe it Out leaflets andposters to promote good practice. It will help you to spare patients’anxiety, pain, inconvenience, disability and even death.

Infection control is an essential component of care and one whichhas too often been undervalued in recent years. The frontlines oftwenty-first century care combine tremendous technology andexpertise side by side with staff shortages and concerns abouthygiene. Patients and their families are concerned about whetherwe are getting the basics right – nutrition, dignity, hygiene.

Hand washing is far less glamorous than hi-tech interventions, butit is known to be the single most important thing we can do toreduce the spread of disease. By encouraging good practice amongmembers of the health care team – and visitors – you will behelping patients.

A safe working environment is a safe caring environment. Thisguidance covers important issues including disposing of waste,managing sharps, blood and bodily fluids as well as achieving andmaintaining a clean clinical environment.You will be able toappreciate how to put the guidance into practice whether younurse in hospital, in general practice or in patients’ homes.

You may also appreciate that improvements need to be made ininfection prevention and control in your workplace. This is anopportunity for you to share evidence on best practice, buildsupport from colleagues, patients, other departments and otherorganisations and present the convincing case for change. It is partof transforming the culture of health care through raisingstandards and designing person-centred services. It is as centralto patient care as effective hand washing.

The RCN is calling for a number of improvements, includingtraining in infection control for all health care staff, 24 houravailability of cleaning teams and onsite provision of staffuniforms and changing facilities. By campaigning together, wecan bring about significant positive improvements for patients,the public and the health care team.

Beverly Malone RN PhD FAAN

General Secretary

Introduction

As part of its Wipe it out campaign the Royal Collegeof Nursing has revised its guidance on good practicein infection prevention and control. This new updatedguidance emphasises the key roles that nursing staffand other health care workers in the NHS andindependent sector have in helping to reduce theprevalence of health care associated infections(HCAIs).

Every health care worker plays a vital part in helpingto minimise the risk of cross infection – for example,by making certain that hands are properly washed,the clinical environment is as clean as possible,ensuring knowledge and skills are continuallyupdated and by educating patients and visitors.

This publication includes information on the generalprinciples of infection prevention and control,including standard infection prevention and controlpractice, decontamination, achieving andmaintaining a clean clinical environment, what to doin the event of an invasive injury/accident, and theimportance of good communication. Two smallsections give guidance on variant Creutzfeldt JakobDisease (vCJD) and methicillin-resistantStaphylococcus aureus (MRSA). There is also a Usefulinformation section with signposts to initiatives andpolicies being implemented around the UK.

The generalprinciples ofinfection preventionand control (standard precautions)

Standard precautions (formerly known as universalprecautions) underpin routine safe practice,protecting both staff and clients from infection. Byapplying standard precautions at all times and to allpatients, best practice becomes second nature and therisks of infection are minimised. They include:

1 achieving optimum hand hygiene

2 using personal protective equipment

3 safe handling and disposal of sharps

4 safe handling and disposal of clinical waste

5 managing blood and bodily fluids

6 decontaminating equipment

7 achieving and maintaining a clean clinicalenvironment

8 appropriate use of indwelling devices

9 managing accidents

10 good communication – with other health careworkers, patients and visitors

11 training/education.


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1. Hand hygiene

Hand hygiene is widely acknowledged to be the singlemost important activity for reducing the spread ofdisease, yet evidence suggests that many health careprofessionals do not decontaminate their hands asoften as they need to or use the correct techniquewhich means that areas of the hands can be missed.The diagram on page 5 demonstrates the handhygiene procedure that should be followed whenwashing with soap and water or using an alcoholhand gel or rub.C T I C E I N I N F E C T I O N C O N T R O L

Hands should be decontaminated before directcontact with patients and after any activity orcontact that contaminates the hands, includingfollowing the removal of gloves. While alcohol handgels and rubs are a practical alternative to soap andwater, alcohol is not a cleaning agent. Hands that arevisibly dirty or potentially grossly contaminatedmust be washed with soap and water and driedthoroughly. Hand preparation increases theeffectiveness of decontamination.You should:

� keep nails short, clean and polish free

� avoid wearing wrist watches and jewellery,especially rings with ridges or stones

� artificial nails must not be worn

� any cuts and abrasions should be covered with awaterproof dressing.

Remove your wristwatch and any bracelets and rollup long sleeves before washing your hands (andwrists). In addition, bear in mind the followingpoints:

FacilitiesAdequate hand washing facilities must be availableand easily accessible in all patient areas, treatmentrooms, sluices and kitchens. Basins in clinical areasshould have elbow or wrist lever operated mixer tapsor automated controls and be provided with liquidsoap dispensers, paper hand towels and foot-operatedwaste bins (NHS Estates, 2002). Alcohol hand gelmust also be available at ‘point of care’ in all primaryand secondary care settings (National Patient SafetyAgency (2004).

All health care workers should bring any lack of, or

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inappropriately placed facilities to the notice of theirmanagers (or matron). They also have a duty of careto patients and themselves and must use facilitiesprovided to prevent cross infection.

Hand dryingImproper drying can recontaminate hands that havebeen washed. Wet surfaces transfer organisms moreeffectively than dry ones and inadequately driedhands are prone to skin damage. Disposable paperhand towels of good quality should be used to ensurehands are dried thoroughly. Hand towels should beconveniently placed in wall mounted dispensers closeto hand washing facilities.

2. Using personal protectiveequipment

Personal protective equipment (PPE) is used toprotect both yourself and your patient from the risksof cross-infection. It may also be required for contactwith hazardous chemicals and somepharmaceuticals. PPE includes items like gloves,aprons, masks, goggles or visors. In certain situationssuch as theatre, it may also include hats and footwear.

Disposable glovesGloves should be worn whenever there might becontact with blood and body fluids, mucousmembranes or non intact skin. They are not asubstitute for hand washing. They should be put onimmediately before the task to be performed, thenremoved and discarded as soon as the procedure iscompleted. Hands must always be washed followingtheir removal.

The choice of glove should be made following asuitable and sufficient risk assessment of the task, therisk to the patient and risk to the health care worker(ICNA, 2002). Nitrile or latex gloves should be wornwhen handling blood, blood-stained fluids, cytotoxicdrugs or other high risk substances.

Polythene gloves are not suitable for use when dealingwith blood and/or blood and body fluids, ie. in aclinical setting. Neoprene and nitrile gloves are goodalternatives for those who are sensitive to naturalrubber latex. These synthetic gloves have been shownto have comparable in-use barrier performance to


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natural rubber latex gloves in laboratory and clinicalstudies.Vinyl gloves can be used to perform manytasks in the health care environment, but are notappropriate when handling blood, blood-stainedfluids, cytotoxic drugs or other high risk substances.Please check the local policy for your workplace.

Disposable plastics apronsThese should be worn whenever there is a risk ofcontaminating clothing with blood and body fluidsand when a patient has a known infection, forexample, direct patient care, bed making or whendecontaminating equipment.You should discardthem as soon as the intended task is completed andthen wash your hands. They must be stored safely sothat they don’t accumulate dust which can act as areservoir for infection. Impervious gowns should beused when there is a risk of extensive contaminationof blood or body fluids.

Masks, visors and eye protectionThese should be worn when a procedure is likely tocause blood and body fluids or substances to splashinto the eyes, face or mouth. Masks may also benecessary if infection is spread by an airborne route –for example, multi drug resistant tuberculosis orsevere acute respiratory syndrome (SARS) – seeinformation on the Health Protection Agency website(www.hpa.org.uk).You should ensure that thisequipment fits correctly, is handled as little aspossible and changed between patients or operations(see Figure 1). Masks should be discardedimmediately after use.

Figure 1: Nurse wearing a mask in the correct position

3. Safe handling and disposal of sharps

Sharps include needles, scalpels, stitch cutters, glassampoules and any sharp instrument. The mainhazards of a sharps injury are hepatitis B, hepatitis Cand HIV. Second only to back injuries as a cause ofoccupational injuries amongst health care workers,between July 1997 and June 2002, there were 1,550reports of blood-borne virus exposures in health careworkers – of which 42 per cent were nurses ormidwives.

To reduce the risk of injury and exposure to blood-borne viruses, it is vital that sharps are used safelyand disposed of carefully, following your workplace’sagreed policies on safe working procedures.Youremployer should provide targeted education andawareness training for all health care workers.

Some procedures have a higher than average risk ofcausing injury. These include intra-vascularcannulation, venepuncture and injection. Devicesinvolved in these high-risk procedures are:

� IV cannulae

� winged steel – butterfly – needles

� needles and syringes

� phlebotomy needles.

You should ensure that:

� sharps are not passed directly from hand to hand

� handling is kept to a minimum

� needles are not broken or bent before use ordisposal

� syringes or needles are not dismantled by handand are disposed of as a single unit

� needles are never re-sheathed

� staff take personal responsibility for any sharpsthey use and dispose of them in a designatedcontainer at the point of use. The container shouldconform to UN standard 3291 and BritishStandard 7320

� sharps containers are not filled by more than twothirds and are stored in an area away from thepublic

� sharps trays with integral sharps bins are in use

� sharps are disposed of at the point of use

� sharps boxes are signed on assembly and disposal

� sharps are stored safely away from the public andout of reach of children

� staff are aware of inoculation injury policy.

If you notice that any of the above procedures are notbeing followed properly by colleagues you shouldseek advice from your infection control team who willprovide education for staff on safe use and disposal ofsharps.

Innovative products are available that can reduce therisk of sharps injuries. While they may be moreexpensive, their cost can be offset against the savingsachieved in reducing sharps injuries. Guidance on themost appropriate evaluated safety devices is availablefrom the NHS Purchasing and Supply Agency – seesources of further information for more details. Forinformation on what to do in the event of an invasivesharps injury, see page 11 of this guidance.

4. Safe handling and disposal ofchemical waste

Your workplace should have a written policy on wastedisposal, which provides guidance on all aspects,including special waste, like pharmaceuticals andcytotoxic waste, segregation of waste and an audittrail. This should include colour coding of bags usedfor waste, for example:

� yellow bags for clinical waste

� black bags for household waste

� special bins for glass and aerosols

� colour coded bins for pharmaceutical or cytotoxicwaste.

All health care and support staff should be instructedin the safe handling of waste, including disposal anddealing with spillages. Trusts should consider systemsfor segregating waste that can be recycled.

If any of theabove are notbeingimplementedhealth carestaff shouldlobby theiremployers.

5. Managing blood and bodily fluids

SpillagesThese should be dealt with quickly, following yourworkplace’s written policy for dealing with spillages.The policy should include details of the chemicalsstaff should use to ensure that any spillage isdisinfected properly, taking into account the surfacewhere the incident happened – for example, a carpetin a patient’s home or hard surface in a hospital.

Collecting, handling and labelling specimensA written policy should be in place for the collectionand transportation of laboratory specimens.Youshould:

� be trained to handle specimens safely

� collect samples (wearing protective clothing) inan appropriate sterile and properly sealedcontainer

� complete form using patient labels (whereavailable) and check that all relevant informationis included

� take care not to contaminate the outside of thecontainer and the request forms

� ensure that specimens are transported inaccordance with the Safe Transport of DangerousGoods Act 1999

� make sure specimens are sent to the laboratory assoon as possible. Under no circumstances shouldspecimens be left on window sills or placed instaff pockets

� once results are available check and enter into thepatient’s records. Any results outside normallimits should be highlighted to the patient’sclinician. Act on any infection control issuesimmediately.

If you feel you need further training in any of theabove, speak to your infection control team who willbe able to provide you with advice and training.

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6. Decontaminatingequipment

As inadequate decontamination has frequently beenassociated with outbreaks of infection in hospitals, itis vital that re-usable equipment is scrupulouslydecontaminated between each patient. To ensure thatcontrol of infection is maintained at a high level, allhealth care staff must be aware of the implications ofsafe decontamination and their responsibilities totheir patients, themselves and their colleagues.

Use table 1 to make an appropriate choice ofdecontamination method.

Decontamination is the combination of processes –cleaning, disinfection and sterilisation – used to ensurea re-usable medical device is safe for further use.

Single use equipment (where the item can only beused once) should not be reprocessed or re-used.Devices designated for single patient use (where theitem can be repeatedly used for the same patient) willbe clearly marked by a symbol. Such devices includenebulisers, disposable pulse oximeter probes andcertain specified intermittent catheters.

Figure 2: Symbol for single use equipment

CleaningThis uses water and detergent (enzymatic cleaner) toremove visible contamination but does notnecessarily destroy micro-organisms, although itshould reduce their numbers. Effective cleaning is anessential prerequisite to both disinfection andsterilisation.

Manual cleaning should be performed with extremecare and only if no other method or device is available.It is more efficient to use an automated/validatedmethod, for example, an automated washer-disinfectoror ultrasonic bath. For more detailed information, seeA protocol for the local decontamination of surgicalinstruments (NHS Estates, 2004a).

DisinfectionThis uses chemical agents or heat to reduce thenumber of viable organisms. It may not necessarilyinactivate all viruses and bacterial spores. Whereequipment will tolerate sterilisation disinfectionshould not be used as a substitute.

Washer-disinfectors should be used only by thosewith the correct training and in conjunction with asuitable detergent that has been recommended by themanufacturer or trust policy. Following the rinsecycle, items should be checked for cleanliness.Machines must be maintained, validated and complywith HTM 2030.

If an ultra sonic cleaner is used the machine should

High risk

Equipment description Level of cleaning needed Examples

Equipment that:

� enters a sterile body cavity

� penetrates the skin

� touches a break in the skinor mucous membranes.

Equipment must be cleanedand sterilised – fullydecontaminated – after eachpatient use. It should be leftin a sterile state forsubsequent use.

Examples include surgicalinstruments.

Medium risk Equipment that touchesintact skin or mucousmembranes.

Equipment does not need tobe sterile at the point of usebut must be cleaned andsterilised (decontaminated)between each patient.

Examples include a bedpan.

Low risk Equipment that does nottouch broken skin or mucousmembranes, or is not incontact with patients.

Equipment must be cleanedand/or disinfected after use.

Examples include anophthalmoscope receiver; a bedframe

Adapted from the Medical Devices Agency publication, Sterilisation, disinfection and cleaning of medical equipment (1996).

Table 1: decontamination according to associated risks

be drained, cleaned, dried, covered and left dry untilrequired for further use. Requirements for testing canbe found in HTM 2030. Log books and records mustbe kept by the designated person for both types ofmachines

Chemical disinfectants are classified genericallyand their biocidal capabilities vary. While most arecapable of inactivating bacteria and envelopedviruses, many are not so effective against nonenveloped viruses – for example, the hepatitisviruses and also cysts and bacterial spores. Efficacydepends on choosing and using the disinfectantcorrectly. Chemical disinfection is not as effective asheat disinfection. For further information on themost appropriate disinfectants to use in acommunity setting, see Infection control guidance forgeneral practice (Infection Control NursesAssociation and Royal College of GeneralPractitioners, 2003). Trusts will have their own policyfor the use of appropriate disinfectants and all healthcare staff who use chemicals must receiveeducation/training before handling.

The use of disinfectants is governed by the Control ofSubstances Hazardous to Health (COSHH) regulations,which ensure that employers must provide staff withinformation, instruction and training.

SterilisationThis ensures that an object is free from viable micro-organisms, including bacterial spores. Both acute andprimary care trusts should actively work towardsachieving central sterilising of reusable equipment,using local sterile services department (SSD) whereavailable.

All SSDs that supply re-sterilised instruments toother organisations are bound by a Europeandirective (93/42/EEC), which safeguards standards ofquality. Advantages include having a cost-effectivesystem that is quality controlled, has a trackingsystem and is managed and operated by trained staffin a purpose-built environment.

Where using your SSD is not possible, alternativesare:

� using pre-sterilised, single-use, disposable items.The advantages include convenience andsuitability for use in areas where decontaminationcould be hard to achieve.

� a bench top vacuum steam steriliser. These mustbe installed, validated and maintainedappropriately according to HTM 2010; MDA DB9804 and MDA DB 2002(06).

All steam sterilisers are subject to the PressureSystems Safety Regulations 2000 and must beexamined annually by a competent person.

The following table shows the times andtemperatures usually used for steam sterilisation:

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134 – 137

126 – 129

121 – 124

2.25

1.5

1.15

3

10

15

Sterilisingtemperature

range incentigrade min – max

Approximatepressure (bar)

Minimum holdtime in minutes

Table 2: steam sterilisation times and temperatures

The Medical Devices Agency bulletin DB 2002 (06)provides guidance on purchase, operation andmaintenance of bench top steam sterilisers (2002). Itdraws attention to the need for:

� daily testing by the user

� periodic testing by a qualified engineer

� operator training

� knowledge of the legal and insurance aspects ofownership and use

� comprehensive record keeping of testing.

Finally, bear in mind that the effectiveness ofdecontamination may be hindered at any stage of theprocess by:

� poor choice of method

� poor technique

� lack of maintenance of equipment

� inadequate monitoring

� poor handling or storage of equipment.


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schedule that details the items and environments tobe cleaned:

� before and after each clinic session

� daily

� weekly

� monthly

� annually.

Additionally, cleaning equipment such as vacuums,floor scrubbing machines and polishers should becleaned and properly maintained. Information onrecommended methods of cleaning and disinfectionshould be available for staff. Detailed guidance isavailable from Infection control guidance for generalpractice (Infection Control Nurses Association andRoyal College of General Practitioners, 2003).

8. Appropriate use ofindwelling devices†

Make sure you use the correct technique when usingindwelling devices as it is vital to reduce the risk ofpatients acquiring infection. 80 per cent of urinaryinfections can be traced back to indwelling urinarycatheters. These infections arise because catheterstraumatise the urethra as well as providing a pathwayfor bacteria and other organisms to enter the bladder.The longer such catheters are in place, the higher therisk of infection.

Similarly, over 60% of blood infections are introducedby intravenous feeding lines, catheters or similardevices. This is because micro-organisms on thepatient’s skin (either those naturally present or thoseacquired whilst in hospital) can gain entry to deepertissues or the bloodstream when a cannula orcatheter is inserted into a vein.

Follow your work place policy on the use ofindwelling devices.You can access furtherinformation on use of intravenous feeding lines;urinary catheters; peripheral intravenous cannulaeand central venous lines at www.rcn.org.uk/mrsa

7. Achieving and maintaining aclean clinical environment

A dirty clinical environment is one of the factors thatmay contribute towards infection rates. Conversely,high standards of cleanliness will help to reduce therisk of cross-infection. Good design in buildings,fixtures and fittings is also important to allowefficient cleaning. According to guidance publishedby NHS Estates – an agency of the Department ofHealth – health care facilities should be patientfriendly and offer a safe environment for care (NHSEstates, 2004b).

Cleaning removes contaminants, including dust andsoil, large numbers of micro-organisms and theorganic matter that may shield them, for example,faeces, blood and other bodily fluids.

In hospitals

NHS Estates has published a variety of guidanceunder its clean hospitals programme, which began in2000. National standards of cleanliness for the NHS(NHS Estates, 2002b) provides trust cleanlinessscores. An implementation toolkit and audit materialsare also available. The NHS healthcare cleaningmanual (NHS Estates, 2004c) acts as a resource to

assist in trainingand settingstandards to helppromote highquality andconsistent servicelevels. PatientEnvironmentAction Teams(PEATs) regularlyinspect hospitalsto assess a widerange ofcleanliness issues

in wards, reception and waiting areas, A&E, corridors,furnishings, linen and external appearance.

In general practicesNurses who work in a GP practice should have aregular planned, written and monitored cleaning

About nine percent of inpatientshave a hospitalacquired infectionat any one time,equivalent to atleast 100,000infections a year(National AuditOffice, 2000)

† Adapted from: Department of Health, Winning Ways -Working together to reduce healthcare associated infectionin England, December 2003

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In the case of aninjury from a

clean/unusedinstrument or

needle, no furtheraction is likely.

If the injury is from a usedneedle or instrument, risk

assessment should becarried out with a

microbiologist, infectioncontrol doctor or consultantfor communicable disease

control. Consent is requiredif a patient’s blood needs to

be taken.

Report the incident to your occupational health department – or A&E out of hours –

and your manager.

Complete an accident form.

Seek help to initiate an investigation into thecause of the incident and risk assessment.

If blood and body fluidssplash into your mouth,do not swallow. Rinseout several times with

cold water.

If blood and bodyfluids splash

into eyes, irrigatewith cold water.

Immediately stop what you aredoing and attend the injury

Encourage bleeding of the wound by applyinggentle pressure – do not suck.

Wash well under running water.

Dry and apply a waterproof dressing as necessary.

Figure 3: managing accidents

9. Managing accidentalexposure to blood-bornevirus

Accidental exposure to blood and body fluids canoccur by:

� percutaneous injury – for example, from needles,instruments, bone fragments or significant bitesthat break the skin

� exposure of broken skin – for example, abrasions,cuts or eczema

� exposure of mucous membranes, including theeyes and the mouth.

Figure 3 illustrates the action that should be takenimmediately following accidental exposure to bodilyfluids, including blood.

Managing the risk of HIVIf there has been exposure to blood, high risk bloodand body fluids or tissue known or strongly suspectedto be contaminated with HIV, the Chief MedicalOfficer’s Expert Advisory Group on AIDS recommendsthe use of antiretroviral post exposure prophylaxis(PEP). Ideally, this is given within an hour of exposureand the full course lasts for four weeks.Wheretreatment is delayed but the source person proves to beHIV positive, PEP can be given up to two weeks fromthe time of the injury. Advice and follow-up carefrom your occupational health department areessential.

Managing the risk of hepatitis B (HBV)The risk of contracting HBV from needlestickexposure in a health care setting is much higher thanHIV because the virus is both more infectious andhas greater prevalence. As a result, the RCNrecommends that all nurses should be vaccinatedagainst hepatitis B with monitoring of antibody titrelevels and boosters, where inoculation injury occursand titres are low. Staff should take responsibility forthis and should contact the occupational healthdepartment if there are any concerns.


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10. Good communication

Anxiety about HCAIs, including MRSA, is often basedon ignorance about the risks of infection and theprecautions to prevent transmission. Nurses can do agreat deal to allay fears by communicating effectively,without breaking confidentiality. For example, nursesshould:

� provide information leaflets for patients, visitorsand staff

� provide notices which describe the precautionsneeded

� talk to patients about how they can helpthemselves

� include support staff in team meetings duringoutbreaks

� tell the patient how their care might be affected bya HCAI and how long precautions will be needed

� ensure that other staff understand the actionsthey need to take – for example, if the communitynurse needs to continue care at home

� inform general practitioners on discharge ortransfer if their patient has acquired a HCAI.

The RCN has produced leaflets for patients andvisitors as part of its Wipe it out campaign.You canobtain copies of these by downloading them from theRCN website at www.rcn.org.uk/mrsa

11.Training

All health care professionals who have a clinicalresponsibility for patients must include infectionprevention and control as part of their every daypractice. The RCN believes all health care staff shouldreceive mandatory infection control training as partof their induction and on an ongoing annual basis. Itis particularly important that knowledge and skillsare continually updated.

The training should cover all the general principles ofinfection prevention and control (as outlined in thispublication), to emphasise the key role that healthcare professionals play in minimising the spread ofinfection; to highlight what can happen as a result ofbad practice and underline the importance of goodcommunication.

Training should include:

� practical hand washing sessions/use of alcoholhand sanitizer

� aseptic technique

� the importance of environmental/equipmentcleaning and whose responsibility

� who to go to for advice/ more information

� trust infection and prevention policies

� what you can do to help yourself, your colleaguesand your patients (uniform, hair, generalhygiene).

Please refer to the RCN infection control checklist(Appendix 1) as a reminder of the key steps.You maywant to photocopy this and display it in yourworkplace.

Variant Creutzfeldt-JakobDisease

Thorough cleaning of instruments is extremelyimportant in reducing the possible transmission of allmicro-organisms – in particular the abnormalprotein prion that is known to cause variantCreutzfeldt Jakob Disease (vCJD). Research showsthat these prions are resistant to all common methodsof decontamination. For information and advice onvCJD, risk assessment and how to handle instrumentsthat may have been used on people who have thiscondition, you should consult your local:

� consultant in communicable disease control

� microbiologist

� infection control nurse.

Further guidance can also be obtained from:Transmissible spongiform encephalopathy agents: safeworking and the prevention of infection (AdvisoryCommittee on Dangerous Pathogens and SpongiformEncephalopathy Advisory Committee, 2003).

References

Advisory Committee on Dangerous Pathogens andSpongiform Encephalopathy Advisory Committee(2003) Transmissible spongiform encephalopathyagents: safe working and the prevention of infection.London: Department of Health.

Department of Health (2003) Winning Ways -Working together to reduce Healthcare AssociatedInfection in England. London: Department of Health.

Health and Safety Commission (2000) Safety ofpressure systems: pressure systems safety regulation.London: HSC.

Health and Safety Commission (2002) The control ofsubstances hazardous to health regulations (fourthedition). Sudbury: HSE Books.

Infection Control Nurses Association (2002) Acomprehensive glove choice. Bathgate: ICNA

Infection Control Nurses Association and RoyalCollege of General Practitioners (2003) Infectioncontrol guidance for general practice. Bathgate: ICNA.(Tel: 01506 811077 for copies)

Medical Devices Agency (1996) Sterilisation,disinfection and cleaning of medical equipment,London: MDA.

Medical Devices Agency (1998) The validation andperiodic testing of bench top vacuum steam sterilisers.London: MDA (DB 1998/4).

Medical Devices Agency (2002) Bench top steamsterilisers - guidance on purchase, operation andmaintenance. London: MDA (DB 2002/6).

National Audit Office (2000) The management andcontrol of hospital acquired infection in acute NHStrusts in England. London: The Stationery Office.

National Patient Safety Alert (2004) Clean hands helpto save lives. London: NPSA (Patient Safety AlertNo.4).

NHS Estates (2004a) A protocol for the localdecontamination of surgical instruments, London:Department of Health.

NHS Estates (2004b) Lighting and colour for hospitaldesign. A report on an NHS Estates funded researchproject. London: The Stationery Office.

Methicillin-resistantStaphylococcus aureus

For information relatedspecifically to MRSAplease read the RCN’sguidance Methicillin-resistantStaphylococcus aureus(MRSA): guidance fornursing staff (2005).RCN members canorder copies by callingRCN Direct on 0845772 6100 and quotingpublication code 002740. Alternatively,members and non-members can find outmore about MRSA byvisitingwww.rcn.org.uk/mrsa

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‘Mortality rates fordeaths involvingMRSA increasedover 15-fold duringthe period 1993-2002.’ (Office ofNational Statistics,2005)


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Hand hygieneNational Institute of Clinical Excellence (2001)Standard principles for preventing hospital acquiredinfections. London: NICE.

National Institute of Clinical Excellence (2003)Infection control, prevention of healthcare-associatedinfection in primary and community care. London:NICE.

Pellowe C, Pratt R, Loveday H, Harper P, Robinson Nand Jones S (2004) The epic project: updating theevidence-base for national evidence-based guidelinesfor preventing healthcare-associated infections inNHS hospitals in England: a report withrecommendations, British Journal of InfectionControl, 15(6), Dec., pp.10-16.

Royal College of Nursing (2005) Methicillin-resistantStaphylococcus aureus (MRSA). Guidance for nursingstaff. London: RCN. Publication code: 002 740.

NHS Estates (1997) In-patient accommodation:options for choice. London: HMSO (Health BuildingNote 4). www.nhsestates.gov.uk

National Patient Safety Agency (NPSA)Cleanyourhandscampaign, www.npsa.nhs.uk

Environment and equipmentDepartment of Health (2004) Towards cleanerhospitals and lower rates of infection. A summary ofaction. London: DH. Available to download fromwww.dh.gov.uk

Infection Control Nurses Association and RoyalCollege of General Practitioners (2003) Infectioncontrol guidance for general practice. Bathgate: ICNA.www.icna.co.uk

Jones E (2004) A matron’s charter: an action plan forcleaner hospitals. London: Department of Health.Available to download from www.nhsestates.gov.uk

NHS Estates (2002) National standards of cleanlinessfor the NHS. Norwich: The Stationery Office.www.nhsestates.gov.uk

NHS Estates (2004) The NHS healthcare cleaningmanual. London: Department of Health.www.nhsestates.gov.uk

NHS Estates (2004c) The NHS healthcare cleaningmanual. London: Department of Health.www.nhsestates.gov.uk

NHS Estates (2002a) Infection control in the builtenvironment (second edition). Norwich: TheStationery Office.

NHS Estates (2002b) National standards of cleanlinessfor the NHS. London: The Stationery Office.

NHS Executive (1997) Washer-disinfectors. London:HMSO (Health Technical Memorandum 2030).

Office for National Statistics (2005) ‘Deaths involvingMRSA: England and Wales, 1999-2003,’ HealthStatistics Quarterly Spring 2005 No 25. London: ONS.

Royal College of Nursing (2005) Methicillin-resistantStaphylococcus aureus (MRSA). Guidance for nursingstaff. London: RCN. Publication code: 002 740.

Useful reading

GeneralChief Medical Officer (2003) Winning ways: workingtogether to reduce health care associated infection inEngland, London: Department of Health.

Department of Health (2004) Towards cleanerhospitals and lower rates of infection. A summary ofaction. London: Department of Health. Available todownload from www.dh.gov.uk

Health, Social Services and Public Safety – NorthernIreland. Available to download fromwww.dhsspsni.gov.uk

Jones E (2004) A matron’s charter: an action plan forcleaner hospitals. London: Department of Health.Available to download from www.nhsestates.gov.uk

National Audit Office (2004) Improving patient care byreducing the risk of hospital acquired infection: aprogress report. London: The Stationery Office.

Scottish Executive. Health Department (2004) TheNHSScotland Code of Practice for the localmanagement of hygiene and healthcare associatedinfection (HAI), Edinburgh: SE.

Welsh Assembly Government (2004) Healthcareassociated infections: a strategy for hospitals in Wales.Cardiff: WAG. www.nphs.wales.nhs.uk

Scottish Executive Health Department (2004) TheNHSScotland national cleaning services specification:healthcare associated infection task force. Edinburgh:SE.

NHS Estates (2001) Infection control in the builtenvironment: design and planning. London: TheStationery Office. www.nhsestates.gov.uk

UniformRoyal College of Nursing (2005) RCN Guidance onuniforms / clothing worn for delivery of patient care.London: RCN. Publication code 002 724www.rcn.org.uk/mrsa

Royal College of Nursing (2005) A uniform approach.A checklist for nursing staff. London: RCN. Publicationcode 002 723 www.rcn.org.uk/mrsa

Clinical wasteDepartment of the Environment (1991)Environmental protection act 1990: wastemanagement: the duty of care: a code of practice.London: HMSO.

Department of the Environment (1992) Theenvironment protection act 1990: parts II and IV: thecontrolled waste regulations. London: DE.

Department of the Environment (1996) Theenvironment protection act 1990: part II: special wasteregulations 1996. London: HMSO.

Health and Safety Commission (2002) The control ofsubstances hazardous to health regulations (fourthedition). Sudbury: HSE Books.

Health Service Advisory Committee (1999) Safedisposal of clinical waste (second edition). Sudbury:HSE Books.

NHS Estates (1994) A strategic guide to clinical wastemanagement for general managers and chiefexecutives. London: NHS Estates.

Parliament (1990) Environmental protection act 1990.London: HMSO.

Parliament (1992) The management of health andsafety at work regulations, London: HMSO (SI no.2051).

Blood-borne virusDepartment of Health (1991) Decontamination ofequipment, linen or other surfaces contaminated withHepatitis B and /or HIV. London: DH (HC(91)33).

Department of Health (1993) Protecting healthcareworkers and patients from hepatitis B, London: DH(HSG(93)40) (plus addendum EL(96)77).

Department of Health (1998) Guidance for clinicalhealth care workers: protection against infection withblood-borne viruses. London: DH (HSC(98)63).

Department of Health (1998) Guidance on themanagement of AIDS/HIV infected healthcare workersand patient notification. London: DH (HSC(98)226).

Department of Health (2000) Hepatitis B infectedhealth care workers. London: DH (HSC(2000)20).

LaundryDepartment of Health (1995) Hospital laundryarrangements for used and infected linen. London: DH(HSG(95)18).

NHS Estates (2002) Infection control in the builtenvironment (second edition). Norwich: TheStationery Office.

Resources available from the RCN As part of its Wipe it out campaign, the RCN hasproduced a range of leaflets and posters to helpnursing staff, patients and visitors promote goodpractice in infection control. To obtain copies and tofind out more about infection control go towww.rcn.org.uk/mrsa

The RCN has also produced a wealth of otherinformation and guidance as part of its Working WellInitiative. Titles – including the following – areavailable to members by calling RCN Direct on 0845772 6100 and quoting the publication code.

� Royal College of Nursing (1999) Losing yourtouch? Avoid latex allergy, London: RCN.Publication code: 000 948

� Royal College of Nursing (2002) Is there analternative to glutaraldehyde? A review of agentsused in cold sterilisation (second edition).London: RCN. Publication code: 001 362

14



15

Useful websites

You may find the following websites useful:

� The Department of Health: www.dh.gov.uk

� The Health Protection Agency (HPA):www.hpa.org.uk

� The Hospital Infection Society: www.his.org.uk

� Infection Control Nurses Association:www.icna.co.uk

� The Medical and Healthcare products RegulatoryAgency: www.mhra.gov.uk

In April 2003, the Medical Devices Agency mergedwith the Medicines Control Agency to form theMHRA. This executive agency of the Departmentof Health produces a variety of bulletins andalerts including advice on single use items, benchtop sterilisers and the decontamination ofendoscopes.

� The National Institute for Clinical Excellence(NICE): www.nice.org.uk

In 2001, NICE produced Standard principles forprevention of hospital acquired infection and in2003, Infection control – prevention of health careassociated infection in primary and communitycare.

� National Patient Safety Agency www.npsa.nhs.uk

The NPSA has developed the cleanyourhandscampaign which targets hand hygiene as a keypatient safety issue.

www.npsa.nhs.uk/cleanyourhands

� NHS Estates: www.nhsestates.gov.uk

For information on their clean hospitalsprogramme and downloadable copies of advice,guidance and audit materials.

� NHS Purchasing and Supply Agency:www.pasa.nhs.uk

This website offers guidance on safety devices.

� The Safer Needles Network:www.saferneedlesnow.net andwww.needlestickforum.net

Glossary

COSHH – Control of Substances Hazardous to Health

Creutzfeldt-Jakob Disease (vCJD) – a disease inwhich rapid progressive degeneration of braintissue results in dementia and eventually death

HAI – hospital acquired infection – any infectionacquired while undergoing treatment,investigation or rehabilitation in hospital

Hand washing – washing the hands with anunmedicated detergent and water (or wateralone), to remove dirt and loose transient flora inorder to prevent cross-infection

HBV – Hepatitis B

HCAI – health care associated infection – anyinfection acquired while undergoing treatment,investigation or rehabilitation in any health caresetting or in community care settings

MRSA – Staphylococcus aureus which is resistant toan antibiotic called methicillin are referred to asmethicillin-resistant Staphylococcus aureus orMRSA. Methicillin-resistant meansflucloxacillin resistant

PEAT – patient environment action team

PEP – post exposure prophylaxis

PPE – personal protective equipment

SARS – severe acute respiratory syndrome

Sterile – free from any living organisms, for example,sterile gloves, sterile catheter

SSD – sterile services department

16


Have you washed your hands?

Hand washing is the single most important step inreducing the spread of disease. Use the six-steptechnique before direct contact with patients andafter any activity that contaminates the hands. Drythoroughly afterwards, using disposable towels.

Do you need to use personalprotective equipment?

Carry out a risk assessment if potentialcontamination by blood or body fluid is likely. Usedisposable gloves, aprons, masks, goggles orvisors to protect yourself and your patient fromthese risks of cross-infection, and when handlingthese substances or hazardous chemicals andsome pharmaceuticals.

Are you preventing sharps injuries?

Keep handling to a minimum and never re-sheath.Dispose of sharps carefully in a special container atthe point of use.

Are you disposing of waste safely?

Ensure that you have been instructed in how todispose of waste safely, including the colour codingof bags used for different types of waste.

Do you deal promptly with spillages?

Spillages must be dealt with quickly, usingappropriate chemical disinfectants as necessary.Ensure you have a thorough knowledge of chemicaldisinfectants.

Do you scrupulously decontaminateequipment?

Meticulously clean, disinfect and sterilise re-usableequipment, as appropriate, to ensure it is safe forfuture use.

Are you maintaining a cleanenvironment?

Ensure your workplace has a regularly planned,written and monitored cleaning schedule, whichdetails both the items and environments to becleaned and how often this should happen.

Do you know what to do in the eventof an accident?

Attend the injury, washing it well in cold runningwater. If bodily fluids have splashed into eyes,irrigate with cold water. If they have splashed into amouth, do not swallow and rinse out several timeswith cold water. Report the incident and seekexpert advice.

And finally, do you know yourworkplace’s procedures?

Ensure that you understand and follow yourworkplace’s written policies and procedures on allaspects of infection control.

Appendix 1

Infection control checklistStandard precautions underpin safe protection and should be used at all times

with every patient. Use the following checklist to guide you.

10 steps to

effective han

d h

ygien

e*

Inspired by nature. Created for superior hygiene.

So

ap u

p ru

bb

ing

palm

to p

almR

ub

with

fing

ers interlaced

Massag

e betw

een fin

gers,

righ

t palm

over b

ack of left h

and

,left p

alm o

ver back o

f righ

t han

d

Scru

b w

ith fin

gers lo

ckedin

clud

ing

fing

er tips

Ru

b ro

tation

ally with

thu

mb

s locked

Rin

se tho

rou

gh

lyW

ork to

wel b

etween

fing

ersD

ry arou

nd

and

un

der n

ailsD

ry palm

s and

backs o

f han

ds

usin

g a p

aper to

wel to

help

remo

ve remain

ing

bacteria

*Dispensers

*Trademark: Kim

berly-Clark Corporation/©Copyright 2000 Kim

berly-Clark Corporation/Publication no. 2244.01 GB

11-2000

Imp

ortan

ce of h

and

wash

ing

Han

ds are u

sually co

nsid

ered to

be o

ne o

f the m

ost co

mm

on

ways th

at cross co

ntam

inatio

n o

ccurs. E

ffective, timely h

and

hyg

iene

can co

ntrib

ute sig

nifican

tly to red

ucin

g th

e risks of cro

ss con

tamin

ation

.T

he h

and

wash

ing

techn

iqu

e ado

pted

mu

st ensu

re that all areas o

f the h

and

s are covered

. Particu

lar attentio

n sh

ou

ld b

e paid

tothe

fing

er tips, b

etween

the fin

gers an

d to

the o

utsid

e and

back area o

f the th

um

bs, w

hich

are often

missed

.O

nce rin

sed th

oro

ug

hly, d

ry the h

and

s carefully w

ith p

aper to

wels an

d ap

ply an

app

rop

riate han

d cream

.

167

89

10

23

45

Wet h

and

s and

forearm

s

April 2005

Published by the Royal College of Nursing

20 Cavendish Square

London

W1G 0RN

Tel 020 7409 3333

www.rcn.org.uk/mrsa

The RCN represents nurses and nursing,

promotes excellence in practice and

shapes health policies

002

741

good practice in infection prevention and control: guidance for

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