universal standard infection control policy

Universal/Standard Infection Control Precautions

Reference Number: 622

Author & Title: Jacqueline Cosgrave, Infection Control Nurse

Responsible Directorate: Corporate

Review Date: April 2014

Ratified by (committee): Operational Governance Committee

Date Ratified: April 2011

Version: 2

Related Procedural Documents

Aseptic Non Touch Technique Policy Blood Borne Virus Policy Clostridium difficile Policy Hand Decontamination Policy Isolation Policy Influenza A, Control and treatment of Linen Policy Diarrhoea and /or Vomiting Policy,

Management of Waste policy, Management and

disposal of Medical Sharps Policy Meningitis Policy MRSA Policy Operating theatre dress policy Scabies Policy Tuberculosis Policy

Document name: Universal/Standard Infection Control Precautions Ref.: 622 Issue date: April 2011 Status: Final

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Index:

1. Introduction _________________________________________________________ 3 2. Purpose of this policy _________________________________________________ 3 3. Aims and Objectives of this policy _______________________________________ 3 4. Duties / Responsibilities _______________________________________________ 4 5. Monitoring Compliance ________________________________________________ 4 6. Risk assessment _____________________________________________________ 4 7. Procedure ___________________________________________________________ 5 8. References _________________________________________________________ 15 Appendix 1: Consultation Schedule ______________________________________ 16 Appendix 2: Risk Assessment guide for selection of protective equipment based on risk of exposure to blood or body fluid ___________________________________ 17 Appendix 3: Moments for hand hygiene __________________________________ 18 Appendix 4: Guidance for the selection of masks __________________________ 19 Equality Impact Assessment Tool __________________________________________ 20 Consultation Checklist ___________________________________________________ 21 Ratification Check List ___________________________________________________ 22


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1. Introduction Universal/Standard precautions are the practices that must be adopted by all healthcare workers (HCW) when potentially coming into contact with any patients blood, tissue or body fluid. They are based on a set of principles designed to minimise exposure to and transmission of a wide variety of micro-organisms. Since every patient is a potential infection risk it is essential that universal/standard precautions are used for all patients all of the time. 2. Purpose of this policy The purpose of this policy is to provide guidance for staff within the Royal United Hospital, Bath NHS Trust about the requirements and processes for implementing Universal/Standard Infection Control Precautions. There are eight key elements to Universal/standard control precautions, all of which when appropriately implemented are designed to reduce the risk of transmission of micro-organisms. The application of transmission based precautions when patients are managed with known infections will support the prevention of the spread of healthcare associated infections. This policy applies to all individuals in the employ of the Royal United Hospital Bath NHS Trust 3. Aims and Objectives of this policy The policy aims to make explicit the principles of infection prevention and control which will minimise exposure to and the transmission of micro-organisms. There are eight key elements of universal/standard infection control precautions: Hand hygiene, Personal protective equipment, Sharps disposal, Waste disposal, Linen handling and segregation, Blood and body fluid spillage procedure, Handling and transport of specimens, Decontamination of equipment and the environment.


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4. Duties / Responsibilities All staff have a responsibility for ensuring that the principles outlined within this document are universally applied. 4.1 Chief executive The Chief Executive has overall responsibility to ensure that the policy is implemented and adhered to across the trust. 4.2 Director Infection Prevention Control (DIPC) The DIPC reports directly to the Chief Executive, Trust Board and is a member of the Clinical Governance Committee and patient safety structures. The DIPC oversees infection control policies and their implementation and is responsible for the Infection Prevention and Control Team. 4.3 Infection Prevention and Control Team The Infection Prevention and Control Team are responsible for developing the policy, for providing expert advice, training and monitoring compliance with the policy. 4.4 Consultants, Managers/Matrons and Senior Sisters Managers/Matrons and Senior Sisters are responsible for the operational implementation of this policy; ensuring their staff are aware of their responsibilities, adhere to the guidance within the policy. They must ensure that new staff have attended Infection Prevention and Control induction. 4.5 All staff The employee has a responsibility to carry out risk assessments and use the appropriate equipment provided. Employees are responsible for ensuring that any breach of this policy is immediately reported to their manager. All staff must attend the mandatory Infection Prevention and Control update at two yearly intervals. Clinical staff have a responsibility towards the safer working practices of their colleagues or co-workers such as students or trainees under their supervision. 5. Monitoring Compliance Infection Prevention and Control Team will audit components of the policy as part of the

annual audit programme with the support of the Audit department. Audits of compliance with the policy will be undertaken by Ward managers/Senior

Sisters using the Saving lives High Impact Interventions audit tools Results of audits are reported at weekly Task Force meeting. Where short falls are identified, Ward managers and Matrons will ensure that

improvement programmes are agreed and put in place to improve compliance. 6. Risk assessment


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Implementation of universal/standard precautions is dependent on an initial risk assessment of the patient, the task being undertaken and the situation. All body fluids may pose a risk of transmission of micro organisms. Staff must select the appropriate protective equipment. The Risk assessment guide for selection of protective equipment based on risk of exposure to blood or body fluid: Appendix 1. will support staff in assessing the risk of contamination to the healthcare workers clothing and skin by the patients blood, body fluids, secretions and excretions. Additional precautions Where a patient is known to have a specific infection or colonisation then reference to specific Infection Control Policy is recommended for additional precautions: Antibiotic Resistant Micro-organisms, Blood borne viruses, Chicken pox, Clostridium difficile, Meningitis, Meticillin resistant Staphylococcus aureus (MRSA), Influenza, Scabies, Transmissible Spongiform Encephalopathy Agents Including CJD and vCJD, Tuberculosis, Viral diarrhoea and vomiting. 7. Procedure 7.1 Hand decontamination Hand decontamination is the most effective means of preventing cross infection (Fraise & Bradley, 2009). All trust employees must receive training in the appropriate hand hygiene techniques on induction into the Trust. Ongoing assessment and training of the techniques are undertaken as part of the Trusts mandatory infection control updates for Trust employees at two yearly intervals. The RUH embraces the Five Moments for Hand Hygiene Appendix 2 ( WHO 2009), aiming to link specific hand hygiene actions to specific infectious outcomes in patients, by giving clear advice on how to integrate hand hygiene into the complex task of care. Appendix 2. Bacteria and viruses cannot penetrate intact skin. It is vital to maintain skin in a good condition and prevent cracking, chapping and drying of the skin. Moisturiser is


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available in all clinical areas to maintain skin moisture. Staff must inform their line manager if their hands become sore or cracked. 7.1.1 Hand decontamination using liquid soap and water The following activities are examples of when hands must be washed using detergent and water: Whenever hands are visibly dirty, After removal of gloves, Following any handling of blood or body fluids, After any microbial contamination (e.g. wound examination, wound dressing,

sputum aspiration etc), Before performing an aseptic procedure, Before preparing, handling or eating food, After visiting the toilet, After patient toileting, After handling laundry, After dealing with patients symptomatic with diarrhoea and vomiting e.g.

Norovirus or Clostridium difficile. This is not an exhaustive list. 7.1.2 Hand decontamination using alcohol based gel or solution. The following activities are examples of when alcohol based gel or solution can be used on socially clean hands: Prior to and following examination of a patient, Prior to handling patient equipment, On entering and leaving the clinical environment, Between social patient contact e.g. ward rounds, Before entering and leaving an isolation room or area, Before and after transfer of patients from / bed/ chair/ trolley, Venepuncture. This is not an exhaustive list. Refer to Hand Decontamination Policy 7.2 Personal Protective Equipment Personal Protective Equipment (PPE) consists of aprons, gloves, masks and eye protection. The primary use of PPE is to protect staff and reduce opportunities for transmission of micro-organisms (ICNA 2002).


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The selection of the PPE is based on a risk of transmission of micro-organisms to the patient and the risk of contamination of the HCW clothing and skin by the patients blood, body fluids, secretions and excretions. Under Health and Safety legislation the Trust has a responsibility to ensure that staff have access to appropriate PPE. Staff have a responsibility to use PPE in appropriate situations (Health & Safety Executive 1999). 7.2.1 Gloves The use of gloves can reduce the risk of acquiring infection through direct skin contact between HCW and patients. Gloves should not be worn unnecessarily or as a substitute for hand decontamination as prolonged and indiscriminate use may cause adverse reactions and skin sensitivity (WHO 2009). Gloves are a single use item. Gloves can reduce the likelihood of contact dermatitis in staff exposed to

chemical agents. Gloves must be worn when direct contact with contact with blood, body fluids,

non-intact skin or mucus-membranes is anticipated. Gloves must be changed between patients and different procedures on the

same patient. Gloves must be disposed of in an orange clinical waste bin. Hands must be decontaminated with soap and water immediately on removal of

gloves. Indications for wearing gloves: Venepuncture, Wound inspection, Cannula insertion, Aseptic Non Touch Technique, Emptying urinary catheter bags/stoma bags, Cleaning soiled equipment, IV drug administration, Invasive procedures, Dealing with body fluids, Surgical procedures use sterile gloves. This is not an exhaustive list. 7.2.2 Sterile gloves Training on the correct procedure for donning and removing sterile gloves must be provided for staff to prevent the contamination of the outer surface of the glove and the hands. 7.2.3 Gloves and latex allergy


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If a healthcare worker has a latex allergy or sensitivity to specific chemicals in gloves, they must report this to their line manager and should seek advice from the Occupational Health Department as alternative gloves must be made available in the persons area of work. Where a patient is known to be allergic to latex, staff must use non-latex gloves. Refer to Skin Management, Protective Gloves and Latex Sensitivity Policy 7.2.4 Disposable aprons and gowns Plastic aprons must be worn to reduce the level of contamination of uniforms/clothing where direct patient care is given and there is potential for the dispersal of pathogens. Such activities may include: Assisting patients with toileting, Bathing, Bed making, Procedures causing splashing of body fluids or blood. This is not an exhaustive list. Sterile gowns protect patients from infection where they are undergoing procedures such as insertion of central venous catheters. The type of apron or gown to be worn depends on an assessment of risk of contact with body fluids: Aprons: Must be worn where there is a risk of blood or body fluid contamination of the

uniform, Must be changed between patients and different procedures on the same

patient, The apron must be disposed in an orange clinical waste bin. as clinical waste, May be worn for decontamination activities, including cleaning and disinfection. Gowns: Full body gowns must be worn by operating theatre scrub staff. These should

be either single use waterproof disposable or re-usable waterproof gowns, Worn where there is a risk of extensive contamination of uniform or clothing, Must be single use and replaced after each episode of care or task, If disposable; discarded in an orange clinical waste bin. For general clinical procedures long sleeved non sterile gowns should fully

cover the area to be protected, Gowns are not required for the routine care of patients with influenza unless

aerosol generating procedures are being performed, Gowns may be required when nursing patients with Norwegian scabies, Gowns may be required when nursing a patient with possible/confirmed viral

haemorrhagic fever.


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Refer to Operating theatre dress policy/ Influenza policy/ Scabies policy 7.2.5 Eye protection Mucous membranes of the eyes and mouth must be protected when there is a risk of blood splashes. Eye protection may be achieved through the use of goggles, visors or spectacles with side pieces. They must be comfortable to wear, fit correctly and allow for clear vision. Eye protection that is designed for multi-use must be cleaned with detergent between each task and patient. Eye protection must be available in all areas especially where splash is more likely: Emergency Department, Endoscopy, Theatres, Central Delivery Suite, Critical Care Unit. Eye protection should be worn where: Splash or spray of blood or body fluid is likely, When dealing with chemicals, During aerosol and sputum generating procedures. 7.2.6 Masks and respirators Masks are worn to protect the wearer from potential exposure to micro-organisms via splashes of blood or body fluid. The use of a mask must be based on an assessment of risk of body fluid exposure. Staff may select a face mask or respirator depending on the level of protection required. Refer to Guidance for the selection of masks: Appendix 3 Masks are rarely worn in general ward environments. Surgical face masks protect the wearer from expelling droplets (>0.5 microns) into the environment. If the mask is fluid resistant, the wearer will be protected from splashes. Respirators are made to specific standards EN 149 2001, FFP2, FFP3. Respirators are worn to protect the healthcare worker from airborne particle (


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Where a mask is required it should be applied prior to entering the isolation room.

Masks must be worn correctly and be close fitting. Handled as little as possible. Changed between operations or patients. Changed if wet. Discarded immediately after removal in an orange clinical waste bin. Hands must be washed on removal of mask. Guidance for the selection of masks: Appendix 3. 7.3 Blood /body fluid spillage Protective clothing, e.g. gloves and apron, must be worn when dealing with blood/body fluid spillage. The area must be made safe to prevent further contamination and protect staff and patients. Blood/body fluid spillage can be divided into groups: Spillage on the floor or a large surface area, Soiling of equipment or where it is not practicable to use a hypochlorite powder. 7.4 Spillage on the floor or a large surface area For spillages on the floor or a large surface area, a 10 000 ppm hypochlorite powder must be used e.g. Titan Sanitizer. Use PPE, wear gloves and apron. Cover the spillage with chlorine releasing powder e.g. Titan Sanitiser. Hypochlorite containing products must not be used on urine spillage as chlorine

gas will be released. Use paper roll to remove the spillage and place in a in an orange clinical waste

bag. Wash area with detergent and water. Dispose of PPE in an orange clinical waste bin. Decontaminate hands using soap and water. 7.5 Small blood spillage on equipment and in other areas where it is not practicable to use hypochlorite powder Use PPE, wear gloves and apron. Clean the area with detergent and water. Surfaces or equipment contaminated with blood should be disinfected with a

chlorine based disinfectant E.g. Actichlor Plus. Dispose of waste in an orange clinical waste bin. Dispose of PPE as in an orange clinical waste bin. Decontaminate hands using soap and water. 7.6 Body fluids e.g. vomit, urine, faeces


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Use PPE, wear gloves and apron. Clear away spillage with paper roll. Wash area with detergent and water using paper roll. Dispose of used paper roll in an orange clinical waste bin. Dispose of PPE in an orange clinical waste bin. Decontaminate hands using soap and water. 7.7 Waste Disposal Waste bins/bags must be of the appropriate UN-approved type, colour, size, Adequate supplies of waste bags/bins must be available to ensure that waste

segregation is able to take place correctly, Waste bag holders are fire-proof, leak-proof, foot pedal operated, secure, well-

maintained and well-cleaned, Signs and notices must be displayed to ensure that staff can quickly refer to

correct information about segregation of waste and the correct container to use, Waste bins and other containers must be kept clean. 7.8 Segregation of waste All waste is to be segregated at the point of use. The most common waste categories are: Orange bag: potentially infectious clinical waste, Yellow bag: Diagnostic specimens from permitted areas only, Sharps bins: yellow lidded sharps bins take standard clinical sharps including

sharps contaminated with medicines; purple lidded bins take sharps contaminated with cytotoxic/cytostatic substances

Yellow burn bins: Recognisable anatomical waste, drugs for incineration must go in separate burn bin (refer to waste policy).

Black bags, General non recyclable waste, non hazardous waste, Clear plastic bags: Waste for recycling i.e. paper, cans, plastic bottles and

containers, separated and put into tied, clear plastic bags & flattened cardboard, loosely loaded,

Hazardous Waste (e.g. solvents and chemicals, aerosols, gas cartridges, chemicals, oils, batteries, inkjet and toner cartridges, tyres, Fluorescent tubes and compact fluorescent lights (CFLs), mercury, sodium lamps, Waste Electrical and Electronic Equipment (WEEE),

Tiger-striped bags for offensive waste, used in selected areas of the Trust. Orange clinical waste bags and tiger striped bags must be closed using the swan necked method and tied with a coded zip tie. Only staff that have been suitably trained and are aware of the correct procedure should be involved in the handling of clinical waste.


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Sharps bins must be kept separate from other clinical waste and MUST NOT be put into clinical waste bags. In order for waste to be traced back to the point of generation: Sharps bins must have the front label fully filled in and signed, Burn boxes must be have the RUH Department name, date and signature of the

person who closed the box written on the box. Refer to Management and Disposal of Waste policy 7.9 Sharps Sharps can be defined as any object in the healthcare setting that could puncture the skin and permit the entry of bacteria or viruses into the body. Sharps include needles, scalpels, suture needles, lancets, scissors, surgical instruments stitch cutters, glass ampoules, intravenous cannulae, vacuum blood collecting systems, fragments of bone and patients teeth. This is not an exhaustive list. 7.10 Inoculation (Sharps) injury An inoculation injury occurs where a needle or other sharp contaminated with blood or other high risk body fluid penetrates percutaneously (through the skin). Such injuries also include cuts, pinches, scratches, bites which break the skin and splashes of body fluids to the eyes. Accidents with needles are the most common, so injuries from sharps are often called needle stick injuries. 7.11 Preventing inoculation injury The emphasis on preventing contaminated inoculation injury must focus on ensuring safe handling practices are in place: Attend Infection Prevention and Control Induction and Infection Prevention and

Control Clinical Update, Use appropriate PPE, Used sharps must be discarded into a sharps container at the point of use.

Needles and syringes must not be disassembled by hand prior to disposal, Do not re-sheath needles, Do not carry loose sharps in your own hands - use a plastic tray, Sharps must not be passed directly from hand to hand, use a tray so that the

same sharp device is not touched by more than one person, Sharps containers must not be filled above the mark indicating they are full, Temporary closure mechanisms should be used when sharps boxes are not in

use, Sharps containers should be located in a safe position, Report all incidents (including near misses) involving contaminated sharps at

the time of occurrence, or as soon as possible afterwards, to the line manager/Supervisor/Team Leader on duty and Occupational Health.


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Refer to Policy for Protection against infection with Blood Borne Viruses Policy/ Medical Sharps Policy 7.12 Linen disposal Used linen is a potential source of infection as it is likely to be contaminated with potentially pathogenic organisms. Gloves and aprons must be worn when dealing with soiled, wet or blood stained

lined. Linen should be bagged by the bedside, never carried through a clinical area by

hand. Linen bags must be half full only. They must not be overfilled. Lined from infected patients or blood stained must be placed in an inner red

alginate bag, and then placed into an outer red plastic bag. When removing soiled linen avoid the production of aerosols. If patients clothing is being laundered at home, place soiled laundry in a water

soluble clothing bag, inside an outer plastic bag. Inform visitors that laundry is awaiting collection in the patients locker.

Refer to Linen Policy 7.13 Pathology specimens All specimens should be handled with care. PPE must be used when handling specimens. All specimens must be safely contained in a leak proof container which is

additionally placed in a sealed polythene bag. The request form should be attached. Ensure the outside of the container, bag and form remain free from

contamination with blood or body fluids, faeces or vomit 7.13 Bio-hazard specimens from known or clinically suspected infected patients The request form must be labelled with inoculation risk (hand written on the

request form or free text on ICE). If there is a risk of spillage of contents then the specimen should be placed

inside a second polythene bag i.e. double bagging. The following bio-hazard specimens must not be sent via the vacuum tube

system; Classic or variant Creutzfeldt-Jakob disease (CJD), Diphtheria, Hepatitis B or C, HIV, Paratyphoid,


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Rabies virus, Tuberculosis, Typhoid.

If Viral Hemorrhagic fever is suspected, the microbiologist must be contacted before any specimens are taken or sent

7.14 Decontamination of equipment Equipment that is used on several patients can be a potential source of infection if not appropriately decontaminated after each use. Selection of the appropriate decontamination method will ensure that the equipment is clean and fit for purpose. Cleaning is an essential stage in the decontamination process and must always precede disinfection and /or sterilization. Check manufacturers instructions for use of suitable cleaning agents. The user of the device is responsible for ensuring that it is visibly clean and free from contamination with blood/body fluids following each procedure and prior to re-use or prior to sending for repair (internally/externally). The user must sign and date the appropriate labels to confirm that cleaning has taken place. During decontamination, the user must check clinical equipment for signs of damage and send for repair or disposal if appropriate. A completed label must accompany each piece of equipment sent for repair. Suitable personal protective equipment must be worn during decontamination procedures to protect the healthcare worker from exposure to microorganisms or infectious agents, where the risk of splash is anticipated. Refer to Decontamination policy for detailed guidance of suitable methods of decontamination 7.15 Last Offices When carrying out the last offices the following should be implemented. Wear PPE; gloves and apron Remove all drains, catheters and intravenous lines except where a post mortem

is required. Contain leakage from wounds and line sited by ensuring they are covered with a

waterproof dressing After carrying out last offices a body bag must be used in the following circumstances: When a body is leaking body fluids or there is gross external contamination with

blood


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Staff must ensure that mortuary staff are aware of the reason for using a body bag

When a patient has or is strongly suspected of having one of the following biohazard conditions:

Anthrax Classic or variant Creutzfeldt-Jakob disease (CJD) Diphtheria Hepatitis B, C HIV Meningococcal septicaemia / meningitis if death occurs before 48

hours of appropriate antibiotic therapy being completed Rabies virus Invasive -haemolytic Streptococcus Group A disease if death occurs

before 48 hours of appropriate antibiotic therapy being completed Tuberculosis Typhoid/ Paratyphoid Viral Hemorrhagic fever

Any soiled patients clothing must be placed in a water soluble clothing bag which must be secured and placed inside a property bag. Any itemised list of contents must be attached.

If in doubt contact Infection Prevention Control - Bleep 7991 8. References Department of Health. Saving Lives: reducing infection, delivering clean and safe care. London: Department of Health. 2007 Department of Health. The Health Act 2008 Code of practice for the prevention and control of healthcare associated infections. London: Department of Health. 2009. Fraise, A and Bradley, Christine (eds) (2009) Alliffes Control of Healthcare associated Infection. London, Hodder Arnold Health & Safety Executive, Control of Substance Hazardous to Health (COSHH) 1999 National Audit Office. Reducing Healthcare Associated Infections in Hospitals in England. London. The Stationary Office. 2009 Pratt et al (2007) Epic2 National Evidence Based Guidelines for Prevention Healthcare Associated Infections, Journal of Hospital Infection 65 supplement 1 Feb Protective clothing Principles and Guidance. Infection Control Nurses Association 2002 WHO guidelines on hand hygiene in health care, 2009


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Appendix 1: Consultation Schedule Name and Title of Individual Date Consulted Dr E Abrishami - Consultant Microbiologist 29/03/2011 Infection Prevention Control Team 29/03/2011 Dr. Susan Murray Clinical Microbiologist 29/03/2011 Dr Sarah Meisner - Consultant Microbiologist 29/03/2011 Mr C Gallegos Divisional Chair Surgery, 29/03/2011 Dr W Hubbard Divisional Chair Medicine 29/03/2011 Francesca Thompson Director Infection Prevention and Control

29/03/2011

Jo Miller Assistant Director Infection Prevention and Control

29/03/2011

Beverley Boyd Clinical Manager (Children) 29/03/2011 Mandy Rumble- Clinical Manager (Emergency Department)

29/03/2011

Caroline Gillice - Matron 29/03/2011 Neil Boyland - Matron 29/03/2011 Jan Lynn Head of Nursing, Surgery 29/03/2011 Heather Cooper Theatre Manager 29/03/2011 Mark Grover Respiratory Nurse Specialist 29/03/2011 Stephen Roberts Occupational Health Manager

29/03/2011

Luke Champion Environment Manager 29/03/2011 Bronia Charity Stores Manager 29/03/2011

Name of Committee Date of Committee Policy Working Group 22/03/2011 Operational Governance Committee 13/04/2011


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Appendix 2: Risk Assessment guide for selection of protective equipment based on risk of exposure to blood or body fluid

Assess actual and potential risk of blood or body fluid exposure in task being

undertaken

No blood/body fluid contact

Potential exposure to

blood/body fluid. High risk of splash

Potential exposure to blood/body fluid.

Low risk of splash patient confirmed as infectious e.g.

Chicken pox, MRSA, Clostridium difficile, TB

1. Gloves not required 2. Apron if clothing may be exposed i.e. moving patient or bed making 3. Eye protection and mask not required 4. Wash hands before and after contact 5. Dispose of linen in white linen bag at bedside 6. Decontaminate equipment between patients

7. Dispose of waste appropriately

1. Wear gloves 2. Wear apron as above and if splash to clothing likely 3. Wear mask/eye protection if appropriate 4. Dispose of soiled linen as infected i.e. red alginate bag then red plastic bag at bedside 5. Dispose of soiled waste in orange clinical waste bags 6. Decontaminate equipment with appropriate method 7. Wash hands after contact and removal of gloves

1. Wear gloves 2. Wear apron 3. Wash hands before and after patient contact and on removal of gloves 4. Wear mask if appropriate 5. Wear eye protection if appropriate 6. Dispose of soiled linen as infected at bedside 7. Dispose of soiled waste in orange clinical waste bags 8. Decontaminate equipment appropriately


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Appendix 3: Moments for hand hygiene The RUH embraces the Five Moments for Hand Hygiene ( WHO 2009), aiming to link specific hand hygiene actions to specific infectious outcomes in patients, by giving clear advice on how to integrate hand hygiene into the complex task of care. 1. Before patient contact; When? Clean your hands before touching a patient when approaching him/her. Why? To protect the patient against harmful germs carried on your hands 2. Before a clean/aseptic procedure: When? Clean your hands immediately before a clean/aseptic procedure. Why? To protect the patient from harmful germs, including the patients own from entering his/her body. 3. After body fluid exposure risk: When? Clean your hands immediately after exposure risk to body fluids and after glove removal. Why? To protect yourself and the healthcare environment from harmful patient germs. 4. After patient contact: When? Clean your hands after touching a patient and his/her immediate surroundings when leaving the patients side. Why? To protect yourself and the healthcare environment from harmful patient germs. 5. After contact with the patients surroundings: When? Clean your hands after touching any object or furniture in the patients immediate surroundings when leaving even if the patient has not been touched Why? To protect yourself and the healthcare environment from harmful patient germs.


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Appendix 4: Guidance for the selection of masks Type of mask Protection provided Indication for use Standard Surgical mask Basic protection

No fluid repellence General patient care &

isolation Immuno-suppressed

patient Short term use Circulating theatre

staff Surgical mask with fluid shield Direct fluid repellence

No eye protection Surgical scrub team During procedures

outside of the operating theatre where fluid exposure is anticipated

Surgical mask with fluid shield and integral visor

Fluid repellence Eye protection

Surgical scrub team A&E

High level protection PFR mask conforming to EN149 (Sometimes called Duck bill) or FFP3 valved respirator mask

High standard Filters 0.2 - .5 microns Lasts up to 8 hours Suitable for high risk

procedures Staff require training to

ensure fit is correct

Tuberculosis - N95 recommended (see TB policy) SARS, Avian flu - FFP3 mask recommended


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Equality Impact Assessment Tool To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval

Initial Screening

Policy, service, strategy, procedure or function: Policy

Lead (e.g. Director, Manager, Clinician): Yvonne Pritchard

Person responsible for the assessment:

Name: Jacqueline Cosgrave Job Title: Infection Prevention Control Nurse Is this a new or existing policy, service strategy, procedure or function? Existing

Who is the policy/service strategy, procedure or function aimed at? Staff Contractors Are any of the following groups adversely affected by the policy? If yes is this high, medium or low impact (see attached notes):

Group Affected? Impact Disabled people: No Race, ethnicity & nationality No Male/Female/transgender: No Age, young or older people: No Sexual orientation: No Religion, belief and faith: No If the answer is yes to any of these proceed to full assessment. This applies whether the impact assessment is high, medium or low. If the answer is no to all categories, the assessment is now complete

1. Does the policy, service strategy, procedure or function include measures which promote equality?

No

2. If yes, what are these measures?


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Consultation Checklist Author; attach this to each copy of the policy being sent to a meeting for comment.

Dear Chairman

Please would you disseminate this document for comment at your next meeting and return any amendments/comments to:

Title of meeting: Date of meeting: Policy Title and Reference: Universal/Standard Infection Control Precautions Name of author: Jacqueline Cosgrave

Are there any elements of this policy which present operational issues that require further discussion? No

If yes, please provide a contact name for the author.

Does the document include a training plan? No / N/A

Does the document include relevant references? Yes

Are up to date National Guidelines included? Yes

If you are the appropriate forum, have the necessary resources been agreed to implement this document? N/A

Is there a plan for policy implementation? N/A

Does your meeting recommend further consultation with groups or staff other than listed in the document? No

Other comments from meeting.

What are the cost implications of implementing this document?

Equipment N/A

Staffing (additional) N/A

Training N/A

Other N/A

Are there any other department affected? N/A Document endorsed without further comment? Yes Further amendments to document suggested? No Name of Chair:

Signature: ____________________________________ Date: __________________


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Ratification Check List Author; attach this to each copy of the policy being sent to a meeting for comment.

Dear Chairman

Please would you disseminate this document for comment at your next meeting and return any amendments/comments to:

Title of meeting: Operational Governance Meeting Date of meeting: Policy Title and Reference: Universal/Standard Infection Control Precautions Name of author: Jacqueline Cosgrave

Are there any elements of this policy which present operational issues that require further discussion? No

If yes, please provide a contact name for the author.

Is the policy referenced? Yes

Are up to date National Guidelines included? Yes

If you are the appropriate forum, have the necessary resources been agreed to implement this document? N/A

Is there a plan for policy implementation? No

Does your meeting recommend further consultation with groups or staff other than listed at the front of the policy? No

Is the policy referenced? Yes

What are the cost implications of implementing this document?

Equipment N/A

Staffing (additional) N/A

Training N/A

Other N/A Document endorsed without further comment? Yes Further amendments to document suggested? No Name of Chair:

Signature: ____________________________________ Date: __________________

Jacqueline Cosgrave, Infection Control Nurse1. Introduction2. Purpose of this policy3. Aims and Objectives of this policy4. Duties / Responsibilities5. Monitoring Compliance6. Risk assessment7. Procedure8. ReferencesAppendix 1: Consultation ScheduleAppendix 2: Risk Assessment guide for selection of protective equipment based on risk of exposure to blood or body fluidAppendix 3: Moments for hand hygieneAppendix 4: Guidance for the selection of masksEquality Impact Assessment ToolConsultation ChecklistRatification Check List

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