standard precautions policy (incorporating personal ... · ... (incorporating personal protective...

Hampshire Hospitals NHS Foundation Trust – Standard Precautions (Incorporating Personal Protective Equipment) – HH(1)/IC/572/16 Due for latest review on 31 December 2018. CHECK THE INTRANET FOR LATEST VERSION

of 22

Standard Precautions Policy (Incorporating Personal Protective Equipment) - HH(1)/IC/572/16

Previous document(s) being replaced

Location Policy No Policy Name

HHFT HH(1)/IC/572/13

Standard Precautions Policy (Incorporating Personal Protective Equipment)

Document Summary

This policy outlines the need for using standard precautions when dealing with:

The blood and bodily fluids of all persons which should be treated as infectious

Sharps safety

Blood and body fluid spillages in a timely and safe manner

Disposal of waste and excreta

Safe handling of linen

Ownership Author Andrea Bullard

Job Title Infection Prevention and Control Nurse

Document Type Level Level 1

Related Documents Document Details Hand Hygiene Policy Protective Isolation Policy Aseptic Technique Policy Glove Policy Management of Acute Febrile Respiratory Viral Infections Policy Guideline for the Management of Pandemic and Avian Influenza Cases Cleaning, Disinfection and Sterilisation Policy Prevention and Management of Needlestick/ Sharps Injuries and Exposure to Body Fluids Policy Waste Management Policy Linen Policy Care of Patients at Death Policy Standards of Dress Policy Epic 3: National Evidence Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England

Relevant Standards CQC Regulations 12

Equality Impact Assessment

Completed by Steve Mullen

Date Completed 15 January 2016

Final Document Approval Committee Policy Approval Group

Date Approved 25 January 2016

Final Document Ratification

Committee Executive Committee

Date Ratified 28 January 2018

Authorisation Authoriser Mary Edwards

Job Title Chief Executive

Signature

Date Authorised 1 February 2016

Dissemination Target Audience All Trust Staff

Dissemination and Implementation Plan


of 22

Action Owner Due by

Publicise detail of new document via Intranet and Midweek message

IPCT and Communication Team

Within 1 week of publication

Communication to all Senior Managers to advise publication of policy

BNHH Healthcare Library On publication

The policy will be available on the intranet and web site BNHH Healthcare Library and Communication Team

Within 1 week of authorisation

Review Review date 31 December 2018

Document Control – Document Amendments

Version No. Details Key amendments to note By whom Date

1 Review of BNHFT & WEHCT policies to produce harmonised HHFT policy

Expansion of bare below the elbow section Expansion of the mask section

IPCT July 2012

2 Amendment following Policy Approval Group

Addition of Glove Selection Risk Assessment

Hazel Gray September 2012

3 3 year review Gloves must be worn when handling sharps or contaminated devices Disposable plastic aprons must be worn when contact with the patient, materials or equipment pose a risk that clothing may become contaminated with pathogenic microorganisms, blood or bodily fluids. Eye protection must be worn when handling Actichlor plus Staff must use safer sharps devices

Andrea Bullard

October 2015


of 22

Contents

1. Introduction ..........................................................................................................4

2. Purpose .................................................................................................................5

3. Scope .....................................................................................................................5

4. Explanation of Terms ............................................................................................6

5. Duties ....................................................................................................................6

6. Hands ....................................................................................................................7

7. Cuts and Breaks in Skin .........................................................................................8

8. Bare Below the Elbow ...........................................................................................8

9. When should Personal Protective Equipment (PPE) be worn? ............................9

10. Gloves ...................................................................................................................9

11. Aprons and gowns ............................................................................................. 10

12. Eye and Face Protection (goggles/visors/masks) .............................................. 11

13. Sharps Management .......................................................................................... 11

14. Dealing with a blood or body fluid spillage ....................................................... 12

15. Disposal of waste and excreta ........................................................................... 13

16. Linen ................................................................................................................... 13

17. Hospital Environmental Cleanliness .................................................................. 13

18. Standard Precautions in Care of the Deceased ................................................. 14

19. Stakeholders Engaged During Consultation ...................................................... 14

20. Training .............................................................................................................. 15

21. Monitoring Compliance with the Document ..................................................... 15

22. References ......................................................................................................... 15

23. Legislation .......................................................................................................... 16

24. Guidance from other organisations................................................................... 16

25. Associated Documentation................................................................................ 16

Appendix A – Equality Analysis Form ........................................................................... 17

Appendix B – Glove Selection Risk Assessment........................................................... 19

Appendix C – Safe use of Actichlor Plus ....................................................................... 20

Appendix D – Guidance on safely dealing with a Blood or Body Fluid Spillage .......... 21

Appendix E – Safe Management of Sharps .................................................................. 22


of 22

1. Introduction

Universal Precautions were first recommended in 1985, by the Centers for Disease Control (CDC) in America, in response to the risk of transmission of HIV to health care workers from patients whose infection status was unknown. Initially they dealt only with bodily fluids capable of containing blood borne viruses. In the late 1980s the UK adopted universal precautions but they were expanded to include all routes of transmission and all body fluids/substances capable of containing pathogenic microorganisms, which could potentially lead to cross infection between patients. Standard Precautions combine the major components of universal precautions and Body Substance Isolation. The underlying principles of Standard Precautions are that the blood, bodily fluids, excretions (excluding sweat), secretions, non-intact skin, and mucous membranes may contain transmissible infectious organisms (CDC, 2007).

An assessment of the risk of exposure to any of the above is an important aspect in the selection and use of standard precautions (HSE, 2003). The application of Standard Precautions during patient care should be determined by the nature of the interaction and the extent of anticipated blood, body fluid, or pathogen exposure. Some interactions (e.g. performing venepuncture), require the use of gloves and aprons, some other interactions (e.g. intubation) require the use of gloves, gown, and face shield or mask and eye protection if necessary (CDC, 2007). Health care workers may face new and challenging circumstances in their practice. It is therefore crucial that education and training is provided by the Infection Prevention and Control team (IPCT) on the principles and rationale for recommended practices. This will facilitate health care professionals towards appropriate decision making regarding the selection and use of Standard Precautions. An example of the importance of the use of Standard Precautions is intubation, especially under emergency circumstances when infectious agents may not be suspected but later are identified (e.g. SARS, Pandemic Influenza). Standard Precautions are also intended to protect patients by ensuring that healthcare personnel do not carry infectious agents to patients on their hands or via equipment used during patient care. It must be remembered that most infectious patients are not a threat to healthy members of staff who carry out Standard Precautions. Good standards of hygiene must be practised by all staff. Staff may need to explain to patients and visitors why staff are required to wear gloves and aprons while delivering hands on care and why relatives and carers who assist with patient care are advised to wear gloves and aprons. Hepatitis B immunisation is strongly recommended for all staff that have potential contact with blood and body fluid through their work. Advice should be sought on first taking up employment in the Trust from the Health 4 Work Department regarding vaccination and immunisation or at any time after.


of 22

Standard Precautions apply to:

Body fluids, which may contain Blood Borne Viruses e.g. blood, blood-stained body fluids, semen, vaginal secretions, tissues, Cerebral Spinal Fluid, amniotic, pericardial, pleural fluids etc.

Body fluids, which may contain other pathogenic micro-organisms, e.g. faeces, urine, vomit and sputum.

2. Purpose

The objectives of this policy are to ensure that all Trust staff including those who work in community settings, contractors and staff who work across other Trust sites are aware of and adhere to the standard precautions of infection prevention and control. It is not always possible to identify people who may have infections and may potentially spread infection to others. It is therefore essential that the blood and bodily fluids of all persons without exception must be treated as potentially infectious. It is also therefore essential that precautions to minimise exposure to, and prevent the unnecessary transmission of a wide variety of micro-organisms are followed at all times. These routine procedures are known as The Standard Precautions (CDC, 2007). These standards are the basic principles of infection prevention and control which should underpin practice at all times. If unsure please contact the Infection Prevention and Control Team for further advice.

3. Scope

This policy and procedure will be applied fairly and consistently to all employees and service users regardless of their protected characteristics as defined by the Equality Act 2010 namely, age, disability, gender reassignment, race, religion or belief, gender, sexual orientation, marriage or civil partnership, pregnancy and maternity. For employees this policy also applies irrespective of length of service, whether full or part-time or employed under a permanent or a fixed-term contract, irrespective of job role or seniority within the organisation. Where an employee or service user has difficulty in communicating, whether verbally or in writing, arrangements will be put in place as necessary to ensure that the processes to be followed are understood and that the individual is not disadvantaged during the application of this policy. The application of this policy is completely clinically based and ensuring prompt testing/treatment would be the priority, however the Trust would endeavour to continue to meet patients’ individual needs as far as is practicable.


of 22

In line with the Equality Act 2010, the Trust will make reasonable adjustments to the processes to be followed where not doing so would disadvantage an individual with a disability during the application of this policy.

This policy complements professional and ethical guidelines and the Nursing and Midwifery Council (NMC) Code of Professional Conduct (NMC 2015).

4. Explanation of Terms

PPE – Personal Protective Equipment is the use of aprons, gloves, eye protection and face masks to protect staff from sustaining a healthcare associated infection.

5. Duties

Postholders

The Chief Executive (CE) has overall responsibility for the strategic and operational management of the Trust ensuring there are appropriate strategies and policies in place to ensure the Trust continues to work to best practice and complies with all relevant legislation in regard to the Standard Precautions policy.

The Director of Infection Prevention and Control (DIPC) is the Trust Director responsible to the board for the delivery of IPC standards.

The Director of Nursing will ensure that the Divisional Directors take clinical ownership of the policy.

The Divisional Operational Directors will ensure that all healthcare workers comply with this policy and that all healthcare workers attend mandatory infection prevention and control training. They are responsible for ensuring adequate facilities and resources are available to adhere to this policy.

The Clinical Service Managers/Leads will ensure that the current version of this policy is available in all of their areas. They will ensure that all healthcare workers comply with this policy and that all healthcare workers attend mandatory infection prevention and control training.

All Trust employees will comply with this policy and inform the Infection Prevention and Control Team about any issues or concerns relating to the policy. All staff will attend mandatory Infection Prevention and Control training annually. Infection control is the responsibility of ALL staff associated with patient care. A high standard of infection control is required on ALL wards and units, although the level of risk may vary. It is an important part of total patient care.

Groups/Committees

The Infection Prevention and Control Team (IPCT) will act as a resource for information and support. They will provide education in relation to this policy which includes mandatory training. They will monitor the implementation of this policy via audit within clinical areas and be responsible for regularly reviewing and updating it.


of 22

The Health4Work department will act as a resource for information, and support and consult with managers, the Infection Prevention and Control Team and healthcare workers regarding the use of personal protective equipment. The Health and Safety Team will act as a resource for information, and support and consult with managers, the Infection Prevention and Control Team and healthcare workers regarding the use of personal protective equipment.

6. Hands Hand hygiene is most effective at the point of care (World Health Organisation, (WHO) 2009). Hands must be decontaminated before and after each and every episode of direct contact with the patient and/or the patient environment (World Health Organisation, 2009; National Patient Safety Agency, 2009). Hands that are visibly soiled with contaminated dirt or organic material, i.e. blood/body fluids must be washed immediately with liquid soap and warm water. It is important that areas of the hands are not missed during hand washing. Adequate drying is extremely important as wet hands are able to carry more bacteria, and skin damage is more likely. Alcohol gel alone is ineffective at decontaminating visibly soiled hands and therefore should not be used in this instance. Hands may be decontaminated with an alcohol gel hand rub (unless visibly soiled) between caring for different patients and different activities. These agents have disinfectant activity and destroy transient micro-organisms, but not spore forming bacteria such as C. diff, or Norovirus. See Hand Hygiene Policy. Antiseptics e.g hibiscrub contain a combination of detergent and micro-biocide such as chlorhexidine or povidine-iodine. Antiseptics should not be used routinely on wards but should be used prior to performing an invasive procedure or an aseptic technique e.g. inserting a central line. Hands should be decontaminated at the point of patient care and at various stages in that episode of care in accordance with the World Health Organisation’s Five Moments for Hand Hygiene (WHO, 2009). See Hand Hygiene Policy.


of 22

Patients, relatives and visitors:

Relatives and visitors should be reminded to wash or gel their hands on entering and leaving the ward.

Patients who are unable to access hand hygiene facilities must be provided with a bowl of warm water and soap or hand hygiene wipes.

7. Cuts and Breaks in Skin

Any existing cuts or lesions should be covered with a waterproof dressing, paying particular attention to hands and forearms.

Any staff with chronic skin lesions to hands or forearms, or persistent skin problems should seek advice on whether they can continue to practice from the Health4Work Department. The member of staff may also be referred to Dermatology.

8. Bare Below the Elbow There is no direct evidence that ‘bare below the elbow’ reduces infection. However there is much evidence that ties, watches, jewellery and sleeves etc can carry bacteria and agents of hospital-acquired infection such as MRSA and Clostridium difficile spores. These microbes are easily transmitted from and between patients, staff and visitors. Hands and arms can be easily decontaminated with alcohol gel or thorough hand washing but sleeves, watches and jewellery cannot. All staff are expected to be ‘bare below the elbow’ when having hands-on contact with patients


of 22

and/or their environment, or entering a clinical area such as a ward, bay, side room or treatment room. See Standards of Dress Policy. This means:

Sleeves should be short or rolled up to the elbow to allow thorough hand hygiene.

Removal of wrist watches, bracelets and stoned rings prior to clinical care as these become contaminated and can pose an infection risk. They also reduce the effectiveness of hand hygiene. Plain wedding bands are acceptable.

No nail varnish, or false/gel nails.

Ties removed or tucked into the shirt to prevent contact with the patient or their environment.

For some staff, whose religious beliefs include the need to remain covered, bare below the elbow can be cause for concern. The Trust is sensitive to this and can provide long covers for sleeves, should this be deemed appropriate.

If long sleeved water repellent gowns are required to be worn for infection control purposes then bare below the elbow will not apply.

9. When should Personal Protective Equipment (PPE) be worn? Selection of personal protective equipment should be based on an assessment of the risk of transmission of microorganisms to the patient, and the risk of contamination of the healthcare worker’s clothing and skin by patients’ blood, bodily fluids, secretions or excretions (Loveday et al, 2014).

Protective clothing is used in addition to normal clothing: uniforms are not considered protective clothing.

Dispose of PPE into the Tiger Stripe bags (Black and yellow stripes).

PPE contaminated with non-infectious body fluids e.g. faeces and urine, can be disposed of in the Tiger Stripe waste stream.

Orange bags will continue to be used for patients in isolation.

10. Gloves

Gloves should be worn in accordance with Appendix B – Glove Selection Risk Assessment.

Gloves must be worn for invasive procedures, contact with sterile sites and non-intact skin or mucous membranes and all activities that have been assessed as carrying a risk of exposure to blood, body fluids, secretions or excretions. (Loveday et al, 2014). Please also refer to the Aseptic Technique Policy

Gloves must be worn when handling sharps or contaminated devices.

Gloves are single use items. Where deemed necessary, they must be put on immediately before an episode of patient contact or treatment and removed as soon as the activity is completed.


of 22

Gloves must be changed between caring for different patients and between different care and treatment for the same patient.

After each procedure/episode of patient care, contact with blood, body fluids or used in an isolation room they must be disposed of as clinical waste and hands decontaminated thoroughly immediately following the removal of the gloves.

Neither powdered nor polythene ‘food’ gloves should be used for patient care activities.

Most gloves used within the hospital are latex free. This includes sterile gloves. Any staff member wishing to use latex gloves must first complete a risk assessment form available in the Glove Policy. Any sensitivity to natural rubber latex in patients, carers and healthcare staff must be documented.

Nitrile gloves must be used for exposure to chemicals. This includes the giving of chemotherapy.

It should be remembered that wearing gloves does not remove the need for thorough hand washing as gloves can become punctured and hands are easily contaminated whilst removing gloves.

11. Aprons and gowns

Disposable plastic aprons should be worn where there is a risk of exposure of clothing to blood, body fluids, secretions and excretions or when coming into contact with a patient with a known infection who is being isolated (with the exception of sweat). Apron and gloves must be worn when in contact with the environment of a patient nursed in isolation.

Disposable plastic aprons must be worn when close contact with the patient, materials or equipment pose a risk that clothing may become contaminated with pathogenic microorganisms, blood or body fluids.

An apron will also protect a uniform from becoming wet and should be worn when bathing or showering a patient.

Full body fluid repellent gowns must be worn where there is a risk of extensive splashing of blood, body fluids, secretions or excretions onto the skin or clothing of healthcare workers.

Plastic aprons and gowns should be worn as single use items for one procedure or episode of patient care and then discarded and disposed of in clinical waste bags.

Yellow plastic aprons should only be worn for isolation rooms and cohort bays. See Isolation Policy

Green disposable plastic aprons should be worn when handing out the meal trays and when assisting patients with their meals.

Aprons of other colours may be worn to identify staff working in specific bays or with specific patients.

Disposable gowns must be worn for contact with patients who have scabies or Norwegian scabies.

Disposable gowns maybe recommended by the Infection Prevention and Control Team for other patients.


of 22

12. Eye and Face Protection (goggles/visors/masks) Facemasks and eye protection (goggles, visors) must be worn where there is a risk of blood, body fluids, secretions or excretions splashing into the face and eyes (e.g. suctioning of patients) and when handling Actichlor and Actichlor plus. Comfort fit and visual acuity will influence the choice of eye protection.

Face Masks The functions of masks are:

To protect the healthcare worker from potential exposure to micro-organisms from splashing of blood/body fluid to the face. Fluid repellent masks are recommended for exposure prone procedures like surgery, intubation of patients, dental and obstetrics.

To protect staff from potentially contaminated aerosols or dusts e.g. when carrying out respiratory suctioning or nail filing in podiatry.

To protect staff from potential exposure to micro-organisms from airborne infectious disease. Respiratory protection (e.g. a particulate filter mask) must be correctly fitted (e.g. fit tested) and should be worn when recommended for the care of patients with respiratory infections which are transmitted by airborne particles (e.g. SARS, MDRTB).

All staff who potentially work with patients who have respiratory viruses or TB should be ‘fit tested’ to ensure there are adequately protected by an FFP3 mask. Contact Health4Work or Infection Prevention and Control for further advice. See Management of Acute Febrile Respiratory Viral Infections Policy.

To function effectively masks should be:

Appropriate for their purpose

Worn correctly and close fitting

Handled as little as possible

Changed between procedures or patients

Changed if they become damp

Discarded immediately after removal as clinical waste

Never reused

The wearing of eye protection and masks may cause some adults and children anxiety. Staff must explain clearly why they are necessary. This is particularly necessary for patients with learning difficulties, Alzheimer’s disease, confusion or other mental health needs.

13. Sharps Management

Sharp instruments frequently cause injury to healthcare workers and can potentially cause transmission of blood borne viruses. Sharps include needles, scalpels, broken glass or any other item that may cause laceration or puncture e.g. bone or teeth.


of 22

Sharps must not be passed directly from hand to hand and handling should be kept to a minimum.

Gloves must be worn when handling sharps or contaminated devices.

Needles must not be re-sheathed, bent, broken or disassembled prior to disposal.

Syringes/cartridges and needles should be disposed of intact.

Staff must use safer sharps devices where assessment indicates that they will provide safe systems of working for healthcare workers.

Disposal of used sharps in inappropriate places can present a considerable risk to other employees and every health care worker has a responsibility to ensure correct, safe, disposal of the sharps that he/she has used.

Always dispose of sharps at the point of use in an appropriate container. A sharps bin should be taken to the bedside.

Do not dispose of sharps with other clinical waste.

Staff carrying out invasive procedures must dispose of their own sharps. Other staff must not ‘clear away’ someone else’s procedure trolley.

Sharps containers should be safely positioned off the floor away from children and the general public.

Sharps containers should be secured to avoid accidental spillage.

Do not remove sharps from the clinical setting.

Sharps containers must comply with BS 7320 and UN3291 standards

Sharps boxes should not have blood or body fluids on their external surfaces. Any contaminant should be removed in accordance with the waste Management Policy prior to collection.

Do not place used sharps containers in yellow bags for disposal.

For guidance on safe use of sharps systems see Appendix D.

14. Dealing with a blood or body fluid spillage

Domestic/housekeeping staff are not to deal with body fluid spills. If body fluid spills occur outside the ward area or outside the building contact the domestic supervisor.

All spillages of blood/bodily fluids should be dealt with immediately.

Appropriate personal protective equipment must be used e.g. nitrile glove and disposable apron for the procedure.

Absorb the liquid with disposable paper towels. Dispose of the towels as clinical waste.

Disinfect the spillage by covering with either chlorine releasing granules or a chlorine releasing solution at 10 000 ppm concentration (Actichlor plus®).

Leave for 2 minutes clean the area up with disposable towels and dispose of as clinical waste.

For urine and vomit spillages, these will need cleaning first with paper towels and then disinfecting with the chlorine releasing solution (Actichlor plus®).


of 22

Large spillages of blood or body fluid visibly stained with blood will have to be dealt with using the spillage of urine procedure.

15. Disposal of waste and excreta

Ensure items that have blood or body fluid contamination are disposed of as clinical waste and sent for incineration.

Ensure that any excreta is disposed of in the macerator or sluice hopper in the dirty utility room.

Suction waste should be disposed of in the suction box receptacles in the dirty utility. These must be removed by the waste porters in a timely manner.

All waste should be safely disposed of in accordance with the Waste Management Policy.

16. Linen

Linen from infected patients or any which is visibly fouled may be a hazard to:

Patients and staff on the ward

Portering staff during transport

Laundry staff

Ensure that any linen contaminated with blood or body fluids is placed into an alginate bag and then clear plastic bag.

If linen is excessively wet please ensure that this item is wrapped in another item of linen or the alginate bag may leak/split.

If patient’s personal items (e.g. pyjamas, dressing gowns) are soiled with blood or bodily fluids please inform the families/carers of this and ensure it is placed in an alginate bag and red bag for the family/carers to take home and launder. No sluicing of clothes should occur at ward level at any time in order to reduce the exposure to bodily fluids.

Only take clean linen into a room when it is needed to be used. Do not store linen at the ends of beds or on lockers for imminent bed changes.

Linen should be in a covered receptacle and not left on open trollies in ward corridors.

17. Hospital Environmental Cleanliness

The hospital environment must be visibly clean, free from dust and spillage and acceptable to patients, their visitors and staff.

Every Health Care Worker (HCW) must report to the domestic services manager any concerns re the cleanliness of the patient environment.

Every HCW must be clear about their specific responsibilities for cleaning equipment in clinical areas.

Shared equipment used in the clinical environment must be decontaminated appropriately after each use.


of 22

Every HCW has a responsibility to report any sightings or problems with pests. This is done by contacting the Facilities Help Desk during normal working hours.

Clean and dirty equipment must be segregated and easily identified. Clean equipment can be identified using the green tape sticker system.

18. Standard Precautions in Care of the Deceased The same precautions taken when the patient is alive should continue upon death. ‘Last offices’ are performed at ward level on all deceased patients. This procedure includes washing, tidying, identifying and shrouding the body. Staff who perform last offices should wear the appropriate protective clothing e.g. aprons and gloves and assess the risk of requiring goggles and/or facemasks if it is anticipated that there may be a risk of splashing of bodily fluids. Certain other preparations may be required at ward level in individual cases e.g. for ‘high risk’ cases thought to be infected with the following:

Hepatitis B, Hepatitis C, HIV (AIDS), Invasive Group A Streptococcal infection, Tuberculosis, Meningococcal septicaemia and other rare diseases – e.g. dysentery, anthrax, plague, rabies, viral haemorrhagic fevers, yellow fever, typhoid and diphtheria.

A Danger of Infection sticker must be placed on the outside of the body bag and the mortuary contacted by phone and notified of the name of the patient and the potential or known infection.

All deceased patients will be placed in a body bag prior to transfer to the mortuary.

19. Stakeholders Engaged During Consultation

Stakeholder Date of Consultation

Infection Prevention and Control (Lead Infection Prevention & Control Nurse)

24 November 2015

Health and Safety (Health and Safety Advisor) 24 November 2015

Safeguarding (Trust Safeguarding Lead) 24 November 2015

Information Governance (Information Governance Manager) 24 November 2015

Assistant Risk and Compliance Manager (Risk and Compliance)

24 November 2015

Divisional Directors and Divisional Directors (Operational) 24 November 2015

Equality and Diversity Lead (Equality & Diversity) 24 November 2015

Head of Health4Work 24 November 2015

Infection Prevention and Control Committee 24 November 2015

Consultant Microbiologists 24 November 2015

Clinical Service Managers/Leads 24 November 2015

Operational Service Managers 24 November 2015


of 22

20. Training

All new staff, whether clinical or not, will attend an Infection Prevention and Control session at Trust induction. Each department must provide local induction for new staff on standard precautions and personal protective clothing. Junior medical staff will have infection prevention and control sessions rostered into their education programme.

Individuals in the Trust should receive annual infection prevention and control training to ensure they are aware of their responsibilities. Education and Training will be provided in accordance with the Trust Training Needs Analysis (Learning and Development Policy). 21. Monitoring Compliance with the Document

NHSLA Minimum requirements

Requirement Reviewed by

Method of Monitoring

Frequency of Review

Committee where Monitoring is Reported to

Effectiveness of policy

Infection Prevention and Control Team

Observations and audits

Annual environmental audits

Infection Prevention and Control Committee

22. References

Health and Safety Executive advisory committee on dangerous pathogens. (2003). Infection at work: controlling the risk. [Online]. Available at http://www.hse.gov.uk Accessed 17 November 2015 Centers for disease control and prevention, (2007). Standard Precautions. [Online] Centers for disease control and prevention. Available at www.cdc.gov/ncidod/dhqp/gl_isolation_standard.html Accessed 17/11/2015. Centers for Disease Control (1987) Recommendations for the Prevention of HIV Transmission in Health Care Settings. MMWR (Aug.21) 36: (2S). Medical Devices Agency (2001) Safe use and disposal of sharps. MDA SN2001 (19). National Patient Safety Agency responds to recent reports on the removal of alcohol hand rub dispensers. 2009. [Online] National Patient Safety Agency. Available at http://www.npsa.nhs.uk Accessed 17 November 2015. NICE Clinical Guideline 2 (2003) Infection Control: Prevention of healthcare associated infection in primary and community care.ISBN:1-84257-303-9. National Institute of Clinical Excellence: Surrey

UK Health Departments (1998) Guidance for Clinical Health Care Workers: Protection Against Infection with Blood borne Viruses. Recommendations of the Expert Advisory

http://www.cdc.gov/ncidod/dhqp/gl_isolation_standard.html%20Accessed%2017/11/2015


of 22

Group on AIDS and the Advisory Group on AIDS and the Advisory Group on Hepatitis. HMSO, London. World Health Organisation 2009. World Health Organisation guidelines on hand hygiene in health care. First global patient safety challenge. Clean care is safer care. [Online] World Health Organisation. Available at http://www.who.int/publications/2009 Accessed 17 November 2015 H.P. Loveday, J.A. Wilson, R.J. Pratt, M. Golsorkhi, A. Tingle, A. Bak, J. Browne, J. Prieto, M. Wilcox. 2014. epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection. P 5 – 6. Accessed 15/10/2015. http://www.his.org.uk/files/3113/8693/4808/epic3_National_Evidence-Based_Guidelines_for_Preventing_HCAI_in_NHSE.pdf Accessed 15 October 2015

23. Legislation

Department of Health 2008. The Health Act 2008: Code of practice for the prevention and control of health care associated infections. SI 277363 1P 1K Oct06. London: Department of Health Publications. Department of Health (1974) Health and Safety at work Act 1974. http://www.hse.gov.uk/legislation/hswa.htm

24. Guidance from other organisations

Department of Health, World Health Organisation, National Institute for Health and Clinical Excellence

25. Associated Documentation

Hand Hygiene Policy Protective Isolation Policy Aseptic Technique Policy Glove Policy Management of Acute Febrile Respiratory Viral Infections Policy Guideline for the Management of Pandemic and Avian Influenza Cases Cleaning, Disinfection and Sterilisation Policy Linen Policy Prevention and Management of Needlestick/Sharps Injuries and Exposure to Body Fluids Policy Waste Management Policy Care of Patients at Death Policy Standards of Dress Policy Epic 3: National Evidence Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England

http://www.who.int/publications/2009%20Accessed%2017%20November%202015

http://www.his.org.uk/files/3113/8693/4808/epic3_National_Evidence-Based_Guidelines_for_Preventing_HCAI_in_NHSE.pdf%20Accessed%2015%20October%202015

http://www.his.org.uk/files/3113/8693/4808/epic3_National_Evidence-Based_Guidelines_for_Preventing_HCAI_in_NHSE.pdf%20Accessed%2015%20October%202015


of 22

Appendix A – Equality Analysis Form

Document Name: Standard Precautions Policy

Part 1 – Policy Author to complete and forward on to an EA Lead for sign off

1. Could the application of this document have a detrimental equality impact on individuals with any of the following protected characteristics? (See Note 1)

Yes/No/NA

Summarise the equality and diversity related elements within the policy

a Age No

b Disability No

c Gender reassignment No

d Race No

e Religion or belief No

f Sex No

g Sexual orientation No

h Marriage & civil partnership No

i Pregnancy and maternity No

2. If ‘Yes’ to question 1, do you consider the detrimental impact to be valid, justifiable and lawful? If so, please explain your reasoning.

Yes

3. Specify with which, if any, individuals and groups you have consulted in reaching your decision.

Part 2 – Equality Analysis Lead to complete and forward back to the Policy Author

Provide a brief summary of the potential impact of the policy and whether sufficient consideration has been given to the Equality Duty.

1. Is this document recommended for publication? Yes If ‘yes’ go to question 3 if ‘No’ complete number 2 below.

2. This document is not recommended for publication because:

a Amendments are suggested as follows:

b A more detailed equality analysis should be undertaken as follows:


of 22

c Other (please specify)

3. Specify with which, if any, individuals and groups you have consulted in reaching your decision.

Name: Steve Mullen Job Title: Risk & Compliance Advisor Date: 15 January 2016

Part 3 – Policy Author to complete on receipt of part 2 and before forwarding for final policy approval

1. I have reviewed the Part 2 assessment and have made the necessary amendments to the policy.

If you have answered ‘no’, please explain why not

Name: Katie Maxey Job Title: Health and Safety Advisor Date: 15 January 2016

Note 1 Under the terms of the Equality Act 2010 public sector Equality Duty, the Trust has a legal responsibility to think about the following three aims of the Equality Duty as part of our decision making and policy development.

Eliminate unlawful discrimination, harassment and victimisation;

Advance equality of opportunity between people who share a protected characteristic and people who do not share it; and

Foster good relations between people who share a protected characteristic and people who do not share it.


of 22

Appendix B – Glove Selection Risk Assessment

Cleaning by General Services staff

General Clean and Isolation

Blood spillages and chemicals

Non sterile Nitrile

Non sterile Nitrile

Food Preparation

Clear Vinyl only

Tasks where there is a low risk of contamination, non invasive clinical care, or environmental cleaning e.g. Oral care Emptying catheter drainage bags Emptying urinals/bedpans and suction jars Handling low risk specimens Clinical cleaning Dressing wounds when contact with blood/body fluids is unlikely e.g. gastrostomy dressings Endotracheal suction Applying creams Touching patients with unknown skin rash/scabies/ shingles Making beds/changing clothing of patients in isolation

Non sterile Nitrile

Procedures involving risk of exposure to BBVs and where high barrier protection is needed e.g. Potential exposure to blood/body fluids e.g. blood spillages, faecal incontinence, blood glucose monitoring, administering enemas/ suppositories and rectal examinations Handling cytotoxic material Handling disinfectants Venepunture/cannulation Vaginal examination in Gynaecology Basic care and specimen collection procedures on patients known or suspected to be high risk of BBV Non surgical dentistry/ podiatry Handling dirty/used instruments Processing specimens in a laboratory

Non sterile Nitrile

Procedures which require a sterile field and high barrier protection e.g.: Lumbar punctures Liver biopsies Clinical care to surgical wounds / drain sites Procedures for Neutropenic patients Insertion of urinary catheters Vaginal examination in obstetrics

All surgery radiological and pharmacy preparation procedures

Sterile Surgeons’ Gloves: Neoprene Nitrile Non powdered Low protein latex

All staff using latex gloves of any type will be required to participate in a skin health surveillance programme

Type of activity

Sterile Nitrile examination gloves


of 22

Appendix C – Safe use of Actichlor Plus


of 22

Appendix D – Guidance on safely dealing with a Blood or Body Fluid Spillage


of 22

Appendix E – Safe Management of Sharps

Basingstoke and North Hampshire Hospital

Do not fill sharps containers above the manufacturer’s marked line, which indicates that they are full.

The temporary closure mechanism should be in place whenever the sharps bin is not in use.

Used sharps containers should be locked in accordance with manufacturer’s instructions.

Royal Hampshire County Hospital and Andover War Memorial Hospital

Sharps bins (Sharpsmart) come ready assembled but staff must ensure that each sharps box is correctly labelled stating the date and the name of the ward or department

These sharps bins have tilt trays which, when the box is 2/3 full, do not return to the tilt position. This prevents sharps from protruding out of the aperture. When the tilt tray no longer returns, staff are required to close, lock, sign and replace the sharps bin

Access plus bins are specifically designed for intra venous infusion lines and other larger items and do not have tilt trays. These bins must be closed, locked and replaced when 2/3 full. These bins must not be placed where patients can access them and should be used in the dirty utility.

In the event of a sharps injury or contamination of broken skin/mucous membranes with blood or body fluids, ensure that the Needle Stick Injury Procedure is followed. It is the responsibility of all staff to ensure that they are aware of the location of the needle stick injury pack to follow in the areas in which they work. See Needlestick/Sharps Injuries and Exposure to Body Fluids Prevention and Management policy.