Independent Hospitals by Karen Foulis

Infection Prevention and Control

Policies and Safe Practice Guidance Manual Independant Hospitals & Clinics

Infection Prevention Solutions Gordon House 1-6 Station Road Mill Hill London NW7 2JU T: 020 8906 2777 F: 020 8906 2233 E: info@infectionpreventionsolutions.co.uk

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Infection Prevention Solutions

INFECTION PREVENTION AND CONTROL CLINICS & INDEPENDENT HOSPITALS POLICIES AND SAFE PRACTICE GUIDANCE CONTENTS Title

Section Number

Policies: Infection Prevention And Control Management Policy Policy Statement for COVID-19 Management in Clinics Recognition and management of an outbreak of infection Management of an outbreak of viral gastro-intestinal illness Antibiotic Prescribing Policy Sepsis

1 2 3 4 5 5a

Safe practice guidance – General: Infection Control Principles - the spread of infection Standard Precautions Hand Hygiene Personal Protective Equipment (PPE) Safe Use and Disposal of Sharps Management of Healthcare Waste Estates & Facilities Management Minor Surgery Environment Environmental Cleaning Spillages of Blood and Body Fluids Laundry management Pest Control Working with animals

6 7 8 9 10 11 12 12a 13 14 15 16 17

Safe practice guidance – Clinical: Decontamination of Medical Devices Decontamination of Endoscopes Single Use and Single Patient Use Medical Devices Aseptic Technique and care of Invasive Devices Asepsis in minor surgical procedures Isolation of Infectious Patients Last offices – care of the deceased Collection and packaging of microbiological specimens Closure of rooms, wards and facilities Infections with specific alert organisms

18 18a 19 20 20a 21 22 23 24 25

Safe practice guidance – Personnel: Management of occupational exposure to blood-borne viruses Management of infections in staff Vaccination programme for staff Uniform and dress code

26 27 28 29

Bibliography

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HAND HYGIENE Effective hand hygiene is the single most important measure in reducing the risk of transmission of micro-organisms from one person to another or from one site to another on the same person. Decontaminating hands as promptly and as thoroughly as possible between service user contacts and after contact with blood, body fluids, secretions, excretions and contaminated equipment/articles is essential in order to minimise the risk of cross-infection. Hands are contaminated with both transient and resident flora: •

Transient flora: are those micro-organisms that are not resident on the skin but are acquired by day-to-day activity including direct contact with service users, contaminated equipment and environmental surfaces. It is these microorganisms that are responsible for the majority of episodes of cross infection. Transient flora includes the vast majority of bacteria, viruses and other pathogenic micro-organisms that our hands come into contact with during the course of daily living. This includes micro-organisms such as Staphylococcus aureus, Clostridium difficile, gram negative bacilli and noroviruses. Transient flora are loosely attached to the skin and are readily removed by the mechanical action of washing, using soap and water, rinsing and drying of hands. Many may also be destroyed by the application of an alcohol based hand gel / rub.

•

Resident flora: are those micro-organisms that live on the skin and provide a protective function. In the vast majority of instances these micro-organisms do not cause cross-infection and it is unnecessary to eradicate them from hands during most healthcare activities. However, in certain circumstances resident flora can pose a risk to susceptible individuals. They are a particular risk during surgery and the insertion of some invasive devices such as central venous cannulae etc. Resident flora are not easily removed by mechanical methods and require the application of skin antiseptics e.g. chlorhexidine or povidone iodine to reduce their numbers to acceptable levels. Thus the use of skin antiseptics is standard practice prior to surgical procedures and the insertion of some invasive devices.

Basic hand care To keep hands in good condition and to perform effective hand hygiene, staff should perform some basic hand care. Use an emollient hand-cream twice a day. Use before and after shifts to help replace the skin’s oils that can be lost through frequent hand hygiene. Hand creams should be for individual use or dispensed from either a wall-mounted container or from a pump dispenser. Pots / tubes of cream should not be used by groups of staff as they can be easily contaminated.

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•

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The Health and Safety Executive (HSE) advises that employers should carry out Health surveillance of their employees to identify individuals at risk of developing occupational contact dermatitis in healthcare. This surveillance should include: Assessing workers' skin condition before or as soon as possible after they start a relevant job to provide a baseline; Regular visual skin inspections by a 'responsible person'. The frequency of the inspections will depend on the nature of the risk, but a brief monthly routine is often appropriate; Telling employees about likely exposures and symptoms to watch out for; Telling employees about how (and whom) to report such symptoms if they occur between inspections.

Ref. HSE Skin at work. Health Surveillance: https://www.hse.gov.uk/skin/professional/health-surveillance.htm Observe the hands for any signs of damage to the skin as this can provide a portal for micro-organisms to enter the body. Cover with a waterproof plaster or dressing before the shift begins and replace if necessary. If cracks or breaks do not heal, then Occupational Health advice should be sought. Dermatitis can be caused by sensitivity to ingredients in hand cleansers. Always seek guidance from Occupational Health or local GP if skin problems on hands do not clear. Hand and wrist jewellery (including wrist watches) should not be worn by staff undertaking direct care. Rings containing stones or mounts should not be worn by care staff as micro-organisms are known to readily colonise such items, providing an on-going source of potential pathogenic micro-organisms. Plain wedding bands are acceptable. Wrist watches are easily contaminated and can prevent thorough hand washing of wrists. Nails should be kept short at all times to reduce the accumulation of micro-organisms. False nails; nail extensions and nail jewellery should NOT be worn by staff having direct service user contact as they too are recognised sources of potential pathogenic micro-organisms and discourage staff from thorough hand decontamination. Long sleeves should not be worn by staff undertaking direct care. In the event that long sleeves are worn, they must be rolled up above the elbows prior to hand washing.

Types of hand hygiene/decontamination Current research advocates a variety of processes to ensure effective hand hygiene and these are described below. The most appropriate of these processes must be used by staff depending on the work that is being undertaken.

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General / clinical / social hand wash This involves the use of liquid soap products, warm running water and disposable paper towels. This activity mechanically removes transient micro-organisms from the hands and is perfectly acceptable for the vast majority of healthcare interventions. Alcohol-based general / clinical / social hand decontamination Alternatively, an alcohol-based product can be used for general hand decontamination in the place of a hand-wash but only if hands are visibly clean and not soiled – see below. Surgical / antiseptic scrub This is an extended hand decontamination procedure which is undertaken e.g. prior to surgical procedures and specific high risk invasive procedures using hand wash products containing certain antiseptic skin cleansers e.g. chlorhexidine or povidoneiodine. Alternatively, alcohol-based products can also be used. (see appendix and additional paragraph at end) The time taken for surgical hand scrubbing will vary depending on product used and if the hands and arms are grossly soiled, the scrub time should be lengthened. However, it is difficult to find concrete agreement amongst the experts regarding the recommended time for surgical hand asepsis, or about a longer initial scrub and subsequent scrub durations. Therefore as most of the literature recommends timings of between 2-5 minutes, clinical teams should agree locally on an acceptable timing, but the recognised extended Ayliffe 6 step technique should be adopted.

Types of hand decontamination products Liquid soap products These products are used for the vast majority of hand decontamination interventions that require the removal of transient micro-organisms. Products should be purchased from an approved supplier of medical products e.g. NHS Supply Chain as these products have been independently evaluated and economies of scale will be achieved with regards to cost. Bar soap must not be used for hand decontamination by staff as it can harbour micro-organisms. Bar soap is acceptable for service user use but should be allocated to each individual rather than being shared. Soap impregnated wipes are also widely available for hand decontamination and can be useful in certain situations e.g. for service users who cannot easily access a hand wash basin after using a commode or prior to meals. Wipes should not be routinely used by health care workers who require a more thorough hand decontamination that is best provided by the use of soap and running water.

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Liquid soap products containing antibacterial agents (as are widely available in supermarkets) are not necessary for routine hand decontamination and should be avoided in health care environments. Some soap formulations are also available as foams. These are acceptable. Alcohol based hand sanitiser (gel/rub/foam) Alcohol-based hand sanitiser products – usually gel / foam are currently recognised as being the primary method of hand decontamination for most health care interventions where rapid hand decontamination is required at the point of use. Alcohol-based products are also useful where adequate facilities are not available e.g. when caring for service users in their own homes. Alcohol is inactivated in the presence of organic matter i.e. body fluids etc. and therefore is not to be used on soiled hands. The emollient added to some alcohol sanitisers to counter the drying effect of the alcohol can build up on the skin and some manufacturers recommend that hands are washed with soap and water when the hands feel sticky or after a maximum of 5–10 applications of products to remove residues. Alcohol-based products should be purchased from an approved supplier of medical products e.g. NHS Supply Chain thus ensuring that an appropriate product suitable for healthcare activities is supplied and of the required strength (usually 70%) and type (usually isopropanol). Alcohol products should be used from wall-mounted dispensers (see below) or can be provided for individual staff use in bottles (“tottles”) that can be attached to uniforms thus ensuring that the product is available at the point of care. Alcohol is not as effective as soap and water in removing Clostridiodes difficile spores or some viruses including Norovirus and must therefore not be used whilst caring for service users with diarrhoeal illness. Antiseptic detergent products (e.g. Chlorhexidine, povidone iodine) These products are designed for use when a higher level of antimicrobial kill is required e.g. when it is necessary to remove / reduce resident as well as transient micro-organisms. This is usually only necessary prior to surgical procedures and certain high risk invasive procedures. Hand wash facilities: Soap and alcohol containers / dispensers All soap and alcohol products should be dispensed from a sealed container which delivers a measured amount of product. The nozzle must be cleaned regularly to prevent clogging and contamination. Open containers and refillable containers must not be used as they can become contaminated with micro-organisms.

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Ideally, containers should be wall mounted with a pump-action and operated with heel of hand or wrist, not fingers. Best practice recommendation to minimise the risk of Pseudomonas aeruginosa contamination, is for alcohol gel dispensers to be located at the point of use not at hand wash sinks or alternatively use individual hand sanitiser bottles / tottles. Paper towels Good quality, soft, absorbent paper towels should be available for use at all hand wash basins. Towels should be dispensed from wall-mounted dispensers to avoid contamination. NB. Electric hand dryers are not recommended in clinical areas due to the risk of contamination arising from the dissemination of contaminated water droplets during use. Hand cream Hand cream should be available for staff use. Ideally, it should be provided in wallmounted dispensers or from a pump-action container. Tubes or jars of hand cream must be avoided as they are easily contaminated. Nozzles must be cleaned regularly to prevent clogging and contamination.

Equipment required for effective hand hygiene in clinical settings All hand wash basins and taps in clinical areas should conform to the requirements of Health Building Note (HBN) 00-10 Part C: Sanitary assemblies (2013), which outlines the minimum requirements for such equipment. This includes the need for: • • • •

elbow / wrist / automatically operated lever taps mixer taps ensuring that water is delivered at an appropriate temperature basins without plugs or overflows taps that are situated so that water does not flow directly into the waste outlet but are off-set

• The provision of adequate clinical hand wash basins is often overlooked. As a general rule, where-ever clinical care is provided e.g. in a clinical or treatment room as well as in service user / resident rooms then a clinical hand wash basin should be fitted within easy reach of staff at the point of care. Facilities may be shared with the service user but adequate soap and alcohol products, together with hand towels must be provided for staff use. Hand wash basins need to be kept clear to facilitate ease of access and toiletries should be kept to a minimum to reduce the risk of contamination. The following basic principles apply: •

A clinical hand wash basin compliant with HBN 00-10 Part C should be available where-ever clinical activity takes place including in service users rooms (if clinical care is undertaken in the room)

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•

Clinical hand wash basins should be used for hand washing only and not for other purposes e.g. disposal of fluids e.g. urine samples, decontamination of equipment, washing of cutlery/crockery etc.

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Clinical hand wash basins must be equipped with warm running water from a mixer tap. Separate taps are not acceptable as they do not allow for water to be delivered at the correct temperature

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Swan-neck taps, if present, should be considered for replacement with taps in accordance with HBN 00-10 Part C when refurbishment is considered

•

Hand wash basins in clinical areas should be equipped with lever (wrist or elbow-operated) taps

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Disposable paper hand towels and liquid hand soap in wall mounted dispensers must be available at each clinical hand wash basin

•

A foot operated pedal bin should be available at each hand wash basin for the hygienic disposal of paper hand towels (used towels do not need to be disposed of as clinical waste unless contaminated by blood or body fluids)

•

A hand washing poster demonstrating an effective hand washing technique should be displayed near hand wash basins in each clinical area

•

Alcohol based hand gel / rub should also be available in wall-mounted dispensers and/or as an individual container for each staff member

Hand hygiene methods To ensure all surfaces of the hands are adequately decontaminated, it is helpful to use a standardised technique. To wash all surfaces thoroughly during a routine hand wash should take 40-60 seconds. However surgical hand scrubbing will take at least 3-5 minutes depending on product used and if the hands and arms are grossly soiled, the scrub time should be lengthened. Some areas of the hands are more frequently missed than others during hand decontamination. It is important to pay attention to all areas of the hands, whilst washing, but paying particular attention to the finger tips and nail area. These are the areas most in contact with the service user and can be heavily contaminated with micro-organisms.

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Application of alcohol-based sanitiser •

ensure hands are not soiled – if necessary, wash with soap and water beforehand

•

dispense a measured dose of the alcohol-based sanitiser into the palm of one hand

•

rub vigorously into all surfaces of the hand up to the wrist until the product has dried

Application of liquid soap •

Wet hands under running water

•

Apply the recommended amount of hand cleanser

•

Rub hands together vigorously to make a lather covering all surfaces up to the wrist using the technique pictured

•

rinse hands thoroughly under running water

•

dry hands thoroughly with clean paper towels

•

turn off taps using elbows or clean paper towels to prevent recontamination

•

discard paper towels into a foot operated pedal bin. Do not lift up the lid of the bin with hands as this will re-contaminate them

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Adapted from the World Health Organization/Health Protection Scotland

Applying hand hygiene principles in clinical practice: WHO “My five moments for hand hygiene” initiative The World Health Organisation (WHO) concept of “5 moments for hand hygiene” has been adopted internationally as a means of providing a user- and service user-centred approach to hand decontamination with minimal complexity and across a wide range of health care settings and professions. The concept of “5 moments” is intended to make it easier to understand the occasions (moments) when there is a risk of micro-organisms’ transmission via the hands, to memorise these “5 moments” and to assimilate them into health-care activities. The

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concept does not define specific and multiple procedures and care situations but helps focus on essential moments embedded within the care sequence that are essential for hand hygiene. Applying the “5 moments for hand hygiene” in the clinic / out-patient / inpatient environment The need for hand hygiene is closely connected with the activities of healthcare workers (HCWs) within the geographical area surrounding the service user. This can be divided into two areas – the service user zone and the health-care area. The service user zone includes the service user and his / her immediate surroundings e.g. all surfaces that are touched by or in direct physical contact with the service user e.g. chair arms, examination couch, linen, tubing etc. It also includes all surfaces frequently touched by staff whilst caring for the service user e.g. monitors, knobs, dials and buttons, rails, chair handles etc. The service user zone is not static – it changes as the service user is moved from place to place and the zone accompanies the individual where-ever he / she goes e.g. from chair -> examination couch etc. The health-care area corresponds to all surfaces in the health-care setting outside the service user zone i.e. other service users and their zones and the wider health-care environment. This environment still poses a risk – particularly from staff who may acquire micro-organisms within the wider health-care environment that are then transferred to service users when the staff member enters the service user zone to provide direct care. Examples include: dirty utility areas, offices, toilets, kitchens, waste disposal areas etc.

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When should hands be decontaminated? Given what we now know about the environment within which the service user is cared for e.g. the service user zone, how do we decide when to decontaminate our hands? There is a useful principle to apply:

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• •

What did I just do that could have contaminated my hands? What am I about to do that could transfer micro-organisms to the service user?

5 Moments 1 Before touching a service user

2 Before clean / aseptic procedure

Examples of care activity • • • • • •

3 After body fluid exposure risk

4 After touching a service user 5 After touching service user surroundings

• • • • •

Before any direct contact with the service user Before applying electrodes etc. Before applying disposable gloves Before venepuncture Before handling / inserting an invasive device After contact with body fluids, excretions, mucous membrane, non-intact skin or wound dressing If moving from a contaminated body site to another body site during care of the same service user After removing gloves After any direct contact with the service user After removing gloves After contact with inanimate surfaces and medical equipment in the immediate vicinity of the service user i.e. within service user zone

As these examples show, hand hygiene is required both before and after contact or procedure. Decontaminating hands before contact or procedure will protect the service user. Decontaminating hands after contact or procedure will protect the HCW and subsequent contamination of the health-care environment.

Surgical Scrub Technique All sterile team members should perform the hand and arm scrub before entering the surgical suite. The basic principle of the scrub is to wash the hands thoroughly, and then to wash from a clean area (the hand) to a less clean area (the arm). A systematic approach to the scrub is an efficient way to ensure proper technique.

The purpose of surgical hand scrub is to: • Remove debris and transient microorganisms from the nails, hands and forearms • Reduce the resident microbial count to a minimum • Inhibit rapid rebound growth of microorganisms.

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Preparation, Procedure and Process: • • • • •

•

The Association for Perioperative Practice (AfPP) advises that staff should be in appropriate theatre attire before commencing surgical hand antisepsis. Scrub suit sleeves must be rolled up well past the elbows Nail varnish, false nails, rings, watches and bracelets should be removed. Any skin abrasions to digits, hands or arms must be occluded with a waterproof dressing. Wear appropriate mask and eye protection or a face shield as guided by local policy to protect mucous membranes of the eyes, nose and mouth during procedures that are likely to generate splashes or sprays of blood, body fluids, secretions or excretions. Nail picks are recommended in UK theatre practice (AfPP 2011), to clean in the subungeal area, however if nails are too short, then a nail brush is recommended. Nail brush use, other than directly to nails, is not recommended (AfPP 2011).

Each step of surgical ‘scrubbing’ consists of five strokes rubbing backwards and forwards and adapts Ayliffe’s six step technique (Ayliffe et al 2000) into nine steps as also advised by WHO. For the first antisepsis of day the hands should be washed with plain soap or an antimicrobial solution under running water before beginning the surgical hand antisepsis (AfPP 2011). The temperature and flow of the water must be adjusted before the procedure is started to achieve comfort and avoid getting the scrub suit wet. Open nail brush and pick pack. Ensuring that no part of the sink or taps is touched wet the hands and arms up to the elbow working from the fingertips towards the elbow in one direction only, keeping the hands higher than the elbows. Wash hands and arms with a dose of antimicrobial solution (5mls) or plain soap (if using alcohol) up to the elbow, working from the fingertips toward the elbows. Load brush with antiseptic and clean tips of finger with brush. Use pick to gently remove debris from underneath tips of nails on each hand, and then discard. Rinse hands and forearms up to elbow. The Surgical Scrub should then be undertaken as in Appendix 7.6 (Surgical Scrub Technique) Surgical hand antisepsis: Application of alcohol hand rub If local policy dictates the use of alcohol hand rub for subsequent hand antisepsis then the surgical hand rubbing technique should be used as in appendix 7.6 (Surgical Scrub Technique) This consists of five strokes rubbing backwards and forwards using the Ayliffe’s six step technique as also recommended by WHO.

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Alcohol hand rub should be allowed to evaporate before donning gloves to avoid the risk of dermatitis.

Footnote: NHS England & NHS Improvement has published a national hand hygiene policy which can be found here: https://improvement.nhs.uk/documents/4957/National_policy_on_hand_hygiene_and_PPE_ 2.pdf

The contents of this local policy reflect the content of the national policy and in addition provide useful guidance to staff on other aspects of hand hygiene.

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Independent Hospitals

Articles inside

Management of an outbreak of viral gastro-intestinal illness Antibiotic Prescribing Policy Sepsis

Standard Precautions

Management of Healthcare Waste Estates & Facilities Management Minor Surgery Environment

Personal Protective Equipment (PPE

Infection Control Principles - the spread of infection

Hand Hygiene

12 12a Environmental Cleaning

1 2 Recognition and management of an outbreak of infection