Standard Universal Precautions Policy
Responsible Directorate:
Public Health
Responsible Director:
Dr Judith Hooper
Date Approved:
25 March 2009
Committee:
Governance Committee
NICE GUIDANCE Once NICE guidance is published, health professionals are expected to take it fully into account when exercising their clinical judgment. However, NICE guidance does not override the individual responsibility of health professionals to make appropriate decisions according to the circumstances of the individual patient in consultation with the patient and/or their guardian or carer.
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Version Control Document Title: Document number: Author: Contributors: Version: Date of Production: Review date: Postholder responsible for revision: Primary Circulation List: Web address: Restrictions:
Standard Universal Precautions Policy 1 Jane O’Donnell Kirklees Infection Prevention and Control Team 3 March 2009 March 2011 Deputy Director Infection Prevention and Control
Standard for Better Health Map Domain:
First domain safety
Core Standard Reference:
C4, C4a, C4d, C4e 1.
Performance Indicators: 2.
To reduce incidence of healthcare associated infections To reduce incidence from cross infection
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Contents
Section
Page
1.
Introduction
4
2.
Associated Policies and procedures
4
3.
Aims and Objectives
4
4.
Scope of the Policy
4
5.
Accountabilities and responsibilities
5
6.
Safe working practices
5
7.
Hand hygiene
6
8.
Personal Protective Equipment (PPE)
8
9.
Sharps
10
10.
Disposal of Body Fluid and Spillages
11
11.
Waste
12
12.
Equality Impact Assessment
12
13.
Training Needs Analysis
13
14.
Monitoring Compliance with this policy
13
15.
References
14
Appendices A B
Equality Impact Assessment Tool Key Stakeholders consulted/involved in the development of the policy/procedure
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15 16
Policy Statement Infection prevention and control is of prime importance within NHS Kirklees and is essential to the safety and confidence of patients, families and carers
1
Introduction Standard Universal Precautions provide guidance on infection prevention and control principles that must be applied by all healthcare workers as a minimum for all patients.
2
Associated policies & procedures This policy should be read in accordance with the following Trust policies, procedures and guidance: ● ● ● ● ● ● ● ● ●
3
Dress code policy for Clinical Staff Hand decontamination policy Waste management guideline Incident reporting Health and safety policies Decontamination, disinfectants and antiseptics policy Decontamination policy The prevention and management of latex exposure policy Management of clinical sharps injuries and exposure to blood and high risk body fluids.
Aims and objectives To protect healthcare workers, patients and visitors from the transmission of infection, whether the risk is known or unknown, thereby reducing / preventing the opportunity for transmission of micro organisms. Standard precautions are infection prevention precautions that should be applied as standard principles by all health care staff to the care of all patients at all times.
4
Scope of the policy This policy must be followed by all NHS Kirklees employees who are developing policy and procedural documents or developing guidance for colleagues. It must be followed by all staff who work for NHS Kirklees, including those on temporary or honorary contracts, bank staff and students. Breaches of this policy may lead to disciplinary action being taken against the individual. Page 4 of 16
Independent Contractors are responsible for the development and management of their own procedural documents and for ensuring compliance with relevant legislation and best practice guidelines. Independent Contractors are encouraged to seek advice and support as required. 5
Accountabilities and responsibilities The Director of Infection Prevention and Control has responsibility to provide assurance to the Board that Infection Prevention and Control policies are in place and audited. The Infection Prevention and Control Team will ensure the policy is reviewed as required and work with Heads of Service to implement necessary changes in practice. Heads of Service are responsible for ensuring that Standard Universal Precaution Policy is brought to the attention of staff and considered by them. Ownership of continuous improvements in Infection Prevention and Control must be from Heads of Service and individual clinicians.
6
Safe working practices Infection prevention and control is based on the use of practices and procedures that prevent, or reduce, the risk of infection being transmitted from a source of infection (e.g. a person, contaminated body fluids, equipment, the environment etc.) to a susceptible individual. The following principles form the basis of these guidelines. They are adapted from the United Kingdom Department of Health (2004) guidance for clinical workers and should be followed at all times. •
Apply good basic hygiene practices with regular hand decontamination.
•
In order to safeguard the health and safety of all patients and health care workers, it is essential that good working practices are adopted at all times. This involves careful handling of all blood and body fluids from all patients, regardless of whether a risk of infection has been identified or not.
•
Cover existing wounds or skin lesions with waterproof dressings.
•
Protect the mucous membranes of eyes, nose and mouth from blood splashes.
•
Health care workers should treat all blood/body fluids as potentially infectious.
•
Hand washing should be practiced between all patient contacts.
•
Appropriate protective clothing, e.g. disposable gloves and plastic aprons must be worn when in contact with blood and body fluids. Eye protection must also be worn if splashing is anticipated.
•
Sharps MUST NOT be re-sheathed or recapped, but must be placed directly into an approved sharps container BY THE USER. Page 5 of 16
7
•
Needles should not be re-sheathed by hand. Ash Jenkers or blue rubber needle guards are used for resheathing dental cartridge syringes. Safety plus dental syringes are used for podiatry for local anaesthetic administration.
•
Hazardous / offensive waste must be transported and disposed of appropriately.
•
All blood spillage must be disinfected immediately with hypo-chlorite granules or solution (spill packs).
•
Additional precautions may be necessary for specific infections, and guidance can be provided by the Trust’s Infection Prevention and Control Team.
Hand hygiene Hand hygiene is a means of achieving a reduction in or removal of visible soiling, transient or resident organisms and/or other hazardous toxic substances. Transient microbes are those micro-organisms that are picked up during daily activities and shed on skin scales. They can be effectively removed or at least reduced to a low level by hand washing. Resident microbes are micro-organisms that are permanently resident on the skin and can only be removed for a short time. Basic principles of hand hygiene Hand washing is the single most important measure in preventing the spread of infection. Hands must be decontaminated immediately before each and every episode of direct patient contact or care and after any activity or contact that could potentially result in hands becoming contaminated. Effective hand decontamination can significantly reduce infection rates. •
Cover any existing cuts / abrasions or any other breaks in the skin with a water proof dressing, replace when no longer occluding site.
•
Wash hands before and after all procedures and after removing gloves.
•
Immediately remove any contamination of the hands with soap and water, dry thoroughly
•
Remove any stoned rings (plain wedding band only) and keep nails short, clean and free from nail polish, false nails. Nail extensions are not permitted.
•
Wrists must be free from watches and jewellery.
•
Health care workers who have direct / social contact with patients or their environment must be bare below the elbow.
•
If for cultural reasons individuals do not wish to be bare below the elbow, single use disposable sleeves may be worn.
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Any health care worker with chronic open skin lesions or infected skin conditions to hands or forearms must avoid direct contact with patients unless they can be covered adequately to prevent cross infection. Health care workers with chronic open skin lesions or skin conditions should seek advice from the occupational health department. An effective handwashing technique involves three stages; preparation, washing and rinsing, and drying. Preparation requires wetting hands under warm running water before applying liquid soap or an antimicrobial preparation. The handwash solution must come into contact with all of the surfaces of the hand. The hands must be rubbed together vigorously for a minimum of 10 – 15 seconds, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers. Hands must be rinsed thoroughly under running water holding hands down before drying with good quality paper towels. Used paper towels should be disposed of in a foot operated pedal bin for domestic waste. Facilities for handwashing Each clinical area must have the following equipment to ensure adequate handwashing: •
Accessible hand wash basin, no plug or overflow
•
Elbow or wrist operated taps
•
Liquid soap
•
Disposable paper hand towels
•
Handwashing poster, indicating the correct handwashing technique
•
Foot operated bin fitted with a black waterproof liner.
Alternative supplements to handwashing – alcohol hand rub Alcohol is an effective alternative to handwashing provided that hands are not visibly soiled. Alcohol hand rub is quicker to use, better tolerated by the hands and can be provided at the point of care. The point of care refers to the patient’s immediate environment in which health care, staff to patient contact or treatment is taking place. Alcohol is not a cleansing agent and is not effective against bacterial spores, eg, Clostridium difficile. Any alcohol hand rub products purchased for use at the point of care must adhere to the European Committee for Standardisation Standard EN1500. All alcohol hand rub products on NHS contracts comply with the EN standard and have passed rigorous safety and in use assessments. In line with current guidance, the National Patients Safety Agency (NPSA) advocates that only minimum quantities of alcohol based handrub should be stored at ward / department level. It is therefore recommended by the NPSA that no more than five litres should be held in storage. This does not include the hand rub at the point of care which is regarded as “in use”. Page 7 of 16
8
•
Application of alcohol hand rub
•
Dispense one application of alcohol hand rub to clean dry hands (free of dirt and organic material).
•
Ensure solution covers all hand surfaces.
•
Rub hands together vigorously, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers.
•
Rub hands together until the alcohol hand rub has evaporated and the hands are dry.
Personal Protective Equipment (PPE) The underpinning principles relating to legislation, state that employers shall take all reasonable steps to ensure that any PPE provided to their employees is properly used and those employees shall use any PPE provided to them in accordance with training HSE (1992). PPE must comply with European community directive on design, certification and testing of PPE and carry the CE mark. Selection of protective equipment must be based on an assessment of the risk of transmission of micro organisms to the patient, and the risk of contamination of the healthcare worker’s clothing and skin by patient’s blood, body fluids secretions or excretions. Gloves •
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, or sharp or contaminated instruments.
•
Gloves must be worn as single use items. Gloves must be changed between caring for different patients, and between different care or treatment for the same patient.
•
Examination gloves are classed as medical devices and as such must conform to European Community Medical Devices Regulations (CE).
•
Powdered gloves or polythene gloves must not be used in healthcare.
•
Gloves are available in a variety of materials. Natural rubber latex remains the material of choice due to its efficacy in protecting against blood borne viruses and dexterity in use.
•
Glove integrity can be damaged if in contact with substances such as isopropanol or ethanol.
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•
Sensitivity to natual rubber latex in patients, carers and healthcare workers must be documented and alternatives to natural rubber latex gloves must be available.
•
Glove material The type of glove chosen should be the most suitable for specific task in terms of flexibility, sensitivity, durability, risk of pathogens being present. -
Natural rubber latex – powder free gloves Natural Rubber Latex gloves with a low extractable protein content remain the material of choice due to flexibility, resealable properties and protection against blood borne viruses. Natural rubber latex gloves are close fitting and do not impair dexterity and can re-seal when punctured and in tests have been found to have much lower leakage rates than vinyl. The use of latex gloves contributes to the prevention of cross infection; risks relating to the wearing of such gloves have become increasingly apparent with sensitivity problems.
-
Nitrile gloves (Acrylanitrile) A high quality nitrile glove is a recommended alternative for latex sensitive patients and healthcare workers. These must always be available for patients and staff diagnosed with natural rubber latex allergy. However allergic reactions to nitrile have been reported.
-
Vinyl gloves Vinyl gloves should be avoided as vinyl has a lower tensile strength and therefore break down in use more frequently. They show an increased permeability to blood-borne viruses making them unsuitable for handling blood and blood-stained body fluids.
-
Storage Incorrect storage can lead to rapid degeneration of rubber and synthetics. Gloves must be stored where the temperature does not exceed 40ºC, avoid sunlight. Stock should be rotated.
-
Disposal Gloves must be disposed of in accordance with PCT waste management guideline and hands decontaminated after the gloves have been removed.
Disposable plastic aprons •
Disposable plastic aprons must be worn when there is a risk that clothing or uniform may become exposed to blood, body fluids, secretions, excretions and excessive skin scales with the exception of sweat. Page 9 of 16
•
Disposable plastic aprons must be worn as single use items for one procedure or episode of patient care and then disposed of according to PCT waste management guideline.
•
Full body fluid repellent gowns must be worn where there is a risk of extensive splashing of blood, body fluids, secretions or excretions.
•
Uniforms / clothing which becomes contaminated must be laundered at the earliest opportunity. Clothing / uniform which is contaminated with visible blood must be changed and laundered at above 65°C.
Face masks / visor protection Face masks or full visor protection must be worn where there is risk of blood, body fluids secretions or excretions splashing into the face and eyes. Eye protection Eye protection must be available in all areas where there is risk of blood and body fluids or hazardous substances splashing into the eyes. These must be decontaminated after use and stored clean. If for single use, dispose of immediately. Eye protection should have side, top and bottom shields and conform to OSHA29 CFR 1910 1030 criteria regarding blood borne pathogens. They should also meet ANS 1287.1 Safety Standard, be impact and shatter resistant and provide a wide range of vision. 9
Sharps Sharps that are handled incorrectly and not disposed of adequately are dangerous. Staff who fail to dispose of used sharps safely cause a hazard to others and are in breach of the Health and Safety at Work Act 1974. All sharps include needles, syringes, glass vials, administration giving sets, disposable razors, blades and stitch cutters, etc, must be discarded into a sharps container. •
Ensure that sharps containers comply to BS 7320, UN 3291.
•
Containers must be assembled as per the manufacturers instructions.
•
The container must be labelled with: -
The date it was brought into use
-
Identification of the practice / clinic department
-
Signature of the person who assembled it.
•
Always dispose of sharps at the point of use in a suitable container.
•
The container must be sited in a secure and safe place, off the floor, away from direct sunlight and radiators and out of the reach of patients / clients or visitors. The temporary closure mechanism must be used when not in use to prevent accidental spillage. Page 10 of 16
10
•
Sharps must not be passed directly from hand to hand and handling should be kept to a minimum.
•
Needles must not be bent or broken prior to use or disposal.
•
Needles should not be re-sheathed by hand. Ash Jenkers or blue rubber needle guards are used for resheathing dental cartridge syringes. Safety plus dental syringes are used for podiatry for local anaesthetic administration.
•
Syringes / cartridges and needles should be disposed of as a single unit.
•
Do not fill sharps containers above the manufacturer’s marked-line – maximum three quarters full.
•
Lock the used sharps container when ready for final disposal, according to the manufacturer’s instructions.
•
Always carry used sharps containers by the handle.
•
Containers should be securely stored prior to collection for incineration and be disposed of after three months regardless of how full they are.
•
Do not dispose of sharps with other clinical waste or place sharps containers in orange clinical waste bags for disposal.
•
Place damaged, used sharps containers into a large secure, rigid container which is properly labelled.
•
Sharps containers must be disposed of by the licensed route.
•
Use of an appropriate transfer container is essential and transport document must be carried in healthcare workers’ vehicles at all times..
Disposal of body fluid and spillages As all body fluids have the potential to carry infectious diseases they should be handled with care. Any spillage should be dealt with immediately. Protective clothing must be worn prior to dealing with any spillage of body fluid and blood. Body and body fluid spillages All spilled blood should be regarded as potentially infected. If spillage kits are not available then the correct dilution of available hypochloride must be used. •
Gloves and an apron must be worn prior to commencement of the procedure.
•
Cover spillage with disposable paper towels. In the event of large spillage, soak the majority of the spillage with paper towels and place in infectious waste and then apply further paper towels to the area. Page 11 of 16
•
Ensure adequate ventilation prior to using disinfection solutions or granules.
•
Pour a hypochlorite solution 10,000 parts per million of chlorine (1%) on to paper towels and leave for at least 2-3 minutes, then discard paper towels into infectious waste bin.
•
Wipe the area thoroughly with disposable cloths, detergent and hot water and dry thoroughly.
•
Discard protective clothing according to Trust’s waste management guideline.
•
Decontaminate hands (hand wash or alcohol hand rub).
If spillage occurs on a carpeted area use detergent and water method, ie: •
Mop up organic matter with disposable cloths or paper towels.
•
Clean surface thoroughly using a solution of detergent and hot water (if available), rinse the surface and dry. If equipment not available use detergent wipes to clean the surface.
•
Dispose of materials as infectious waste.
•
Clean bucket / bowl in fresh hot soapy water and dry, if this equipment is used.
•
Dispose of protective clothing according to Trust’s waste management guideline.
•
Wash hands.
•
Steam clean carpet if machine is available within health centres contact the cleaning teams.
Broken or punctured skin Rinse the wound under running water, encourage the wound to bleed. Follow guideline on Management of Clinical Sharps Injuries and exposure to blood and high risk body fluids. 11
Waste Waste contaminated with blood or body fluids should be discarded into orange infectious waste bags for incineration, ensuring that no fluid leaks from the bag. Follow NHS Kirklees Waste Management Guideline.
12
Equality impact assessment This Policy was found to be compliant with this philosophy (see Appendix A).
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13
Training needs analysis The Trust is committed to the training and continuing development of all staff including independent contractors. All induction programmes and infection prevention and control mandatory training will include Standard Universal Precautions.
14
Monitoring compliance with this policy The Trust will have key indicators for the monitoring of Infection Prevention and Control: •
Essential Steps audits to ensure standard universal precautions policy is being implemented.
•
Percentage of incident reports identifying a failure in compliance with this policy.
•
Percentage of clinical and non-clinical staff undertaking mandatory annual infection prevention and control training.
•
Quality indicators will be a part of normal performance monitoring against a set of local, regional and nationally standards. (Nationally the evidence for Standards for Better Health will be superseded in 2009 by the Care Quality Commission).
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15
References Clark L Smith W, 2002, Protective Clothing, Principles and Guidance, London, ICNA •
Expert Advisory Group on Aids and Advisory Group on hepatitis 1998 Guidance for Clinical Health Care Workers: Protection against Infection with blood-borne viruses. London: Department of Health.
•
Health and Safety Executive 1992 Personal Protective Equipment at Work Regulations: Guidance on Regulations, London HMSO.
•
Health and Safety at Work Act 1974, HMSO, London
•
MDA SN 2001 (10) Safe Use and Disposal of Sharps.
•
National Institute for Clinical Excellence 2003 Prevention of Health Care Associated Infections in Primary and Community Care, London NICE.
•
The Health Act 2006. Code of practice for the Prevention and Control of Healthcare Associated Infections, London HMSO. (Revised January 2008.)
•
Standards for Better Health, legislative basis Section 46 of the Health and Social care (Community Health and Standards) Act 2003
•
Department of Health 2006 Health Technical Memorandum 07 – 01 Safe Management of Healthcare Waste, London, HMSO
•
Department of Health 2006 Essential Steps to Safe Clean care, HMSO, London.
•
Standardisation ECF.Chemical disinfectants and antiseptics – hygienic hand rub – test method and requirements. Brussels: European Committee to Standardisation 1997.
•
National Patient Safety Agency. Patient Safety Alert September 2008. Clean hands Save Lives. NPSA
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Appendix A Equality Impact Assessment Tool Insert Name of Policy / Procedure Yes/No 1.
Does the policy/guidance affect one group less or more favourably than another on the basis of: • Race
No
• Ethnic origins (including gypsies and travellers)
No
• Nationality
No
• Gender
No
• Culture
No
• Religion or belief
No
• Sexual orientation including lesbian, gay and bisexual people
No
• Age
No
• Disability - learning disabilities, physical disability, sensory impairment and mental health problems
No
2.
Is there any evidence that some groups are affected differently?
No
3.
If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?
4.
Is the impact of the policy/guidance likely to be negative?
5.
If so can the impact be avoided?
-
6.
What alternatives are there to achieving the policy/guidance without the impact?
-
7.
Can we reduce the impact by taking different action?
-
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-
No
Comments
Appendix B Key stakeholders consulted/involved in the development of the policy/procedure Key Participant Yes/No
Feedback requested Yes/No
Feedback accepted Yes/No
Kirklees Infection Control Committee
Yes
Yes
Yes
NHS Kirklees Policy Development Group
No
Yes
Yes
Stakeholders name and designation
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