Infection Control Manual

CET: Infection Prevention and Control Manual

INFECTION PREVENTION AND CONTROL MANUAL

Infection Prevention and Control Manual

Contents List 1

Scope ................................................................................................... 4

2

Responsibilities ................................................................................... 5

3

Basic Microbiology and Their Properties.......................................... 6

4

Spread of Infection .............................................................................. 7

5

Chain of Infection ................................................................................ 8

6

Rationale for Standard Infection Control Precautions ................... 12

7

Personal Hygiene .............................................................................. 14

8

Hand Hygiene .................................................................................... 16

9

Personal Protective Equipment ....................................................... 19

10

Sharps Management and Safe Disposal ......................................... 27

11

Blood and Body Fluid Spillage Management .................................. 34

12

Waste Management ........................................................................... 36

13

Linen Management ............................................................................ 41

14

Maintaining a Safe & Hygienic Environment. ................................. 42

15

Vehicle and Equipment Cleaning ..................................................... 45

16

Flood Response .................................. Error! Bookmark not defined.

17

Aseptic Non-Touch Technique ........................................................ 59

18

Peripheral Cannulation ..................................................................... 54

19

Urinary Catheters .............................................................................. 57

20

Management of open wounds .......................................................... 58

21

Specific Communicable Diseases ................................................... 60

22

Category III Diseases .......................... Error! Bookmark not defined.

23

Biological Incidents .......................................................................... 75

24

Pandemic Flu ..................................................................................... 77

25

Staff Exclusion from Work ............................................................. 111

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26

Staff Immunisation ............................................................................ 95

27

Audit and Review .............................................................................. 97

28

Equality Impact Appraisal .................. Error! Bookmark not defined.

29

Associated Documentation .............................................................. 97

30

Reference ........................................................................................... 98

Appendix 1 Hand Washing Technique with Soap and Water ................. 100 Appendix 2 Alcohol Handrub hand hygiene Technique ......................... 101 Appendix 3 Occupational Exposure to Blood or Body Fluids ............... 102 Appendix 4 Flow Chart for Decontamination Prior to Service/Repair .. 103 Appendix 5 Change control reference: Updated page information...... 121

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1

Scope

1.1.

The infection prevention and control manual has been developed as part of Wellington Free Ambulances on-going commitment to promoting optimal standards of infection prevention and control within the organisation. This Manual was developed to support the Infection Prevention and Control Policy.

1.2.

Prevention and control of infections are essential cornerstones of clinical care for ensuring patient and staff safety in all settings. It has been recognised that the ambulance service has an important role to play in supporting our healthcare partners in reducing healthcare associated infections (HCAIs).

1.3.

This manual encompasses evidence based best practice and has been specifically designed to support staff in minimising the risks associated with the control of infection. It must be emphasised that every member of staff has a responsibility to reduce such risks, and adherence to the guidance and procedures contained in this manual will help ensure patient and staff safety.

1.4.

The subject of infection prevention and control is broad and complex, incorporating a vast number of topics. This manual largely simplifies our approach to key areas in today’s modern ambulance. The manual has been subjected to further validation by external specialists in infection prevention and control, and has in addition received approval from the Infection Control Nurses at HVDHB/ CCDHB

1.5.

This manual provides Standard Infection Control Precautions as the template for its structured format. This manual attempts to deliver information relevant to each link to enable the reader to follow and appreciate the underlying principles based around treating all patients blood and body fluid as if it is potentially infectious. This in itself minimises a large area of risk from infection and cross contamination as the status of the vast majority of patients we convey is generally unknown.

1.6.

Traditionally the ambulance service has classified infectious diseases into three categories, 1, 2 & 3. However, in adopting the comprehensive use of Standard Infection Control Precautions, the need to retain the special measures of Categories 1 and 2 has now been negated. The routine use of Standard Infection Control Precautions is totally appropriate to the successful management of patients that previously fell within these two categories of 1 and 2, having been withdrawn, leaving only those patients with diseases in categories 3 (III) as requiring special measures.

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2

Responsibilities

2.1.

All Wellington Free Ambulance staff have responsibilities to protect themselves, as well as making all reasonable efforts to safeguard the welfare of their patients and all other persons encountered in their daily duties. Adherence to the guidance and procedures contained in this manual will significantly assist staff in achieving this goal.

2.2.

All Managers and staff with education and staff development roles, operational duties or support service accountabilities are responsible for the implementation and monitoring of compliance with the standards contained in this manual. This applies to the operation of the manual and/or in the supply of all specified equipment, materials and facilities.

2.3.

Staff delivering direct patient care must also comply with their responsibilities stated within the Infection Prevention and Control Policy and its associated clinical care procedures.

2.4.

The Executive Manager Clinical Services (or delegate) will be responsible for monitoring the auditing process in compliance with the manual. The ICWG are responsible in maintaining an ongoing review of this manual and will ensure that it remains current, and therefore continually reflects evidence based best practice in the field of infection prevention and control. Day to day responsibility for this manual will be devolved to the Infection Control Managers.

3

Basic Microbiology and their Properties

3.1.

Microorganisms are thought to have been the first living organism on earth. The term microorganism, or microbe, is used to describe any organism which is too small to be seen with the naked eye. Many microorganisms live independently of humans and those that are dependent exist in a host-organism relationship that is generally harmless, and may even be mutually beneficial. Microorganisms perform many useful functions in the ecological chain, being responsible for the breakdown of dead matter from plants and animals. They are also used in the production of beer, wine, yoghurt, cheese, and bread.

3.2.

Microorganisms capable of causing disease are referred to as pathogenic organisms. These include viruses, bacteria, fungi, protozoa and Prions. Infection is a pathological process which involves the damaging of body tissues by pathogens, or by the toxic substances produced by these pathogens. They generally thrive and multiply in darkness, warmth and moisture, and infection is usually accompanied by signs and symptoms in the localised area of the

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patient, e.g. pain, swelling and/or fever. Pathogenic microorganisms may be classified as follows.

3.3.

Viruses are different to other organisms in that they consist of a core of one type of nucleic acid, either deoxyribonucleic acid (DNA) or ribonucleic acid (RNA) surrounded by a protein shell called a capsid.

The purpose of the capsid is to protect the virus and to assist it to attach to the target host cell. When inside the human cell, the virus takes over the nuclear control of the cell and alters the cellular metabolism so that it makes new virons. Viruses are usually fragile and do not survive for long outside a living cell, like rhinoviruses, that can survive for short periods and are responsible for colds, more commonly spreading on hands and by direct contact than through the air by coughs and sneezes. Viruses are smaller than bacteria and not susceptible to antibiotics, but there are a few anti-viral drugs available which are active against a limited number of viruses.

3.4.

Bacteria are usually unicellular organisms, with a typical cell being able to carry out many different metabolic activities to increase in size and reproduce. A single bacterium can convert itself overnight into a colony with a population of millions. Some bacteria form spores when environmental conditions are not suitable and can survive for a long time in the environment. Clostridium difficile is one example, which is responsible for antibiotic-associated diarrhoeal infections. Bacteria are susceptible to a greater or lesser extent to anti-biotics, but through the mechanism of changing their genetic composition; drug resistance can occur.

3.5.

Fungi (Pathogenic) are considered to be plants that lack the green pigment, chlorophyll that plants use for photosynthesis. Depending on how they grow, fungi are described as mould or yeasts. Fungal diseases are referred to as mycoses and are divided into those that affect the skin like ringworm, athlete’s foot, and those deep infections that affect the whole body causing systemic infections, such as aspergillus. A common yeast infection is thrush, caused by an organism called Candida albicans.

3.6.

Prions Infectious agents, smaller than viruses. Unlike other pathogens, prions contain no DNA or RNA. Their only known component is a protein with an abnormal constituent protein in the brain. Thought of as being the cause of the transient spongiform encephalopathies (TSE), for which there is no evidence of a conventional infectious agent. They are thought to be found in the central nervous system (CNS) and also in other tissues such as the lymph glands and tonsils. A new type of prion is thought to have evolved to cause bovine spongiform encephalopathy (BSE) in cattle and resulting in variant Creutzfeldt-Jakob disease (vCJD) in humans.

Prion disease is fatal, infectious, neurodegenerative disorders with no known immunisation or treatment.

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3.7.

Worms are not always microscopic in size but, larger than bacteria.

Pathogenic worms do cause infection and some spread from person to person. Examples include threadworm, tapeworm, hookworms and roundworms. Prevention often relies upon personal hygiene, clean water supplies, quality of food and adequate cooking.

3.8.

Protozoa are microscopic single-celled microorganism, larger and more complex than bacteria and some can be pathogenic. Protozoa include paramecium and amoebae, which can be pathogenic. They have a tough outer cell membrane instead of a cell wall and ingest solid particles of food to obtain nutrients. They are considered to be the lowest form of animal life and have lifecycles involving only the functions of movement, nutrition, excretion, respiration and reproduction. Examples of medical importance include Giardia lamblia, which cause enteritis, and the malaria parasite. Protozoa, like malaria have lifecycles that include sexual and asexual phases.

4

Spread of Infection

4.1.

Direct Contact occurs when one person infects the next person i.e. via the skin, mucous membranes, or personal contact with contaminated body secretions/excretions. Sexually transmitted diseases are also examples of this mode of spread. Physical contact with infected site, such as contact with discharge from wounds or skin lesions e.g. shingles, impetigo.

4.2.

Indirect Contact is said to occur when an intermediate carrier is involved in the spread of pathogenic microbes from the source of infection to another person. Examples includes: Aerosol, Fomites, Hands, Ingestion, Inoculation, Vectors,

4.3.

Aerosols – Droplet spread of infection produced by sneezing and coughing can be spread through the air and infect others by inhalation e.g. chicken pox, measles and mumps. The common cold and influenza are often cited as examples, but it is more likely spread by hands. Dispersal of skin scales may be associated with transfer of potentially harmful microbes, but may not be via droplet infection, e.g. could also be contamination of adjoining surfaces and equipment.

4.4.

Fomites – are defined as any object which becomes contaminated with organisms from a patient or member of staff which can potentially transmit them to another person e.g. aspirators, splints, resuscitation equipment, linen or practically any inanimate object. The object could be used directly on another patient or could contaminate the hands of healthcare workers.

4.5.

Hands – Organisms require a mode of transport, and hands are known to be the main source of cross infection and contamination.

Remember that the hands of patients can also be effective in carrying microbes to other body sites and equipment. Bacterial contamination

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without apparent soiling of the hands has been shown during contact with patients. Dirty activities such as dealing with body secretion/excretions result in much heavier contamination of the hands, even when gloves are worn.

4.6.

Ingestion – Infection by ingestion can occur when organisms capable of infecting the gastro-intestinal tract are ingested. When these organisms are excreted faecally by infected person, faecal-oral spread may occur. Organisms can be carried by fomites or hands, or in food and drink, e.g. Hepatitis A, Campylobacter, and Salmonella are some of the pathogens passed on by poor hygiene practices.

4.7.

Inoculation – infection can occur following a sharps injury, when blood contaminated with Blood Borne Virus is inoculated into the blood stream or where there has been blood/body fluid splashes to broken areas of skin or exposed mucous membranes. Bites from humans can cause infection and rabies can be spread from infected animal bites. When on hospital wards, cannulae and peripheral lines inserted by ambulance crews that have been inserted in sub-optimal conditions e.g. in an emergency, will be removed as soon as practicable and re-inserted in aseptic conditions to lower the risk of infection.

4.8.

Vectors – are animals or insects that passively transmit pathogenic microbes, in the NZ our common house fly is the most prevalent.

Exotic species, such as iguana or snakes are a problem with transmitting salmonella to people who come into contact with their skin. Reptiles may also excrete potentially harmful microbes, so there is a risk of infection if a person is in contact with faeces and then does not wash their hands. Further examples include mosquitos and malaria, tick bites and Leptospirosis from rats.

4.9.

Absorption – is not a route of entry for infection through healthy intact skin.

5

Chain of Infection

5.1.

This refers to the process by which infection can be spread from one susceptible host to another, and can be thought of as a continuous chain. Each link must be present for infection or colonization to proceed, and breaking any of the links can prevent the infection.

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5.2.

Infectious Agent can be a primary pathogen or a Commensal given the right opportunity. To break the chain of infection, the causative organisms must be destroyed or rendered harmless. In the ambulance setting, many infection prevention and control measures are aimed at removing this link, e.g. the use of disposable equipment, good personal hygiene or maintaining effective decontamination procedures.

5.3.

The Reservoir

5.3.1.

This is everywhere the organism causing the infection can be found.

This can include: •

Patients

•

Staff

•

Equipment

•

Environment

•

Animals/insects

•

Food/water

5.3.2.

Patients and staff are potentially at risk of contracting infections from each other. Ambulance staff have more control over circumstances that lead to these occurrences than their patients and so are at less of a risk.

5.3.3.

The role and responsibility of the Occupational Health Services, as well as of individual practitioners in minimising risks to both patients and staff is crucial to the process of risk reduction. Hazards are associated with practices as well as exposure to microorganisms that are in healthcare settings. Patients and staff are at risk from practices and from each other.

5.3.4.

It is almost impossible to legislate for all eventualities when an exposure to infection may occur. Health professionals must always be aware of the level of risks from their practices, especially of the Page 9 of 105

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many disease producing microorganisms present in blood, body fluids, secretions and excretions of seemingly healthy and undiagnosed person. By far the best accepted advice is that standard infection control precautions need to be undertaken at all times when dealing with patients and especially when in the presence of blood and body fluids.

5.3.5.

Ambulance environments and equipment can become contaminated with chemical residues, debris, dust, soil, etc, as well as with organic matter and potentially infectious organisms. A safe environment and equipment is achieved by removing or destroying contamination and thereby preventing microorganisms or other contaminants reaching a susceptible site in sufficient quantities to initiate infection or other harmful response. The ‘decontamination’, which is used to describe this process, consists of cleaning, disinfection and sterilisation. Sterilisation is currently not undertaken in ambulance service settings.

5.3.6.

Animals generally mean cats; dog; birds; rabbits; rodents; and include reptiles and fish. These animals, like humans, can be host for a wide variety of organisms that are potential pathogens (Zoonoses) for people and other animals. Zoonoses can be transmitted from animals to humans either directly or indirectly by bites; scratches; aerosols; ectoparasites; accidental ingestion; or via contact with contaminated soil; food; water or unpasteurised milk.

5.3.7.

Insects remain a problem. Infestations can occur in any part of a healthcare establishment or vehicle, but is mainly found in boiler rooms; ducts; drains; and kitchens where shelter, warmth, food and water are in abundance. Infesting creatures range from cockroaches, ants to rodents. Cockroaches have been known to be reservoirs of drug-resistant salmonella.

5.3.8.

Safe food and water is necessary to avoid widespread illness due to infectious diseases. The effects of food poisoning range from mild gastrointestinal symptoms to significant illness and death. The solution to the problems of avoiding contamination lies in: proper hygiene; proper cooking; proper handling; proper storage; and providing a clean hygienic working environment. Surfaces and equipment can easily be contaminated with inadequately washed hands following contact with patients, especially those with gastrointestinal infections, as well as maternity, paediatric, elderly and psychiatric patients when faecal soiling is likely.

5.4.

The Portals of Exit and Entry

5.4.1.

These are the routes by which a pathogen leaves its host and by which it enters another. Interventions such as insertion of invasive devices, e.g. urinary catheters, intravenous lines etc can provide portals of exit and entry. The main portals of entry are:

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5.4.2.

The Respiratory Tract – Through inhalation of organisms. (e.g. respiratory tuberculosis; chicken pox; mumps and diphtheria).

5.4.3.

The Alimentary Tract – Through ingestion of contaminated food or water. (e.g. salmonellosis and dysentery).

5.4.4.

The skin and mucosa – Either by the passage of organisms through damaged skin, as with infected wounds, or by the inoculation of organisms. (e.g. hepatitis B, hepatitis C transferred from contaminated needles).

5.4.5.

The placenta – Via transfer of organisms from maternal circulation to the foetal circulation. (e.g. HIV, rubella, cytomegalovirus and syphilis).

5.4.6.

There are a number of routes by which infectious agents can leave their host. The exit route may be the same as that of entry, e.g. the respiratory tract in tuberculosis, or a different route, as in salmonella infections, where the route of entry is usually via the mouth and the exit route is the faeces.

5.4.7.

Susceptible Host - For infection to occur once an organism has reached its target, the host must be susceptible. The competence of the body’s innate and acquired defence mechanisms will affect whether or not illness occurs and the chain of infection may be broken at this point. In infectious diseases, the final outcome can depend as much, if not more, on the susceptibility of the person as on factors relating to the microorganism itself. Some people are at increased risk of infection. Those who are: •

Extreme ages, very young children and the elderly;

•

Immunocompromised;

•

Suffering from chronic illness, e.g. sickle cell anaemia, rheumatoid arthritis, diabetes mellitus;

•

Receiving certain medications e.g. steroids, cytoxics for cancer or connective tissue disease;

•

Anybody with a break in the body’s defences e.g. surgical wounds, skin lesions, indwelling devices such as intravenous lines/catheters; and

•

Someone whose behaviour increases their risk for a particular disease, e.g. unprotected sex and HIV, sharing needles and Hepatitis B.

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5.4.8.

Host Defence Mechanisms

5.4.9.

Non-specific defence mechanisms are natural barriers which protect against invasion by pathogens. In addition, specific immune mechanisms are activated if an organism, for instance the measles virus is able to evade the non-specific defence system. This specific response may not prevent an attack, but will ensure that a memory of the measles virus is retained so that the system can react quickly and destroy the virus when it is next encountered.

6

Rationale for Standard Infection Control Precautions

6.1.

Effective control and prevention of healthcare associated infections (HCAI) should be imbedded into everyday practice and applied consistently by everyone. In the pre-hospital environment there are three high risk areas for the transfer of infection to patients:

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6.2.

Direct or Indirect transfer:

6.2.1.

Direct contact transmission involves skin-to-skin contact and physical transfer of microbes from an infected or colonised patient to susceptible host. Direct contact may also occur between patients by means of healthcare workers hands. Indirect contact transmission occurs when a susceptible host comes into contact with a contaminated object (fomite) such as a: blanket, splint or stretcher.

•

Invasive devices e.g. I.V cannulation, urinary catheters.

•

The emergency environment

6.2.2.

In addition, ambulance staff who come into contact with patient’s blood or body fluids may be exposed to occupational risk from blood borne viral infections. The most likely means of transmission of these viruses to ambulance staff is by accidental inoculation incidents such as: sharps injury; bites; or by blood splashing onto broken skin or mucous membranes.

6.3.

Body fluids which could possibly contain bacterial and/or viral pathogens are: •

Faeces

•

Urine

•

Vomit

•

Sputum

Note: Faeces, urine, vomit and sputum, if contaminated with blood could also contain BBV. 6.4.

6.4.1.

The following may also contain the organisms of HIV or Hepatitis B/C: •

Blood

•

Blood-stained body fluids

•

Semen

•

Vaginal secretions

•

Body tissues

•

CSF, amniotic, pericardial, pleural fluids etc.

•

Exudate or other tissue fluid from burns or skin lesions

Most blood/body fluid exposures in healthcare settings are preventable. Standard infection control precautions are a simple set of effective practices designed to protect ambulance staff and

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patients from infection. As it is not always feasible to identify those who are infected with bacterial and viral pathogens and take precautions only with them, these practices are used when caring for all patients.

6.4.2.

All blood and body fluids are potentially infectious and standard infection control precautions are necessary to prevent exposure to them. Decisions regarding the level of precautions to use should be proportionate to the possible risk based on the nature of the procedure to be undertaken, and not on the actual or assumed infection status of the patient.

6.4.3.

Remember that healthy skin is a protective barrier; micro-organisms can be washed off. Breaks in the skin, cuts and abrasions can provide an entry for pathogenic organisms and should be covered with a latex free waterproof dressing.

7

Personal Hygiene (Should be read in conjunction with the Wellington Free Ambulances Uniform Policy).

7.1.

One of the key principles of operating effective standard infection control precautions is the need for each and every staff member to practice good standards of personal hygiene.

7.2.

First impressions are important and as a form of non-verbal communication, they often determine the attitude which will be conveyed within the clinician/patient relationship. A neat, well groomed appearance will impart an impression of an efficient, professional person representing an efficient, professional ambulance service.

7.3.

It is essential that a high standard of personal hygiene and appearance is maintained by all staff. Patients and the public expect staff to have a neat and clean appearance, this in the first instance involves close and constant attention to personal hygiene standards, which if maintained will help minimise the risk from cross-infection. A dirty or sloppy appearance might be taken to indicate a lack of professional pride and poor personal hygiene standards.

7.4.

Bare below the elbow should be strictly adhered to by clinical staff to ensure effective hand hygiene procedures can be undertaken at all times.

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8

Hand Hygiene

8.1.

Hands are the most common way in which microorganisms, particularly bacteria and viruses might be transported and subsequently cause infection, especially to those who are most susceptible to infection. In order to prevent the spread of microorganisms to those who might develop serious infections through this route while receiving care, adequate hand hygiene must be performed. This is considered to be the single most important practice in reducing the transmission of infectious agents, including healthcare associated infections (HCAIs), during delivery of care.

8.2.

The hand hygiene procedure being undertaken should consider the potential/actual hazards that have or might be encountered, the subsequent potential/actual contamination of hands, and any risks that may present as a result. The nature of the work - patient/client interaction will often determine this along with the vulnerability of individuals.

8.3.

Healthy, intact skin provides an effective barrier against infection.

Therefore it is essential that all cuts, abrasions, open lesions etc are covered with a waterproof dressing. Any member of staff who becomes affected with skin conditions such as extensive skin lesions, dermatitis or psoriasis must seek medical advice from the Occupational Health Department, and should be removed from direct patient care until the current condition resolves.

8.4.

Repeated hand washing and over wearing of gloves can cause irritation or sensitivity, leading to dermatitis or allergic reactions. This can be minimised by early intervention by contacting Occupational Health for advice.

8.5.

It cannot be over emphasised that regular hand hygiene is one of the most crucial interventions in the prevention of cross-infection in healthcare.

8.6.

The diagram below shows the areas of skin that are commonly missed during poor hand hygiene.

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Wrists & Forearms

8.6.1.

Appendix 1 and 2 illustrates the optimal hand decontaminating techniques

8.6.2.

To reduce the possibility of poor hand hygiene:

8.6.3.

Bare below the elbow will be adopted by all staff performing direct patient care, unless wearing issued clothing for health & safety or inclement weather. Sleeved items can be rolled or pushed up while performing hand hygiene, then replaced if required.

8.6.4.

Sleeved items should be removed or rolled up to elbow level whilst performing hand hygiene practices within clinical care settings.

8.6.5.

Finger nails should be short and clean. On no account is nail polish (clear or coloured) and/or false nails permitted when performing direct patient care.

8.6.6.

Only a plain band (wedding ring style) will be acceptable as hand jewellery.

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8.6.7.

Wrist watches are not to be worn and bracelets are not permitted unless they are the approved “medic-alert” type or are worn for medical reasons (supported by a doctor’s letter) or for cultural reasons. These are to be removed whilst performing hand hygiene practices and clinical procedures.

8.7.

Hand Care

8.7.1.

To protect the skin on hands from drying and cracking, where bacteria, in particular, may thrive and to protect broken areas from becoming contaminated, particularly when exposed to blood and body fluids, undertake the following instructions.

8.7.2.

Cover all cuts and abrasions with a latex free waterproof dressing.

8.7.3.

If you have skin lesions; cuts or grazes that cannot be adequately covered, contact Occupational Health or your GP for further advice and guidance.

8.7.4.

Hand creams can be applied to care for the skin, however, only individual tubes of hand cream should be used or hand cream from wall mounted dispensers.

8.7.5.

Creams used should not affect the action of hand cleaning solutions being used or the integrity of gloves.

8.7.6.

Communal tubs, in particular, should be avoided as these may contain bacteria over time.

8.7.7.

Anti-bacterial soaps, perfumed soaps, or other solutions, might cause skin problems for some individuals if used frequently.

8.7.8.

If you are experiencing skin problems, pay particular attention to a good hand care routine. If there is no improvement, report any skin problems to your Manager, Occupational Health or General Practitioner in order that appropriate skin care can be undertaken and the risks of harbouring microorganisms while providing care for others can be avoided.

8.8.

When to perform hand hygiene

8.8.1.

Hands should be cleaned at a range of times, however in order to prevent healthcare associated infections (HCAIs) at the most fundamental times during care delivery and daily routines, when caring for those sick and vulnerable the “Your 5 moments for Hand Hygiene” should be followed.

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8.8.2.

All of the Five Moments aim to stop germs moving between what we call patient zones. A patient zone is any area dedicated to one single patient for the duration of their stay or their visit. As mentioned above, this area will have a set of germs from that patient; this is normal and not all of the germs will be capable of causing infection, however, some may. The application of the Five Moments for hand hygiene can stop these germs moving out of the patient zone and into the wider healthcare environment or into other patient zones.

Your 5 moments for hand hygiene at the point of care*

*Adapted from the WHO Alliance for Patient Safety 2006

Adapted from World Health Organisations ‘Five moments for hand hygiene’.

8.8.3.

Moment one is before patient contact. This moment is equally important to everyone who works in healthcare. Germs are on everyone’s hands regardless of what our job is. If you are going to be

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in contact with a patient for any reason, for example to help them stand up or sit down, or to help them to move from an area, you must clean your hands to stop any germs that are on your hands moving onto the patient.

8.8.4.

Moment two is before a clean/aseptic task. This moment aims to make sure that when you do anything that goes through a patient’s natural defence, i.e. their skin; no germs from the patient’s surroundings are pushed into the patient. Clinicians must always stop at this moment to clean their hands.

8.8.5.

Moment three is after body fluid exposure risk. This moment is to protect you from germs that may be present in patient body fluids. If you have been cleaning any area or object that has been in contact with body fluids you must stop afterwards and clean your hands after you remove gloves. Gloves do not replace the need for hand hygiene.

8.8.6.

Moment four is if you touch a patient for any reason (such as the examples provided for moment one), germs from the patient will move onto your hands. Before you leave that patient’s side you must stop and clean your hands. This is to make sure that germs from the patient you have touched do not move onto you, the area outside the patient’s treatment zone, room or home, and most importantly that germs from the patient you have touched do not move onto another patient.

8.8.7.

Moment five is after contact with a patient’s surroundings. Everyone, including patients have germs living on them. The aim of moment five is to stop germs moving from one patient area to other ambulance areas. If you have contact with a patient’s surroundings, for example in the home, you must stop and clean your hands before you leave to another job/area.

8.9.

Hand Hygiene Incident Reporting

8.9.1.

Any incidents where failures in hand hygiene have occurred or where there are product/facilities issues that affect adequate hand hygiene, and in turn health, safety and welfare. These should be reported as per the Wellington Free Ambulances incident reporting Policy and Procedures.

9

Personal Protective Equipment

9.1.

The Control of Substances Hazardous to Health (COSHH) Regulations 2002 requires employers to undertake their own risk assessment, and to bring into effect measures necessary to protect workers and others who may be exposed, as far as is reasonably practicable.

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9.2.

For the purposes of this manual, Personal Protective Equipment (PPE) is defined as being all equipment that is intended to be worn or held by a person at work, which protects them against the transmission of micro-organisms.

9.3.

Employees have a responsibility to wear PPE that has been provided by the Wellington Free Ambulance and to co-operate with management on matters of health and safety.

9.4.

The Protective Personal Equipment at Work Regulations (1992) requires that PPE is to be supplied and used at work wherever there are risks to Health and Safety that cannot be adequately controlled in other ways.

9.5.

The Regulations also require that PPE: • Is properly assessed before use to ensure it is suitable and sufficient; • Is maintained contamination;

and

stored

properly

away

from

potential

• Is provided with instructions on how to use it safely; and • Is used correctly by employees.

9.5.1.

Selection of protective equipment must be based on an assessment of the risk of transmission of micro-organisms to the patient or to the staff member, and the risk of contamination of the staff members clothing and skin by patient’s blood/body fluids, secretions or excretions.

9.5.2.

Ambulance uniform itself is not considered as PPE, and so PPE must be worn in any situation where there is danger or potential danger to the individual from blood/body fluid splashing etc. It is not sufficient to rely upon helmet visors to protect staff from fluids and droplet spray.

The Wellington Free Ambulances general issued PPE for infection control consists of the following: •

Disposable medical gloves;

•

Disposable plastic aprons;

•

Disposable paper suits;

•

Disposable face masks;

•

Eye protection.

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9.5.3.

The choice of protective equipment selected depends on the dynamic risk assessment and anticipated risk of exposure to body fluid during the particular activity. Many general clinical activities involve no direct contact with body fluid and do not require the use of protective clothing, for example, taking a pulse, ECG, blood pressure or temperature

9.5.4.

Staff must use their judgement in determining the likely requirements in each case using the following guidance: Exposure Risk

Level of Protection

No exposure to blood/body fluids anticipated

No protective clothing

Exposure to blood/body fluids anticipated, but low risk of splashing

Wear gloves and apron

Exposure to blood/body fluids anticipated, with high risk of splashing

Wear gloves, apron and eye/mouth/nose protection

9.6.

Gloves

9.6.1.

The use of gloves as a method of barrier protection reduces the risk of contamination, but does not eliminate it.

9.6.2.

It is highly recommended that ambulance staff wear gloves for two main reasons: •

To prevent pathogenic organisms from being transmitted to patients and from one patient to another by the staff members hands.

•

To reduce the risk of the staff member themselves acquiring an infection through contact with blood/body fluids, non-intact skin or mucous membranes.

9.6.3.

Staff should firstly familiarise themselves with the sizes available.

Their choice in selecting the most appropriate size should be based on a comfortable fit that is not too tight to become restrictive, but equally not too loose as to compromise grip and/or increase the risk of puncture.

9.7.

Provided gloves are correctly used, they can perform the following functions:

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9.7.1.

Provide a protective barrier and prevent gross contamination of the hands when in contact with blood and body fluids, secretions; excreta; mucous membranes and non-intact skin.

9.7.2.

Reduce the likelihood that organisms from the hands of personnel will be transmitted to patients during invasive or other patient care procedures that involve touching mucous membranes and non-intact skin.

9.7.3.

Reduce the likelihood that hands of personnel contaminated with organisms from a patient or fomite can transmit these organisms to another patient.

9.7.4.

Protect the skin against certain hazardous substances, e.g. cleaning chemicals, petrol, diesel, oil.

9.8.

Ambulance staff need to be aware that the inappropriate use of gloves can be a hazard and has been associated with cross infection/contamination.

9.8.1.

The unnecessary wearing of gloves may also result in missed opportunities for hand hygiene and increase the risks for crosscontamination.

9.8.2.

Defects in gloves may be present and hands could be potentially contaminated during their removal. Therefore, it is important that hands should always be decontaminated after using gloves.

9.8.3.

Note: The use of gloves should never be viewed as a substitute for appropriate hand washing.

9.9.

Key Messages for Glove Use:

9.9.1.

Gloves are effective in reducing the contamination of hands and help limit possible transmission of pathogens.

9.9.2.

Avoid vinyl gloves, they tear easily and offer little protection in the event of a sharps injury. Polythene gloves should not be used during healthcare activities.

9.9.3.

Gloves do not contamination.

9.9.4.

Ambulance staff should remember that failing to remove gloves may contribute to the transmission of organisms.

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9.9.5.

Ambulance staff should plan the sequence of procedures in a rational manner which limits the use of gloves and to use non-touch techniques as much as possible during care. The emphasis should be on minimising the need for glove use and more on using alcohol hand rub and soap and water.

9.9.6.

Use of petroleum-based hand lotions or creams may adversely affect the integrity of latex gloves.

9.9.7.

At no time must gloves be washed or alcohol gel applied to save changing or removing gloves.

9.9.8.

Note: The unnecessary use of gloves in situations where their use is not appropriate should be avoided.

9.10.

Recommendations on Glove Use:

9.10.1. The use of gloves does not replace the need for hand cleansing by either alcohol hand rub or hand washing with soap and water.

9.10.2. Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, or other non-intact skin will occur.

9.10.3. Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient.

9.11.

When wearing gloves, change or remove gloves in the following situations:

9.11.1. During patient care if moving from contaminated body site to a clean body site on the same patient.

9.11.2. After touching a patient, before moving onto other tasks.

9.11.3. After touching a contaminated site and before touching a clean site or the environment.

9.11.4. Double gloving for procedures with large amounts of blood or body fluids, and for invasive procedure on high risk patients.

9.12.

Staff should make every effort to avoid the gloves becoming punctured during use. For incidents where such risks are increased, e.g. when attending an RTC etc, crews should consider wearing two pairs of gloves as an additional precaution. However, staff should remain mindful that the practice of ‘double gloving’ is only an added

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safeguard, and so the wearing of debris gloves over disposable gloves is still indicated in circumstances where the potential for glove puncture is evident.

9.13.

Remember that under the principles of Standard Infection Control Precautions, the purpose of wearing gloves is to prevent the spread of infection in either direction, i.e. staff to patient, as well as patient to staff. Therefore, gloves should not be donned prematurely, e.g. while travelling/ driving to a call, but should ideally be placed on the hands just prior to contact with the patient.

9.14.

Emergency treatment should never be withheld in the absence of wearing gloves, however, ensure hands are thoroughly washed at the earliest opportunity. Any member of staff who develops a skin irritation on their hands should complete an Incident Report Form (IR1) in addition to seeking advice from a manager, which may result in a referral to Occupational Health for further assessment and advice.

9.15.

Glove Donning Technique:

9.15.1. No special technique for use of non-sterile gloves. Pull gloves on in a convenient manner.

9.15.2. Interlock fingers after the gloves are in place to ensure a comfortable fit and free movement.

9.16.

By following the Uniform Policy, damage to gloves by puncturing via hand jewellery or finger nails should not occur.

9.17.

Recommended Glove Removal Technique:

9.17.1. Grasp the palm of the first glove just below the wrist; 9.17.2. Roll the glove towards the fingertips so that it turns inside out; 9.17.3. Hold the removed glove by the fingertips of the remaining gloved hand; 9.17.4. Place two fingers of the bare hand inside the cuff of the remaining glove; 9.17.5. Roll the second glove towards the fingertips with the bare hand until the first glove is inside the second glove; 9.17.6. Continue to remove until both gloves are inside out;

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9.17.7. Dispose of used glove into a clinical waste bag; 9.17.8. Decontaminate hands using alcohol hand rub or wash and dry hands thoroughly.

9.17.9. Note: It is the outside of the glove which is in contact with potentially infected material, and the possibility of exposure to unprotected skin is at its greatest when the gloves are removed.

9.18.

Aprons

9.18.1. Single use disposable plastic aprons are recommended for general use and should be worn when there is a risk that clothing or uniforms may become exposed to blood/body fluids, secretions and excretions or other organic substances. Plastic aprons should only be worn as a single use item for one procedure or episode of patient care only.

9.18.2. Since the front of the body is the part most frequently contaminated, the single-use plastic apron is deemed to provide adequate protection for staff in most instances. Plastic aprons should also be worn during any cleaning activity or on any occasion where the front of the uniform is at risk of being soiled.

9.19.

The apron should be removed immediately after use by:

9.19.1. Tearing the neck strap first and then the waist ties; 9.19.2. Folding/rolling into a ball, only touching the inside of the apron; and Discard as clinical waste.

9.19.3. Hand hygiene must be performed immediately after disposing of the apron.

9.19.4. The disposable paper suits are not required routinely. However, these are provided for use when the risk of contamination or soiling of the uniform is considered beyond the scope of a disposable apron, such as when dealing with infections caused by more hazardous organisms or chemical spills.

9.20.

Disposable Face Masks

9.20.1. The use of disposable face masks should not be required routinely, as they would normally only be worn for illnesses caused by more hazardous organisms. However, they should be worn if there is a risk of blood or body fluid being splashed into the mouth, or if the patient is prone to severe episodes of coughing or sneezing. It may also

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prove sensible under these circumstances to encourage the patient to similarly wear a mask, in that it would help to contain the spread of any infection.

9.20.2. If undertaking CPR or airway maintenance procedures, such as intubation, airway aspiration, or nebulising should particularly prompt the crew to wear a face mask. Especially for confirmed or suspected cases of: • Pulmonary Tuberculosis; • Measles; • Meningitis; and • Respiratory diseased patients such as HIV – related or multidrug resistant tuberculosis.

9.21.

To remove the mask:

9.21.1. Untie or break bottom ties, followed by top ties or elastic and remove by handling ties only and discard appropriately.

9.21.2. Disposable face masks are for single use only, and should be discarded as clinical waste.

9.21.3. In order to minimise the possibility of cross contamination, under Standard Infection Control Precautions, and whenever possible, staff should always attempt to avoid close proximity to a patient's face and inhaling the patient’s breath.

9.22.

Disposable high efficiency masks or respirators

9.22.1. They must not be touched unnecessarily and must be discarded when wet. They must not be pulled up and down to keep away from the face, but renewed after each episode of use. They are a single use item and must be disposed of as clinical waste.

9.23.

Pocket resuscitation masks

9.23.1. Pocket resuscitation masks eliminate the need for mouth-to-mouth contact during resuscitation, when other equipment if not available.

Their use will not only aid resuscitation, but also minimise the risk of cross contamination. These masks are re-usable; however, the oneway valve is single patient use only and the valve must be disposed of as clinical waste. After use, the mask should be cleaned with detergent and disinfectant and a new one-way valve installed.

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9.24.

Safety Eyewear

9.24.1. This item of PPE is supplied as personal issue to all operational staff.

Safety eyewear should be worn on any occasion where there is a risk of blood or body fluids coming into contact with the eyes, or when similar risks arise from activities such as vehicle or equipment cleaning.

9.24.2. The eyewear should be cleaned after general use with warm water and a detergent solution, if they have come into contact with blood/body fluid, then disinfectant should be used following cleaning with a detergent solution. Cleaning should take place on a monthly basis if they have not been worn.

9.24.3. Note: This type of safety eyewear is not intended for major chemical incidents, or where physical impact damage could occur.

10

Sharps Management and Safe Disposal

10.1.1. In healthcare, all employers should provide a safe working environment in which safe equipment is available and where staff are appropriately trained in the hazards posed by handling sharps and body fluids.

10.2.

Employee responsibilities

10.2.1. Employees must comply with any safety policies or procedures put in place to protect their health. Employees must also protect their own health and safety by using any protective clothing issued to them.

Employees also have a duty to ensure that their actions do not harm the health and safety of others, e.g. the careless disposal of a sharp in a bag could injure another member of staff, cleaner or person transporting the waste.

10.2.2. It is the responsibility of the user to always dispose of used sharps directly into a correctly assembled sharps container (BS 7320 /UN 3291 standards).

10.2.3. Therefore, employees must use and dispose of all sharps provided by the Wellington Free Ambulance correctly; in accordance with their training and the instruction they received to use them safely.

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10.3.

General

10.3.1. The safe handling of sharps is a critical factor in the successful control of infection. Inoculation injuries arising from exposure to contaminated sharps represent a recognised route of infection spread, and subsequent risk to ambulance staff. It is therefore imperative that all staff adhere closely to the following precautions and procedures in order to minimise the risks associated with the use of sharps.

10.3.2. The term ‘Sharps’ obviously applies to a wide range of individual ambulance and hospital equipment. However, these may be more broadly classified as: • Needles; • Lancets; • Syringes with an integral needle; • Cannulae; • Drug Ampoules/Containers; • Razors; • Scalpels/Blades; • Bone fragments, including teeth; and • Single use laryngoscope blades / Magill forceps & spikes from giving sets (which can tear through a clinical waste bag) 10.3.3. All sharps are for single patient use only, and must be correctly stored at all times in their original packaging and in their designated containers and/or storage compartment in the vehicle or response bag.

10.3.4. Staff must ensure that disposable gloves are worn as a minimum when handling sharps, and that the utmost of care is taken to avoid glove punctures and subsequent skin injury. All sharps items, including large items such as laryngoscope blades/Magill forceps, must be disposed of as clinical waste into designated sharps containers.

10.3.5. All procedures involving the use of sharps must only be practised by staff who have received recognised and relevant training, and as a result are duly authorised to perform the required procedure. Extreme care must be taken when attempting invasive procedures on patients who are restless or aggressive.

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10.3.6. Cannulation and other procedures involving the use of sharps should only be attempted in a stationary ambulance. The needle should only be removed from its sheath once the puncture site has been prepared, and only then just prior to the intended use of the item.

Under no circumstances are needles to be re-sheathed at any time, including during disposal.

10.3.7. Wellington Free Ambulance provides several sizes of sharps containers, both for cupboard use in an ambulance, and smaller variations for insertion in the Resuscitation Pack as appropriate to the standards required (BS 7320 /UN 3291). It is important that staff only replace sharps containers approved and supplied by the Wellington Free Ambulance.

10.3.8. All staff are reminded not to use sharps containers for any other purpose other than for the disposal of sharps. I.e. not as: pen holders; small equipment storage. This poor practice can lead to needlestick injuries due to misinterpreting the use of container.

10.4.

Safe disposal of sharps

10.4.1. Staff should familiarise themselves with the assembly instructions and locking devices on each of the sharps containers provided by the Service.

10.4.2. The start date should be entered on each container as soon as it is put into use, together with its point of origin, i.e. vehicle fleet number and/or bag number, in addition to the station name.

10.4.3. All used needles and sharps must be disposed of immediately after use, and placed directly into a sharps container by the person who has used the item. It is vital that sharps are never disposed of into waste bins, plastic bags, blankets, drugs packs etc, or anywhere other than in a recognised sharps container.

10.4.4. The use of safety devices such as safety cannulae and safety lancets does not alter the need to safely dispose of used sharps.

10.4.5. The Wellington Free Ambulances incident reporting mechanism should be used for any near miss incidents such as needles incorrectly disposed of. (Please read the Wellington Free Ambulances Incident Reporting Policy) 10.4.6. Paper or plastic packaging should not be placed into sharps containers, as this reduces their capacity. However, should removal of the packaging present any risk of subsequent injury, then the packaging and the sharps should be disposed of together.

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10.4.7. Needles and syringes must always be disposed of as one unit. Never attempt to re-sheath, or separate a needle from its syringe.

10.4.8. If the outside of the sharps container should become contaminated, wipe clean using detergent and a disinfectant.

10.4.9. The sharps container should be changed when it becomes two thirds full or when the sharps will no longer drop cleanly through the flap.

This must take place as soon as practicable, after either of these events has occurred. Under no circumstances should items be forced through the flap, and fingers must be kept out of the container at all times.

10.4.10. Staff must never attempt to transfer the contents from one container to another, e.g. from a small to a large sharps box.Used sharps containers that become damaged must be placed into a larger secure container with the outer compartment appropriately labelled.

10.4.11. The openings of sharps boxes must be closed and secured, prior to placing in the clinical waste bin on station. Sharps boxes must never be placed in a clinical waste bag.

10.4.12. Incidents where adequate and appropriate measures have not been taken to dispose of sharps, thereby putting others at risk of injury, must be regarded as adverse incidents and reported using the Wellington Free Ambulances incident reporting procedures 10.5.

Accidental Inoculation Injuries (Needlestick/Blood body fluid splashes) (To be read in conjunction with the Wellington Free Ambulances Exposure to Blood Borne Viruses and Post Exposure Prophylaxis Procedure and Staff Welfare Policy).

10.5.1. Under the precautions of Standard Infection Control Precautions, all blood and body fluids must be regarded as infectious, so any exposure should be viewed as a potential hazard to ambulance staff.

It is therefore imperative that any accidental inoculation incident that involves contact with blood or body fluids is treated with the utmost care, and with close attention to the following procedure.

10.5.2. Incidents involving risk of blood-borne infection may include: • Needlestick or other sharp injury; • Contamination of broken skin with blood/body fluids; • Contamination of broken skin with blood/body fluid soaked clothing or linen;

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• Blood/body fluid splashes to mucous membranes, e.g. eyes or mouth; • Oral contact with a person’s blood, vomit or mucous, e.g. after performing direct mouth-to-mouth resuscitation; and • Human / Animal bites or scratches (where the skin is broken).

10.6.

Post Exposure Action

10.6.1. The following course of action must be taken if any of the above incidents occur: 10.6.2. Ensure the sharp, if present, is disposed of safely into a sharps container.

10.6.3. Encourage bleeding from the wound, but do not suck.

10.6.4. Wash the site immediately with soap and water, or apply alcohol disinfectant for five minutes if unable to access conventional handwashing facilities. For both methods, do not scrub the area as you may make the wound larger by breaking down the edges.

However, still wash the wound thoroughly with soap and water at the earliest opportunity, and cover with an impermeable waterproof dressing.

10.6.5. Treat blood or body fluid splashes to the eyes with ample irrigation of water or saline; remember to first remove contact lenses if worn.

Splashes to the mouth should be washed with copious amounts of water. Wash the face thoroughly with soap and water.

10.6.6. Notify Central Emergency Communications (CECL) and arrange immediate attendance at the nearest A&E department (you have become a patient). The hospital will require details of how the incident occurred, as well as all information relating to the source patient. In the majority of cases this process will of course be made easier by the fact that the patient and the staff member will be treated at the same hospital.

10.6.7. However, the potential exists for staff to sustain sharps or splash injuries when either the source of the contamination is not known, or when the patient involved refuses to travel. In each of these cases, it is still essential that the staff member reports immediately to their nearest A&E department, in order for the degree of risk to be assessed.

10.6.8. It is likely that blood samples will be sought from the member of staff, as well as the source patient if present, though the patient has the

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right to refuse. The source patient should be provided with appropriate information about the implications of these tests and appropriate time to consider and discuss them.

10.6.9. Information relating to the crew member’s Hepatitis B, and Tetanus immunisation status would also be helpful in this situation, so staff should maintain a current awareness of their vaccination record.

10.6.10. On completion of the risk assessment, the assessing practitioner may offer a course of prophylactic treatment. This will be fully discussed with the individual member of staff, and may be commenced before all investigations have been completed. Prophylactic treatment may be halted before completion if tests later come back to show there was no risk.

10.6.11. Advise CECL of the situation at the earliest opportunity, who will arrange notification to the relevant Line Manager, or Team Manager Operations as appropriate. Complete an online Incident Report Form.

10.7.

Reporting procedure

10.7.1. All accidental inoculation incidents must be reported by telephone to Occupational Health as soon as possible, and act on any further advice or guidance as provided.

Complete an incident report form as soon as possible 10.7.2. CECL, TMOs and Operational Managers should make sure the injured person receives the appropriate and immediate assistance from Occupational Health Services (OHS) and/or A&E Department and that all relevant details are documented.

10.8.

Staff are able to access additional counselling and support following an incident via their line manager, OSH/HR or Clinical Services.This could involve support from an infection control specialist within OHS or counselling via an external counselling service. (Thinkwell)

10.9.

When is Post Exposure Prophylaxis Considered

10.9.1. PEP should only be considered when there has been exposure to blood or other high risk body fluids known to be or strongly suspected to be infected with HIV. Fluids include amniotic fluid, vaginal secretions, semen, human breast milk, CSF, peritoneal fluid, pericardial fluid, pleural fluid, and synovial fluid, saliva in association with dentistry, unfixed organs and tissues.

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10.9.2. Strongly suspected includes individuals with clinical symptoms highly suggestive of HIV disease or individuals from countries where HIV is highly prevalent who may not yet have had a blood test.

10.9.3. Strongly suspected does not include an injury from an unknown source e.g. an inappropriately discarded needle in the healthcare setting or in a public place, nor an individual with a single life-style factor e.g. IV drug abuser.

10.9.4. PEP should not be considered following contact through any route with low risk materials e.g. urine, vomit, saliva, faeces, unless they are visibly blood stained.

10.9.5. If PEP is indicated, it should be started as soon as possible after the incident, ideally within one hour of the exposure incident. (The Department of Health recommends it may be worth considering PEP even if 1-2 weeks have elapsed since the incident).

10.9.6. Ongoing advice e.g. regarding return to work can be obtained from Occupational Health or the individuals GP. Health Protection Agency Recommendations: 10.9.7. Blood Samples to be taken 10.9.8. Initial baseline blood sample on first attendance (for archiving by Virology Department) 10.9.9. At six months the client may wish to be tested for one or more of the 3 BBVs. 10.9.10. If the source is known or highly suspected to be a BBV carrier then testing can be offered at 6 weeks, 3 and 6 months.

10.9.11. If there is evidence of acute infection, refer for specialist management e.g. possible combination therapy for HCV.

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10.9.12. If the source patient has not been tested and the risk is assessed as significant test as follows: Time

Hepatitis C

Hepatitis B

HIV

10ml clotted sample for archiving at time of incident 6 Weeks

PCR

Surface Antigen

3 Months

PCR & Antibody

Surface Antigen

6 Months

Antibody

Surface Antigen (Surface Antibody)*

Antigen/Antibody combined test Antigen/Antibody combined test Antigen/Antibody combined test

10.10. Occupational exposure to blood or body fluids 10.10.1. Note: See appendix 3 for Details

11

Blood & Body Fluid Spillage Management

11.1.

General

11.2.

The effective management of blood and body fluid spillage is a crucial factor in the successful control of infection. Exposure to any such fluid presents a risk to the health of all persons involved within the working environment of the ambulance service. However, these risks are easily minimised by following the principles of Standard Infection Control Precautions, in addition to maintaining a routine approach to simple cleaning and disinfection procedures. It is of course essential that all blood and body fluid spillages are cleaned and disinfected as soon as is practicable.

11.2.1. In general, the volume of most blood or body fluid spillages that occur on a daily basis are not excessive. They can be safely managed by the wearing of PPE, normally gloves and apron as a minimum However, for the occasions when these provisions are considered insufficient, the use of the Body Fluid Disposal Kits (spillage kits, biohazard kits) should be utilised as detailed below.

11.3.

Blood/Body Fluid Disposal Kits

11.3.1. All Wellington Free Ambulance vehicles must carry the means to enable staff to successfully manage blood and body fluid spills.

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all Wellington Free Ambulance vehicles. The design and purpose of these kits take account of the risk of exposure to blood and body fluid spills in vehicles.

11.3.2. Body Fluid Disposal Kit contains: • Instructions for Use, (6 steps); • Disposable Gloves (wrapped up in yellow biohazard bag); • Disposable Apron; • Super Absorbent Powder Sachet; • Disinfectant Pump Spray; • Disinfectant Wipe Sachet; • Bonded Wipes; • Scoop/Scraper; and • Biohazard Waste Bag 11.3.3. A supply of Body Fluid Disposal Kits should be maintained on each Wellington Free Ambulance vehicle at all times.

11.4.

Method of Application (Spillage Kits)

11.4.1. Appropriate items of PPE, e.g. gloves and apron should be worn. If the volume of spillage requires the usage of absorbent powder, the contents of the sachet should be sprinkled accordingly. If further absorbent powder is required, open another Body Fluid Disposal Kit for additional supplies.

11.4.2. Once the fluid has congealed, the bulk of the spill can now be removed using the cardboard scoop and scraper. The contaminant, along with the scoop and scraper, must then be placed into the biohazard waste bag provided.

11.4.3. The area should now be thoroughly cleaned using the vehicles issued detergent cleaner and disposable paper towel. The disinfectant should now be sprayed onto the contaminated area, and then left for a period of three minutes. The area should then be dried with the disposable bonded wipes, disposing into the biohazard bag.

11.4.4. Finally, all the remaining items from the Body Fluid Disposal Kit should now be placed into the biohazard waste bag, along with the disposable items of PPE. If access to conventional handwashing facilities is likely to be delayed, the hands should be decontaminated with the disinfectant wipe as a temporary measure. Alcohol hand rub

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is also carried on all vehicles and should be fully utilised as a hand disinfectant.

12

Waste Management (To be read in conjunction with the Wellington Free Ambulances Clinical Waste Procedure and Waste Management Policy)

12.1.

All members of the Wellington Free Ambulance have a legal responsibility for the safe and proper disposal of waste. This includes waste produced from Service establishments, and in particular, all items of waste generated from operational activities and patient care interventions. It is crucial that staff recognise and understand their individual responsibilities in complying with the Wellington Free Ambulances waste disposal procedures, and seeks advice and guidance from local managers if any area of uncertainty should arise.

In this way, the health and safety of staff, patients and any other persons with whom we come into contact, can be suitably protected.

12.2.

Types of Waste:

12.2.1. Domestic Waste includes all household waste, glass, aerosols and batteries, but excluding any item generated from a clinically related activity.

12.2.2. Offensive/hygiene waste describes waste which is non-infectious and which does not require specialist treatment or disposal, but which may cause offence to those coming into contact with it.

Offensive/hygiene waste includes waste previously described as human hygiene waste; sanitary towels; incontinence pads; and nappies (sanpro waste), and does not need to be classified for transport.

12.2.3. Examples of offensive/hygiene waste include: incontinence and other waste produced from • human hygiene; • sanitary waste; • nappies; • medical/veterinary items and equipment which do not pose a risk of infection, including gowns, plaster casts etc; • animal faeces and soiled animal bedding.

12.2.4. Disposing of sanpro waste as offensive waste does not apply to individuals who are self-caring in their own home environment.

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12.2.5. Clinical Waste is any used disposable item which comprises of, or contains any human tissue, blood or other body fluid, excretions, drugs or other pharmaceutical products, swabs or dressings, syringes, needles or other sharp instruments, and any other waste arising from any clinical intervention, which may prove to be hazardous or cause infection to any persons coming into contact with it.

12.2.6. Laryngoscope blades and similar non-sharps (Magill forceps) should be disposed of in a sharps box, which will go for incineration for disposal.

12.2.7. Hazardous waste is any waste that is potentially toxic or has a dangerous nature to people or the environment. New regulations (Hazardous Waste Directive July 2005) have been introduced because of the extra risks such waste has to the health of people and the environment on how it is managed, transported and disposed of.

12.2.8. Limbs and body parts are retrieved limbs, body parts and tissue which should accompany the patient to hospital. The limbs and tissue should be contained in a clinical waste bag appropriately and clearly labelled to distinguish it from other infectious waste.

12.2.9. Limbs, body parts and tissue that are clinically assessed to be beyond re-attachment or use should be contained in a clinical waste bag marked for incineration only, and sealed with a plastic tie/tag.

The bag should be identifiable by marking the bag with WFA, date and vehicle fleet number and call sign.

12.2.10. Infectious Waste regulations require that the hazardous properties of all waste are assessed. The Hazardous Waste Directive (HWD) identifies 14 properties in waste that are deemed to be hazardous.

Hazard H9 refers to: • Infectious substances containing viable microorganisms or their toxins, which are known or reliably believed to cause disease in man or other living organisms.

• Infectious waste is defined by the Hazardous Waste Directive in H9 Infectious as: “Substances containing viable microorganisms or their toxins which are known or reliably believed to cause disease in man or other living organisms.”

12.2.11. HWD acknowledges that many waste streams contain pathogens, but where there is a low level present or the concentration is at a naturally occurring level, or where the infectious part has been removed by specific segregation at source, the waste would not be considered hazardous according to H9.

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Note: WFA has separate policies to cover the handling and disposal of other forms of waste, e.g. Hazardous waste, confidential paper waste, date expired drugs, etc.

12.2.12. Segregation of Waste •

Different types of waste require different procedures to ensure their safe and appropriate disposal. It is therefore essential that waste is correctly identified and segregated at source, in order to remove all avoidable risk during subsequent handling, storage and transportation.

•

Similarly, care must be exercised in segregating items of nondisposable equipment and linen from clinical waste, prior to adopting the relevant cleaning and decontamination process.

However, an alternative course of action may be required in the case of a ‘Category 111’ patient, whereby crews should work under the guidance of the hospital or specialist staff. Safe and effective waste segregation requires the use of colour coded storage bags and containers, appropriate to the waste type.

•

All items of clinical waste must be placed in the appropriate receptacle at source, as soon as is reasonably practicable. This should always be performed by the person immediately involved in the generation of the waste, particularly where the use of sharps is concerned.

•

Prior to departure, crews should make every effort to ensure that no items of clinical waste are left on scene. Where sharps are used away from the vehicle, the sharps boxes carried in the response bags should be utilised as appropriate, along with clinical waste bags for any other contaminated item.

•

Under no circumstances should any item of clinical waste be placed in any domestic waste bin, or left abandoned outside designated containers, e.g. in the rear of ambulances, etc.

12.2.13. Handling and Storage of Clinical Waste •

The importance of personal protection, and in particular hand hygiene, is once again emphasised for all staff engaged in the handling of clinical waste. It is essential that staff apply an impermeable waterproof dressing to any cuts or abrasions during any period of duty, in addition to the wearing of protective equipment where necessary.

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•

All staff must wear disposable gloves as a minimum when handling clinical waste. This also applies to the handling of clinical waste bags, boxes or bins, where the use of additional protection, e.g. aprons, should be considered if leakage is suspected. Remember that all used disposable protective items should themselves be disposed of as clinical waste. Any spillage or contamination resulting from the movement of clinical waste must be thoroughly cleaned and disinfected at the earliest opportunity. This will ordinarily involve the use of detergent, followed by disinfecting, or Body Fluid Disposal Kits on vehicles etc. Any such incident must be reported to line managers, followed by the completion of an IR 1 Form.

Note: For incidents which involve a needlestick or blood splash injury, refer to Section 11 Management of Accidental Inoculation Incidents.

12.2.14. Clinical waste collection responsibility for the final collection of clinical waste from Wellington Free Ambulance sites is held by an external contractor. However, storage sites for clinical waste bins have been designated and marked at Wellington Free Ambulance locations.

12.2.15. Untoward waste incidents are incidents where inadequate and inappropriate measures involving the disposal of clinical waste, sharps, or pharmaceutical waste thereby putting others at risk of injury and cross-contamination, must be regarded as adverse incidents and reported using an IR-1 form.

13

Linen Management

13.1.1. In WFA, the term ‘linen’ refers to all materials that require laundering.

As most linen have the potential to harbour microorganisms, it is important that all service linens are appropriately managed in order to minimise any risk from cross contamination. Although the risks of cross infection from linen are small, particular attention should be directed at those items utilised in the direct care of patients.

Ambulance blankets are naturally the main items of linen used in this respect, along with supplementary articles such as pillow cases, canvasses and carry sheets.

13.2.

Segregation of Linen

13.2.1. For laundry purposes, linen must be segregated into one of the following groups: •

Used Linen

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Linen which has been in general use, but has not been contaminated by blood or body fluids.

•

Contaminated Linen Linen which has become contaminated by blood or body fluids, or which has been used in the care of a patient with a known infectious disease or infestation.

13.2.2. The importance of hand care is again emphasised, together with the need for staff to apply an impermeable waterproof dressing to any cuts or abrasions during any period of duty.

13.2.3. Staff must exercise all due care when preparing items for laundering.

Disposable gloves and aprons must always be worn as a minimum, particularly when handling contaminated linen. Items of linen should always be held away from the body to reduce the risks of contact with uniform.

13.2.4. Safe and effective linen segregation calls for the use of colour coded storage bags, appropriate to local arrangements and laundry type. All items requiring laundry must be bagged at source, after ensuring that any item of equipment etc. has firstly been removed. All Wellington Free Ambulance operational vehicles must carry an adequate supply of alginate bags to allow compliance with the following procedures.

13.3.

Staff Uniform and Clothing Care (To be read in conjunction with the Wellington Free Ambulances Uniform Policy).

13.4.

The majority of bacteria and viruses will not survive away from the host and would not present a high risk of infection transmission on clothing during general wearing whilst on duty. However, visible soiling or contamination where there are a greater number of organisms might be an infection risk, and is likely to affect patient confidence.

13.4.1. Staff should change into a clean uniform at the start of each shift.

Once off duty, staff should always change into ‘home’ clothes as soon as possible – preferably before leaving the workplace.

13.4.2. The uniform itself is not considered as PPE, and so PPE must be worn in any situation where there is danger or potential danger to the individual from blood/body fluid splashing etc.

13.4.3. In general, the responsibility for uniform laundering currently rests with the individual member of staff. Uniforms or other work clothes

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should be washed as soon as possible and in accordance with the care label instructions – preferably on a hot a wash as the fabric will tolerate. Tumble drying and ironing are part of the heat process.

13.4.4. Operational uniform and clothing worn by non-uniformed responding managers should not be dry cleaned as this is generally a chemical clean, not heat clean.

13.4.5. Where necessary in order to avoid overloading, wash uniforms separately from other clothes. There is no evidence of cross contamination, but overloading the machine will reduce wash efficiency.

13.4.6. In the majority of cases, staff uniform can and should be included as part of the general domestic washing arrangements undertaken by each member of staff. All the components of the laundry process contribute to the removal or killing of micro-organisms on fabric. It is likely that dilution/flushing is the main contributor. There is no conclusive evidence of a difference in effectiveness between commercial and domestic laundering in removing micro-organisms.

13.4.7. On occasions, uniforms may be exposed to splashes of blood or body fluids. This should be avoided as far as possible by the use of PPE – disposable aprons. For cases where extensive soiling or contamination is foreseeable, a disposable suit should be worn as an outer garment, in addition to any other PPE items necessary. After use, the apron or suit should be disposed of as clinical waste and the uniform checked to ensure it has been fully protected.

13.4.8. If, despite all efforts, heavy contamination of the uniform occurs with either blood or body fluids soaking through to the skin, arrangements should be made for the crew to return to base for a shower to remove any skin contamination and a uniform change. Operational staff are expected to keep at least one complete spare uniform in their station locker.

13.4.9. Contaminated uniform may be treated as ‘Used linen’ and placed in a white laundry bag, unless heavily contaminated with blood or body fluids from a known or suspected infectious patient, in which case bag as ‘Infectious linen’, to be laundered by a contracted laundry company.

13.5.

Conclusion

13.5.1. There is no conclusive evidence that uniforms or other work clothes pose a significant hazard in terms of spreading infection;

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13.5.2. Public perception believes there is a risk. The public do not like seeing uniformed staff away from the workplace; 13.5.3. A ten minute wash at 60oc is more than sufficient to remove organisms encountered by ambulance staff on a day-to-day basis.

13.5.4. Using detergents mean that many organisms can be removed from fabrics at lower temperatures. MRSA is completely removed following a wash at 30oc.

14

Maintaining a Safe & Hygienic Environment.

14.1.

The cleanliness of premises and vehicles is an important component in the provision of clean safe care. The HDC code of patient rights clearly sets out that patients have a right to be treated in an organisation that meets the required levels of safety and quality Whilst there have been significant improvements in the cleanliness of our premises and vehicles, there is still room for improvement.

14.2.

The maintenance of high standards of cleanliness on all surfaces and equipment is a crucial factor in the prevention and control of infection.

All staff have an individual responsibility to keep the ambulance and equipment clean and thus reduce the risk of cross contamination/infection to themselves, their colleagues and their patients. This can only be achieved by every staff member participating in frequent and routine cleaning activities.

14.3.

Whilst all dust, dirt and moisture can harbour infection, the key risks are associated with contamination arising from contact with blood and body fluids, mucous membranes or damaged skin. In all cases the surface or equipment must be thoroughly cleaned and disinfected in order to destroy any pathogenic micro organisms.

14.4.

Effective management of blood and body fluid spills is a crucial factor in controlling the spread of infection. Exposure to any such fluid constitutes a risk to staff and others within the immediate environment. These risks can be minimised by dealing promptly with the spillage, by appropriate cleaning and disinfection.

14.5.

In general, the volumes of most blood or body fluid spills that occur are not excessive, e.g. blood smeared on a sharps box and can be managed by wiping with a surface wipe. In the event of a larger spill where this method would not be sufficient, the use of absorbent Page 42 of 105

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powder from a spillage kit must be used. All items required are supplied with in the spill kit.

14.6.

Colour-Coding for Cleaning

14.6.1. The Wellington Free Ambulances colour-coding system, which is based on hospital colours should be followed at all times by all staff undertaking cleaning activities. If there is a shortage of colour-coded materials or equipment, the TMO should be informed immediately and an Incident Report Form completed and Stores/Logistics informed for replenishment.

RED

BLUE

GREEN

YELLOW

Washroom floors, Showers, Sinks, Toilets.

Ambulance vehicles, Offices and Public areas.

Kitchen/Food & Drink preparation areas.

Hospital Isolation areas.

14.7.

Ambulance Station/ Environmental Cleaning

14.8.

Dust, dirt and liquid residues will increase the risk in transmitting infection. They should be kept to a minimum by regular cleaning and by good design features in equipment, fittings and fixtures.

14.9.

A written cleaning schedule should be devised specifying the persons responsible for cleaning, the frequency of cleaning and methods to be used and expected outcomes.

14.10. Work surfaces and floors should be smooth-finished, intact, durable, washable and should not allow pooling of liquids or / and be impervious to liquids.

14.11. Hands must be washed thoroughly following any cleaning session.

Communal nailbrushes must not be used.

14.12. Keep mops and buckets clean, dry and store inverted. Mop heads should be removable for frequent laundering or single use if this is not possible. Provide single use, non-shredding cloth or paper roll for cleaning.

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14.13. Keep equipment and materials used for general cleaning separate from those used for cleaning up body fluids.

14.14. Preferably colour code cleaning equipment, such as mop heads, gloves, cloths & buckets for designated areas and have signs clearly displayed in all areas, indicating the colour coding system, to aid compliance.

14.15. Use general purpose detergent for all environmental cleaning (following the manufacturers’ instructions) even when subsequent disinfection is required.

14.16. When replacing paper hand towels, these must be put into the holder, and not placed on top. Paper towel and liquid soap dispensers of the cartridge type must be cleaned regularly.

14.17. Vacuum cleaner bags and filters must be changed as necessary and the brush cleaned of hair and fluff before storage.

14.18. Crockery and cutlery should be washed immediately after use in hot water and general-purpose detergent. Wherever possible, leave to air-dry or, if necessary, dry with disposable heavy-duty paper towel.

14.19. It is usually sufficient to clean floors by removing dust with a properly maintained filtered vacuum cleaner. They can then be cleaned by washing with hot water and general purpose detergent, using mops or suitable scrubbing machine.

14.20. Food preparation surfaces should be cleaned regularly with hot water and general-purpose detergent. These areas should be kept in good repair to facilitate cleaning. Ovens and microwaves must be cleaned after use.

14.21. Refrigerators should be defrosted and cleaned regularly in accordance with manufacturer’s instructions. Should a spillage occur or food become stale, the whole interior of the fridge should be cleaned with hot water and general purpose detergent and dried thoroughly.

14.22. Anti-slip shower mats must be washed with hot water and generalpurpose detergent and hung in a clean dry place when not in use.

(Cork type shower mats are not to be used).

14.23. Shower rooms and hand basins must be cleaned regularly with a cream cleanser, using a disposable cloth which can be discarded into a black waste sack.

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14.24. Toilets should be cleaned with a toilet brush, if soiled, using a toilet de-scaling liquid.

14.25. Toilet brushes should be cleaned by flushing the cistern and rotating the brush as the clean water comes through; tap on the edge of the toilet to remove excess water, air-dry and store dry in brush holder.

14.26. Waste bins must be cleaned regularly inside and outside with hot water and general purpose detergent. Sack holders should also be cleaned regularly as above.

15

Vehicle and Equipment Cleaning

15.1.

The relevance of maintaining high standards of hygiene and cleanliness has an even greater significance to the interiors of ambulance vehicles and the equipment carried. The very nature of ambulance work determines that all interior surfaces are prone to becoming dirty and dusty during normal everyday activity. This can lead to a rapid build up of contamination, which if left unchallenged, potentially creates an ideal breeding ground for infectious organisms to grow and multiply. All items of equipment can potentially become a source of cross infection; it is of particular importance that close attention is given to their respective cleaning and disinfection procedures.

15.2.

It is therefore imperative that all staff meet their individual responsibilities in keeping the vehicle and equipment clean, and thus help to reduce the risks of cross infection/contamination to themselves, their colleagues and their patients. This can best be achieved by all staff participating in frequent and routine cleaning activities - most importantly between each patient.

15.3.

Under the principles of standard infection prevention and control, it is important that ambulance equipment is maintained in a clean and hygienic condition at all times. This highlights the need to regularly check and clean equipment, with any shortfalls being addressed as soon as operational demands allow. In particular, it is vital that any equipment contaminated with either blood or body fluids is cleaned and disinfected at the earliest opportunity.

15.4.

All decontamination procedures should be carried out as soon as possible, once the patient has been placed in the care of the hospital staff. These will ordinarily be undertaken by the driver of the vehicle, leaving the attendant to finalise any outstanding matters of patient handover, or patient report form completion.

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15.5.

A suitable cleaning schedule for each vehicle should be designed, agreed and maintained by staff and monitored by supervisors/managers on a regular basis. No emergency call should ever be delayed as a result of a vehicle being washed or cleaned.

Crews must use their judgement in determining the most appropriate time to attend to vehicle and equipment cleaning in order to avoid any disruption to the vehicles deployment.

15.6.

The Vehicle Exterior

15.6.1. The exterior surfaces of all ambulance service vehicles must be maintained in a consistently clean and hygienic condition. Vehicle wash facilities on stations should be utilised as necessary. Careful attention should be paid to all aspects of safety, including adherence to any locally applied instructions.

15.6.2. The use of PPE should also be considered and would ordinarily include eye protection and disposable aprons, particularly when using manually operated vehicle wash systems. Hand protection is important and rubber household gloves, or ‘debris gloves’ should be worn.

15.6.3. If pressures of operational requirements prevent a thorough cleaning of the vehicle exterior, attention should be prioritised to the relevant safety and legislative requirements i.e. windscreen, windows, lights, indicators, reflectors, mirrors and number plates and particularly any areas where dirt is likely to be transferred to the crew’s hands e.g. door handles.

15.7.

The usual detergent based cleaning agents are satisfactory for general exterior vehicle cleaning; however, if the exterior has become contaminated with blood or body fluids, the detergent clean should be followed by disinfection to eradicate the potential source of infection.

PPE (disposable gloves and apron) should be worn in this case and these items must be disposed as clinical waste.

15.8.

Vehicle Interior Cleaning – After Each Patient Journey

15.8.1. Used blankets, pillow cases, sheets etc must be changed between patients.

15.8.2. Vehicle and equipment cleaning should take place after each patient episode. It is good practice to use detergent wipes in order to clean all surfaces that may have been touched or contaminated, including stretcher handles and clinical surfaces. This need only take a few minutes.

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15.8.3. Where an ambulance has become contaminated with blood or body fluid, cleaning must take place following handover of the patient at their destination and prior to the next call of duty. Decontamination should normally be carried out where there is access to hot water and cleaning equipment. However, where the spillage is small this can be dealt with using the decontamination equipment or spillage kits carried by all vehicles. Decontamination equipment is disposable and should be placed in a clinical waste bag and removed.

15.8.4. Disposable cloths and paper towels can be used for management of blood and body fluid spillages (see section on Spillage Management).

15.9.

The Vehicle Interior – Daily Clean

15.9.1. All interior surfaces that become directly contaminated should be cleaned as soon as possible. This process must always include detergent as the primary cleaning agent, followed by the use of disinfectant if the contamination is likely to include blood or body fluid.

Remember to use PPE as necessary, and discard any disposable items that have been in contact with blood or body fluid as clinical waste. It is also advisable to provide as much ventilation as possible during cleaning activities, so vehicle doors and windows should be opened accordingly, weather permitting.

15.9.2. The vehicle floor should be mopped clean on a regular basis throughout the shift. As the floor carries a comparatively low risk of cross infection, this can be undertaken satisfactorily using hot water and general detergent. However, if blood or body fluids have been involved, then the use of disinfectant after the removal of the organic material.

15.9.3. On most occasions, the floor will be mopped clean at hospitals. So staff should ensure that they utilise a mop suitable for ambulance cleaning purposes. The same principles will apply at ambulance stations, where the colour coding system should be followed. Mops should be changed before moving to a different vehicle to clean.

15.9.4. Clinical waste bags should be placed in a clinical waste bin at the receiving hospital. Where this is not possible, they should be disposed of at the earliest opportunity. At the end of a shift, clinical waste bags are not to be left on a vehicle; they must be removed, tied and put in the appropriate place for collection. Sharps boxes may be left on the vehicle but should be in the temporary closed position. The interior of the vehicle should be checked for sharps and other discarded clinical waste; and if found it should be removed.

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15.10. Vehicle Interior Cleaning – Rostered Clean 15.10.1. All ambulance vehicle interiors should be subjected to a comprehensive clean on a rostered basis. Operational demands will make it very difficult for this to be done consistently unless time is allocated to this task, therefore the comprehensive clean should be clearly rostered as part of a written vehicle cleaning schedule. It is recommended that this level of clean is undertaken in conjunction with vehicle servicing to reduce loss of unit hours. The comprehensive clean must ensure that detachable items are removed in order that all surfaces can be accessed for cleaning.

15.10.2. Ensure that appropriate items of PPE are worn and the vehicle is well ventilated. All walls, ceiling and the inside of cupboards can then be cleaned. Usually a general detergent clean using disposable towels or cloths will suffice, however any areas visibly contaminated with blood or body fluids should be cleaned with the appropriate disinfecting agent after the organic material has been removed.

15.11. GENERAL 15.11.1. Remember it is good practice not to spray fluids above head height, nor directly onto or around electrical fittings. When such needs arise, the fluid should firstly be sprayed onto disposable paper/cloth before being applied to the specific area. It should also be remembered that the process of drying is an important element for infection prevention and control, so this should be aided wherever possible by leaving the vehicle in a well ventilated position and using disposable paper towels/cloth to aid the drying process.

15.11.2. To support staff with this requirement, a list of general equipment has been produced, which are specific to each individual item of nondisposable and disposable single patient use. This lists the necessary actions to help ensure that either disposal or effective cleaning and disinfection measures are appropriately applied in each case.

15.12. Decontamination of Equipment 15.12.1. The aim of decontaminating equipment is to prevent potentially harmful pathogenic organisms reaching a susceptible host in sufficient numbers to cause infection.

15.12.2. Certain items of equipment are classified as ‘single-use only’, do not re-use. A single-use device is used on an individual patient during a single procedure and then discarded. It is not intended to be reprocessed and used again, even on the same patient.

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15.12.3. The symbol below is used on medical device packaging indicating ‘do not re-use’ and may replace any wording.

15.12.4. Re-useable medical devices e.g. stretchers, splints, BP cuffs, finger probes etc, should be appropriately decontaminated between each patient using a risk assessment model. The same procedures should be applied to all detachable items removed from the vehicle.

15.13. Risk Assessment for Decontamination of Equipment 15.13.1. The re-use of single patient use products is not advisable unless the outcomes have been taken into account.

15.13.2. The Consumer Protection Act 1987 will hold a person liable if a single use item is re-used against the manufacturer’s recommendations

.RISK

APPLICATION OF ITEM

MINIMUM STANDARD

MINIMAL

Items / surfaces not in contact with the patient e.g. floors, walls

Clean & dry

LOW

Items / surfaces that come into contact with healthy skin e.g. mattresses, rails,

Clean & dry but, if contaminated with blood, body fluids or suspected transmissible organisms - disinfect

MEDIUM

HIGH

In contact with intact mucous membranes, or if contaminated with virulent or readily transmissible organisms e.g. respiratory equipment, auroscope earpieces, thermometers

In contact with a break in the skin or mucous membrane, or for introduction into normally sterile body areas e.g. forceps, cannulae, dressings

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Disposable covers or single use item

Sterilise or single use

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15.14.

15.15. Cleaning and Disinfection of Equipment Note: It is recommended as best practice for Wellington Free Ambulances that where possible; equipment used for patient care should be for single patient use and disposable. This method statement identifies items which may require cleaning, disinfection and reuse, gives best practice guidance on this, and provides a generic method.

EQUIPMENT

RECOMMENDED CARE

Airways

Single use – disposable

Bedpans / Urinals

Single use – disposable Liners single patient use only.

Outer - hot soapy water dry thoroughly

Blood Glucose Monitor

Clean between each use. Refer to manufacturer’s instructions.

Body Bags (Disposable)

Single patient use only.

Buckets

Empty, wash with detergent and dry thoroughly after each use. Store inverted

Carry / Wheel Chair

Check fabric and straps intact. After each patient use clean with detergent wipes and dry thoroughly.

If contaminated with blood / body fluids

Clean with detergent then disinfect, dry thoroughly

Cervical Collars Re-usable

After each patient use - ensure material is intact and equipment is functional. Wipe with damp cloth, detergent and water. Disinfect using disinfectant wipes.

If contaminated with blood / body fluids Defibrillator & ECG Monitor

If contaminated with blood / body fluids Endo-tracheal Tubes / Catheter mounts

Dispose of as clinical waste Daily and after each patient - Wipe with detergent wipes.

Dry thoroughly with absorbent towels.

Clean with detergent wipes dry thoroughly with absorbent towels and disinfect using disinfectant wipes Single use - disposable

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Facemasks Resuscitator, bag and mask.

Single use - disposable

Entonox mouth piece & tubing

Single use disposable Wipe cylinder head with a detergent wipe

Oxygen masks and tubing

Single patient use - disposable.

Forceps, Magill’s, Spencer Wells, Stylets

Single use – disposable of into rigid yellow container.

Hand held Radio

Clean using instructions.

Intravenous cannulae

Single use – disposed of as sharps

Lancet devices

Single use – disposed of as sharps

Laryngoscopes

Single use - Blades and handles are disposed of into rigid yellow container

Linen

Use disposable where possible.

Re-usable – place in appropriate bag for laundry or disposal

Mops

Use colour coded disposable mop heads.

detergent

wipe.

Follow

manufacturer’s

String mops, are difficult to dry, can quickly become a source of infection.

Regularly replace the water during use After use, all equipment should be checked, cleaned, dried and returned to the storage area Nebulisers & tubing

Single use – disposable

Pillows

The pillow should be encased in an intact waterproof cover. Clean with detergent and hot water – dry thoroughly using absorbent towels. If integrity of cover is breached – dispose of pillow as clinical waste and replace

Safety Helmet

Check visor, strap and casing intact. Clean using detergent wipe

Shears

Clean between patients, wash in detergent and dry thoroughly after each patient

Sagar Splints Re-usable - after each patient use

Ensure material is intact and equipment is functional. Wipe with damp cloth, detergent and water. Blood/body fluid contamination, disinfect after cleaning with detergent.

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Sphygmomanometer Cuffs

Stethoscopes After each use Stretcher mattresses and frame

Wash with detergent and air dry.

Contamination with bodily fluids requires detergent and disinfectant. If difficult to remove they may require disposal and replacement.

Wipe earpieces and bell with disinfectant wipes.

Earpieces must be changed when damaged.

Check that mattress cover is intact. After each patient use clean with detergent wipe and dry thoroughly with absorbent towels. Cover with draw sheet / disposable sheet and change between each patient. If patient is known or suspected to be infectious, disinfect after cleaning.

If mattress cover is damaged this mattress should be reported and replaced.

Urinary Catheters (Disposable)

Single patient use only.

Tympanic Thermometers

Single use ear pieces – wipe machine over with a detergent wipe

Umbilical scissors / clamps

Single use – disposable

Vomit bowls (disposable)

Single patient use only.

Dispose as clinical waste

15.16. Flowchart for Decontamination Prior to Service or Repair See Appendix 4

16

Aseptic Non-Touch Technique

16.1.

Asepsis is defined as the absence of pathogenic organisms and is extremely challenging to achieve in the pre-hospital environment.

Aseptic Technique is a method used by clinicians to keep wounds, other susceptible body sites and sterile instruments free of microbial contamination by adopting a non-touch technique. Adopting the precautions of aseptic technique plays a vital role in preventing the transmission of infection.

16.2.

Aseptic non-touch technique should include:

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16.2.1. Keeping the exposure of susceptible sites to a minimum; 16.2.2. Ensuring appropriate hand decontamination prior to the procedure; 16.2.3. Additional hand gel application during activities when hands have handled non-sterile items (e.g. opening a packet); 16.2.4. Using gloves where appropriate, and changing them if they become Contaminated; 16.2.5. Ensuring that all fluids and materials used are sterile; 16.2.6. Checking that all packs used are sterile and show no evidence of damage; 16.2.7. Ensuring that contaminated and non-sterile items are not placed in the clean field or ‘sterile area’; 16.2.8. Handling sterile items with confidence and not touching ‘key parts’ (parts which come into contact with / are placed inside the patient) 16.2.9. Not reusing single-use items; and 16.2.10. Reducing staff and / or bystander activity (wherever possible) in the immediate vicinity of the area in which the procedure is to be performed.

16.3.

Key Parts

16.3.1. Needle shaft 16.3.2. Cannula tubes (any part beyond the winged area over the needle) 16.3.3. Luer loc connections on all infusion lines and devices 16.3.4. Tip / male luer part of syringes 16.3.5. Spike of infusion sets 16.3.6. Endotracheal tubes (any part below the point which will lay at the patients lips) 16.3.7. Any area of dressings that come in direct contact with damaged skin / puncture sites on patients

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17

Peripheral Cannulation (To be read in conjunction with training procedures as this supports local and national policy).

17.1.

Peripheral intravenous cannula insertion is a commonly performed procedure and has an associated risk of infection because of the potential for direct microbial entry to the bloodstream. Intravenous cannulae may be contaminated by the patient’s skin flora at the insertion site or by the introduction of other organisms via the cannula hub or injection port.

17.2.

There are two sets of actions outlined below as good practice; these are concerned with: A. Insertion B. Ongoing care.

17.3.

Insertion

17.3.1. Hand Hygiene •

Decontaminate hands before and after each patient contact and before applying examination gloves.

•

Use correct hand hygiene procedure. See previous advice and guidance.

17.3.2. Personal Protective Equipment •

Wear examination gloves.

•

Gloves are single-use and should be removed and discarded immediately after the care activity.

•

Aprons and eye/face protection are indicated if there is a risk of splashing with blood or body fluids.

17.3.3. Skin Preparation •

Use 2% chlorhexidine gluconate in 70% isopropyl alcohol, and allow to dry.

17.3.4. Dressing

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•

Use a sterile, semi-permeable, transparent dressing to allow ongoing observation of insertion site.

17.3.5. Documentation •

Date and time of insertion should be recorded on the dressing and on the Patient report form.

17.3.6. General Peripheral Cannulation Insertion Procedure •

Evidence has shown that performing peripheral cannulation increases the risk of healthcare associated infections, therefore when the practitioner has taken the clinical decision to cannulate the patient, the following best practice should be applied:

•

Apply the tourniquet (single use and disposable).

•

Palpate the vein.

•

Decontaminate your hands.

•

Make a clean field – using the cannulation pack clean field sheet or if necessary the sterile cannula dressings pack.

•

Clean the site for venepuncture using 2% chlorhexidine gluconate in 70% isopropyl alcohol – do not re-palpate the vein.

•

Leave skin to dry for 30 seconds.

•

Choose a cannula, open the pack and place the cannula aseptically in the clean field.

•

Decontaminate your hands and don gloves.

•

Insert the cannula according to WFA competency manual, ensuring that the insertion site is not touched. If insertion attempt is not successful, the same cannula should not be used again.

•

Use a sterile, semi-permeable, transparent dressing to secure the cannula.

•

Prepare the needle free device and attach to the cannula after disinfecting with the 2% chlorhexidine gluconate in 70% isopropyl alcohol equipment wipe.

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17.4.

•

Dispose of any items used in the appropriate waste receptacles.

•

Remove gloves and dispose of as clinical waste.

•

Decontaminate hands.

•

Record the date and time of insertion on the dressing label.

•

Place the label on the dressing at the furthest point from the insertion site.

•

Record the date and time of insertion on the Patient report form.

•

If any of the above steps cannot be performed due to circumstances beyond your control e.g. life threatening or environmental conditions, the inserted device must be classified as EMERGENCY INSERTED and must be recorded on the Patient report form and verbally advised as such when handing the patient over to the receiving hospital staff, so that the cannula can be replaced aseptically as soon as it is possible to do so.

•

Always ensure that the giving set and any syringes used for administering drugs through the cannula are handled aseptically using the non-touch of key-parts technique..

Ongoing Care Procedures

17.4.1. Hand Hygiene •

Decontaminate hands before and after each patient contact and before applying examination gloves.

•

Use correct hand hygiene procedure. See previous advice and guidance.

17.4.2. Site Inspection •

Regular visual observation for device patency.

17.4.3. Dressing

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•

An intact, dry, adherent transparent dressing should be present.

17.4.4. Cannula Access •

Use 2% chlorhexidine gluconate in 70% isopropyl alcohol, and allow to dry prior to accessing the cannula for administering fluid or drugs.

18

Urinary Catheters

18.1.

All staff undertaking catheterisation must have received formal training and be competent in catheter insertion, replacement and maintenance.

18.2.

Urinary catheter insertion and catheter care sterile packs, sterile gloves and aprons are available for use by all trained staff. Aseptic technique must be applied throughout the procedure. To ensure that hand hygiene is maintained, liquid soap and paper towels need to be carried by staff for use in patient homes.

18.3.

Hands must be washed with soap and water, followed by alcohol handrub. If running water is not available, detergent wipes should be used prior to alcohol handrub. Hands must be cleaned before donning gloves and after removal.

18.4.

For urethral and suprapubic catheters, the choice of catheter material and gauge will depend on an assessment of the patient’s individual characteristics and predisposition to blockage.

18.5.

For urethral catheterization, the meatus must be cleaned before insertion of the catheter, in accordance with Wellington Free Ambulance guidelines/policy. An appropriate lubricant from a single-use container must be used during catheter insertion to minimize urethral trauma and infection.

18.6.

In general, the catheter balloon should be inflated with 10ml of sterile water in adults and 3-5ml in children.

18.7.

All staff should be aware of the risk of infection for the patient if catheter bags are not cared for correctly when transporting patients.

Urinary catheter drainage bags must not be: • Placed on the floor; and • In the patients lap during manual handling.

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18.8.

Catheter bags should be: • Kept below the bladder at all times to prevent backflow.

• All staff need to be aware of the risk of infection for the patient if catheter bags are not cared for correctly when transporting patients.

19

Management of open wounds (To be read in conjunction with the Wellington Free Ambulances training programme and procedures for wound management).

19.1.

Wounds can be categorised as acute or chronic. Ambulance staff come into contact with both in the course of their duty, and therefore should have the means to manage both effectively. The primary objective in wound care management is not only to control haemorrhaging, but to also prevent infection and cross contamination.

19.2.

Examples of acute wounds include those received as a result of trauma, perineal wounds following child birth, burns etc.

19.3.

Chronic wound is defined as any wound which has remained unhealed for longer than 6 weeks, the reason for delay are complex and multiple, but include leg ulcers, post operative wounds etc.

• Patient Risk Factor for Chronic Wounds • Age; • Inability to maintain adequate personal hygiene; • Incontinence; • Medication e.g. Steroid therapy; • Glucose control; • Nutritional assessment; • Microbiology / MRSA status, recent screen result; • Patient interference, non-compliance; • Debilitating illness or immunocompromised; • Mobility; • Impaired tissue perfusion, Dependent oedema, Lymphoedema; • Obesity; • Dementia/Confusion.

• Pressure needs assessment e.g. Waterlow.

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19.4.

The principles of effective wound management remain the same. The key points are outlined below:

19.5.

Hands should be decontaminated prior to patient contact and between sites, and if appropriate, gloves should be worn. With acute wounds, every effort should be made to keep the area free from infection by following the procedures for ANTT, and where available, sterile gloves should be used if touching the wound directly.

19.6.

Wound assessment must be based upon patient risk factors and to identify the extent of the wound, underlying injury such as fracture, entry and exit wounds, bruising and haematoma, signs of haemorrhage or infection and findings should be recorded on the patient report form.

19.7.

If there are signs of haemorrhaging then pressure needs to be applied to the wound using a sterile ambulance dressing and the dressing secured using a bandage. If further blood seeps through the dressing then a further dressing should be applied.

19.8.

Acute wounds which are contaminated or open fractures should be irrigated with normal saline in accordance with Wellington Free Ambulance procedures before being covered with a sterile wound dressing.

19.9.

If no active bleeding is occurring, then the wound should be covered with a sterile wound dressing and secured.

19.10. All wounds should be covered for the duration of the journey using a sterile wound dressing. Covered wounds should remain covered unless there is a clinical need to remove any dressing. Used dressings should be disposed of as clinical waste.

19.11. Non chemical burns should be covered at the earliest opportunity with gel dressings and/or cling film and transported to hospital.

19.12. Prophylactic antibiotic treatment: For those staff qualified to do so, Intravenous access should be gained and antibiotics should be administered to all victims with open fractures in accordance with Wellington Free Ambulance procedures. In the pre-hospital care rapid transport scenario, prophylactic antibiotic treatment is unnecessary when transport times are short (<60 minutes).

19.13. Signs and Symptoms for Wound Infection 19.13.1. Classical signs of infection include Erythema; heat; swelling; and pain. Current accepted criteria for diagnosis of infection include:

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• Abscess or pus; • Cellulitis; • Increased exudates/discharge; • Delayed healing/ Discolouration; • Friable bleeding granulation tissue; • Unexpected pain/tenderness; • Pocketing/bridging at base of wound; • Abnormal smell or malodour when not normally present; • Wound breakdown.

19.13.2. Pain and wound enlargement is the most significant features of wound infection.

20

Specific Communicable Diseases

20.1.

General

20.2.

The purpose of this Section is to provide clarification of those communicable diseases, which may be encountered by staff.

20.3.

On the rare occasions that crews are required to transfer patients with open wounds (e.g. external fixators etc.) then advice should be sought from the hospital's Infection Control Team (ICT) via the clinicians. This is to ensure that the intended journey plan is compatible with the needs of both the patient, and any other patients who may be travelling at the same time.

20.4.

In general, it will be seen that only in specific circumstances will any special procedures or action by ambulance staff be required, other than closely following Standard Infection Control Precautions.

Equally, the majority of patients do not require the provision of special travel arrangements, as these are normally only necessary in 'Category III' cases.

20.5.

As a consequence, the need to routinely convey patients with infectious illnesses as a single patient journey is a rare occurrence.

20.6.

Hepatitis

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20.6.1. Hepatitis is a general term referring to inflammation of the liver. It can be caused by many factors, including viruses, drugs and chemicals.

Currently there are five different types of viruses that are known to cause Viral Hepatitis, i.e. A, B, C, D, & E. However, the A, B, & C viruses are those which are most likely to be encountered by ambulance staff. These viruses work by entering the body and then attacking the liver, causing inflammation and destruction of the liver cells.

20.6.2. Any incident resulting in staff exposure to HEP B or C contaminated blood or body fluids must be reported as soon as possible at the hospital to which the patient has been conveyed, or to the nearest A&E Department in cases of non-conveyance. In addition, the Occupational Health Department (HR) must be fully informed of all events, as well as meeting the requirements of WFAs reporting procedures.

20.7.

Hepatitis A Virus (HAV)

20.7.1. This disease is caused by a virus and is commonly referred to as Infectious Hepatitis (Yellow Jaundice). The virus is present in the stools of an infected person, so it is mainly transmitted by the faecaloral route. However, the disease can also be contracted from eating contaminated food.

20.7.2. Anyone who is not immune to this virus can become infected, especially children. The virus is present in the stools for approximately two weeks before the person shows any signs of illness. In some cases, there may not even be any signs or symptoms evident.

20.7.3. The illness can start with a fever, tiredness, loss of appetite, nausea and diarrhoea. After a few days, the patient may also become jaundiced, although this is uncommon in children. In some cases, the patient may also pass urine of a darker colour.

20.7.4. There is no specific treatment for Hepatitis A, other than general bed rest. Full recovery can, however, take several weeks. There is a vaccine available for this illness, although it is normally only recommended for those who travel to countries where Hepatitis A is prevalent.

20.7.5. Other than exercising Standard Precautions, particularly hand washing after contact with the patient, there are no special procedures required by ambulance staff.

20.8.

Hepatitis B Virus (HBV)

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20.8.1. Hepatitis B is found in all of the body fluids of an infected person, including blood, semen, vaginal fluid, saliva, breast milk and urine.

For this reason, the virus can be transmitted through sexual contact, injection or puncture of the skin with contaminated sharps. It can also be transmitted by contact with blood or body fluids via open cuts, sores, and mucous membranes, as well as from mother to baby during childbirth.

20.8.2. The symptoms are similar to those of Hepatitis A, although again they may be mild or even absent. Some infected people can continue to carry the virus in their blood, although they may appear well. These people are referred to as 'carriers' and can consequently pass on the disease to other susceptible persons. Some carriers may eventually develop long term liver problems, such as liver cancer.

20.8.3. Other than rigidly adhering to Standard Precautions, there are no special measures required by ambulance staff. There is a safe and effective vaccine provided by the Occupational Health Department, and this forms an essential means of protection for all members of staff at risk of contact with blood or body fluids.

20.9.

Hepatitis C Virus (HCV)

20.9.1. Previously known as non-A, non-B hepatitis, Hepatitis C is a parenterally (any route other than ingestion) transmitted virus. It is generally a mild illness, with a vague onset of anorexia, abdominal discomfort, nausea and vomiting. However, some people with the infection may have no symptoms for many years. Around 50-60% of infected people may develop a chronic infection, putting them at risk of developing cirrhosis or liver cancer later in life.

20.9.2. Hepatitis C is spread by blood to blood contact, which as a consequence places drug misusers in the key risk group. Prior to 1991, transmission may have been associated with blood transfusions, although the chances of this would have been extremely small. Since 1991, all potential blood donors have been screened for Hepatitis C. The disease can also be spread through sexual contact, although the risks are as yet unquantified.

20.9.3. The incubation period ranges from 2 weeks to 6 months. Current estimates suggest that around 300,000 people in the UK could be suffering from chronic Hepatitis C infection. The disease, and its associated infection risk, can remain in the carrier's blood for many years.

20.9.4. There is no vaccine available for Hepatitis C at present. Although treatment with Interferon is now licensed in the UK, it is thought to be only 20-40% effective. Again there are no special measures required

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by ambulance staff, other than consistently applying Standard Precautions.

20.10. Human Immunodeficiency Virus (HIV) 20.10.1. Acquired Immunodeficiency Syndrome (AIDS) results from infection with the Human Immunodeficiency Virus (HIV). Transmission of HIV occurs from fluid-to-fluid contact with body fluids from an infected person, notably the blood, semen, or vaginal fluids. The disease attacks the body's natural immune defence system, which ultimately renders the person vulnerable to other infections. These in themselves would not ordinarily pose a threat to people with normal immunity; however, they can have serious consequences for the HIV carrier.

20.10.2. An AIDS diagnosis may be made when an HIV infected person develops an illness, or illnesses, associated with having a suppressed immune system. This can occur several years after becoming infected with HIV. 20.10.3. Clinical signs that are indicative of HIV infection include: swollen glands, fatigue, weight loss, skin rashes, night sweats and mild fever.

However, these conditions can also be attributed to a host of other illnesses of far less significance, so they should therefore be considered in context.

20.10.4. Although the virus is capable of infecting others, it must be stressed that the disease is not easily transmitted. It can only be contracted by sexual or direct blood-borne contact with an infected person, as well as from mother to baby during pregnancy. Routine screening measures in the UK have now eliminated transmission by means of blood product and organ transplantation, albeit some risk may still exist in foreign countries. Therefore, normal social contact with HIV infected people presents no risk to ambulance staff.

20.10.5. Other than closely adhering to Standard Precautions, there are no special procedures required for the management and conveyance of HIV/AIDS patients.

20.11. Pulmonary Tuberculosis (TB) 20.11.1. TB is a bacterium that can affect any part of the body, although it has particular significance when present in the lungs. It is generally spread by the airborne (droplet) route, although it may be destroyed by the recipients own defence mechanisms and thereby prevent any illness occurring.

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20.11.2. Where illness does follow, the symptoms can become evident in a few weeks, or even after several months have elapsed following exposure. These may include coughing and sneezing, which can be accompanied by sputum with possible blood staining. Other potential symptoms include chest pain, loss of appetite and weight, and fever with night sweats.

20.11.3. The disease is usually diagnosed by chest x-ray, and by examining a specimen of sputum. Most ambulance staff will have been routinely vaccinated against TB as a child; however, all staff are screened on entry to the Service and are subsequently vaccinated where necessary. TB can be completely cured by treatment, which is delivered via a course of tablets.

20.11.4. As with other illnesses, the best defence against TB is by the adoption of Standard Precautions. Staff's own immunity will in itself form a first line of defence. The avoidance of breathing while in close proximity to a patient's face and their exhaled air should be maintained wherever possible.

20.11.5. Patients who cough or sneeze should be encouraged to do so into a paper tissue, while turning their head away from others. Any tissues used for such purposes must be carefully discarded as clinical waste, followed by careful attention to hand washing procedures. The use of the disposable face mask should also be considered for these patients, particularly if a diagnosis of TB is known or suspected. This applies to both the crew and the patient, as well as to any other persons travelling in the vehicle.

20.11.6. Staff are reminded that the face mask is for single patient use only, and that it should be discarded as clinical waste on completion of the assignment.

20.11.7. If a patient has been prone to episodes of unprotected coughing and sneezing whilst in the ambulance, it would be wise to conduct localised cleaning and disinfection. This should include wiping over those areas that have been in close proximity to the patient, using detergent and disinfectant. Particular attention should be given to the horizontal surfaces, as these are where droplets from an aerosol origin are likely to settle. Remember that all used tissues and disposable items of PPE should be discarded as clinical waste.

20.12. Meningitis 20.12.1. Meningitis is an illness that involves the inflammation of the membranes covering the brain and spinal cord. It can be caused by a variety of different organisms, including bacteria and viruses. Viral Meningitis is the more common disease, and despite the fact that it

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cannot be treated by antibiotics, is rarely proved serious and the patient recovers after a few days.

20.12.2. However, Bacterial Meningitis is a serious illness which requires urgent treatment with antibiotics. The bacteria which can cause this form of meningitis include the meningococcus and Haemophilus influenza type b (Hib). Besides meningitis, these bacteria can also cause septicaemia (blood poisoning), thereby adding a further serious complication to this illness.

20.12.3. The meningococcal and Hib bacteria live naturally in the back of the nose and throat of 10-20% of normal healthy people. Spread occurs by droplets (during sneezing, coughing etc.) from the nose and mouth of these carriers. However, the bacteria cannot live for more than a few seconds outside the body, so the contact with carriers has to be very close, e.g. kissing etc. The bacteria cannot be contracted from objects, or from sources such as water supplies or swimming pools.

20.12.4. People of any age can carry the bacteria in their nose and throat without becoming unwell. Only on rare occasions do the bacteria overcome the body's defences and cause illness. The time between contracting the bacteria and becoming ill is usually 2-10 days.

However, it is not yet understood why these bacteria cause illness in certain people at certain times.

20.12.5. The symptoms of meningococcal disease include severe headaches, fever, vomiting, drowsiness or altered levels of consciousness, discomfort from bright light, neck stiffness and a rash of small redpurple spots or bruises. The rash can appear anywhere on the body and spreads rapidly. Furthermore, it will not fade if pressed on firmly by an object, such as a glass. It is harder to see on dark skin, so check paler areas like palms of the hands, soles of the feet, the stomach, inside the eyelids and on the roof of the mouth. If the rash is present, the disease is in an advanced stage and urgent treatment is necessary.

Picture courtesy Prof P Brandtzaeg

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20.12.6. Other than the use of Standard Precautions, there are no special procedures required for the management of meningitis cases.

Although prophylactic antibiotics are in existence, they do have side effects that can outweigh the risks associated with contracting the disease. Therefore, the use of antibiotics will generally be restricted to those members of staff who have performed high risk procedures, such as mouth-to-mouth resuscitation. Even then, this would only normally occur after the patient's diagnosis has been confirmed as meningococcal disease.

20.12.7. Any exposure of this nature must be reported to the local A&E hospital, which should ideally be the same hospital as to which the patient has been conveyed. The risk will then be assessed by the medical staff, and treatment initiated if appropriate. Contact should also be made with the Occupational Health Department in order to advise them of the situation. In addition, it will be necessary to comply with all WFA reporting requirements.

20.13. Methicillin Resistant Staphylococcus Aureus (MRSA) 20.13.1. Staphylococcus aureus is a common bacteria that lives harmlessly in the nose, throat and on the skin of around 30% of the population.

However, like many organisms, it can cause infection if transferred into a wound or into the body via a drip or catheter.

20.13.2. MRSA is a strain of the same Staphylococcus aureus organism.

Although most strains have an acquired resistance to many antibiotics, MRSA has developed a resistance to most. This means that if an infection occurs, the choice of antibiotic used to treat the infection is particularly limited.

20.13.3. Those most at risk from MRSA infections are hospitalised patients, who have undergone surgery and, as a consequence, have breaks in their skin. These patients may already have weakened defence mechanisms as a result of their condition, and this leaves them particularly vulnerable to infection. It is therefore essential to ensure that all patients have any wounds covered at the earliest opportunity, prior to transportation.

20.13.4. There is no evidence to suggest that MRSA presents any risk to ambulance staff or their families, although it is possible for crews to become a cross infection risk to other patients. It is for this reason only that hospital staff may be observed wearing barrier clothing when dealing with MRSA infected patients, as opposed to any need for personal protection.

20.13.5. From an ambulance service perspective, the best defence measures that can be adopted to prevent staff becoming a cross-infection risk

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are essentially Standard Precautions. It is in any case imperative that these are routinely considered for all patient contact, and applied where necessary. These include giving close attention to all matters of personal hygiene, as well as to the use of PPE if contact with blood and/or body fluid is likely.

20.13.6. The importance of carefully attending to hand washing procedures, both before and after patient handling, cannot be overemphasised.

Remember that the alcohol disinfectant can be used as an alternative to conventional hand washing facilities, when these are unavailable.

However, remember also that the hands must still be thoroughly washed with soap and water at the earliest opportunity.

20.13.7. Patients with MRSA do not normally require any special travel arrangements, and therefore do not require a dedicated A&E or PTS vehicle for their journey.

20.13.8. The only exception will generally involve those patients with open skin lesions that are unable to be covered by an impermeable dressing. For any such patient, the advice of the hospital's Infection Control Team (ICT) should be sought, via a member of the hospital staff. This will require the crew to provide details of the intended journey plan, together with an account of any other patients who are due to be conveyed during the same journey.

20.13.9. If the resultant advice indicates that the patient should be conveyed on a singular basis, then CECL or the respective PTS Control must be informed in order for the appropriate rescheduling arrangements to take place. The crew should then wear items of PPE as necessary, which will involve the use of disposable gloves and apron as a minimum.

20.13.10. On completion of the journey, any surfaces which have been in contact with the patient should be cleaned using detergent, followed by disinfectant. Used items of disposable PPE, along with any used cleaning materials must then be discarded into a clinical waste bag.

20.14. Clostridium difficile 20.14.1. Clostridium difficile is the major cause of antibiotic associated diarrhoea and colitis, an infection of the intestines. It is an anaerobic bacterium (i.e. it does not grow in the presence of oxygen) and its usual habitat is the large intestine, where there is very little oxygen. It produces spores that can survive for a long time in the environment, and most commonly affects elderly patients with other underlying diseases.

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20.14.2. C. difficile can cause diarrhoea, ranging from a mild disturbance to a very severe illness with ulceration and bleeding from the colon (colitis) and, at worst, perforation of the intestine leading to peritonitis.

The patient may present with watery diarrhoea which may be green in appearance, fever, loss of appetite, nausea, abdominal pain and tenderness.

20.14.3. C. difficile can be fatal; laboratory tests have identified over 100 different types of which type 027 is of particular concern because it causes a greater proportion of severe disease and appears to have a higher mortality.

20.14.4. C. difficile bacteria can be found living in the large intestine of a small proportion (less than 5%) of the healthy adult population. It is also common in the intestine of babies and infants. The â&#x20AC;&#x2DC;goodâ&#x20AC;&#x2122; bacterial population of the intestine normally keeps it in check. However, when antibiotics have killed off these good bacteria, C. difficile is able to multiply in the intestine and produces two toxins that damage the cells lining the intestine. The result is diarrhoea. Because it develops in this way, the patients who are most at risk of infection with C. difficile are those who have been treated with broad spectrum antibiotics, e.g. co-amoxiclav, quinolones and cephalosporinâ&#x20AC;&#x2122;s [those that affect a wide range of bacteria, including intestinal bacteria], those who have been treated with multiple courses of antibiotics, or extended treatment with antibiotics.

20.14.5. Although some people can be healthy carriers of C. difficile, in most cases the disease develops in the health care setting after crossinfection from another patient, either through direct patient to patient contact, via healthcare staff, or via a contaminated environment. A patient who has C. difficile diarrhoea excretes large numbers of spores in their liquid faeces which can survive for a long time in and be a source of hand to mouth infection for others. If these others have also been given antibiotics, they are at risk of C. difficile disease.

20.14.6. In the out of hospital setting, the use of Standard Precautions including gloves and aprons, and strict hand washing technique should be adopted to prevent the risk of cross infection. Ambulance staff should not rely solely on alcohol gel as this does not kill the C. difficile spores.

20.14.7. Close attention should be paid to cleaning the environment with detergent and chlorine based disinfectant. However, there is no restriction on the transfer of patients, who have had C. difficile associated diarrhoea and are now clinically asymptomatic, i.e., they no longer have diarrhoea. Once someone has recovered clinically they are not a risk to others even if they continue to carry C. difficile in their stool for a period provided that they observe the normal personal hygiene precautions of hand washing after using the toilet.

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20.14.8. A patient with a formed stool and who is continent is not considered to present a risk for environmental contamination or cross infection.

20.15. Norovirus 20.15.1. Norovirus is the most common cause of infectious gastroenteritis (diarrhoea and vomiting) in England and Wales. The Illness is generally mild and people usually recover fully within 2-3 days; there are no long term effects that result from being infected. Infections can occur at any age because immunity is not long lasting.

20.15.2. The disease was historically known as 'winter vomiting disease' due to its seasonality and typical symptoms. It is also known as small round structured virus (SRSV) or Norwalk-like virus.

20.15.3. Outbreaks of Norovirus gastroenteritis are common in semi-closed environments such as hospitals, nursing homes, schools and cruise ships. When an outbreak occurs in a hospital it is often necessary to close affected wards to help control the outbreak. It is vital that anyone who is feeling unwell with gastrointestinal symptoms, vomiting and or diarrhoea, should not visit hospitals or attend work as this increases the risk of spreading the infection to patients and staff.

20.16. Norovirus is highly infectious. Particular attention to good hygiene measures should be observed during outbreaks. It is very important to wash your hands with soap and water after contact with someone who is ill and after using the toilet, especially if you are suffering from symptoms. Thorough cleaning of hard surfaces with a bleach solution, paying particular attention to the toilet and toilet area and cleaning up vomit and the surrounding area quickly will help to reduce environmental contamination and reduce the risk of infection in others coming into contact with these surfaces later on.

20.17. Definition of Diarrhoea: 20.17.1. An increased number (2 or more) of watery/liquid stools (i.e. type 6 & 7) that is greater than normal for the patient, within a duration of 24 hours.

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Type 1 Type 2 Type 3 Type 4 Type 5 Type 6 Type 7

Constipated stool Constipated stool Formed stool Soft-formed stool Loose stool Diarrhoea Diarrhoea

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20.18. Specific Communicable Diseases â&#x20AC;˘ Incubation period: The interval between contracting an infection and the appearance of the first symptoms. â&#x20AC;˘ Infective period: The time during which a person is capable of passing on the infection.

INFECTION

INCUBATION PERIOD

MODE of TRANSMISSION

DURATION of INFECTIVITY

MANAGEMENT

CHICKENPOX

2-3 weeks.

Commonly13-17 days.

Respiratory transmission and direct contact with lesions.

From 1-3 days before the appearance of the rash until 6 days after

CLOSTRIDIUM DIFFICILE

In most cases the disease develops in the healthcare setting after cross-infection from another patient, either through direct patient to patient contact, via healthcare staff, or via a contaminated environment.

Until diarrhoea ceases. A patient with a formed stool and who is continent is not considered to present a risk for environmental contamination or cross infection.

CREUTFZFELD-JAKOB ENCEPHALOPATHY

Most people who get a C. diff infection will get symptoms while they are taking antibiotics.

However, symptoms can appear up to 10 weeks after they have finished taking antibiotics.

1-20 years but not exactly known.

Standard Precautions.

Pregnant staff should seek advice from Occ Health Dept.

Standard Precautions.

Additional cleaning of the environment using a chlorine based disinfectant.

Via brain/nervous tissue or pituitary extracts

Unknown

DIARRHOEA Amoebic Dysentery

2-4 weeks

Ingestion/faecal

As long as organism is present

Campylobacter

3-5 days

Ingestion/faecal

As long as organism is present

Clostridial

6-24 hours

Usually from meat products

Not directly transmissible from person to person

Giardiasis

7-10 days

Ingestion/faecal

As long as organism is present

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Standard Precautions.

Seek advice from hospital staff ref any additional measures.

Standard Precautions.

Additional cleaning of the environment using a chlorine based disinfectant.

Infection Prevention and Control Manual

Rotavirus

48 hours

Faecal/oral Possibly respiratory

As long as organism is present

Salmonella

6-72 hours

Ingestion/faecal

As long as organism is present

Shigellosis DIPHTHERIA

1-7 days 2-5 days

Ingestion/faecal Direct

HEPATITIS A (HAV)

2-6 weeks (average one month)

HEPATITIS B (HBV)

6 weeks-6 months (average 2-3 months)

HEPATITIS C (HCV)

2 weeks - 6 months

Faecal/oral, contaminated food & water Via blood/body fluids, sexual contact and from infected mother to baby Blood-borne - small risk of sexual transmission

As long as organism is present 2-3 weeks or while organism is present From one week before until one week after onset of jaundice Whilst virus is present in blood and body fluids

HUMAN IMMUNODEFICIENCY VIRUS (HIV) IMPETIGO

Variable Seroconversion usually takes up to 6 months 1-5 days

Via blood/body fluids, sexual contact, and from infected mother to baby Respiratory route or direct contact

LEGIONNAIREâ&#x20AC;&#x2122;S DISEAS

2-3 days

LEPTOSPIROSIS (Weil's Disease) MALARIA

4-19 days Usually 10 days Variable (dependant on species) 1-2 weeks

Respiratory transmission from environmental sources (water) Via water or food contaminated with rodent urine Mosquito borne Respiratory route

2-10 days

Respiratory route

MEASLES HAEMOPHILUS MENINGITIS

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Standard Precautions.

Standard Precautions.

Immunisation.

Standard Precautions.

Immunisation.

From one week before onset of symptoms, and indefinitely in the chronic carrier For life

Standard Precautions.

Until effectively treated(usually 24 hours), or as long as lesions are present Spread from person to person is unknown

Standard Precautions.

May be excreted for months but person to person spread is rare Not transmissible from person to person Up to 4 days before, until 4 days after onset of rash As long as organisms are present

Standard Precautions.

Standard Precautions.

Standard Precautions.

Standard Precautions.

Standard Precautions.

Immunisation.

Standard Precautions.

Prophylaxis only if mouth

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MENINGOCOCCAL MENINGITIS

2-10 days

NEONATAL MENINGITIS

Respiratory route

Until 48 hours after effective treatment

From birth canal

Until effective treatment

Faecal oral route; risk of infection from aerosols of projectile vomit. Environmental contamination, especially of toilets. Contaminated food and water, especially bivalve molluscs.

Respiratory route and hands

During & for 48 hours after resolution of symptoms. The infective dose is extremely low.

NOROVIRUS

Usually 24 to 48 hours.

PERTUSSIS (Whooping Cough)

1-3 weeks

PNEUMOCOCCAL PNEUMONIA PNEUMOCYSTIS CARINII

1-3 days

POLIOMYELITIS

7-14 days Up to 35 days in paralytic cases

PYREXIA (Travel & Non-Travel)

Consider tropical disease dependant on causative organism 2-3 weeks

Respiratory route

1 week before onset of rash until 4 days after

2-6 weeks

Prolonged skin to skin contact

Until all mites and eggs have

RUBELLA (German Measles)

SCABIES

Possible respiratory transmission but usually endogenous Endogenous infection in immuno-suppressed patients Usually faecal-oral spread

to mouth resuscitation has been performed Standard Precautions.

Prophylaxis only if mouth to mouth resuscitation has been performed Standard Precautions.

Prophylaxis only if mouth to mouth resuscitation has been performed Standard Precautions.

Additional cleaning of the environment using a chlorine based disinfectant.

1 week before, until 3 weeks after onset of symptoms Until 48 hours after effective treatment Unknown

Standard Precautions.

Faeces can remain infected for up to 6 weeks. This includes post-immunisation in children

Standard Precautions.

Standard Precautions.

Standard Precautions.

Standard Precautions.

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Standard Precautions.

Pregnant staff should seek advice from Occ Health Dept Standard Precautions.

Infection Prevention and Control Manual

SHINGLES

13-21 days (Follows earlier Chickenpox

Direct contact with lesions

TETANUS

3-21 days

From soil

TUBERCULOSIS

1-3 months

Respiratory transmission

TYPHOID FEVER

1-3 weeks

Faecal oral Food and water

PARATYPHOID FEVER

1-10 days

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been destroyed Whilst blisters remain, can cause chickenpox in susceptible individuals Not transmitted from person to person Until effective chemotherapy renders cultures negative. TB of the lungs is infectious and remains so while organism is present in the sputum (up to 2 weeks after start of chemotherapy) Whilst organism is present in faeces or urine

Standard Precautions.

Standard Precautions.

Standard Precautions.

Standard Precautions.

Infection Prevention and Control Manual

21

Biological Incidents (Should be read in conjunction with the Wellington Free Ambulances Major Incident Plan and CBRN documents and training programmes).

21.1.

Biological agents include: • Anthrax • Botulism • Plague • Severe acute respiratory syndrome (SARS) • Smallpox • Viral haemorrhagic fevers (VHF)

21.2.

These organisms do not survive easily in the general atmosphere and the risk is therefore minimal.

21.3.

None of the diseases present an immediate risk to life and there is time to seek expert medical advice from A&E and Health Protection Agency (HPA) via CECL.

21.4.

Only staff trained in the use of specialised Chemical Personal Protection Equipment (CPPE) and associated decontamination procedures, particularly for chemical, biological, radiological and nuclear (CBRN) threats or incidents, should be within the cordons of an incident in which such agents are thought to be involved. All other staff should remain at a safe distance and await support from trained staff and specialist advisors.

21.5.

Should staff be inadvertently contaminated they should isolate themselves and report to the Ambulance Incident Officer who will arrange appropriate decontamination.

21.6.

National reserve stocks of equipment known as ‘PODS’ are strategically placed throughout the country and are available to assist DHBs in dealing with incidents involving large numbers of casualties.

21.7.

Most of the equipment used in these situations are single use and disposable. This includes all of the chemical protection suits, filters equipment and medical counter measures, and in addition includes the equipment used within the NHS specification shower decontamination units.

21.8.

Incidents of this nature are normally dealt with by the implementation of specific major incident/contingency plans. All staff should ensure that they know where copies of these plans are kept and are familiar with their content.

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21.9.

The Wellington Free Ambulance Emergency Preparedness Department will ensure that such plans are current and reflect known biological threats and include expert advice contact details.

21.10. Remember that the Wellington Free Ambulance has trained staff and equipment to deal with CBRN incidents.

21.11. Immediate Incident Management 21.11.1. When the cause of an incident is unknown, you should use these safety triggers: STEP 1

ONE CASUALTY

Approach using normal procedures.

STEP 2

TWO CASUALTY

Approach with caution, consider all options.

Report on arrival, update CECL

STEP

2

THREE

CASUALTY or MORE Do NOT approach Withdraw Contain Report Isolate yourself and REQUEST SPECIALIST HELP

NOTE: Do NOT compromise your own safety or that of your colleagues or the public. Update CECL providing a METHANE assessment as soon as possible.

21.12. Mnemonic for rapid incident assessment METHANE My call sign/major incident alert Exact location Type of incident Hazard Access Number of casualties & severity Emergency services present or required

21.13. Biological Incident Action Guide

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21.13.1. Be alert to the unusual, the unexpected, and the case that ‘just doesn’t fit’: • An unusual illness (e.g. sudden unexplained febrile death, critical illness or pneumonia death in a previously healthy young adult).

• An unusual number of patients with same symptoms.

• An illness unusual for the time of year (e.g. ‘flu’ in summer).

• An illness unusual for the patient’s age group (e.g. ‘chickenpox’ in a middle-aged adult).

• An illness in an unusual patient (e.g. cutaneous anthrax in a patient with no history of contact with animals, animal hides or products).

• An illness acquired in an unusual place (e.g. tularaemia acquired in the UK).

• Unusual clinical signs (e.g. mediastinal widening on CXR; sudden onset of symmetrical flaccid paralysis) • Unusual progression of an illness (e.g. lack of response to usually effective antibiotics; ‘chickenpox’ rash predominant on extremities) 21.13.2. Take a thorough clinical history. Remember to ask the patient about: • Occupation (what is their job and where do they do it?).

• Travel abroad? (Countries and areas visited, with dates; rural or urban; use of antimalarial drugs; bed nets; insect repellents; immunisations; unprotected sex; unusual events e.g. animal bites.

• Family and other contact with pets or animals, insect bites, food.

• What they think might have caused their illness?

21.13.3. You may be the first person to recognize that a CBRN incident has occurred. Make sure you are familiar with the Major Incident Plan.

22

Pandemic Flu (To be read in conjunction with the Wellington Free Ambulances Pandemic Flu Plan and Business Continuity Plan)

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22.1.

Everyone will be involved in the fight against pandemic influenza in terms of treating the sick and preventing further spread of the infection.

22.2.

Infection control assumptions

22.2.1. The principles of infection control for pandemic influenza are based on the assumption that pandemic influenza has similar properties to seasonal influenza: 22.2.2. Person-to-person spread of human influenza viruses is well established.

22.2.3. The patterns of transmission observed during outbreaks of influenza in healthcare settings suggest that droplet and contact (direct and indirect) are the most important and most likely routes of spread.

22.2.4. For some pathogens, aerosols generated under specific circumstances may be associated with an increased risk of pathogen transmission. While this may be possible for influenza, the general consensus is that droplet and contact transmission are of far greater importance.

22.2.5. How infectious an individual is depends on how severe their symptoms are; 22.2.6. People will be most infectious just after their symptoms start.

22.2.7. Adults will usually be infectious for up to five days after symptoms begin and children for up to seven days, although longer periods of virus shedding have been found in a small proportion of children.

22.2.8. Virus excretion may be considerably longer in immunocompromised patients.

22.2.9. Virus may be recovered from infected people before they show symptoms, but there is little published evidence to support person-toperson transmission of influenza from a pre-symptomatic individual to a person who does not already have the infection.

22.2.10. Seasonal influenza viruses can survive on environmental surfaces, especially on hard, non-porous materials such as stainless steel.

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22.2.11. Influenza viruses are easily deactivated by washing with soap and water, alcohol based hand rub and household detergents and cleaners.

22.3.

What Is Pandemic Influenza

22.3.1. Influenza (flu) is a familiar infection in NZ, especially during the winter months. The illness, caused by an influenza virus can be mild or severe and can at times lead to death.

22.3.2. Generally some groups of people are more susceptible than others, especially the elderly, young children and people with certain health conditions. This is why the flu vaccination is given to these groups of people every year.

22.3.3. Pandemic flu is different from ordinary flu because it occurs when a new influenza virus emerges into the human population and spreads from person to person worldwide.

22.3.4. As it is a new virus, the entire population will be susceptible because no one will have any immunity to it. Therefore healthy adults as well as the elderly, young children and people with existing medical conditions will be affected. The lack of immunity in the UK population will mean that the virus has the potential to spread very quickly between people. This will result in many more people becoming severely ill and many more deaths.

22.4.

Signs and Symptoms of Influenza

22.4.1. Most significant • Fever • Cough or shortness of breath • Sudden onset of illness 22.4.2. Other symptoms • Headache • Malaise • Chills • Aching muscles • Sore throat • Runny nose, sneezing

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• Loss of appetite 22.5.

Principles of Containment and infection control

22.5.1. Limiting transmission of pandemic influenza in the healthcare setting requires: • timely recognition of influenza cases; • instructing staff members with respiratory symptoms to stay at home and not come in to work; • segregation of staff into those who are dealing with influenza patients and those who are not; • consistent and correct use of appropriate infection control precautions to limit transmission (standard infection control precautions and droplet precautions); • the use of personal protective equipment (PPE) according to risk of exposure to the virus; • maintaining separation in space and/or time between influenza and non-influenza patients; • restricting ill visitors to the facility; • environmental cleaning and disinfection; • education of staff, patients and visitors about transmission and prevention of influenza; • treatment of patients and staff with antiviral drugs which can reduce • infectiousness and the duration of illness; and • vaccination of patients and staff.

22.5.2. NZ has a stockpile of antiviral drugs sufficient for the treatment of all symptomatic patients up to clinical attack rates of 50%. Higher clinical attack rates would require prioritisation of use.

22.5.3. During the first wave of a pandemic, a specific pandemic vaccine will be largely unavailable due to the time it takes to be able to identify the specific strain. Prioritisation would take place in accordance with Ministry of Health policy. Therefore, attention to non-pharmaceutical methods of control as outlined in this section will be particularly important in reducing exposure.

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22.6.

How Is Pandemic Flu Caught and Spread to Others?

22.6.1. Pandemic flu is spread from person to person by close contact. Here are some examples of how this infection can be spread: 22.6.2. Infected individuals can pass the virus to others through large droplets when coughing, sneezing and even talking within a close distance (usually 3 feet or less).

22.6.3. The virus can be passed on by direct contact with an infected individual. Shaking or holding hands with an infected individual followed by touching your own mouth, eyes or nose without first performing hand hygiene will also allow the virus to spread to you.

22.6.4. The influenza virus can be spread when environmental and inanimate objects, such as equipment, door handles, light switches become contaminated with the virus. Once again, if a person touches these objects and then touches his/her mouth, eyes or nose without performing hand hygiene, their chances of catching the virus are increased.

22.6.5. In some circumstances, the virus can also be passed on in fine airborne droplets or on dust particles. This is not considered to be a major route of transmission.

22.7.

Infection Control Precautions

22.7.1. Standard infection control precautions and droplet precautions must be used for patients with or suspected of having pandemic influenza.

Standard precautions are a set of broad statements of good practice to minimise exposure to and transmission of a wide variety of microorganisms. Standard precautions should be applied by all healthcare practitioners to the care of all patients all of the time.

22.7.2. Standard infection control precautions and droplet precautions must be used for patients diagnosed or suspected of having pandemic influenza.

22.7.3. Good staff and patient hand hygiene is vital for the protection of both parties.

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22.7.4. Good respiratory hygiene is essential.

22.7.5. The use of PPE should be proportional to the risk of contact with respiratory secretions and other body fluids, and should depend on the type of work/procedure being undertaken.

22.8.

What You Can Do To Protect Yourself and Others from Pandemic Flu and Other Infections at Work?

22.8.1. Ensure that you are aware of the Wellington Free Ambulances infection control Procedures and Guidance document and that you are following them correctly.

22.8.2. Use PPE (gloves masks and disposable apron) when there is a risk of contamination with blood and body fluids.

22.8.3. When carrying out aerosol generating procedures e.g. CPR; intubation; airway aspiration; nebulisation; use appropriate PPE i.e. you should wear FFP3 mask (fit tested); disposable apron; eye protection and gloves.

22.8.4. Cover your nose and mouth when sneezing and coughing and use disposable single-use tissues for wiping/blowing nose. Dispose of used tissues as clinical waste. CATCH IT! BIN IT! KILL IT! 22.9.

How You Can Help Protect Your Family at Home?

22.9.1. Members of your family, especially children, are much more likely to be exposed to the influenza virus at school, in the workplace, using public transport or through general contact with other members of the public.

22.9.2. It is likely that you will come into contact with many individuals with flu during the course of your work. It is important that you follow your general infection control guidance to reduce the risk of spreading infection to others.

22.9.3. Always wash hands before you leave work and soon after you arrive home.

22.10. Hand hygiene 22.10.1. Effective and timely hand hygiene is crucial to reducing the risk of spreading infection. All staff should have ready access to alcohol hand gel when hand wash facilities are not available.

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22.10.2. Bare below the elbow should be strictly adhered to by clinical staff to ensure effective hand hygiene procedures can be undertaken at all times. Non clinical staff should limit the amount of hand and wrist jewellery to maximise hand hygiene effectiveness.

22.10.3. Wash your hands frequently using soap and water or alcohol hand rub before and after contact with any person.

22.10.4. Avoid touching your eyes, nose or mouth with contaminated hands (gloved or ungloved).

22.10.5. Washing your hands after coughing, sneezing, using tissues or contact with respiratory secretions and contaminated objects will reduce the risk of spreading flu to others.

22.10.6. Hand hygiene includes hand washing with soap and water and thorough drying, and the use of alcohol-based products that do not require the use of water. If hands are visibly soiled or contaminated (for example, contaminated with respiratory secretions), they should be washed with soap and water and dried. When using an alcohol hand rub, hands should be free of visible dirt and organic material.

22.10.7. Hands should be decontaminated, even if gloves have been worn, before and after all contact with an infected patient or their bed area/stretcher/carry chair (including inanimate objects), removal of protective clothing and cleaning of equipment.

22.10.8. All staff, patients and visitors should clean their hands when entering and leaving areas where care is delivered.

22.11. Applying droplet precautions for pandemic influenza 22.11.1. In addition to standard precautions, droplet precautions should be used for a patient known or suspected to be infected with influenza, which is transmitted by droplets that can be generated by the patient during coughing, sneezing or talking. The following are considered to be aerosoling-generating procedures: • Nebulising; • Intubation, • Cardiopulmonary resuscitation; • Manual ventilation; and • Airway aspiration.

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22.11.2. To avoid unnecessary exposures, only those healthcare workers needed to perform the procedure should be present.

22.12. Management of a coughing and sneezing patient 22.12.1. Patients, staff and visitors should be encouraged to minimize potential influenza transmission through good hygiene measures: 22.12.2. Cover nose and mouth with disposable, single-use tissues when sneezing, coughing, wiping and blowing noses.

22.12.3. Dispose of used tissues in nearest waste bin.

22.12.4. Wash hands after coughing, sneezing, using tissues or contact with respiratory secretions and contaminated objects.

22.12.5. Keep hands away from the eyes, mouth and nose.

22.12.6. Some patients (for example older people, children) may need assistance with containment of respiratory secretions; those who are immobile will need a container (for example a plastic bag) readily at hand for immediate disposal of tissues and a supply of hand wipes and tissues.

22.12.7. Where possible, in common waiting areas or during transport, coughing and sneezing patients should wear surgical masks to minimise the spread of respiratory secretions and reduce environmental contamination.

22.13. What You Should Do If You Have Symptoms or Are Ill? 22.13.1. Staff are to follow the Wellington Free Ambulances sickness and absence policy when suffering from ‘influenza like symptoms’, If you feel ill whilst at work, report it immediately to CECL or your TMO in accordance with reporting sick procedures. Do not simply carry on working.

22.14. If you develop symptoms whilst off duty: • Stay at home. Do not go into work; • Report unfit for duty; and Page 84 of 105

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â&#x20AC;˘ Seek advice from the flu line.

22.15. Entering the patients home 22.15.1. The home of a patient suffering from Pandemic Influenza does not present more of a risk than that of a person suffering from any other respiratory illness.

22.16. Transportation: 22.16.1. Patients must not be automatically admitted to hospital if they have influenza. However, it can be anticipated that some patients who are initially managed in the community will require hospital admission and transportation by ambulance. If transfer is essential, ambulance staff must be advised in advance and appropriate precautions used e.g. use of PPE and general infection control procedures.

22.16.2. Coughing and sneezing patients should be transported on their own whenever possible. However, if pressure upon the service occurs, two patients with symptoms of pandemic influenza may be transferred together. Symptomatic patients should be encouraged to wear a surgical mask to assist in the containment of respiratory secretions and reduce environmental contamination of the ambulance.

22.17. Personal Protective Equipment 22.17.1. Overview 22.17.2. PPE should be worn to protect staff from contamination with body fluids to reduce the risk of transmission of pandemic influenza between patients and staff and from one patient to another. Standard infection control precautions will apply at all times.

22.17.3. All surgical masks should be fluid repellent. PPE should comply with the relevant BS EN standards (European technical standards as adopted in the UK) where these apply.

22.17.4. Use of PPE When there is no need for airway resuscitation immediately and it is judged to be unlikely to be needed during transfer 22.17.5. When the ambulance crew are aware that the patient is suffering from influenza like symptoms, or cannot ascertain whether the patient has influenza-like symptoms, the following PPE should be used. Note, a new set of PPE should be used with each new patient contact.

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General environmental & equipment cleaning No aerosol generating procedures performed. (Within 3 meters of patient). (no presence of blood/body fluid) Aerosol generating procedures performed (CPR; intubation; airway aspiration; nebulising)

Gloves

Disposable plastic apron

Surgical face mask

x

x

x*

x

x

x

x

FFP3 respirator (fit tested)

Eye protection

x*

x

x

* DRA = Dynamic Risk Assessment

22.17.6. If the patient does not have influenza like symptoms, then standard infection control precautions should be used.

22.17.7. Use of PPE when there is a need for resuscitation either immediately or the patient is unstable and it is judged that airway resuscitation may be needed during transport 22.17.8. In this situation, if the crew are aware that the patient suffers from influenza like symptoms, or cannot ascertain whether the patient has influenza-like symptoms, they should use appropriate PPE (Gloves, FFP3 respirators, eye protection and disposable plastic apron), which would allow resuscitation (aerosol generating procedure) to begin without delay.

22.17.9. If the patient does not have influenza like symptoms, then standard infection control procedures should be used, whether or not resuscitation is needed immediately or considered likely during the journey.

22.18. Wearing Personal Protective Equipment (PPE) 22.18.1. Surgical masks â&#x20AC;˘

When in the presence of a symptomatic influenza patient (within 1 metre), surgical masks and aprons should be worn to provide a physical barrier and minimise contamination of the nose, mouth and uniform by droplets. The mask should be disposed of as clinical waste.

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•

When performing aerosoling generating procedures, an FFP3 respirator should be worn, see below.

•

Note: Under the principles of standard infection prevention and control precautions, you will already be wearing surgical masks when performing aerosoling procedures such as CPR, intubation and airway suctioning in protection against possible tuberculosis and meningitis – this is therefore just an extension of practice you are already familiar with.

22.18.2. FFP3 (Filtering Face Piece level 3 – highest protection) •

A disposable respirator (i.e. an EN149:2001 FFP3) or a nondisposable respirator (i.e. EN140:1998 FFP3) should be worn when performing procedures that have the potential to generate aerosols:

• CPR; • Manual respiration; • Intubation; • Airway aspiration; and • Nebulising 22.18.3. Fitting the respirator correctly is critically important for it to provide proper protection. Every user should be fit tested and trained in the use of the respirator. In addition to the initial fit test carried out by a trained fitter, a fit check should be carried out each time a respirator is worn. A good fit can only be achieved if the area where the respirator seals against the skin is clean shaven. Beards, long moustaches and stubble may cause leaks around the respirator.

Disposable respirators should be disposed of as clinical waste.

22.18.4. Eye protection • Should be considered when there is a risk of contamination of the eyes by splashes and droplets from aerosoling generating procedures. There should be an individual dynamic risk assessment at the time of providing care.

22.18.5. Cleaning & Decontamination • It is imperative that all staff meet their individual responsibilities in keeping the vehicle and equipment clean and thus help to reduce the risks of cross infection/contamination to themselves, their

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colleagues and their patients. This can best be achieved by all staff participating in frequent and routine cleaning activities - most importantly between each patient. There are no requirements for “deep cleaning” specifically for pandemic flu.

• The relevance of maintaining high standards of hygiene and cleanliness has an even greater significance to the interiors of ambulance vehicles and the equipment carried during an outbreak.

The very nature of ambulance work determines that all interior surfaces are prone to becoming dirty and dusty during normal everyday activity. This can lead to a rapid build up of contamination, which if left unchallenged, can create an ideal breeding ground for infectious organisms to grow and multiply.

• All items of equipment can potentially become a source of cross infection; it is of particular importance that close attention is given to their respective cleaning and disinfection procedures. Any equipment used should preferably be single use disposable. Re usable, equipment must be appropriately decontaminated immediately after use.

• The immediate frequently touched surfaces i.e. stretcher, mattress; handles and patient equipment must be decontaminated between patients, using detergent and hot water (or disposable detergent spray or wipes) followed by wipe down with disinfectant spray or wipes. Spillages of blood/body fluid will require chlorine releasing agent disinfection as per standard practice. Upon completion of transfer of patients with influenza, the vehicle should be cleaned by the crew as for after individual patient journey before further use.

Used blankets, pillowcases, sheets etc. must be changed between patients.

22.18.6. Vehicle interior cleaning – after each patient journey • Vehicle and equipment cleaning should already be taking place after each patient journey. Cleaning should normally be carried out where there is access to hot water and cleaning equipment, however, wipes and sprays are supplied to every vehicle to enable touch surface cleaning to take place at any location. Remember: • Blankets, pillow cases, sheets etc should be changed between patients.

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• Frequently touched surfaces such as, medical equipment, stretcher and door handles should be cleaned, especially when known to be contaminated with secretions, excretions or body fluids.

• It is good practice to use detergent wipes in order to clean all regularly touched surfaces after each patient journey, this need only take a few minutes.

• Cleaning equipment is disposable and should be placed in a clinical waste bag and removed.

22.18.7. Vehicle interior – daily clean •

All interior surfaces that could become contaminated (touch surfaces) should be cleaned as soon as possible. This process must always include detergent as the primary cleaning agent, followed by the use of disinfectant. Remember to use PPE as necessary, and discard any disposable items as clinical waste. It is also advisable to provide as much ventilation as possible during cleaning activities, so vehicle doors and windows should be opened accordingly.

•

The vehicle floor should be mopped clean on a regular basis throughout the shift. As the floor carries a comparatively low risk of cross infection, this can be undertaken satisfactorily using hot water and general detergent.

•

On most occasions, the floor will be mopped clean at hospitals. So staff should ensure that they utilise a mop suitable for ambulance cleaning purposes. The same principles will apply at ambulance stations, where the colour coding system should be used.

•

Clinical waste bags should be placed in a clinical waste bin at the receiving hospital. Where this is not possible, they should be disposed of at the earliest opportunity. At the end of a shift clinical waste bags are not to be left on a vehicle, they must be removed, tied, identified and put in the appropriate place for collection.

22.18.8. Environmental (station/office) cleaning •

Staff are responsible for helping to clean the environment to reduce the possible contamination by the flu virus and this should be done at least daily.

•

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and stair banisters should be frequently cleaned throughout the day.

•

Frequently touched surfaces such as, computer terminals, phones and tables should be cleaned prior to using and afterwards.

Electrical items should not be cleaned using water; specific cleaning equipment/materials should be used and, where they are available, follow the manufacturer’s instructions.

•

Domestic staff must be trained in correct methods of wearing PPE and precautions to take when cleaning ambulance stations.

22.18.9. Staff uniforms •

During a pandemic, healthcare workers should not travel to and from work places of duty in uniform.

•

Ambulance stations and other healthcare facilities should provide changing rooms/areas where staff can change into uniforms upon arrival at work.

•

Ideally, hospital/facility laundry services should be used to launder uniforms.

•

If there are no laundry facilities available then uniforms should be transported home in a tied plastic alginate bag and laundered separately from other linen in a domestic washing machine, washed at the optimum temperature recommended by the detergent manufacturers that is appropriate to the maximum temperature the fabric can tolerate, then ironed or tumble-dried.

22.18.10. Crockery and utensils • No special precautions, beyond those required to conform with standard infection control precautions, are recommended for dishes and eating utensils used by a patient or staff member with pandemic influenza. Dishes and eating utensils should be washed in a dishwasher with a hot rinse.

22.18.11. Furnishings • All non-essential furniture, especially soft furnishings, should be removed from reception and waiting areas on ambulance sites, treatment rooms. The remaining furniture should be easy to clean and should not conceal or retain dirt and moisture.

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• Books, newspapers and magazines should be removed from the reception and waiting area.

22.18.12. Management of Waste • No special handling procedures beyond those required to conform with standard infection control precautions are recommended for clinical (also known as infectious) and non-clinical waste that may be contaminated with influenza virus.

• Waste generated within the clinical setting should be managed safely and effectively, with attention paid to disposal of items that have been contaminated with secretions/sputum (for example paper tissues and surgical masks) in addition to other routine and domestic waste management.

22.18.13. Linen and laundry • Linen should be categorised as ‘used’ or ‘infected’ as guidance on Hospital laundry arrangements for used and infected linen.

• Both ‘used’ and ‘infected’ linen must be handled, transported and processed, in a manner that prevents skin and mucous membrane exposures to staff; contamination of their clothing and the environment; and infection of other patients.

22.18.14. Uniforms • Whilst the appropriate use of personal protective equipment will protect clothes from contamination, during the pandemic you may wish to consider not travelling to and from work in any work clothes. Uniforms can be laundered in a domestic washing machine in water as hot as the fabric will tolerate, then tumble dried and ironed. Uniform should be transported home in a sealed plastic bag and washed separately from other linen, in a load not more than half the machine capacity, in order to ensure adequate rinsing and dilution.

22.18.15. Being Prepared

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• Currently all organisations have developed contingency plans in order to try to maintain essential services in the event that large numbers of people become ill.

• You will be required to work differently in order to manage staff shortages and to prevent the spread of infection; • You can be prepared by knowing what to do and by becoming familiar with the Wellington Free Ambulances pandemic flu plans; • Remember the signs and symptoms of influenza; • If you are ill whilst at home, do not come into work. Follow the Wellington Free Ambulances reporting sick procedures; • If you become ill whist on duty, do not carry on working. Inform CECL or your Duty Manager immediately.

• Above all else, you must observe strict personal hygiene.

23

Staff Exclusion from Work

23.1.

The following table gives advice on the minimum period of exclusion from work for Wellington Free Ambulance members suffering from an infectious disease (case) or in contact with a case of infection in their own homes (home contacts). Advice can be sought from your GP, Occupational Health Department (OHD – via HR) or the Service GP (via HR)

Minimum exclusion period Disease

Period of infectivity

Case

Home contact

Chickenpox

Infectious for 1–2 days before the onset of symptoms and 6 days after rash appears or until lesions are crusted (if longer)

Six days from onset of rash

None. Non-immune pregnant women should seek medical advice

Conjunctivitis

Until 48 treatment

Until stops

None

Erythema infectiosum (slapped-cheek syndrome) Erythrovirus B19

Four days before until 4 days after onset of rash

hours

after

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discharge

Until clinically well

None.

Pregnant women should seek medical advice

Infection Prevention and Control Manual

Gastroenteritis (including salmonellosis and shigellosis)

As long as organism is present in stools, but mainly while diarrhoea lasts

Until clinically well and 48 hours without diarrhoea or vomiting. GP, ICT, OHD, HPU or EH may advise a longer period of exclusion

GP,HPU, EH will advise on local policy

Glandular fever

When symptomatic

Until clinically well

None

Giardia lamblia

While diarrhoea is present

Until 48 hours after first normal stool

None

Hand, foot and mouth disease

As long as active ulcers are present

One week or until open lesions are healed

None

Hepatitis A

The incubation period is 15â&#x20AC;&#x201C;50 days, average 2830 days.

Maximum infectivity occurs during the latter half of the incubation period and continues until 7days after jaundice appears

One week after onset of jaundice

None â&#x20AC;&#x201C; immunisation may be advised (through OHD or GP)

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HIV/AIDS

For life

None

None

Measles

Up to 4days before until 4 days after rash appears

Four days from onset of rash

None

Meningitis

Varies with organism

Until clinical recovery

None

Mumps

Greatest infectivity from2 days before onset of symptoms to 4 days after symptoms appear

Four days from onset of rash

None

(German

One week before until 5 days after onset of rash

Four days from onset of rash

None

Streptococcal sore throat and scarlet fever

As long as organism is present in throat, usually up to 48 hours after antibiotic is started

Until clinically improved (usually 48 hours after antibiotic is started)

None

Shingles

Until after the last of the lesions are dry

Until all lesions are dry â&#x20AC;&#x201C; minimum six days from onset of rash

None

Tuberculosis (TB)

Depends on part infected.

Open TB usually becomes non-infectious after two weeks of treatment

In the case of open TB, until cleared by TB clinic.

No exclusion necessary in other situations

Will require medical followup

Threadworm

As long as eggs present on perianal skin

None but treatment

Treatment necessary

Typhoid fever

As long as case harbours the organism

Seek advice from GP or HPU

Whooping cough

One week before until 3 weeks after onset of cough (or 5 days after start of antibiotic treatment)

Until clinically well, but check with GP or HPU

Rubella measles)

requires

Seek advice from GP or HPU None

SKIN CONDITIONS Minimum exclusion period Disease

Period of infectivity

Case

Impetigo

As long as purulent lesions are present

Until skin has healed or 48 hours after treatment started

Head lice

As long as lice or live eggs are present

Exclude until treated

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Home contact None. Avoid sharing towels None. Avoid sharing hair brushes.

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Ringworm Exclusion not always necessary until an epidemic is suspected

None

1. Tinea capitis (head)

As long as active lesions are present

As long as active lesions are present

None

None

2. Tinea corporis (body)

As long as active lesions are present

None

None

Scabies

Until mites and eggs have been destroyed

Until day after treatment is given

None should family)

Verrucae (plantar warts)

As long as wart is present

None (warts should be covered with waterproof dressing for swimming and barefoot activities)

None

3. Tinea pedis (athleteâ&#x20AC;&#x2122;s foot)

24

Staff Immunisation

24.1.

General

24.1.1. The immunisation programme for all operational members of WFA Service staff is managed under contract by Occupational Health Service (OHS). It is one of a wide range of services delivered by the Occupational Health Team, whose primary aim is to protect the health of staff in the workplace. However, it must be remembered that immunisation is not available against all infections, and neither is it guaranteed to be 100% effective. Therefore, immunisation should not be regarded as an alternative to practicing high standards of hygiene, infection prevention and control.

24.1.2. NOTE: If staff members develop any signs or symptoms of an infectious disease, they should seek advice via their GP, Infection Control Team, Occupational Health Services or by contacting their Line Manager.

24.2.

Vaccination Programme

24.2.1. The primary aim of vaccination is to protect the individual who receives the vaccine, but particularly important for healthcare staff, vaccinated individuals are also less likely to be a source of infection to others. This reduces the risk of immunocompromised and unvaccinated individuals being exposed to infection. This means that

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(GP treat

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individuals that cannot be vaccinated will still benefit from this routine vaccination programme.

24.2.2. Ambulance staff have a duty to themselves as they are at risk. They have a duty to their patients not to infect their patients and they have a duty to their families. You solve those responsibilities by being vaccinated.

24.2.3. On entry to WFA Service, all new entrants to operational duties are routinely screened for their immunity status. Screened for: • Tuberculosis • Polio • Tetanus • Rubella • Measles • Varicella (Chicken Pox) • Hepatitis B • Hepatitis C • HIV.

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25

Audit and Review

25.1.

This manual will be reviewed on a two yearly basis by Executive Manager â&#x20AC;&#x201C; Clinical Services (or delegate) and amended accordingly if required. The review will be led by the Infection Control Managers in consultation with the members of the Infection Control Working Group.

25.2.

This timescale will be reviewed in light of any adverse incidents or risks identified, (or in light of any new legislation or organisational change) to the Wellington Free Ambulance and / or its staff or patients.

25.3.

This timescale will be reviewed in light of any significant changes to clinical practice or guidelines as identified.

26

Associated Documentation

26.1.

WFA Aseptic and Clean Technique Procedure

26.2.

WFA Prevention of Blood Borne Viruses Procedure

26.3.

WFA Safe Handling and Disposal of Sharps Procedure

26.4.

WFA Standard (Universal) Infection Control Precautions Procedure

26.5.

WFA Infection Prevention and Control Policy

26.6.

WFA Hand Hygiene & Care Procedure

26.7.

WFA Occupational Health Policy

26.8.

WFA Uniform Policy

26.9.

WFA Health & Safety Policy

26.10. WFA Major Incident Plan 26.11. WFA Business Continuity Plan

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26.12. WFA Welfare Policy

27

References

Ambulance Service Association (2004) National Guidance and Procedures for Infection Prevention & Control. London: ASA Ayliffe, G. (1986) Nosocomial infection: the irreducible minimum. Infection control, 7(2), pp. 92-95.

Department of Health (2004) Towards cleaner hospitals and lower rates of infection.

London: DoH. Department of Health (2004) A Matron’s Charter: an Action Plan for Cleaner Hospitals. London: DoH. Department of Health (2006) Standards for Better Health. London: DoH. Department of Health (2007) Saving Lives: a Delivery Programme to Reduce Healthcare Associated Infections including MRSA – Challenge 6 and Challenge 8 Department of Health (2007) Uniforms and Workwear: an evidence base for developing local policy. London: DoH. Department of Health (2007) Saving Lives: reducing infection, delivering clean and safe care. London: DoH. Department of Health (2008) From Deep Clean to Keep Clean: Learning from the Deep Clean Programme. London: DoH. Department of Health (2009) Health and Social Care Act 2008: the Code of Practice for the Prevention and Control of Healthcare Associated Infections (the ‘Code of Practice’) (Department of Health, updated January 2009).

Hartley, J.C., Mackay, A.D. & Scott, G.M. (1999) Wristwatches must be removed before washing hands. BMJ. Page 318 Health Protection Agency (2008) Guidelines for Infection Prevention & Control in the Community. Kent: KHPU Health Protection Agency (2008) CBRN Incidents: clinical management & health protection. London: HPA. Health & Safety Executive (2002) COSHH: A brief guide to the Regulations what you need to know about the Control of Substances Hazardous to Health Regulations 2002 (COSHH). London: HSE Health & Safety Executive. The Health and Safety at Work etc Act 1974 sections 2 and 3. Section 2 covers risks to employees and Section 3 to others affected by their work e.g. patients. London: HSE.

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Health and Safety Executive (1999) Management of Health and Safety at Work Regulations 1999 (Management Regulations), that extend the cover to patients and others affected by microbiological infections, and include control of infection measures. London: HSE. Health & Safety. â&#x20AC;&#x2DC;Securing Health Togetherâ&#x20AC;&#x2122;, the Health and Safety Executive (HSE) long term strategy for Occupational Health that commits HSE/Health and Safety Commission and their fellow signatories (including the Department of Health) to a 20 per cent reduction in ill health caused by work activity by 2010.

Horton, R. Parker, L. (2002) Informed infection control practice 2nd ed. London: Churchill Livingstone.

IHCD (2004) Basic Ambulance Service Training Manual. London: ASA Infection Control Nurse Association (2002) Hand Decontamination Guidelines.

Infection Control Nurses Association / Regent.

Prat, R. Pellowe, C. Wilson, J. Loveday, H. Et al (2007) epic2: National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection, 65, pp. S1-S64. Elsevier, Science Direct.

National Patient Safety Agency (2007) Colour Coding Hospital Cleaning Materials and Equipment: Safer Practice Notice 15. London: NPSA National Patient Safety Agency ( 2007) The National Specifications for Cleanliness in the NHS: a Framework for Setting and Measuring Performance Outcomes. London: NPSA National Patient Safety Agency (2008) Clean Hands Save Lives: Patient Safety Alert National Patient Safety Agency (2009) My five moments for hand hygiene: Enabling staff to understand the important moments to clean their hands. London: SpokenImage LTD. NHS Estates (2004) The NHS Healthcare Cleaning manual. DoH. Royal College of Nursing (2005) Good Practice in Infection Prevention and Control.

London: RCN. Sax, H. Allegranze, B. Uckay, I. Larson, E. Boyce, J. Pittet, D. (2007) My five moments for hand hygiene: a user-centred design approach to understand, train, monitor and report hand hygiene. Journal of Hospital Infection. 67, pp. 9-21.

Elsevier, Science Direct.

UK ambulance service clinical practice guidelines (2006) Part 2 Section 4: Trauma Emergencies.

World Health Organisation (2006) World alliance for patient safety: glove use (technical) information sheet 6. Geneva: WHO. http://www.who.int/household_water/resources/emergencies.pdf 03/09/09)

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(Accessed

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Emergency treatment of drinking water at point-of-use. WHO technical note for emergencies No. 5 http://www.who.int/water_sanitation_health/hygiene/envsan/tn05/en/index.html (Accessed 03/09/09) Health advice- how to clean up safely following flooding http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947420817 03/09/09)

(Accessed

Health advice â&#x20AC;&#x201C; general information following flooding http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947339369 03/09/09)

(Accessed

http://www.hpa.org.uk/flooding (Accessed 03/09/09)

Appendix 1 Hand Washing Technique with Soap and Water

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Appendix 2 Alcohol Handrub hand hygiene Technique

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Appendix 3 Occupational Exposure to Blood or Body Fluids

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Appendix 4

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Flowchart for Decontamination Prior to Service or Repair

Does the item require dismantling to ensure decontamination?

Has the item been in contact with blood or body fluids?

No

Yes

Yes

Can ambulance personnel dismantle the item?

Yes

Decontaminate using the appropriate method.

Complete a Decontamination certificate stating method used and sign

No

Dismantle and clean using Standard Infection Control Precautions.

Is it visibly soiled?

Yes

Visible soiling must be removed from external surfaces Ensure Decontamination Certificate completed appropriately

No

No Clean using a detergent. Dry thoroughly.

Complete decontamination certificate Complete and attach decontamination

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Appendix 5

Change Control Reference Page Number

Section(s)

Date

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Key Changes