Useful contact numbers Reporting of infectious disease or an outbreak of infection Infection - its causes and spread Standard precautions Management of sharps and the prevention of sharps injuries Decontamination of medical equipment/devices Cleaning of nebulising equipment Cleaning and storage of suction equipment Environmental cleaning Disposal of clinical waste Col ection of specimens for laboratory examination Exclusion of staff from work Immunisation of service users Care of urinary catheters Management of MRSA (Meticil in resistant Staphylococcus aureus) Management of Clostridium difficile Management of cases and outbreaks of scabies Management of cases and outbreaks of diarrhoea and vomiting Blood borne viruses Aseptic Technique Appendices and other useful information Appendix 1 Hand decontamination technique poster Appendix 2 Decontamination prior to service and repair form Appendix 3 NHS colour coding poster for cleaning equipment Appendix 4 Clinical waste poster Appendix 5 Mattress, duvet and pil ow audit tool Appendix 6 Bristol stool chart Appendix 7 Risk assessment and patient transfer form Infection Prevention and Control Team 0121 612 1627 or Mobile: 07870 584559 Health Protection Agency (HPA) Care Quality Commission (CQC) Environmental Health Local Authority Contracting Team City Hospital Microbiology *(if unable to contact cal the Infection Prevention & Control Team) Please add any other relevant numbers you wish below:- rEpOrTiNg Of iNfECTiOUS diEaSES Or
aN OUTbrEak Of iNfECTiON
Any registered medical practitioner (i.e. GP) who On suspicion of an outbreak, keep accurate
becomes aware or suspects that a resident written records of events including:
he/she is attending is suffering from a notifiabledisease is required to inform the Consultant in • Residents details Communicable Disease Control (CCDC) and local • Date/time of start of outbreak Health Protection Agency (HPA) (contact details • Samples sent with date and result if available given on page 3). • What action has been taken • Record of who it has been reported to Although the General Practitioner is legal y • Details of staff if suffering with the same responsible for formal notification, any suspicionof an outbreak of an infectious disease or an This information wil be required to manage the outbreak of infection in a care home should be outbreak and wil be required by the Infection reported by the home manager or designated Prevention and Control team and the HPA.
person to your local Health Protection Agency (HPA) immediately for further investigation and management. They should be contacted if for • There are two or more individuals with vomiting and/or diarrhoea (amongst residents and/or staff). • Two or more individuals are suffering from the same infectious il ness e.g., scabies, Influenza • High sickness rate amongst staff who appear to be suffering the same infectious disease The care manager/deputy also has a duty to

• Infection Prevention and Control Team at Sandwel Primary Care Trust • Local Environmental Health Department (If considered to be food related) • The owners of the home • The General Practitioners of the residents Good Infection Prevention and Control is infections and related guidance' and should be essential to ensure that people who use health read in conjunction with al other relevant and social care services receive safe and current policies and guidelines within the effective care. Infection Prevention and Control is an important part of a Care Homes effectiverisk management strategy to improve the quality of residents care and the health and As far as is reasonably practicable, a safe safety of staff. The philosophy of this manual is working environment, wel maintained and safe to encourage individual responsibility by every equipment, and safe systems of work should be member of staff working within the Care Home.
provided by employers, for their employees, Al staff have a legal responsibility to ensure under the Health and Safety at Work Act, high standards of prevention and control of (1974). Similarly, under this Act, employees infection and home owners and managers are must comply with the policies and protocols in responsible for ensuring that there are effective place for their safety, and also have a duty of arrangements in place for the control of care towards other employees, and residents of healthcare associated infections. This document aims to provide clear, concise, Compliance with infection prevention and practical guidance on the management of control wil be monitored through practice Infection Prevention and Control in line with audit, appraisal, personal development plans ‘The Health and Social Care 2008: Code of and supervision. practice on the prevention and control of accountability for infection prevention and control in a care home setting
Home manager
infection prevention and Control link Worker
The above table provides an example of an accountability structure within care homes. It is recognisedthat each home wil differ in its management structure however, each home must identify clear lines ofaccountability for infection prevention and control in order to register with the Care QualityCommission (CQC) and to meet the requirements of the Code of Practice 2008.
iNfECTiON - iTS CaUSES aNd SprEad
The majority of micro-organisms (germs) that parasites
live in our body, on our skin and surround us in Some can cause infection and are spread from our environment are usual y harmless however, person to person, e.g. scabies. some micro-organisms when given the right opportunity can cause infections, and these are Are infectious protein particles, e.g., the prion known as pathogens. causing (New) Variant Creutzfeldt-Jakob Micro-organisms are classified as: The Spread of infection
Micro-organisms which cause infection may These are classified into different groups and can be pathogenic. They are susceptible to agreater or lesser extent to antibiotics e.g.
• One's self (endogenous) Staphylococcal aureus (found nearly • Other people (exogenous) everywhere in the environment i.e. soil, air).
• The environment A feature that distinguishes infection from A virus is much smal er than bacteria, they other non-infectious diseases is that it can be need a host cel to replicate and can survive out spread from person to person. This usual y of the body for only a short time. Antibiotics do occurs in two ways.
not work against viruses although anti-viral drugs are available e.g. Acyclovir. Most viral Occurs when micro-organisms from one site on infections are self-limiting. the body where they normal y live transfer to another site where they invade and cause Can either be moulds or yeast. An example of mould that can cause infection in humans is Exogenous/Cross infection
Trichophytyon rubrum - which is one cause of This occurs when infections are acquired by ring worm, another example is Candida cross infection from other people, equipment albicans, commonly cal ed Thrush. and the environment.
Microscopic free living organisms e.g., Giardia
lamblia which causes diarrhoea.
iNfECTiON - iTS CaUSES aNd SprEad
Direct contact: person to person contact i.e., Gastro-intestinal infection may result from scabies, sexual y transmitted diseases.
ingestion of food and water contaminated with Indirect contact: transfer of infection can also microorganisms or from cross-infection from occur from sharing contaminated objects e.g.
individuals already infected e.g., aerosols bed pans, urinals etc.
created during diarrhoea/vomiting episodesmay result in transmitting gastro-intestinal Hands of carers are the most common vehicles of cross-infection.
inoculation/blood body fluid Transmission
Transmission of blood-borne infection can Spread occurs when germs/organisms are occur via contact with infected blood or body expel ed into the air by an infected person and fluid e.g., Hepatitis B may be transmitted inhaled by another person for example TB. The fol owing an inoculation/sharps injury or chances of acquiring infection from inhaling through unprotected sexual y contact.
organisms are low. More commonly, respiratorysecretions such as those from influenza or colds There are a number of factors that need to are acquired by contact with secretions on come together for someone to develop an hands, handkerchiefs and surfaces. infection (see figure 1 next page as anexample). Good infection control practice aimsto stop the spread of infection by puttingpractices in place to break this chain ofinfection. Fol owing the guidelines within thismanual wil help staff break the chain.
Infectious agent eg.
Susceptible host (someone (found in water, milk and food) who eats contaminated food) Portal of Entry (ingestion of contaminated food) (contamination of food) Means of transmission (on contaminated equipment HaNd HygiENE
Hand hygiene refers to decontamination of the hands by either washing with soap and water Hands should be decontaminated either by or the application of alcohol hand rub washing with liquid soap and water if visibly products. The importance of hand hygiene in soiled or decontaminated with alcohol hand the prevention of cross infection particularly in rub if visibly clean: healthcare settings is wel documented. Micro-organisms (germs) passed from one • handling, serving or eating food individual to another during the delivery of • handling invasive devices such as urinary care may potential y be harmful however, a catheter or PEG tubes good hand decontamination technique can • administering medicines minimise the risks. • contact with wounds or dressings Mil ions of organisms can be found on our hands and skin, these are either resident, or • procedures involving handling residents resident organisms live deep within the
• going to the toilet/helping others to the epidermis of the skin, for example in skin crevices, hair fol icles, sweat glands, and • cleaning up anything that comes out of the beneath the finger nails. They protect the skin body for example, urine, vomit or diarrhoea from other, more harmful bacteria that are not • removal of gloves easily removed, and are therefore rarely associated with cross infection. • blowing or wiping noses • handling pets Transient organisms are usual y located on the
• any procedure that might make the hands surface of the skin and are easily passed dirty such as, handling waste, soiled linen or through direct contact with other people, the environment, equipment, or other body sites for example by blowing the nose. The ability totransfer easily means that transient organismspose a significant risk to vulnerable individuals.
However, unlike resident organisms, transientorganisms are easily removed by theapplication of thorough hand hygiene practices. HaNd HygiENE
‘5 moments of Hand Hygiene' (WHO 2009)
In addition to the above advice as a general rule ‘the 5 moments of hand hygiene' approach defines the key moments when care workersshould perform hand hygiene when in contactwith residents. The approach recommends careworkers clean their hands:• Before and after contact with residents• Before a clean or aseptic procedures, such as a dressing or urinary catheter insertion • After exposure to blood and body fluids • After touching residents surrounding or HaNd HygiENE
Hand washing:
When washing hands always fol ow the hand Health care workers should not:
washing technique poster located at the sink 1. Wash hands in food preparation areas (see figure 2 or appendix 1 for an example) fol owing delivery of physical care to residents. 2. Wash hands in a sink where contaminated equipment such as commode pans and bedpans are cleaned. for hand washing health care workers should:
• Not wear rings (other than a wedding ring),
wrist watches, bangles and other jewel ery • keep nails short and free from nail varnish• Wet hands under continuous running water • Wet the hands up to the wrists before applying cleanser/soap • Rub palm to palm to make a lather, then part fingers to wash in between • Wash the back of one hand with the palm of the other, then change over, parting the fingers to wash in between • Hold the fingers of one hand with the fingers of the other, and rub in a half circle motion, then change over • Wash the thumbs wel • Wash the wrists • Dry the hands thoroughly with a disposable paper towel do not use terry towels in a carehome setting • Use the paper towel to turn off the tap, then dispose of towel into a waste bin HaNd HygiENE
alcohol based hand rub products
• Products with an added emol ient are Alcohol hand rubs provide a quick and easy recommended to decrease the likelihood of alternative to hand washing at the point of drying the skin of the user however, it may care. Gel can be either carried by the staff be necessary to wash the hands periodical y member or placed in key locations to al ow to remove the build up of emol ient on the ease of access at the point of care. Mobile gel bottles should also be provided to place ondressing/procedure trol eys etc.
• Rubs must always be rubbed in using the eight step technique located at the hand wash basin. • Each application of alcohol hand rub should be sufficient to wet the hands completely and is then rubbed into al areas of the hands fol owing the hand wash technique for approximately 15 seconds or until the product has evaporated. please Note: alcohol hand gel should not be used when in contact with residents with
? Clostridium difficile (C.diff) or residents suffering from diarrhoea or diarrhoea and vomiting
Hand hygiene products
The choice and location of alcohol based hand Liquid soap and/or alcohol-based hand gels products in the care home should be subject to should be used for al routine hand risk assessment that is, it should be user decontamination in the care home. friendly and of no risk to vulnerable residents.
However, if possible dispensers should be near Liquid soap should be dispensed from a single to the point of care. If this is not possible staff use cartridge in a wal mounted dispenser; should be provided with personal gel Refil able dispensers must not be used as they dispensers attached to their uniform. can lead to contamination of the soap. Thedispenser should be regularly maintained andcleaned. Bar soap must not be used as bacteria cangrow in bar soap, which can then become areservoir and source of infection. Bar soap maybe used by individual residents for their ownuse but not by healthcare staff. HaNd HygiENE
moisturising cream
people have frail skin, which is easily torn. It is Encourage the use of moisturising creams therefore essential that at work jewel ery is however, communal tubes and pots should be kept to an absolute minimum i.e. a plain gold avoided because of the potential risk of cross infection. Staff should have access to freestanding or wal mounted dispensers of residents hand hygiene
moisturising cream. Residents must be offered the opportunity andencouraged to decontaminate their hands after Any product causing a rash, cracking or using the toilet and before meals. If it is not soreness of the hands, should be stopped practical or possible for residents to access a immediately, and reported to the home hand wash basin before meals, moist hand manager who should arrange for an alternative wipes can be used.
product. Seek medical advice if the problemcontinues.
Hand drying
Hands should be dried using paper towels
dispensed from a wal dispenser. Hand blowers
are not appropriate in a care home where staff
are decontaminating hands. Towel ing towels
must not be used.
access to hand hygiene products
Hand hygiene products should be easily
accessible to healthcare staff particularly where
direct care is provided to residents that is, in
residents rooms. Care staff must have access to
dispenser refil s and paper towels out of hours
to ensure continuous supply of soap.
Organisms can also be carried on items of
jewel ery. Rings, bracelets, wrist watches,
earrings, body piercings or jewel ery can al
harbour germs. Some rings with stones, can
also be a Health and Safety risk, as elderly
Standard precautions relate to a range of These precautions include: measures, such as the wearing of personal protective equipment e.g. gloves and aprons, • Hand hygiene (section 1) and hand hygiene to minimise the spread of • The use of personal protective equipment organisms from one place to another. • Safe handling and disposal of sharps • Safe handling and disposal of clinical waste Al blood and body fluids are potential y infectious, and it is not always possible to • Safe handling of contaminated linen identify people who may spread infection to others. In order to prevent transmission of • Safe handling and management of blood infection from person to person, it is imperative and bodily fluid spil ages (section 6) that al staff, at every level, understand and • Decontamination of re-usable devices and comply with, basic standard precautions, which equipment (section 3) apply to everyone in the delivery of health • Maintenance of a clean environment Standard precautions apply to blood, al bodyfluid excretions and secretions, non-intact skin,and mucous membranes. Several of theprecautions above arecovered in more depth in their corresponding sections. Please referto relevant section The Use of personal protect Equipment
key points
• Gloves must be easily accessible to staff and disposable gloves
stored to prevent contamination preferably Since June 1998, examination gloves have been in a wal dispenser.
classified as a medical device. This means that • Gloves should be worn for any anticipated they must comply with European law, contact with blood or body fluids, secretions, regardless of the material from which they are excretions, non-intact skin, and mucous made, and carry a ‘CE' mark, which demonstrates that safety and product • Gloves should also be worn when in contact performance have been monitored. They with chemicals etc such as when cleaning should conform to BS EN 455 Parts 1, (freedom equipment or the environment.
from holes), 2, (requirements and testing for • Gloves must be removed as soon as the task physical properties, and 3, (requirements and is completed and hands washed.
testing for biological evaluation). • Gloves may need to be changed during one episode of care on the same resident if the • A risk assessment should be carried out prior carers move from a dirty procedure to a to glove use, in order to determine the best clean procedure on the same resident i.e. size and type of glove.
changing a resident's pad and then changing • Gloves must be assessed for the nature of or adjusting a wound dressing.
the task to be undertaken, such as sterile or • The routine wearing of gloves for purposes other than exposure to blood and body • Staff should be instructed in the use of fluids or when in contact with chemicals gloves, in terms of putting on, taking off, and should be discouraged.
appropriateness of use. • Gloves should be single use, wel fitting, and Plastic/co-polymer gloves must NOT be used as powder free. The glove material of choice protective equipment in a healthcare setting.
must be careful y considered but general y a They have welded seams which often split, are good quality vinyl glove is sufficient for care porous, and poor fitting, compromising dexterity and safety. This type of glove is oftenused in the catering industry.
plastic aprons and gowns
1. Sterile gowns are used primarily in hospital plastic aprons:
or primary care settings, during operative 1. The purpose of wearing a plastic apron is to protect the clothing from contamination by 2. Within the care home setting, gowns are not microorganisms, blood or body fluids. necessary, unless exceptional circumstances 2. Plastic aprons are recommended for use as a apply. (This would be highly unusual, and barrier when performing tasks that carry a would be under the direction of the Health risk of contaminating the uniform of the Protection Team or the Infection prevention healthcare worker, such as: and control team (IPCT). • Handling body fluids, masks, visors, eye protection
• Emptying urinary catheters In most instances, within the care home setting, • Changing dressings,(Clean apron) the use of masks, visors, and eye protection, is • Bed bathing, bathing or showering not necessary unless advised to by the HPA or • Handling dirty equipment Infection Prevention and Control team. • Handling waste• Dirty laundry 1. Masks should not be worn for routine care • Dealing with spil ages 2. The routine use of a respirator or mask for 3. Plastic aprons are single use and must be conditions such as TB is not necessary discarded after completion of the intended (advice should be taken from the IPCT). 3. Visors and eye protection are necessary only 4. A clean plastic apron should be worn when for procedures where there is a high risk of undertaking dressings and aseptic splashing of blood and body fluids into the mucous membranes.
5. A clean green (or blue) plastic apron must be worn for handling and serving food.
As already stated for gloves, aprons should beeasily accessible to staff, and stored inconvenient, clean dry areas, but away fromsources of contamination, preferably in a waldispenser. SafE maNagEmENT Of SHarpS aNd
legal requirements
• Providing sharps disposal equipment close to Health care professionals, other health service staff and residents continue to receive sharps • Banning the practice of re-capping injuries due to the inappropriate use and • Use of PPE i.e. gloves disposal of sharps. Most sharps injuries can be • Ensuring appropriate vaccination (e.g. prevented and there is a legal requirement on hepatitis B vaccine) is readily available to at employers to take steps to prevent healthcare risk workers and students free of charge staff being exposed to infectious agents from • Workers need to report any accidents or incidents involving sharps to their employer The Health and Safety at Work Act 1974 states • Policies and procedures need to be in place that, "it shal be the duty of every employer to to ensure that injured health care workers ensure, so far as reasonably practicable, the are provided with post exposure prophylaxis health, safety and welfare at work of al his/her and any necessary medical tests where employees". The employer is required to provide appropriate information and instruction • Employers are required to provide training with the appropriate safety equipment, training on the prevention of sharps injuries and the and supervision to ensure that their employees risk of blood borne viruses are protected at work. • Employers must release workers who are required to attend training and training must In May 2010 a new European directive was be provided at induction and on an annual introduced to ensure the further protection of basis for clinical staff.
healthcare workers exposed to the risk of sharps injuries. This directive becomes law in May 2013 and applies to al workers in hospitals and healthcare sector including staff working in the private and public sector including studentsand agency staff.
The main requirement of EU directive
2012/32/EU on the prevention of sharps
injuries in the healthcare sector:

• Risk assessment must be carried out to assess the risk of exposure to blood borne infections from sharps injuries.
• Where there is a risk of exposure, employers need to identify how exposure can be eliminated or prevented by the implementation of safe procedures for usingand disposal of sharps SafE maNagEmENT Of SHarpS aNd
Safe use and disposal of sharps
• Do not dispose of sharps with other clinical • Make sure the sharps box is safely and properly assembled. • Do not place used sharps containers in • Sharps boxes must be stored safely away out yel ow bags for disposal. of the reach of the public and other • Any damaged used sharps containers must vulnerable persons.
be placed into a larger secure sharps • Sharps boxes must be stored off the floor at container which is properly label ed. waist height. To avoid reach or bending • Dispose of used sharps containers as advised when disposing of sharps.
by the waste col ection service. • Staff must complete the signature label on the front of the container on assembly and when locking the container.
management of sharps injuries/mucous
• Sharps must not be passed directly from hand to hand and handling should be kept to A sharps injury or needlestick injury is defined • Needles must not be bent or broken prior to, as an injury where a needle or other sharp contaminated with blood or other high-risk • Always dispose of sharps at the point of use body fluid penetrates the skin. This may also in a suitable container. Take a sharps include bites from an infected person, which container to the point of use.
break the skin. If the sharp is contaminated • Ensure that sharps containers comply with with blood there is a risk of transmitting BS 7320 and UN3291 regulations. infectious agents such as hepatitis B or C and • Needles must not be re-sheathed (cap put back on) Syringes/cartridges and needles must be disposed of as one unit. For the purpose of these guidelines, a mucous • Do not fil sharps containers above the membrane injury may be defined as an injury manufacturer's marked line. where blood or other high risk body fluid • Use the temporary closure mechanism when penetrates the moist membranes lining the not in use to prevent spil ages should the bin mouth, nose and eyes.
• Lock the sharps container when ready for first aid: Any one sustaining a sharps/mucous
final disposal in accordance with the membrane injury should undertake basic first manufacturer's instructions. • Sharps containers should be disposed of when the manufacturer marked line has been reached or at the intervals specified by local procedures. • Always carry used sharps containers by the SafE maNagEmENT Of SHarpS aNd
Sharps injury first aid
Staff must be made aware of the following first aid at induction and this should be reiterated on a
Encourage bleeding of the wound. do not suck, rub or scrub the wound
Wash thoroughly under running water and dry well
apply a waterproof plaster/dressing
report injury to your manager and complete incident procedure
Seek medical advice from a&E, your, gp, or the occupational health adviser
mucous membrane injury
• Rinse blood or body fluid splashed in the mouth or eyes with large amounts of water • Leave contact lenses in place initial y, irrigate eyes thoroughly, remove lenses and repeat • Ensure contact lenses are cleaned thoroughly with appropriate cleaning fluid and sterilising solution before putting back ineyes. • Dispose of solution after use. all sharps/mucous membrane injuries must be
reported immediately to the person in charge
and an incident form completed.

SafE maNagEmENT Of SHarpS aNd
action by person in charge – based on risk
• A high risk injury from a known or strongly suspected HIV positive source wil indicate that Post Exposure Prophylaxis (PEP) should be considered fol owing a risk assessment by the medical doctor. Ideal y this should be 1. is the tissue involved high risk?
given within 1-2 hours of the injury. Blood, amniotic fluids, vaginal secretions, Therefore prompt action is required breast milk, body cavity fluids, semen, fol owing any injury.
exudates or other tissue fluids – these are al classed as high risk.
• Hepatitis B vaccine/immunoglobulin may be offered fol owing an assessment by the Urine, vomit, saliva or faeces are not classed as being high risk unless they are visibly blood • Tetanus/diphtheria/polio vaccine or tetanus immunoglobulin may be offered fol owing an 2. is the type of exposure high risk?
assessment by the medical doctor.
Percutaneous (Sharps/needlestick injury), broken skin or mucus membrane are classed if in doubt take obtain advice immediately.
as high risk.
If the injury involves both high risk tissue (as in 1.) AND a high risk exposure then (as in 2.) • Send employee to own GP, A&E Department or Occupational Health Adviser without • Assist employee to complete accident/incident form. • Identify source/resident if possible. • The level of risk wil be assessed by the doctor in A&E or Occupational Health and blood specimens taken from the injured staffmember. • If possible, blood may be required from the resident for testing (but only with their consent). dECONTamiNaTiON Of mEdiCal
Micro-organisms are always present in the Disinfection is a process used to reduce the environment and al staff in care homes have a number of micro-organisms, but not usual y of responsibility to ensure that inanimate objects bacterial spores. The process does not (e.g. furniture, wheelchairs, re-usable medical necessarily kil or remove al micro-organisms, devices etc.) in the care home environment are but reduces their number to a level which is not decontaminated properly to minimise the risk harmful to health. Heat disinfection methods of infection to residents, staff and visitors. (e.g. dishwashers, washing machines, bedpan washer's disinfectors, steam cleaners etc.) are Decontamination is a general term for the more reliable than chemical methods and destruction or removal of microbial should be chosen whenever practicable. contamination to render an item safe. This wil include methods of: • Disinfection • Sterilisation Cleaning is a process, using general-purpose detergent and hot water (<45°C), to physical y remove contaminants, including dust, soil, large numbers of micro-organisms (germs) and theorganic matter (e.g. faeces, blood) that protectsthem . Cleaning remains the single most effective wayof reducing the risk of infection from theenvironment and is the first stage beforedisinfection or sterilisation is attempted. Thevalue of cleaning cannot be overemphasised.
Without cleaning an item first, it may not bepossible to disinfect or sterilise it properly. dECONTamiNaTiON Of mEdiCal
Chemical disinfectants
Examples of environmental chemical disinfectants are: Wide range of bactericidal, virucidal, sporicidal and fungicidal Inactivated by organic matter, particularly if used in low Corrosive to some metals.
Diluted solutions are unstable and should be freshly prepared.
2. Sodium,
Agent of choice for dealing with spil ages of blood or bloodstained body fluids. HOWEVER, DO NOT USE ON URINE (NadCC). may be in the
SPILLAGE because chlorine gas wil be released.
form of tablets, powers or
Undissolved tablets, powders and granules wil remain stable when stored dry but unstable when in solution.
See Table 1 for appropriate uses and strengths of solution.
3. alcohol
Good bactericidal, (including tubercle bacil i), fungicidal and some virucidal activity. Not sporicidal.
Does not penetrate wel into organic matter. Must be used onphysical y clean surfaces.
Inflammable and toxic. Care must be taken when using forenvironmental disinfection.
Use dilution of solution available chlorine
Parts per mil ion (ppm) Blood and blood stained fluids spil s 10,000 (100mls to 1 litre of water) 1,000 (i.e. 10mls of chlorine to 1 litre of water) * Approximate values of some brands of Thick Bleach dECONTamiNaTiON Of mEdiCal
Skin disinfectants
disposable plastic apron and gloves. If there is Skin disinfectants* are often cal ed antiseptics, any risk of splashes into the face when which are chemical disinfectants that are gentle cleaning, then additional face protection is also enough to be applied to skin and living tissue.
needed e.g. face visor or mask and goggles in They are intended for skin disinfection only, addition to the disposable plastic aprons and NOT for environmental disinfection. Examples of skin disinfectants are: 3. Always consider how new equipment and • Biguanides e.g. Chlorhexidine furniture item wil be cleaned before it is • Alcohols e.g.Ethanol, Isopropanol (Alcohol purchased Always consult with manufacturer instructions and ensure it meets with infection • Iodine, Iodophors and other iodine prevention and control guidelines. 4. Before purchasing cleaning chemicals or disinfectant always check the instruction to * Skin disinfectants are not usual y ensure it is suitable for the job to be done.
Check its effect against certain recommended unless a resident has MRSA germs/organisms and how long it can be stored.
5. Fresh disinfectants should be used at the Sterilisation is a process that removes or correct strength and the recommended destroys al micro-organisms including spores minimum contact time.
and viruses. Al items entering a sterile part of the body e.g. bladder, or coming into contactwith broken skin/mucous membranes, must be 6. Satisfactory disinfection of equipment of the majority of residents equipment tin care homescan be achieved using general-purpose The majority of manufacturers produce single- detergent and warm water (<45°C) water. For use medical devices in ‘ready-to-use' sterile cleaning after infectious cases it may be packs e.g. urinary catheters, wound care packs appropriate to use a suitable dilution of etc. Sterilisation of reusable instruments would chlorine-based disinfectant e.g. for cases of not be appropriate in a care home setting.
diarrhoea/vomiting, C.diff, MRSA.
a. Hypochlorite (household bleach) - 1 in 100 1. Items that have been decontaminated by (0.1% available chlorine or 1,000 parts per any of the three processes outlined above mil ion available chlorine (ppm Av.Cl.) MUST always be stored dry. So to make it easy this would mean 10mls of 2. In each situation thorough cleaning, using bleach diluted in 1 litre of water, but always general-purpose detergent and warm water read the manufactures instructions as the (<45°C) must precede any method of strength of bleach may vary.
disinfection or equipment. Staff undertakingcleaning must always use clean equipment and 7. Chlorine-based agents are commonly wear suitable personal protective clothing i.e.
dECONTamiNaTiON Of mEdiCal
risk categories for decontamination
available for decontamination, and the risks to The choice of method of disinfection or staff and patients. The risks to residents from sterilisation depends on a number of factors, equipment and the environment may be which include the type of material to be classified as fol ows: treated, the organisms involved, the time High risk
Items in close contact with a break in skin or mucous membrane or introduced into a normal y sterile body area Surgical instruments, syringes, needles, vaginal speculae, dressings, urinary and other catheters. Single use disposable instruments must be used whenever possible.
Items in contact with mucous membranes or other items contaminated with particularly virulent or readily transmissible organisms, or items to be used on highly susceptible patients. Bedpans, commode pans and urinals.
Suitable method
Disinfection required i.e. washer disinfector, alternatively use disposable
Items in contact with normal and intact skin Examples
Washing bowls, chairs, stethoscopes, walking frames
Suitable method
Cleaning with detergent and hot water and drying usual y adequate
Or rEpair SEE appENdiX2

Anyone who inspects, services, maintains or transports healthcare equipment has a right to expectthat the equipment has been appropriately decontaminated to remove or reduce the risk ofinfection. The care home is responsible in ensuring that appropriate documentation, which indicatescontamination status of the item, accompanies the healthcare equipment for inspection, service,maintenance or repair, as per MHRA DB2003(05) June 2003 (see Appendix 2 - This form can also bedownloaded from Failure to comply with legislative requirements could leave the care home open to prosecution.
dECONTamiNaTiON Of mEdiCal
Single-use – The expression ‘single-use' means
that the medical device is intended to be used on an individual patient during a single procedure and then discarded. It is notintended to be reprocessed and used on another patient and is against the law to do so.
For example the practice of using single use syringes for drawing up and administrating medication and then washing between usesmust not take place. The symbol below is used on medical device packaging indicating ‘do not reuse' and mayreplace any wording. The manager must ensure that al staff are aware of this symbol.
Single patient use some
marked as single patient use. This means it can be used more than once on the same patient i.e.
oxygen masks or nebuliser masks. Alwaysfol ow the manufactures instructions forcleaning between uses.
dECONTamiNaTiON Of mEdiCal
decontamination of equipment
Equipment or site routine or by whom acceptable alternative or
preferred method additional recommendation
1. Disposable, single use or 2. Single resident use baths, Showers
After each resident use, wash Consider purchasing a combined using disposal cloths and hand hot and domestic detergent/ disinfectant product.
water and general-purpose For residents with open wounds nb: for hydrotherapy detergent. Rinse wel and al ow to ensure surfaces of both is cleaned and jacuzzi type baths and disinfected before and after refer to manufacturers' bath mats
The use of bath/shower mats is Disposal paper bath mats be used (for use outside the
not advocated but if they are they and domestic instead of bath mat.
should be cleaned between each resident use.
Between residents, wash with If contaminated with blood clean bed frames and
hand hot general-purpose with hand hot water and general detergent solution and dry.
purpose detergent rinse and dry.
Wipe with 10,000 ppm (1%) hypochlorite solution rinse and dry.
bedpans, Urinals and
Residents to have their own An automatic washer disinfector or Commode pans
(preferably label ed) bed- macerator is recommended for al care homes. If there is no bed-pan washer disinfector/macerator in the home OR machine is out of order, empty 1. Bed-pen washer disinfectant contents of pans/ urinals/commode pans into sluice hopper or toilet 2. Place single-use disposals and (avoiding splashes) then: their contents into macerator.
1. Place disposables in a yel ow plastic Nb. Operate equipment according bag for incineration or registered to the manufacturers' 2. Clean re-usable bedpan holders/urinals/commode pans with hand hot water and general-purpose detergent, rinse and dry. dO NOT WaSH COmmOdE pOTS ETC
Take to designated room i.e. dirty
utility or designated area/sink
Return to resident's room. if the home
does not have an automatic washer
disinfector for commode pots, the
commode pots must be designated to
dECONTamiNaTiON Of mEdiCal
Equipment or site routine or by whom acceptable alternative or
preferred method additional recommendation
and Commode
Residents with diarrhoea and vomiting to have their own 1. 1. Cleaned with hand hot water and general purpose detergent, rinsed and dry.
2. Disinfect surfaces by wiping with 1,000ppm (0.1%) hypochlorite solution, rinse and al ow to air dry.
Use correct colour coded cleaning equipment for different areas in Discard at the end of each shift In outbreak situation or cleaning and when otherwise rooms of infectious residents mop head and cloths should be disposedof after each room or sent to the Wash after use with hot water and laundry for washing Send to laundry for heatdisinfection in washing machine atthe end of each shift.
After use by infectious residents clean Treat removable container and lid surfaces with general-purpose as for "Bedpans". Wash frame and detergent solution, rinse and dry.
seat with hot water and general Disinfect surfaces by wiping with purpose detergent solution on a 1,000ppm (0.1%) hypochlorite daily basis and when visibly soiled.
solution rinse and dry.
If no dishwasher available: Wash Wash (and heat disinfect) in using hand hot water and general- dishwasher suitable for purpose detergent, rinse and al ow to commercial purposes. Al ow to dry air dry using racking system or dry in dishwasher.
using disposal paper towels/kitchen rol . Avoid the use of tea towels.
Launder or dry clean at least Change after some episodes of
isolations (barrier nursing). Check with annual y as per cleaning schedule.
the Infection Prevention and Control dECONTamiNaTiON Of mEdiCal
Equipment or site routine or by whom acceptable alternative or
preferred method additional recommendation
Launder duvet and cover in the same way as other bed linen: • Between residents • 6monthly/annual y as schedule Fol ow manufacturer's instructions for laundering. See Section: Laundry floors (dry)
1. Vacuum clean daily or Do not use brooms in resident areas 2. Dust - attracting dry mop floors (wet cleaning of Wash daily or as appropriate with
For known contaminated areas wash hot general-purpose detergent first with general-purpose detergent solution. Disinfection is not solution, fol owed by disinfecting routinely required.
with 1,000 ppm (0.1%) hypochlorite solution. Al ow to dry.
flower vases
When changing water/flowers, dispose of water into sluice hopper or toilet, wash vases with general- purpose detergent solution before re-filing with clean water.
After use, wash vases with general- purpose detergent solution and store dry and inverted furniture and fittings
Damp dusting with hand hot water and general purpose detergent Hand washing
See Section: Hand Hygiene Hair combs
Single resident use only.
Where hairdressing facilities are Wash regularly.
provided procedure should be in place to ensure al equipment is cleaned Hair curlers
Wash after use with hand hot Residents with scalp conditions should water and general-purpose have their own hair curlers detergent and al ow to dry Wash daily when in use and when Pay particular attention to visibly soiled with hand hot water & connecting parts.
general-purpose detergent. Al ow to dry. Deep clean as per schedule Hoist slings
Single-resident slings to be sent to Refer to manufacturer's instructions laundry on a weekly basis and with regard to washing temperatures.
when visibly soiled.
Shared slings for clothed residents to be sent to laundry on at least weekly as per laundering schedule and when visibly soiled.
Disposable slings are available dECONTamiNaTiON Of mEdiCal
Equipment or site routine or by whom acceptable alternative or
preferred method additional recommendation
Incontinent residents to have fluid Always refer to manufacturer's mattress
Impermeable (i.e. waterproof) NB: Do not use disinfectant Covers on mattresses. Covers to be: unnecessarily as this damages the 1. Washed with general-purpose mattress cover.
relieving mattresses detergent solution and dried using disposable cloths or paper towels or wipe with detergent wipes or 2. Check condition and integrity of mattresses on a weekly basis. Six monthly or annual audit to be undertaken. Plastic cover should be unzipped and the foam inner coreinspected for any fluid ingression.
Ref to mattress audit tool, Sandwel Mattresses that become soiled or damaged should be replaced.
Alternatively disposable mops heads dry, dust attracting
Return to laundry daily.
Return to laundry daily, store dry between uses.
mop bucket
Wash with hot water and general-purpose detergent. Store dry ininverted position at the end ofeach shift.
Treat as Crockery and Cutlery Do not wash medicine pots in hand See Guidelines on Nebulisers Oxygen masks
Single resident use only (dispose of Fol ow manufacturer's instructions.
and tubing
after each resident). Replace when Retain in manufacturer's wrapping visibly soiled.
until required.
Launder pil ow and cover in the same way as other bed linen: • Before use by another resident • Annual y as a routine measure Fol ow manufacturer's instructions for laundering. See Section: Audit pil ow condition 6/12 dECONTamiNaTiON Of mEdiCal
Equipment or site routine or by whom acceptable alternative or
preferred method additional recommendation
Wet Saving
Disposable single resident use.
NB: No sharing of razors.
Rinse in hot water after use.
Single resident use.
Daily cleaning of resident's room.
Use hand hot water and general- purpose detergent and al ow to receivers
Process through washer disinfector Care staff or wash with hand hot water and general-purpose detergent and dry If not single use should be cleaned Single use scissors must be disposed with hand hot general-purpose of immediately after use.
detergent solution, dried and wiped with 70% alcohol wipe.
Stands for drips, pEg
Wash with general-purpose If contaminated with blood, wash with feeds etc.
detergent and hot water between hand hot water and general-purpose detergent fol owed by disinfecting resident use and when soiled.
with 10,000 ppm (1%) hypochlorite solution rinse wel and al ow to dry.
Fol ow manufacturer's Wipe with 70% alcohol NB: Staff with ear infectionsshould not use stethoscopes.
See Section: Cleaning and Storage of Care staff Suction Equipment Toilet seats
Wash daily or when visibly soiled If grossly contaminated, hand hot with hand hot water and general- and domestic water and general-purpose detergent; purpose detergent then dry.
dry using disposable cloths or paper towels fol owed by wiping with hypochlorite 1-1000pmm. Rinse wel Wash weekly or when visibly soiled When grossly contaminated, wash with hand hot water and general- and domestic with hand hot water and general- purpose detergent. Use washing purpose detergent, dry using machine for soft toys.
disposable paper towels fol owed by wiping with 1,000 ppm (0.1%) hypochlorite solution or 70% alcohol wipe. Rinse wel and dry.
NB: Heavily contaminated soft toys may have to be destroyed.
dECONTamiNaTiON Of mEdiCal
Equipment or site routine or by whom acceptable alternative or
preferred method additional recommendation
Wash shelves and frame with hand hot water and general-purpose detergent and dry before and after Urinary catheter bag
See Section: Care of the Urinary Catheter Guidance Urine measuring jug
See Section: Care of the Urinary Catheter Guidance Change uniform daily and wash at It is recommended that a spare the 30 degree or at the highest uniform is available to staff at al temperature suitable for the times. Do not travel to work in your uniform change at work.
Walking aids
Between residents and when visibly soiled, wash with hand hot walking stick etc)
water and general-purpose detergent and dry.
Wash hand basins
Clean with general-purpose detergent or cream cleaner on a daily basis. Disinfection notnormal y required.
Clean with general-purpose detergent wipes between residents or when visibly soiled.
Wheelchairs should be deep cleaned weekly.
replacement and purchasing of equipment and furniture
Damaged and worn items may become difficult or impossible to clean effectively. Replacement of damaged items should not be delayed. A regular planned check of equipment and furniture such as commodes, waste bins mattresses, arm chairs etc should be undertaken by the home manager and worn or damaged items replaced. Please note when inspecting soft furnishings i.e. arm chairs etc the covers should be unzipped and an internal inspection carried out.
Prior to the purchase of new equipment a risk assessment should be undertaken to ensure al items can be cleaned effectively and meet infection prevention and control guidance.
The manufactures cleaning instructions should always be considered prior to purchase.
ClEaNiNg Of
NEbUliSiNg EqUipmENT
It is important that nebulising equipment is • Replace nebuliser chamber every month for kept clean in order to reduce the likelihood of short-term chambers or every 12 months any colonising organisms causing infection in for long term chambers. The mask/mouthpiece and tubing should be replaced every 3-4 months or sooner if An important issue related to nebulising damaged or if unable to decontaminate equipment is its reuse. Where nebulisers are label ed by the manufacturers as "single use" • Al nebuliser equipment should be single they may be used only once then discarded. If, resident use only. however equipment is label ed as "single • Ensure that the compressor unit is not patient use" it can be reused by the same placed on the floor when in use. person if cleaned adequately after each use.
Always fol ow the manufacturers' guidance on Stage ii:
decontamination and replacement of For long-term chambers, in addition to the nebulising equipment. cleaning process described in Stage I manufacturers may recommend further The fol owing guidance relates to equipment cleaning processes the details of which should deemed as "single patient use", that is, it can be supplied with the nebulising chamber.
be reused by the same person and has been taken from Recommendations of the Nebuliser The nebuliser casing should be cleaned using a Project Group of the British Thoracic Society detergent wipe daily. The equipment should be Standards of Care Committee (1997). included on any equipment cleaning schedules. Cleanliness of the equipment should be monitored by the homes audit Cleaning procedure for al types of nebuliser: • Disassemble nebuliser and mask/mouthpiece at least daily (or after use if used intermittently). • Wash in warm water and general-purpose • Al ow to dry completely. • do not store in plastic bag.
Run the compressor for a few moments after use to ensure tubing is dry. Moist or dirty equipment could cause chest infections. ClEaNiNg Of
• Suction bottle liners should be disposed of It is important that only staff trained in the as clinical waste. correct procedure for suctioning and in the • For each attempt at suctioning, a new, correct use of the equipment should undertake disposable suction catheter or yankauer • Dispose of used suction catheters and In addition, it is necessary to fol ow yankauers as clinical waste. manufacturers' instructions at al times and • Change the connection tubing at least that al electrical equipment should undergo weekly (more frequently if necessary). an electrical safety check at least annual y and • Change the filter of the suction machine as a written record kept. per manufacturer's instructions or at least when it becomes moist or discoloured. • Use disposable gloves and apron when Please note that equipment that performing suctioning on a resident. accommodates suction liners must be used. • Eye and mouth protection may be necessary When the suction machine is to be used on fol owing a risk assessment. more than one resident: • Hands should be washed and dried prior to the donning of gloves and immediately Before the suction machine is used on a fol owing their removal. Used gloves and different resident, always ensure: aprons should be disposed of as clinical • The outer casing of the machine is wiped down using a disposable damp cloth whilst Suction equipment
the machine is disconnected from the Prior to initial use of suction equipment on a electricity supply. resident, ensure that al disposable items are • A new suction catheter or yankauer is used. new and clean that is: • A new filter is used (these are single patient • Connection tubing • New suction tubing is attached to the • Sterile suction catheter/yankauer suction machine. • Suction bottle liner • A new disposable suction bottle liner is Ensure the outer casing of the suction machine is also clean: wipe this down using a damp cloth whilst the machine is disconnected from Storage of suction equipment when not in use: the electricity supply. Ensure that the suction liner container is clean • Always wash and dry the suction bottle before the suction equipment is stored Whilst the equipment is in use on a single • Always insert a new suction bottle liner.
• Always remove used suction tubing before • Using personal protective equipment, as • New suction tubing and a suction catheter above (a risk assessment wil determine need not be attached during storage. These whether eye and mouth protection are also can be attached immediately prior to next use of the equipment. • A disposable suction liner should be used • Always remove the used filter and replace and discarded according to manufacturer's with new before storage.
instructions but no longer than 72 hours (more frequently if it becomes ful ) and replaced with a new one. ClEaNiNg
Service providers need to demonstrate that Cleaning with detergent alone is sufficient for they provide and maintain a clean and items and surfaces remote from the resident appropriate environment which facilitates the and in contact with intact skin prevention and control of healthcare associated infections (Criteria 2 code of definition of cleaning responsibilities
practice). The essence of good cleaning is that It is vital to clearly identify cleaning things not only look clean afterwards, but that responsibilities within each area of the home. they are clean. Al users of healthcare premises It is the responsibility of each home manager have a right to assume that the environment is to ensure that there is a clear, written and wel one where infection hazards are adequately publicised cleaning responsibility framework.
The Revised NHS Cleaning Manual 2009 and In most Care Home environments, the majority the National Specification of Cleanliness: of cleaning duties wil be undertaken by a Guidance on the setting and measuring of dedicated cleaning team or person.
outcomes in Care homes can be used as reference and can assist care home providers Care staff
to achieve compliance with CQC registration Some cleaning duties maybe undertaken by requirements. These documents can also help care staff this may include resident's Care home manager in the formulation of local equipment such as monitoring equipment, clean schedules and methods statements. hoists walking frames, therapy equipment etc. definition of cleaning
Cleaning is the physical removal of A smal amount of cleaning tasks maybe accumulative deposits of dust, dirt, grease and al ocated to maintenance staff this may include organic material. This wil achieve a reduction wheel chairs, bed frames, resident's fans etc in micro-organisms (germs) but wil not but wil vary between homes. The cleaning and necessary destroy them. Cleaning wil maintenance duties of maintenance staff does however, reduce levels or micro-organisms to a not remove the responsibilities of care to staff level where the risk of infection is minimal to clean equipment between use. providing correct cleaning methods are Cleaning procedures should remove not redistribute micro organisms (germs and viruses). Therefore strict adherence to cleaning methods should be maintained. Cleaning cloths if used from one contaminated area to another can transfer germs increasing the risk of cross infection.
Thorough cleaning with a detergent and water fol owing the manufactures instructions in regard to diluting solutions etc, fol owing correct cleaning methods fol owed by drying wil control the levels of micro-organisms.
Cleaning wil also prevent unpleasant odours and the transfer of potential y infectious ClEaNiNg
Al duties relating to cleanliness must be clearly It is essential that al staff carrying out cleaning defined and should be clearly and accurately duties have been trained in the methods to be reflected in job descriptions and in agreed work used, use of cleaning equipment, and schedules. Work schedules should be as prevention and control of infection. Training detailed and complete as possible. They should and supervision should be provided prior to describe each cleaning task to be performed in staff working unsupervised.
a particular area and indicate approximately when it wil be done.
Staff carrying out cleaning duties must have training records that are signed and dated by Each cleaning task to be performed in each the trainer and trainee. These records should area of the home should be identified and be stored in the employees personnel file.
al ocated to a staff group. Tasks should be al ocated into schedules for: • Cleaning staff Storage of domestic equipment
• Maintenance staff if appropriate Dedicated storage cupboards/rooms should be provided for domestic equipment. This Schedules wil provide a work instruction to room/cupboard must be regularly cleaned and staff and act as a monitoring tool for managers.
Schedules should be reviewed 6 monthly. Staff should take care to read and ful y understand the work schedules that apply to their work areas and to fol ow them closely.
Where service users have responsibility for the cleaning of their own rooms a schedule would not be required but the principles of the NHS cleaning manual and the national specification for cleanliness in care homes should be used to formulate the residents care plan.
• Empty buckets down a suitable disposal The home should have a colour coded system for al cleaning equipment i.e. mops buckets • Remove gloves, apron and wash hands.
and cleaning cloths. This system should be fol owed at al times by al staff undertaking For body fluid spil ages fol ow the spil age cleaning activity. If there is a shortage of colour-coded materials or equipment, the supervisor/manager should be informed immediately. See Appendix 3 for examples of Storage of domestic equipment
the NHS colour code Dedicated storage cupboards/rooms should be provided for domestic equipment. This Equipment should be disposable or suitable for room/cupboard must be regularly cleaned and laundering. A risk assessment should be undertaken to identify the frequency of disposal or laundering but as a general rule Carpet and curtain cleaning
mop heads and cleaning cloths should be Schedule should be in place for the cleaning of laundered after use or daily. carpets and curtains. Carpets should be inspected on a regular basis and cleaned as a Al cleaning equipment must be disposed of minimum six monthly. Carpets must always be after use in barrier rooms or when cleaned after spil ages of body fluids etc.
contaminated with blood and body fluids.
Equipment used in barrier rooms can be Curtains should be cleaned or laundered laundered providing appropriate laundering annual y, when visibly contaminated and after facilities are available i.e. washing machine and vacation of the room. Spare curtains should be available so that soiled curtains can be changed as needed or fol owing a terminal clean at the Equipment must always be stored clean and end of barrier nursing. dry after use in a dedicated room or storage cupboard. Cloths and mops act as an ideal Cleaning with pressurised steam
medium for micro-organisms. If cleaning The use of steam cleaning machines, as part of material are left wet or moist and reused the the overal cleaning regime to be used in next day a few bacteria wil have become healthcare buildings, is increasing.
mil ions by the next day and if reused these wil be redistributed onto surfaces lead to a Steam cleaning uses superheated dry steam delivered under pressure. It has a dual cleaning and disinfectant function: the high temperature main principles of cleaning
of the steam is very efficient at kil ing micro- • Wear plastic apron and gloves organisms, while the pressurised steam loosens • Prepare fresh solutions daily dirt and greasy deposits, which are then pul ed • Use the correct colour coded clean dry cloth into the machine using vacuum suction. for the area/item to be cleaned • Clean from high to low surfaces Correct training in the use of steam cleaners is • Clean from clean to dirty surfaces particularly important. Staff must undergo • Wipe surface and dry or al ow to air dry training before using such equipment also • Damp dusting is preferable to dry dusting commercial y available steam cleaning • Dispose or change cloth or mops after use machines vary considerably in quality and • Change bucket water frequently as it wil effectiveness. Careful consideration should be quickly become contaminated given to the relative merits of products on the ClEaNiNg
procedure for dealing with blood spills
general principles when dealing with spillages
Always wear personal protective equipment • Hypochlorite solutions should not be used (PPE) when dealing with blood spil s on soft furnishings • Make the area safe, i.e. do not al ow people to walk through the spil age. • Make the area safe, i.e. do not al ow people • Al cuts, sores or abrasions must be covered to walk through the spil age and never leave with a waterproof dressing. the spil age unattended. • Wear disposable gloves and apron. • Al cuts, sores or abrasions must be covered • Pick up any broken glass, china, needles or with a waterproof dressing. sharp objects with a dustpan and brush. DO • Wear disposable gloves and apron. NOT pick up sharps with hands. • Pick up any broken glass, china, needles or • Wash the area thoroughly with warm water sharp objects with a dustpan and brush. DO NOT pick up sharps with hands. • Leave to dry. • Smal spots of blood can be wiped up with • The area can be shampooed or, if disposable paper towels soaked in bleach. appropriate, dry cleaned or steam cleaned. • Larger blood spil s can be covered with • Discard gloves, aprons and any wipes/towels disposable paper towels, and a hypochlorite into a clinical waste bag and seal the bag solution gently poured over the spil age. • Leave for at least two minutes then careful y • Wash hands and dry thoroughly. gather up the soiled towels. Wash the area thoroughly with hot water and detergent Tidying and disposal
and al ow to dry. Wipe over again with a Referred to in Improving Cleanliness and hypochlorite solution. Infection Control (PL CNO (2007) as "de- • Discard any remaining hypochlorite solution cluttering", al deep clean initiatives should commence with planned exercises to tidy the • Discard gloves, aprons and any towels into home and ensure that storage areas are the orange hazardous waste bag and seal effectively used, and to condemn and dispose the bag appropriately. of redundant equipment. This should be done • Wash hands and dry thoroughly. under the supervision of the manager and permission obtained before equipment is An alternative to hypochlorite solution are condemned or disposed of. Sodium Dichloroisocyanurate (NaDCC) granules or tablets. Always fol ow the manufacturer's instructions. Do not use on soft furnishings.
diSpOSal Of
CliNiCal WaSTE
Clinical waste generated every day in care Under health and safety law, care homes or homes can present risks to the health and employers generating clinical waste must safety of residents, staff and visitors in the care ensure that the risks from it are properly home, and the general public if it is not control ed. Remember you have a legal Duty of properly segregated, handled, transported and disposed of in accordance with the fol owing relevant legislation. • Assess the risk • Develop policies As a result of significant legislative changes • Put arrangements in place to manage the healthcare organisations and the staff that risks; and monitor the way these work within these organisations have a legal arrangements work and moral duty to dispose of waste properly in • Audit the segregation of waste within the accordance with statutory ‘duty of care' requirements. These recent changes have implications on the way that clinical waste is If you do not comply you may be prosecuted. defined and it is disposed of. Guidance for healthcare providers generating clinical waste Al clinical waste needs to be segregated so it is available online at can be disposed of appropriately, on the basis of the hazard it poses. The fol owing guidance aims to ensure the safe handling, segregation, storage and disposal of clinical waste generated within the care home environment. Guidance on local policy should be sought from the Environmental Health Officer (EHO) with responsibility for waste management. Category of waste (fig 1)
Clinical infectious Waste
Non sharps waste that For general household Non sharp non infectious is known or likely to Incontinence aids, Contaminated aprons Empty catheter bags, aprons and gloves Al waste from barrier rooms diSpOSal Of
CliNiCal WaSTE
1. Staff training
• Do not use staples to seal the sack, as they Staff working in areas where clinical waste is do not provide a secure closure and may generated must receive training on its proper puncture the sack. management and a record of this training kept • Label sacks to indicate their origin, for by the Person in Charge of the care home. It is example, by coding on the sack itself, by also helpful to staff if posters are displayed at suitable permanent marker, by a label appropriate locations within the care home showing clearly the name of the care home, showing the different types of waste. See or by pre-printed self-adhesive labels or tape, or by a pre-coded sack tie. • Label ‘new' waste sacks before placing into 2. What is clinical waste?
sack holders unless they are to be sealed The Department of Health's ‘Health Technical with a pre-coded sealing sack tie. Memorandum (HTM) 07-01: safe management • Do not al ow ful sacks to come into contact of healthcare waste now segregates clinical with the body; be thrown, dropped or waste into two categories of materials: supported by hand from below. • Arrange for col ection of waste from clinical • Waste that poses a risk of infection (see fig 1 areas e.g. sluice rooms, at appropriate for examples of waste) frequency. Where waste accumulates in • Medicinal waste smal quantities daily, the interval between col ections ought to be as short as And Non Clinical waste definitions practicable and preferably not less than Offensive/hygiene waste (see fig 1 for examples • Wash (and disinfect, if appropriate) sack holders on a weekly basis and when visibly 3. Handling clinical waste before disposal
When handling clinical waste staff must ensure • Wear the appropriate personal protective clothing as indicated by a risk assessment. • Place waste in waste sacks in enclosed hands free lidded bins/sack holders at the point of generation. • Foot operated waste bins that are broken must be reported to the home manager for • Avoid hand to mouth contact at al times. • Replace sacks at least daily or when three- • Do not transfer loose contents from sack to • It is recommended to seal sacks with a plastic tie, closure or heat sealers, purpose- made for clinical waste sacks. diSpOSal Of
CliNiCal WaSTE
4. Storage of clinical waste awaiting collection
Bulk clinical waste storage containers (wheelie Waste auditing is a legal requirement, and not bins) or storage areas/rooms should be: just best practice. Regular audits are recommended to enable home manager to • Reserved for clinical waste only. Clinical monitor the effectiveness of waste segregation.
waste for incineration must be separated from household waste destined for Audits should involve the observation, registered landfil by storing in different recording and classification of each waste item label ed bulk storage containers. as it is placed in the receptacle. This ful audit • Of sufficient capacity to match proposed should be undertaken annual y and should frequency of col ection. cover al waste streams.
• Wel lit and ventilated. • Sited away from food preparation and Additional observation or ‘spot checks' of general storage areas, and from routes used waste should be undertaken as part of the regular infection prevention and control audits • Total y enclosed and secure. undertaken by the home manager to further • Provided with separate storage for sharps reinforce home policy, raise awareness and to identify training needs. Results of audits must • Sited on a wel -drained, impervious hard be fed back to staff at staff meetings and standing floor. minuted as evidence.
• Readily accessible but only to authorised • kept locked when not in use. • Capable of being opened from inside in the event of anybody accidental y shutting • Secure from entry by animals and free from insect or rodent infestations. • Provided with wash-down facilities. • Provided with washing facilities for staff. • Clearly marked with warning signs. • Provided with access to first-aid facilities. • Col ected at least weekly.
• Equipped with appropriate protective equipment and spil age kit(s). • Washed (and disinfected, if appropriate) on a weekly basis and when visibly soiled.
Safe handling of laundry
• Hand wash basin is required for staff hand hygiene for staff. • Al cuts, sores or abrasions must be covered • Supply of aprons and disposable gloves for with a waterproof dressing. staff use preferably stored in a wal • Wear disposable apron. • Wear gloves if laundry is soiled or wet • Washing powders and other substances • If laundry is heavily blood stained or must be kept in a locked storage cupboard. infected it must be washed separately, in a Material safety, data sheets for hazardous water soluble bag. substances must be obtained and be • Care should be taken when removing used available for reference. linen from beds etc as linen can be • Written guidelines for the use of the contaminated with micro-organism which washing machine and dryer should be can spread into the environment.
available within the laundry • Used linen must not be placed on the floor • Domestic staff should have a schedule for on chairs or tables etc.
cleaning the laundry environment. • Used linen must be placed directly into a linen bag or skip. Therefore the skip/bag should be taken to the room to avoid having to carry used linen to the skip • Staff should always wear a disposable apron • After handling laundry, discard protective whilst handling laundry. clothing, wash hands and dry thoroughly.
• Disposable gloves should be worn if linen is soiled or contaminated • Linen should be removed from beds with laundry facilities
care to avoid creating dust and placed in appropriate container at the bedside. • Laundry contaminated with blood or body fluids should be contained in a water soluble • A designated laundry area, ideal y sited so or soluble stitched bag* prior to being that soiled articles are not carried through placed in a normal linen bag - this al ows areas where food is stored, prepared, contaminated laundry to be placed straight cooked or eaten. into the washing machine on a sluice cycle, • There should be a clear flow from dirty to therefore reducing the risk of clean with a designated area for soiled laundry, separate from where clean laundry • After removal of protective clothing, staff is handled and stored. should wash and dry their hands thoroughly. • The laundry floor must be of a smooth, impermeable and easily cleaned material. • These bags wil only operate in an The wal s must be in sound condition and industrial/commercial type washing machine. If in doubt, contact the washing • A commercial/industrial washing machine machine manufacturer. with both a sluice and hot water cycle professional y instal ed and serviced. A service agreement which supports prompt repair or replacement of the machine is Linen can be divided into three categories and treated accordingly: Used linen WHiTE
Al linen used except foul/infected linen should be placed in a bag. Placed in a water soluble bag immediately after removal and then placed in a RED bag. * check your type of washing machine first linen heat liable
Should be washed at the highest temperature possible fabrics according to the items fabric care instructions laundering of linen and clothing
1. Used linen
Temperature maintained at 65°C for no less than 10 minutes or 71°C for no less than 3 minutes A sluice cycle is necessary for foul linen. Linen should be transferred in its water soluble bag into the washer without opening. Storage of linen
• There should be separate areas for drying, ironing and storage of linen, wel away from used linen to prevent cross contamination. • Linen should be stored in a dry, raised area not in bathrooms or sluices. Sending laundry to commercial laundry
• A private laundry company may stipulate a colour coding system. Al staff must be aware of this and comply ful y. • Staff should be supplied with enough uniforms to wear a clean uniform daily.
• Staff who contaminate their clothes with blood/body fluids should always change as soon as possible. • Clothes for work purposes should be washed as soon as possible on as hot a wash as the fabric wil al ow. • Shoes should be cleaned immediately if contaminated with body fluids using general-purpose detergent and hot water. Always wear personal protective clothing. routine laundering of mattresses, duvets and
pillow cases
• Wash the mattress cover: mattresses
Before use by another resident • There is evidence that mattresses, duvets, Monthly as a routine measure and pil ow cases can al harbour micro- • Dispose of damaged mattress covers organisms that can be implicated in cross • Dispose of mattress if it becomes soiled infection. A risk assessment must be • Pressure mattresses if rented should be undertaken on al beds to indentify the need returned to the company for for a suitable fluid-repel ent cover. The decontamination after use mattress cover must be checked for soiling and routinely washed down with hot water and general-purpose detergent on a • Some care homes use duvets as wel as, or monthly basis, and always fol owing any instead of sheets and blankets. Homes using contamination with blood or body fluids. duvets should only do so if they have • If contamination with blood or body fluids appropriate facilities/arrangements for has occurred, additional disinfection with a laundering them. hypochlorite solution is also required. It • Where duvets are used, a suitable duvet should be noted, however, that some cover should be used at al times. The covers pressure relieving mattresses can only be used on duvets are not usual y a fluid- cleaned with certain cleaning agents, so the repel ent type as this would be manufacturer's instructions should be uncomfortable for the resident, therefore fol owed. Covered mattresses should also be the cover as wel as the duvet inside is prone washed down with hot water and general- purpose detergent before being used for a • The duvet and the cover should be laundered in the same way as other bed • The mattress cover should be dried linen because the risk of soiling and cross thoroughly after washing, in order to reduce infection is the same as for other bed linen. the potential for multiplication of organisms Duvets should always be laundered before and this is best achieved using disposable being used for a different resident, prior to being put away for storage, or when it • The condition of the mattress cover should becomes soiled or contaminated. Routine be checked at each linen change so that laundering is also recommended at least 6 covers that have become damaged or their monthly. Fol ow the manufacturer's integrity is compromised in any way can be instructions for laundering. replaced. An audit of the mattress cover must be undertaken no less frequently than 6 to 12 monthly depending on home risk assessment for frequency ( see auditing of bed mattresses , pil ows and duvets) • Damaged mattress covers should not be used. Mattresses that become soiled should Wash the duvet and cover: Wash the pil ow: Before use by another resident Before use by another resident Annual y as a routine measure pillows and pillow cases
Since pil ow cases can also easily become auditing of mattresses, duvets and pillows
contaminated they should be laundered in the A regular audit of bed mattresses must be same way as other bed linen. undertaken which includes the removal of the mattress cover if in use and a thorough Unless a pil ow is covered with a fluid-repel ent inspection of the mattress, pil ows and duvets.
cover, there is also potential for the pil ow Sandwel PCT provides a mattress audit tool for inside to become contaminated. Where this is this purpose. Audit documentation should be the case, the pil ow wil also require laundering retained for two years as evidence that an in the routine manner, fol owing audit has been undertaken. See appendix 5.
manufacturer's instructions. As for duvets, pil ows should also be routinely laundered at least 6 monthly. Fluid-repel ent pil ow covers should be washed down in the same way as mattress covers. iSOlaTiON/barriEr NUrSiNg Of rESidENTS
Isolation Barrier/Nursing is the use of infection isolation precautions are divided into two
control practices to control the spread of, and eradication of pathogenic organisms. Within the care home setting, traditional strict barrier • Source/Standard isolation nursing is not usual y recommended. • Protective isolation The General Practitioner or Infection Source/Standard isolation is designed to
Prevention Team may recommend a modified prevent the spread of infection from infected version for clients who develop acute residents to other residents, staff and visitors. symptoms of possible infectious disease. It is important for staff to appreciate that when protective isolation protects the resident from
caring for someone with a known or suspected his/her environment. These residents are infectious disease, there is the potential for susceptible to infection i.e. those with cross infection if basic infection control immunodeficiency disease. principles are not fol owed. The table fol owing gives guidance on the It must be remembered that blood and body barrier/isolation precautions required for fluids can be a source of infection, therefore specific diseases. Additional advice can be application of standard infection control obtained from the Infection Prevention and precautions are necessary for safe practice.
Control team, Sandwel PCT.
When isolation nursing is being considered contact should be made with the Infection Prevention and Control team. Isolation in care homes is the exception rather The precautions necessary to prevent the spread of disease depends on: • The route by which the disease is transmitted e.g. airborne i.e. flu. • The condition of the resident e.g. a person with salmonel a infection who is continent and is able to maintain good hygiene presents a lower risk than the resident with the same disease who is confused and iSOlaTiON/barriEr NUrSiNg Of rESidENTS
guidance on the barrier/isolation precautions required for specific diseases
infection/organism infectious material precautions/comments
Acquired immune deficiency Blood and blood stained Standard infection prevention and control syndrome(AIDS) or HIV precautions. Wear gloves and aprons for handling body fluids. Isolation is not required.
Isolate until asymptomatic i.e. has returned to normal bowel habits for 48 hours Respiratory secretions and Isolate for about 1-2 days before the onset of fluid from spots symptoms until about 7 days after rash appears or until lesions crusted/dried (if longer) Pregnant staff should be excluded from care of resident and should check with GP for immune Clostridium difficile (C.diff) Isolate until asymptomatic i.e. has returned to normal bowel habits for 48 hours. Designate a toilet if possible Diarrhoea cause unknown Isolate until asymptomatic i.e. has returned tonormal bowel habits for 48 hours. Obtain a Escherichia Coli (E.coli) 0157 Isolate until asymptomatic i.e. has returned to normal bowel habits for 48 hours (Seek Infection Prevention and Control advice) designate a toilet Isolate until asymptomatic i.e. has returned to normal bowel habits for 48 hours Barrier until diagnosed and then as below.
a) Suspected whilst Until 1 week after onset of jaundice Blood/body fluids and faeces b) Type A (infectious Blood/body fluids Standard precautions barrier nursing not required unless risk of bleeding. Aprons and Blood/body fluids gloves for contact with blood and body fluids Blood/body fluids Carrier status of B or C iSOlaTiON/barriEr NUrSiNg Of rESidENTS
infection/organism infectious material precautions/comments
Contact with infected skin Until lesions crusted and dry Respiratory secretions Isolate for duration of il ness Contact with colonised or Isolation precautions not usual y required in infected site i.e. wound, skin care homes( See MRSA section 18) lesion or environment Isolate until asymptomatic – normal bowel action for 48 hours Resistant organisms Depends on site of infection Seek advice from Infection prevention and Until asymptomatic – normal bowel action for Until asymptomatic – normal bowel action for Barrier nurse til treated, See Scabies guideline) Until lesions are crusted. Providing lesions are Secretions from the lesions covered. Barrier nursing is not required. Gloves and aprons should be worn when in contact with lesions. Pregnant staff should be excluded from care of resident. Visitors should be warned Until asymptomatic – normal bowel action for48 hours Sputum, urine wound See advice from health protection Open (includes pulmonary,urine, and draining lesions) iSOlaTiON/barriEr NUrSiNg Of rESidENTS
for source/standard isolation (barrier nursing)
N.B. Masks are not routinely advocated unless the following is required:
advised by the Health Protection Team Personal protective equipment should be kept 1. Single room
outside the room if possible and be discarded Preferably with own toilet and wash facilities. into the clinical waste stream after use. N.B. Where practical, residents should be cared for in a room with hard surface flooring, with a dedicated toilet or commode. Where carpets Avoid vigorous bed making which distributes are in situ these must be cleaned at the end of organisms/skin scales around the room. Visibly the infectious period.
soiled linen should be placed into a water soluble bag at the bed-side. 2. Hand hygiene
See Section: Hand Hygiene. You may in addition wish to consider having alcohol hand rub Disposable crockery and cutlery are not within the room. (N.B Where isolation is due to necessary. Wash crockery and cutlery in a C.diff infection or Diarrhoea and vomiting, commercial dishwasher alternatively, wash in alcohol hand rub should be used and must be hot soapy water and rinse wel and dry. washed with soap and water.
6. laboratory specimens/other request forms
3. personal protective equipment
See comments column Appendix 1 Infections Ensure staff wear: requiring isolation/barrier precautions • Disposable plastic colour coded aprons i.e. yel ow for al patient care procedures 7. Clinical waste (orange hazardous bag)
however, aprons are NOT necessary when Discard clinical waste either: entering room to talk to a resident, deliver • Into a foot operated pedal bin in the resident's own room • Disposable non-sterile gloves for contact with blood/body fluids/ for general care and • Into a smal bag and disposed of into the handling equipment.
• Protective clothing should be provided nearest clinical waste bin outside the room near to the door on a iSOlaTiON/barriEr NUrSiNg Of rESidENTS
8. Sanitary facilities
Where possible the resident must use his/her own toilet. Provided the resident is continent there is no need to disinfect the toilet and normal daily cleaning is sufficient. If disposable bedpans/urinals are used, dispose of in a macerator. keep the plastic bedpan holder within the room and disinfect when no If a commode is used keep it within the room for use by that resident only. Wear gloves and apron, when emptying. If non-disposable bedpans/urinals are used, disinfect in bedpan washer/disinfector. dO NOT WaSH paN iN
HaNd WaSH baSiN
9. Cleaning
The normal routine for domestic cleaning including hovering, dusting, cleaning of hand wash basin and toilet etc. should be continued.
As far as possible, use designated cleaning equipment or disposables for that room. For viral gastroenteritis (Norovirus) or for C.diff the room and sanitary equipment once cleaned with detergent and water should be disinfected using a chlorine based cleaner (i.e. Milton or household bleach). Particular attention should be paid to touch points i.e. door handles, tables arm rest, walking frames etc.
10. Visitors
Visitors should be advised of the risk of infection and guidance issued on necessary infection control precautions to adopt. They should also be asked to decontaminate their hands before leaving the room. In some situations visitors may be restricted, advice should be sought from the infection prevention and control team.
11. last offices
See Section 11: Last Offices.
laST OffiCES
procedure following death
It is vital that dignity, respect and religious The same infection control procedures that preferences are observed when preparing a were applicable in life continue after death.
body for transfer to a funeral director/chapel of Staff should use standard infection control rest fol owing death. The fol owing guidelines precautions e.g. disposable gloves and refer only to the necessary infection control disposable plastic aprons when handling any practices to prevent the risk of transmission of body fluids. Any additional precautions that infection and not to the broader requirements were being undertaken prior to death should of last offices e.g. different cultural and religious beliefs. Careful y remove al drainage bags and invasive It is highly unlikely that a care worker in a care devices, if appropriate. N.B. If there is any home wil be exposed to significant risk of possibility that the death may be referred to acquiring an infectious disease, as a result of the coroner, al tubes and devices must be left the minimal handling required of the last in place and should be spigotted/sealed with offices process. The registered person in the waterproof dressings. Leakage from other home must be familiar with the relevant orifices should be covered with waterproof standard(s) relating to the resident's religious, cultural and last wishes in the event of terminal care, or death, to be included in the individual body bags
Body bags are available but would not be for routine use by care homes. Funeral directors Senior staff should be available to guide and wil arrange for the transportation of the body support junior staff through the last offices and should be informed if there is a risk of infection. The funeral directors wil use body bags as appropriate.
The circumstances of a death where infection may be a factor may need to remain confidential. Care home staff may be aware that the deceased has been suffering from a communicable disease. Registered and professional healthcare staff wil be aware of their professional codes of conduct to maintain confidentiality. Al other staff must be aware of relevant guidance relating to confidentiality.
Advice should be given to funeral directors regarding what precautions may be necessary but information on the resident's infection should not be disclosed.
fOOd HygiENE
Why is food hygiene important?
• Al foods may be potential y hazardous if not 1. Cover al cuts/grazes with a blue waterproof handled correctly. plaster when working within a food • Good food practices are essential to preparation area. minimise the risk of food poisoning. 2. Use colour coded aprons in food preparation areas, whilst serving food or feeding a To minimise the risks it is important to follow
resident and when entering the kitchen. the guidelines below:
3. Pets must not be al owed in food • A dedicated food preparation area, i.e. preparation areas. kitchen which must only be used for the 4. Strict hand hygiene should be adhered to purpose of food storage and preparation. before food preparation and when feeding • Only designated personnel, properly trained in food hygiene should be employed to work 5. Perishable food brought in for residents from outside the home should be clearly • Unauthorised, non-designated personnel marked, dated and placed in a food should not be al owed into the kitchen. In refrigerator. If the food is not consumed exceptional circumstances, e.g. care homes within twenty four hours it should be with a smal number of residents, other discarded with the agreement of the persons may be permitted access but only resident/family. under the proper supervision of trained 6. Food supplement drinks should be stored as per manufacturers' recommendations. Once • Food preparation should not, general y, be opened the drinks should be consumed undertaken by carers but if unavoidable, within four hours.
separate, clean protective clothing must be 7. Refrigerator temperatures must be recorded worn and personnel must be aware of daily and action taken if temperature personal hygiene issues. In particular, requirements are not met.
thorough hand washing is essential, see section: Hand Hygiene. Food preparation should take place first prior to care activities or cleaning duties.
• It is advisable that staff handling food which may include serving and feeding residents should be suitable trained to undertake these tasks safely. • Staff or residents affected by diarrhoea and vomiting should under no circumstances, be al owed into the kitchen, See Section: Management of Cases and Outbreaks of Diarrhoea and Vomiting. • Al food preparation must be undertaken in accordance with the principles of Hazard Analysis and Critical Control Points (HACCP), i.e. ensuring food safety at al times. Further specific advice on food safety can be obtained by contacting your local Environmental Health Department. COllECTiON Of SpECimENS fOr labOraTOry
Before col ecting a mid-stream specimen (MSU) 1. To col ect an adequate amount of tissue or the genital area should be washed with soap fluid, uncontaminated by organisms from and water (no antiseptics should be used) from any outside source, but preserving any the front to the back. In addition, the labia organisms that may be present. should be separated in women and the foreskin 2. To ensure that the specimen is correctly retracted in men before the urine flow identified by label ing, and sent to the commences. The first part of the stream is laboratory with an accurately completed passed into the toilet and the middle into a clean container. The urine must be col ected in 3. To transport the specimen from the resident an appropriate specimen bottle containing to the laboratory safely and with the guidelines for specimen collection
Sputum specimens should not be routinely • As a general rule the more material sent for col ected only on request of a GP.
examination the greater the chance of Care needs to be taken that the specimen is isolating the causative organism. sputum and not saliva. An early morning specimen is preferable and specimen • A specimen container appropriate for the containers need to be sterile. samples should be used. • Ideal y, samples should be col ected before It is important to avoid contaminating the the commencement of antibiotic therapy or outside of the specimen container when before applying an antiseptic to a wound. col ecting stool samples. A universal sample When it is necessary to col ect a specimen container two thirds ful is adequate. If virology during antibiotic therapy, the specimen examination is requested then prompt dispatch should be col ected just before the dose is to the laboratory is required.
given. Similarly if an antiseptic is in use for a wound the specimen should be col ected If sending stool samples in the case of an before application. outbreak of diarrhoea liquid stool (number 6 or 7 Bristol stool chart should be sent) if semi solid stools are sent these wil not be examined Catheter specimens should be obtained from by the laboratory as this is not classed as the self sealing col ection port using a sterile syringe. The port should be wiped with an alcohol swab and al owed to dry. Samples should never be obtained by breaking the closed drainage system. Specimens should not be col ected as a routine measure but to investigate a suspected infection. COllECTiON Of SpECimENS fOr labOraTOry
Wound swabs
Specimen transport
If the wound is dry immerse the swab in sterile Specimens should be sent to the laboratory normal saline or water before swabbing. with the minimum of delay to ensure a greater chance of any organisms present surviving and • Clean the wound with sterile saline prior to being identified. If a delay in transportation to the laboratory is anticipated please contact • Col ection of pus is appropriate from your local laboratory for advice on appropriate • Swabbing of recent or acute wounds should include the areas showing signs of infection. • Swabs taken from chronic wounds should be Any specimen may contain potential y taken from, for example, the ulcer base and pathogenic material. To avoid presenting a not the eschar (dead tissue). hazard to anyone in contact with the specimen • Chronic wounds should only be swabbed if it is most important to avoid contaminating the showing signs of infection outside of the container and to ensure that it is • Avoid swabbing areas that are "clean". securely closed and handled. Specimens should • Rotate the swab gently around the wound be sealed in a specimen transport bag.
Specimens not transported in a transport bag wil not be processed. Specimens with visible laboratory request form and specimen
exterior contamination wil not be processed Although the initial request for laboratory Specimens must not be stored in a refrigerator
investigation is usual y made by medical staff, which is routinely used for storing food or
and should be signed by them, specimens are frequently col ected by care staff. It is important to ensure that information on the specimen container is consistent with the Information accompanying specimens must be accurate and relevant and should consist of: • Relevant resident details • Name of General Practitioner • Current or intended antibiotic therapy • Relevant clinical details i.e. raised temperature, pain swel ing, type and site of wound/ or specimen etc CarE Of pETS
• Pet foods should be stored in air tight Pets can often enhance the quality of life for containers away from food for human the ageing and the il . However, animals can harbour many infectious micro-organisms • Not al owed into food which can cause infection in humans e.g.
preparation/consumption areas, clinical rooms (e.g. treatment room, sluice room) or the laundry room. Sensible infection control precautions can • Prevented from visiting residents who are il reduce this risk to an acceptable level. The with diarrhoea and vomiting. Person in Charge of the home must ensure that • The named person is responsible in ensuring a named, knowledgeable person is responsible that animal excreta are removed from cat for resident animals (pets) in the home. The litter trays on a daily basis. handler of any animal visitors brought to the home must acknowledge the authority of the Person in Charge of the home and comply immediately with any instructions given. resident animals (pets)
If appropriate, the named person should ensure that al pets are: • Ful y vaccinated. Veterinary certificates regarding appropriate vaccinations should be kept in a safe place within the home. • Treated with a broad-spectrum helminthicide (i.e. ‘wormed') every three • In a ‘healthy' condition. If pets become il e.g. with diarrhoea, they must be excluded from resident contact and the advice of a • Regularly groomed and checked for signs of infection e.g. fleas (ectoparasites). If fleas are found the pet is to be treated with an approved insecticide. • Pets should be regularly checked for • Feed using designated stainless steel or earthenware bowls and in designated areas only. At the end of feeding, bowls should be removed, washed and stored dry. CarE Of pETS
animal visitors to the home
general hygiene measures
• Animal visits to the home, whether initiated by staff or residents themselves, must be by • Any member of staff handling the animal prior arrangement with the Person in Charge must wear a disposable plastic apron. of the Home. The potential visit should be Immediately afterwards the apron must be discussed and assessed by the Person in removed and the hands and forearms Charge. In addition, pets must be in a thoroughly washed. ‘healthy' condition and free from il ness. • Aprons and gloves must be worn for • The first arranged visit must take place in changing bedding or fish tank water the presence of the Person in Charge. The • Fish tank water must not be emptied down handler must report to the Person in Charge hand wash basins. Water should be on arrival at and departure from the Home. disposed of down a toilet, sluice or external • Visiting dogs must be brought into the Home on a lead. Cats must be brought to • Cloths and cleaning utensils should be the Home in a cat box. disposed of after use.
• After touching the pet or visiting animal al The resident's bedding should be protected concerned (patients, staff, visitors) must with a plastic sheet and draw sheet or wash their hands and forearms thoroughly.
incontinence pad if the animal visitor is to be placed on the bed and these removed immediately when the visit is over The fol owing advice must be given to animal visitors must not visit:
• Residents who are il with diarrhoea and The pet should not be allowed to approach
any resident(s) without the handler first
• Whether the resident is likely to be al ergic to the animal's fur/hair. • Whether the resident wishes to be visited. • Fol owing the visit, the hands and forearms of al those having had contact with the animal must be thoroughly washed. EXClUSiON Of STaff frOm WOrk
The fol owing tables give the minimum recommended periods of exclusion for the common communicable diseases. Once these minimum times have elapsed the majority of staff wil no longer be infectious. Ful recovery may take longer, so that a member of staff may not be wel enough to return to work some time after the minimum exclusion period.
Outbreaks of diarrhoea and vomiting
In the event of an outbreak of gastrointestinal infection the PCT, Health Protection Team (HPT) and a local Environmental Health Officer (EHO) may undertake a review of hygiene procedures together with an inspection of food hygiene Additional environmental cleaning and disinfection wil be required. Most diarrhoea and vomiting infections are spread when a person has symptoms. Affected staff should therefore stay at home until clear of symptoms for at least 48 hours.
female staff (pregnancy)
Chickenpox: can affect the pregnancy of a
woman who has not previously had the disease. If a woman is exposed in the pregnancy she should inform her GP or german measles (rubella): if a woman who is
not immune to rubel a is exposed to this infection during pregnancy she should inform her GP or midwife immediately.
EXClUSiON Of STaff frOm WOrk
advised minimum exclusion periods
The fol owing tables give the minimum recommended periods of exclusion for the common communicable diseases and can be used as a guide. In individual cases the Staff members, GP, or the Consultant in Communicable disease Control at the Health Protection Agency may be able to advise when a staff member is fit to return to work.
incubation period when infectious
Exclusion of
of infected person
Whilst active lesions present.
treatment recommended Campylobacter 2-5 days
Whilst having symptoms Until symptom free 1 to 2 days before to 5 days after For 5 days from onset of Female staff see comment Whilst eye is red and discharging No exclusion buttreatment is diarrhoea &
Whilst having symptoms of Until symptom free diarrhoea and/or vomiting Variable but usual y 2 weeks or less Until bacterial examination is clear E. coli 0157
May be up to 3 weeks glandular fever 4 – 6 weeks
Whilst virus is present in the saliva Until the person Head lice
Whilst lice or eggs remain None. Parents should be advised to treat theirchild. See head liceadvice sheet Hepatitis a
From 14 days before to 7 days after Until 7 days from onset the appearance of first symptoms of jaundice and theperson feels wel Not infectious under normal Hepatitis b
Until person feels wel conditions (Standard precautionsshould be adhered with) EXClUSiON Of STaff frOm WOrk
incubation period when infectious
Exclusion of
of infected person
Hepatitis C
Until person feels wel Whilst lesions present (cold sore)
Not infectious under normal conditions (Standard precautions should be Until lesions crusted Whilst lesions present adults 1 day before until 5 days
Children 3 days before until 9 days
after onset
From a few days before to 4 days 5 days from onset of rash after the appearance of the rash Whilst organism is present Until clinical y recovered in the nasopharynx meningitis
Until person feels wel From 6 days before to 5 days from onset of 9 days after onset of il ness Whilst organism is present As advised by HPU Scalp / body
Whilst active lesions present (Symptomatic pets should also be treated) 7 days before to 5 days after 5 days from onset of rash Female staff see EXClUSiON Of STaff frOm WOrk
incubation period when infectious
Exclusion of
of infected person
Whilst having symptoms of Until symptom free diarrhoea and/or vomiting Typhoid and
Whilst mites remain alive Whilst having symptoms of Until symptom free and diarrhoea and/or vomiting 2 consecutive negative stool samples at intervals of not more than 48hours Day sore throat starts to 24 hours after commencing antibiotics commencing antibiotics Until 7 days after rash appears Exclude only if rash weeping and cannot becovered (Can lead tochickenpox in susceptibleor non-immuneresidents/staff). Whilst eggs stil being produced.
(Eggs can survive for 2 weeks in the Treatment advised Until person feels wel Only when sputum contains and 2 weeks after treatment started Typhoid or
Until negative stools Exclude cases who are food handlers until 6 negative stool specimens taken at one week commencing 3 weeks after completion of antibiotic therapy Whilst warts are present 5 days from commencing 2 – 4 days before until antibiotic treatment 21 days after start of coughing immUNiSaTiON Of SErViCE USErS
immunisation in the care home
Which vaccines are offered to adults in care
Issues relating to the immunisation of residents are covered in the fol owing guidance Immunisation of care home staff is not within Influenza (flu) is a highly infectious disease the scope of the guidance. However, it is seen caused by influenza viruses. There are three as good practice to ensure records are kept and types of influenza virus: A, B and C and these maintained annual y of the influenza and cause virtual y al of the clinical signs of Hepatitis B immunisation status of al staff. influenza which occur every year mainly during the winter months. The flu virus attacks the What is immunisation?
respiratory tract. The virus is spread mainly by Immunisation is the induction of artificial respiratory droplets in the air produced by immunity through the administration of a coughing or sneezing. The incubation period vaccine or immunoglobulin (antibodies). The before the onset of symptoms is between three term is commonly used interchangeably with days and one week. Flu general y lasts up to a vaccination. Vaccination is the administration week but cough and malaise may persist for up of one or more doses of vaccine. As a result of this and if vaccination is successful the vaccinee is immunised (acquires immunity) against a Influenza infection is different from having a specific infectious disease and becomes cold - the symptoms of flu come on suddenly immune to that disease. and include fever, headache, extreme tiredness and an aching body. A dry sore throat and Storage of vaccines in the care home
stuffy nose are other common symptoms of the Vaccines must be stored in a vaccine refrigerator al owing air to circulate around the packages. They should not be stored in the refrigerator door. A maximum /minimum thermometer must be used and temperatures monitored and recorded daily. Vaccines must not be kept at temperatures lower that 0°C as freezing can cause deterioration of the vaccine. NBNot sure if you think this information may beof use with the care staff too vitamin D may be effective in reducing influenza incidence and severity would need a little write up immUNiSaTiON Of SErViCE USErS
What is in the flu vaccine?
are there any contraindications to influenza
Because of their changing nature, the World vaccine?
Health Organisation (WHO) monitors influenza viruses throughout the world. Each year the There are very few individuals who cannot WHO makes recommendations about the receive influenza vaccine. The vaccine should strains to be included in vaccines for the not be given to those who have had: forthcoming winter. Flu vaccine contains • A confirmed anaphylactic reaction to a components of two types of influenza A and previous dose of the vaccine. one type of influenza B viruses. Because the flu • A confirmed anaphylactic reaction to any virus is continual y changing and different types component of the vaccine. circulate each winter, a new flu vaccine has to • The vaccines are prepared in hen's eggs and be produced each year which means that it is should not be given to individuals with necessary to be vaccinated with flu vaccine known anaphylactic hypersensitivity to egg What protection against flu will immunisation
Confirmed anaphylaxis is rare. Other al ergic conditions such as rashes may occur more In general influenza vaccines provide 70-80% commonly and are not contraindications to protection against infection with prevailing further immunisation. influenza strains. Protection lasts for about one year. In the elderly, protection against infection Minor il nesses without fever or systemic upset may be less but immunisation has been shown are not valid reasons to postpone to reduce the incidence of bronchopneumonia, immunisation. If an individual is acutely unwel , hospital admissions and mortality. immunisation may be postponed until they have ful y recovered.
After immunisation, antibody levels may take up to 10-14 days to reach protective levels.
Are there any adverse reactions to flu vaccine?
While influenza activity is not usual y significant Pain, swel ing or redness at the injection site, before the middle of November, the influenza low grade fever, malaise, shivering, fatigue, season can start early and therefore the ideal headache, myalgia and arthralgia are among time for immunisation is between September the commonly reported symptoms. A smal and early November. painless nodule (induration) may also form at the injection site. These reactions usual y Will flu vaccine cause flu?
disappear within one to two days without INFLUENZA VACCINE CANNOT CAUSE INFLUENZA. It contains inactivated virus and it is impossible to acquire influenza infection Immediate reactions such as urticaria, angio- from an inactivated vaccine. Many people wil oedema, broncho-spasm and anaphylaxis can express concerns about annual influenza occur rarely; most are likely due to vaccination as they may mistakenly believe that hypersensitivity to residual egg protein. a previous dose of the vaccine gave them flu.
They should be advised that many other organisms cause respiratory infections similar to flu during the winter months which flu vaccine wil not prevent. Some people may experience mild flu like symptoms for up to 48 hours after immunisation as their immune system responds to the vaccine but this is not immUNiSaTiON Of SErViCE USErS
What protection against pneumococcal
Pneumococcal disease is the term used to disease will the vaccine provide?
describe infections caused by bacteria cal ed A number of studies have shown that Streptococcus pneumoniae. Pneumococcal pneumococcal polysaccharide vaccine gives infection causes a broad range of disease in substantial but not complete protection against older people. It is the most common cause of the serious forms of pneumococcal infection serious pneumonia. As wel as infecting the such as septicaemia. The effectiveness of the lungs, pneumococcal bacteria can infect the vaccine against invasive pneumococcal disease blood stream causing invasive pneumococcal is likely to be around 50- 70% in older age groups. disease. It is responsible for causing the more serious consequences of pneumococcal Who should have pneumococcal vaccine?
infection such as septicaemia, meningitis or a It is recommended that al those aged 65 years more serious form of pneumonia al of which and over be offered pneumococcal vaccine as are more likely to lead to death than non pneumococcal infection is likely to be more invasive infections. common and/or serious in this age group. Streptococcus pneumoniae is becoming are there any contraindications to
increasingly more resistant to antibiotics and as it becomes harder to treat prevention by There are very few contraindications to immunisation is increasingly more important. pneumococcal vaccination. The vaccines should not be given to those who have had: Old people are at risk from infection • a confirmed anaphylactic reaction to a particularly if they are already il , have no previous dose of the vaccines spleen or have a weakened immune system.
• a confirmed anaphylactic reaction to any The increased risk of pneumococcal disease component of the vaccines begins in those over 45 years and rises sharply in those over 75 years of age. It has been Confirmed anaphylaxis is rare and a careful estimated that there may be more than 18,000 history of the event wil often distinguish admissions and over 3,400 deaths due to between true anaphylaxis and other events pneumococcal pneumonia each year in those that are either not due to the vaccine or are people over 65 years of age. This is likely to be not life threatening. an underestimate. are there any adverse reactions to
What is pneumococcal vaccine?
There are two types of pneumococcal vaccine: Local reactions such as mild soreness, redness • 23- valent polysaccharide vaccine which can and induration (hardening) at the site of be used for adults over the age of 65 years injection may occur lasting no longer than 1-3 and adults and children over the age of five days. Occasional y a mild fever or muscle pain years old in at risk groups. The may occur. There is no risk of pneumococcal polysaccharide vaccine stimulates the body vaccine causing pneumococcal disease or to produce antibodies that help to protect infection as it does not contain live bacteria. against 23 of the 90 types of pneumococcal bacteria –these 23 types cause about 96% of UpTakE Of aNNUal iNflUENZa VaCCiNE
al pneumococcal disease in the Uk. CarE HOmE rECOrd fOrm
• 7- valent conjugate vaccine currently only licensed for use in children in at risk groups Appendix 8 provides a template that can be who are under five years old, its used for the recording of residents and staff effectiveness in preventing disease in adults vaccination uptake.
is not currently known. CarE Of UriNary CaTHETErS
Urinary catheters are necessary for a number assessment of need
of reasons however, infection is an inevitable Al residents who are catheterised in care consequence of long term catheterisation and homes must have clear documentation as to septicaemia is a significant risk and can lead to why the catheter is in place. This must be clearly documented in their care plan. When accepting new residents from an acute Therefore, the correct management of urinary setting with a catheter is situ always carry out a catheters by al carers is essential in reducing ful assessment to determine the reason for the severity and consequence of urinary tract catheterisation, never assume that just infection in those residents with a urinary because a catheter is in place it needs to be.
Residents must have regular assessment for the continuing need of a urinary catheter and this Al care and clinical staff who have must be documented in their care plan. responsibility for the insertion and on going management of urinary catheters must be Urinary catheterisation should only be used as trained and deemed competent. Support in the a last resort. Alternative methods should be assessment and management of urinary considered and used whenever possible.
catheters is also available from the continence team telephone number is available on the For further advice and support contact contact page.
Sandwel PCT's, Continence Team on Where residents undertake their own catheter management staff must ensure they have received training in hand hygiene and the techniques and principles of catheter care.
CarE Of UriNary CaTHETErS
• Support the night drainage bag on a urinary day drainage
catheter bag stand ensuring the bag remains lower that the bladder • Al catheterised residents other than those • The bag should be removed using apron and who are permanently confined to bed gloves and disposed of each day should wear a leg bag during the day which is wel supported by straps or sleeve holder • Ensure that the resident has an effective bowel regime to prevent constipation Link System - This applies to patients who require a leg bag by day and a higher capacity bed bag by night. The leg bag is not disconnected from the catheter but rather the night bag is connected to the drainage tap of the leg bag. To prevent infections residents in
residential or nursing home care must have a
new night bag every night with disposal of the
used bag.
CarE Of UriNary CaTHETErS
• Wipe the drainage tap with a detergent • It is essential to ensure that effective wipe before and after emptying. drainage is maintained. The catheter and • Remove your gloves and apron and tubing must not be constricted by the decontaminate your hands before residents' clothing or direct pressure. undertaking the next task. Drainage bags must be emptied before becoming overful , however, regular opening Ensure the catheter stand is decontaminated should be avoided unless essential. on a regular basis and when visibly soiled. • Position the catheter bag lower than the level of the residents' bladder and avoid Changing drainage bags
twisting or kinking of the tubing. It is recommended that drainage bags be • keep the outlet off the floor at al times. changed every 5-7 days. Otherwise they should only be replaced if leaking or blockage occurs, or when the catheter is changed.
• Wash the genital area daily with mild soap and warm water. If bathing, empty the • Wash hands before and after the procedure.
drainage bag beforehand but do not Clean disposable non-sterile gloves and disconnect the bag from the catheter. apron must be worn.
• If the resident uses a leg bag during the day • Disconnect the catheter.
link this to an overnight drainage bag at • Remove cover from the new sterile bag and night therefore avoiding any break in the connect to catheter by a non-touch • Take care not to contaminate the sterile end Emptying the drainage bag
of the new bag as it is inserted into the • Decontaminate your hands. • Wearing wel fitting disposable gloves and • Secure using appropriate method and apron empty the drainage bag into a observe drainage.
container. The container should preferably • Empty urine into the toilet/sluice hopper be disposable or if not, then an appropriate and dispose of empty drainage bag into a and effective method of decontaminating clinical waste bag.
the container between residents is required.
• Remove and discard gloves and apron.
Reusable urinals pots and jugs should be • Wash hands.
processed through a washer disinfector. If a washer is not available the urinal must be Changing the catheter
washed with detergent and hot water, dried • Always assess the need for the catheter thoroughly and returned to the resident's • A record of the date the catheter needs to room for their exclusive use only.
be replaced must be documented in the • Where a catheter bag is emptied directly residents care records and this is dependent into the toilet extreme care must be taken on the type of catheter used and to avoid contamination of the bag outlet tap by touching the toilet rim or bowl. • If it is practical to discontinue urinary • Under no circumstances should urine bag catheterisation and the resident is agreeable "rounds" be undertaken as there is a high to this then risk of urinary tract infection can risk of contamination and cross infection be greatly reduced. Advice can be obtained between residents with a catheter. from your continence advisor. • On no account should staff move from one resident to another using the same container for drained urine.
CarE Of UriNary CaTHETErS
Signs of infection
Observe the resident for signs of urinary tract Urosheaths are attached to the penis and are infection. One or more of the fol owing may not invasive. They do not create the same risk indicate current infection: of infection as urinary catheterisation. • Cloudy offensive smel ing urine If urosheaths are used, fol ow manufacturer's • Blood in the urine guidance as to frequency of change and • Pain/discomfort in urinary tract general management.
• Raised temperature • Nausea/vomiting intermittent catheterisation
• General malaise There are advantages to intermittent catheterisation including improved quality of life and reduction of urinary tract infections.
The resident may undertake intermittent self • Obtain a specimen of urine for testing catheterisation or intermittent catheterisation may be undertaken by a relative or carer • Ensure that the resident drinks at least 1-2 providing they have received training: litres of fluid daily, unless contraindicated. • Seek medical advice if a resident displays intermittent self catheterisation
any of the symptoms listed above The resident intermittently passes a catheter into the bladder to assist in the drainage of Obtaining a catheter specimen of urine (CSU)
urine where normal voiding is not possible.
• Decontaminate your hands. Wear wel fitting This is a clinical y clean technique undertaken disposable gloves and apron. by the resident. • Always take the specimen from the sample port on the drainage bag tubing not the The relative or carer intermittently catheterises • Wipe the sample port with a detergent or the resident to assist in the drainage of urine alcohol wipe and al ow to dry. where normal voiding is not possible. This is a • Insert a syringe into the sample port and clinical y clean procedure. The relative / carer aspirate the urine sample into the syringe. should obtain ful consent from the resident • After obtaining sample dispose of syringe prior to undertaking intermittent safely, remove gloves and apron catheterisation. • Decontaminate your hands.
Types of catheter
There are two types of catheter available: Suprapubic catheters are inserted into the coated and uncoated (plastic) however, choice bladder through an incision in the abdominal of catheter should be guided by your wal and are managed in the same way as a continence advisor and resident choice: urethral catheter. a) Coated: a pre-lubricated plastic catheter, which needs soaking in tepid water to activate The same principles apply as to a urethral the lubricant. This is for single use only (one catheter, but in addition the skin around the entry site should be cleansed with warm water.
b) Uncoated: plain plastic catheter, can be There is usual y no need for a dressing. reused (number of uses may depend on manufacturer), cleaned and stored as manufacturer's guidelines CarE Of UriNary CaTHETErS
The procedure
To undertake intermittent catheterisation the resident wil need to be assessed by a continence advisor. For intermittent self catheterisation, the resident would normal y undertake this procedure entirely independently after sufficient teaching, supervision and support from the relevant continence advisor. Intermittent catheterisation is not performed under aseptic conditions but requires: • Thorough decontaminating of hands before and after the procedure. • Carers and relatives to wear wel fitting disposable gloves and apron. • Voiding of urine either directly into the toilet or into a clean container. • The frequency is dependent upon the resident's needs.
administration of feeds
The aim of this guidance is to provide practical It is important to explain to the resident what advice concerning infection control issues wil happen before enteral feeding starts. The related to enteral feeding within care home resident should be positioned with head and settings. The document "Prevention of shoulders raised to more than 30 degrees healthcare-associated infection in primary and during feeding and for least one hour after. community care" (NICE, 2012) has been adapted and should be read in conjunction Minimal handling and a non-touch technique with the fol owing guidance. should be used to connect the administration system to the enteral feeding tube. Wash Education of residents, carers and healthcare hands before and after handling the Only staff, carers and residents who have Administration sets and feed containers are for received education and training in the single patient use and once opened, must be techniques and principles of hand discarded after a maximum of 24 hours. decontamination, enteral feeding and management of the administration system, Check the feed against the prescribed regime, should be preparing and administering enteral expiry date and integrity of the feed and its container, prior to use. Fol ow-up training wil be arranged local y and Date and time of opening of feed should be support is usual y available for the duration of clearly recorded. enteral feeding, from your hospital nurse specialist, dietician or enteral feed company. When scissors are required, use sterile when
available or ensure that non-sterile scissors
preparation and storage of equipment and
are washed, dried and then wiped with an
alcohol wipe, before and after use.
It is not necessary to wear gloves, however effective hand decontamination must be If a resident has a nasogastric tube, prior to carried out before handling equipment and each feed administration, the position of the tube should be checked. It is acknowledged that pH sticks provide a more accurate acidity Pre-packaged, ready-to-use feeds should be test than litmus paper. please note that litmus
used in preference to feeds requiring paper is no longer recommended for
decanting, reconstitution or dilution. nasogastric testing.
Feeds should be stored in a clean, dry Single use syringes must not be re-used under
environment, according to the manufacturer's any circumstances; this includes syringes for
instructions and adhering to food hygiene flushing as well as bolus feeding. There are
however, syringes on the market that are
Enteral feeding pumps should be regularly designated for re-use on the same resident.
maintained and cleaned, fol owing These 50 ml syringes are acceptable for
manufacturer's instructions. flushing, giving medicines and feed but mUST
be used in accordance with manufacturer's
Pumps should be included on the homes guidelines on cleaning and storage.
equipment cleaning schedules and the cleanliness monitored through the homes audit Any syringe used for flushing should be at least NOTE: Tap water for drinking/enteral feeding
30ml capacity and if re-usable, washed, dried should be directly from a mains supply and
thoroughly and stored in an airtight container not a cold water tank. do not use water for
until ready for re-use. drinking or enteral feeding, from an en-suite
sink, bathroom or toilet area, as this presents
The enteral feeding pump should be kept clean.
a cross infection risk.
Detergent wipes should be available to remove feed drips and debris etc. The pump must be cleaned daily.
Ready to use feeds may be given for a whole administration session, up to a maximum of 24 Ideal y feeds should not be interrupted once in progress. If during feeding, the pump has to be paused, or the resident disconnected from the Do not add any water, medication or other feed, it is essential that the tube to the resident substance directly to the feed unless prescribed be flushed after disconnection and before for this purpose. reconnecting. Whilst disconnected, a clean end cap should be in place on the giving set. Sterile feeds opened for a bolus feed, can be resealed and stored on the top shelf of the Hanging time is the total time the opened feed fridge, for a maximum of 24 hours, then is held at room temperature and this should discarded. If re-sealing is not possible, the feed not exceed 24 hours. should be discarded. The tube should always be flushed using fresh Care of insertion site and enteral feeding tube
tap water prior to and fol owing administration of feed or medication. If more than one medication is to be administered, ensure that The stoma should be washed daily with mild they are never mixed and that the tube is soap and water and dried thoroughly as part of flushed before and after each medication. In the daily personal hygiene routine. If there is addition, the tube should be flushed every 6-8 evidence of over granulation (extra skin) or hours when not in use. excoriated skin around the stoma site, advice regarding management can be obtained from The purpose of giving water flushes for a your Nutritional Nurse Specialist. resident, who is receiving enteral feeding, is not only to provide the prescribed amount of fluid but to also keep the feeding tube patent.
The enteral feeding tube should be flushed with freshly run tap water or cooled freshly boiled water, before and after feeding or administering medications. Enteral feeding tubes for residents who are immunosuppressed or where the tip of the feeding tube is post pyloric (bypasses the stomach) should be flushed with either cooled freshly boiled water or sterile water from a freshly opened container. NOTE: Tap water for drinking/enteral feeding
Percutaneous endoscopic gastrostomy (PEG) should be directly from a mains supply and
tubes should be rotated in the tract daily from not a cold water tank. do not use water for
day 1 fol owing insertion. drinking or enteral feeding, from an en-suite
sink, bathroom or toilet area, as this presents
2 weeks post PEG placement, the external a cross infection risk.
fixation plate on the PEG should daily, be loosened, cleaned, rotated and pushed in/out, as advised by the Nutritional Nurse Specialist Seek advice from the resident's Pharmacist or and then re-secured to a comfortable position General Practitioner for the most suitable unless otherwise instructed. preparation for enteral tube administration e.g.
liquid, syrup etc.
Radiological y inserted gastrostomy tubes and percutaneous endoscopic jejunostomy (PEJ) Always flush the tube before, after and tubes are to be dried thoroughly and NOT between each drug administration. dO NOT
miX mEdiCaTiONS, admiNiSTEr THEm
If the resident has a bal oon inflated gastrostomy tube, your Nutritional Nurse displacement of tube and replacement
Specialist wil provide training regarding the checking of bal oon volume. • Nasogastric tubes
If a nasogastric tube becomes displaced or is blockage
removed, do not reinsert the same tube. To prevent blockage al enteral feeding tubes Staff who are competent to repass another be should be flushed with freshly run tap water nasogastric tube should check the or cooled freshly boiled water, before and after placement of the tube with pH sticks. feeding or administering medications. Enteral feeding tubes for residents who are • pEg tubes
immunosuppressed or where the tip of the If the tube was inserted less than four weeks feeding tube is post pyloric (bypasses the previously then contact your specialist nurse stomach) should be flushed with either cooled freshly boiled water or sterile water from a freshly opened container. If the tube has been in place for longer than four weeks it is imperative to insert a tube into When flushing, a push/pause technique is the stoma immediately to preserve the tract. A advised to create turbulence and thus assist in similar FR gauge tube such as a Foley or a keeping the tube clear from a build up of feed suction catheter is acceptable. Fol owing this, a and/or medications. referral to the Nutritional Nurse Specialist or Dietician for further advice or action is If the enteral feeding tube does become blocked gently instil cooled freshly boiled water or sterile water from a freshly opened container with a 50ml syringe into the tube, if no success, use a 20ml syringe. If warm water has not been successful, gently instil soda water using a 20ml syringe. If these actions do not clear the blockage seek advice from your Nutritional Nurse Specialist or Dietician. mouth care
It is important that advice is taken when using any product/ water during mouth care, especial y if the resident has an unsafe swal ow. Mouth care should be carried out twice daily, using a toothbrush and toothpaste unless advised otherwise. Foam mouth sponges should not be used.
Artificial saliva sprays can be used to help maintain a moist mouth. Mouthwashes may be used for oral hygiene. Some mouthwashes are available in a gel consistency that can be applied directly to the gums.
For further advice contact the Dentist, Dental Hygienist or Speech and Language Therapist if the resident has an unsafe swal ow.
maNagEmENT Of mrSa
(meticillin resistant Staphylococcus aureus)
MRSA causes the same types of infections that ordinary strains of Staphylococci cause –skin, MRSA is a strain of Staphylococcus aureus, wound and soft tissue infections, pneumonia, which is a common bacterium, carried urinary tract infections and septicaemia. harmlessly on the skin or the nose of about one person in every three. MRSA stands for It is necessary to treat a clinical MRSA infection "Meticil in resistant Staphylococcus aureus".
in a resident in the same way as you would This means that the antibiotic "Meticil in" or treat any other infection i.e. with appropriate "Flucloxacil in" (its prescribed equivalent) is not effective in the treatment of infections caused by this type of Staphylococcus aureus.
Alternative antibiotic therapy in the treatment Certain factors were identified that potential y of MRSA infections is required which may carried a higher risk of contracting MRSA, include drugs which have significant side • Intravenous devices • Surgical wounds • Pressure sores The most common route of spread is on the • Urinary catheters hands of staff. MRSA carried on the hands of • Immunocompromised patients staff can be transmitted directly to another • Frequent hospital admissions Transmission may also occur by environmental Within the community setting, there is little contamination (dust, equipment, etc). It has evidence that MRSA is a general hazard to also been suggested that transmission may visitors, staff or their families, including occur through an airborne route such as pregnant women, babies, and young children. shaking bedclothes during bed making. Colonisation and infection
MRSA may colonise the skin (i.e. live harmlessly without causing an infection,) therefore, colonisation does not usual y require treatment It is unnecessary to treat MRSA colonisation in the community, however in exceptional circumstances this may be requested if the resident is undergoing particular procedures in hospital or the home has particular risk factors.
In these circumstances the hospital wil liaise with the home to organise treatment for the maNagEmENT Of mrSa
routine screening is not routinely indicated in
the community and should only be
1. In an outbreak situation (where there is evidence of cross infection) and this wil be initiated by the Infection Control 2. Prior to pre-planned admission to hospital for elective surgery/investigation if previously known MRSA patient.
3. On request for pre-operative screening from the hospital.
4. If the patient has an acute wound which looks infected.
5. Prior to catheterisation The fol owing swabs should be obtained: Nose (one swab both nostrils) Rotate swab around the anterior nares (Nostrils) Groin (one swab both groins) Rotate swab firmly across each groin Swab any lesions using a zigzag technique. Label with site and position of wound/lesion Only If the patient is catheterised.
• Moisten swabs in sterile saline/water if the area is dry.
• Swabs can be sent on one Microbiology form label ed MRSA Screen.
NB if there are signs of clinical infection at a site the swab i.e. pus, pain, heat or the resident is pyrexia the specimen or swab should be submitted on a separate request form requesting culture and sensitivity, as swabs for MRSA wil be screened only for MRSA.
maNagEmENT Of mrSa
Topical creams/ointments used for the treatment of MRSA infections, particularly when applied to large broken areas are usual y discouraged due to the potential emergence of further resistance, which can be a significant If treatment is already commenced at the time of admission to the home it should be completed according to the prescribed regime. Eradication Therapy (decolonisation)
An attempt at eradication may be considered but should be discussed with the Infection Prevention and Control team: Apply neat to damp skin Daily for 5 days. (the whole body with Antiseptics should be used particular attention to once a week.
with care in patients with armpits, groins under eczema, dermatitis or the breasts) and wash off more delicate aging skin.
If there is chlorhexidine sensitivity consult mupirocin nasal ointment
Apply a smal blob onto a If mupirocin resistance cotton bud and rotate consult advice. The use of into the anterior nares. nasal mupirocin alone for clearance of nasal carriage of patients, or staff, who also have skin breaks, is not recommended.
After washing clean towels and clothes should be used as far as reasonably practicable. Disposable cloths should be used rather than flannels and these should be disposed of after use . Sponges should not be used, as they wil support the growth of bacteria. Bed linen should be changed daily if possible during the treatment to prevent re-colonisation from used linen.
maNagEmENT Of mrSa
general mrSa management principles within
care homes
If the resident is to be transferred to hospital or • The presence of MRSA does not preclude has an appointment in a unit within the acute admission/re-admission to a care home. hospital e.g. X-Ray, Outpatient Department • It is not necessary to isolate residents in care etc., the receiving hospital/home must be homes because they are colonised/infected informed of the residents' MRSA status, if known. A patient risk assessment transfer form • Department of Health guidelines advise that should be used.(Appendix 6) residents with invasive devices (catheters, PEG feeds, etc.) known to be colonised/infected with MRSA should not Transport of residents by ambulance
share a room with other residents with The fact that a resident has MRSA must never delay or prevent clinical attention, such as • Disposable gloves and disposable plastic investigations, or treatment. apron should be worn when handling blood and body fluids as for any other resident. Residents with MRSA do not present a hazard • Cuts, sores and wounds in residents and to ambulance staff or their families. staff administering personal care must be kept covered with a waterproof dressing.
If a known MRSA positive resident has to travel • As with al resident care, (MRSA or not), by ambulance, the Ambulance service should hand hygiene is the single most important be informed in advance in order to undertake means of preventing cross infection. the appropriate risk assessment. • Changing dressings or providing other nursing care for MRSA positive residents should be carried out in their own room. last offices
• Equipment such as commodes and baths The precautions taken during the laying-out of should be cleaned thoroughly with general- the deceased are the same as those observed purpose detergent and hot water and during life. Any lesions should be covered with fol owed by bleach after use. impermeable dressings. A plastic body bag is • Linen should be handled as for any other not necessary.
• Cutlery, crockery and clinical waste should be dealt with in the normal way. • Ensure the general environment is kept scrupulously clean. The resident's bedroom should be thoroughly cleaned and carpets vacuumed daily. Mop head and cleaning cloths should be disposed of after use ClOSTridiUm diffiCilE
Clostridium difficile (C.difficile) is a spore The il ness ranges from mild to explosive foul- forming bacteria. These spores are shed in smel ing diarrhoea however, C.difficile may also large numbers from the bowel in faeces and lead to a more severe infection. Complications are resistant to air exposure, drying and heat associated with C.difficile infection include and the spores can survive for long periods in dehydration, electrolyte imbalance, pseudo the environment. membranous colitis, colon perforation and toxic megacolon. Clinical features include: C.difficile is commonly found in the large intestine of 2-3% of healthy adults, where it is • Foul-smel ing explosive watery diarrhoea kept under control by the normal intestinal • Abdominal pain. flora (DH 2007). A major defence against • Fever (in some cases) C.difficile infection is the maintenance of normal intestinal bacteria. When the normal it is associated with:
balance of bacteria in the gut is disrupted • Commencing antibiotic therapy-it usual y usual y through the use of antibiotics, C.difficile starts within 5-10 days but clinical infection are al owed to multiply and produce a toxin may be up to 2 months. The use of broad that irritates the bowl. This may result in mild spectrum and multiple antimicrobial agents to severe diarrhoea, colitis and occasional y given concurrently or sequential y increases the pseudomembraneous colitis, which can be fatal • Proton-pump inhibitors Although the majority of C.difficile infection occurs within the long term care or hospital • Bowel surgery setting, it is not uncommon to have C.difficile • Underlying il ness infection in the community environment. Al age groups can be affected; however C.difficile mainly affects the older population with 80% of reported cases being in the over 65 age group.
Children under the age of 2 years are not usual y affected. The more virulent strain of C.difficile (027) has caused severe disease, mortality and outbreaks in hospitals. C.difficile has become an increasing problem within healthcare environments. It is essential that care workers are aware of the measures required to prevent and control the spread of this organism should it occur in a care home ClOSTridiUm diffiCilE
Treatment and management
• Patients need to be reviewed regularly to Residents presenting with the above symptoms enable monitoring and effective should be reviewed urgently by their GP who management of the C.difficile infected should consider the fol owing: • Wherever possible and the residents • If diarrhoea persists assessment of the condition al ows, stop pre-existing systemic resident's need of re-hydration and monitor antibiotic therapy.
potassium, magnesium and renal function is • Anti-motility treatment e.g. codeine, loperamide should not be prescribed if C.difficile is suspected, as these may Al residents presenting with diarrhoea of aggravate colitis symptoms, which may unknown cause should be isolated in their result in toxic mega-colon.
bedroom preferably with en-suite facilities if possible until microbiology laboratory results • Proton-pump inhibitors and morphine are available to confirm causative factor(s).
should be reviewed as these may contribute Outbreaks of C.difficile are usual y due to cross to the severity of symptoms.
transmission and should not occur if the fol owing precautions are fol owed: • Residents with C difficile infection should always have baseline blood count and urea and electrolyte testing performed • Residents identified as suffering from C.difficile infection should be isolated in • If mild and moderate disease first line their bedroom preferably with en-suite toilet treatment is oral metronidazole 400mgs 8 and hand wash facilities. If unavailable a hourly for at least 10 days and up to 14 days, designated commode or toilet should be irrespective of whether symptoms settle prior to completion of the course. • They should remain in isolation until 48 hours without diarrhoea and a normal stool.
• If diarrhoea does not settle promptly (within 5 days) switch metronidazole to oral monitor the residents condition
vancomycin 125mgs 6 hourly. Oral • Record vital signs i.e. blood pressure vancomycin is not absorbed by the gut, but temperature etc four hourly. is active against C.difficile so no vancomycin • Maintain fluid balance and a stool chart. See assays or levels are required. • It is important to accurately monitor the • Severe symptoms may required the resident patient's fluid balance.
to be transferred into hospital and managed • If patient is dehydrated ensure they are promptly seen by their GP and appropriate action taken.
• Relapse is common (up to 20%) especial y if • Carers must deliver basic aspects of care and broad spectrum antibiotics are re- take steps to prevent the patient becoming dehydrated, malnourished or the patient's skin breaking down.
• If the resident does not start to improve • High impact intervention tool must be used promptly or shows any signs of deterioration for every case of C.difficile (Saving Lives the GP should contact the Microbiologist to discuss the patient's treatment options and consider referral to hospital. ClOSTridiUm diffiCilE
infection prevention precautions
• If a commode is used advice regular cleaning • Disposable gloves and aprons must be worn with a bleach solution around the commode when performing care or bed making.
frame is required. The commode pot should • Health care workers should ensure that be process through a washer disinfector and scrupulous hand hygiene occurs fol owing returned to the resident's room. If a washer patient contact and contact with the disinfector is not available care staff must environment. Alcohol hand gel is ineffective careful y empty the pot down the toilet against C.difficile spores. Please refer to taking care not to contaminate the seat and hand decontamination section surrounding area. The commode pot should • Encourage residents to wash their hands be taken to a sluice facility and washed with with soap and water after using toilet detergent and hot water fol owed by sodium facilities and prior to eating or drinking. hypochlorite 1,000ppm ( Bleach) Residents who are unable to perform this • Staff must ensure care is taken not to task should be offered assistance or a contaminated surfaces and surrounding area disposable wipe by care staff.
when cleaning commode pots. The • Food and drink should not be left uncovered commode pot should be dried with paper in the resident's room as this wil easily towels and returned to the resident's room. become contaminated with C.difficile Commode pots must not be washed in hand wash basins used for hand washing.
• Any food items which are uncovered must • Staff must take care when handling pads and be washed prior to consumption e.g. fruit.
linen contaminated with faeces. Pads, linen etc must be placed directly into a waste or linen bag, closed and taken directly to the • Visitors to residents infected with C.difficile disposal point. See waste and linen should not be discouraged; however advice should be sought if visitors are sick or frail.
• It is not necessary for visitors to wear gloves and aprons unless participating in close • Daily change of bed linen contact activities.
• Linen should be placed in a red alginate bag • Visitors should wash their hands with soap and placed inside a secondary bag and and water before leaving the room and removed from the room immediately.
should not visit other residents.
• The alginate bag must be placed directly into the washing machine separately from other disposal of waste
laundry and washed on the highest • Al waste must be disposed of as clinical temperature and tumble dried.
waste. Clinical waste (Orange hazardous • Hand must be washed with soap and water waste bag) bags must be removed promptly after removal of gloves.
from the room or area.
disposal of urine and faeces
• Staff must wear apron and gloves when handling body fluids • A flush toilet is preferable ClOSTridiUm diffiCilE
Cleaning of equipment
Transfer to other healthcare organisations
• Single-use equipment if appropriate and • Residents must not be transferred to other facilities until free from diarrhoea for 48 • Clean al clinical equipment with detergent and water fol owed by sodium hypochlorite • If the resident is acutely unwel and transfer 1,000ppm (Bleach) to secondary care is required relevant personnel must be informed e.g. admitting Cleaning of the environment
hospital/ambulance crew, identifying • Use yel ow disposable cloths and dispose infection risk on transfer form immediately after use.
(see appendix 6).
• Designated mop and bucket for isolated patients and patient toilet.
• General cleaning of the environment to be carried out at least daily with sodium hypochlorite, paying particular attention to bedside tables, horizontal surfaces, toilets, toilet flushes and taps.
Terminal clean (cleaning a room once the
resident is free from symptoms for 48 hours)
• When a resident is symptom-free the room should be deep cleaned, al washable surfaces must be cleaned with detergent and water fol owed by sodium hypochlorite • Carpets must be steam cleaned.
• Equipment must be cleaned prior to removal • Any toiletries, unwanted items or disposal items must be disposed of as clinical waste even if unopened (e.g. sterile dressing • Unused linen to be placed in red alginate bags and taken to the laundry.
• Curtains must be removed prior to terminal cleaning. Hanging of the clean laundered curtains should be performed once the room has been cleaned.
ClOSTridiUm diffiCilE
What is the treatment?
What is clostridium difficile?
Clostridium difficile is a spore forming bacteria medical management:
found in the bowel of a smal percentage of the In mild cases treatment may not be required or adult population, and in these people is part of may be restricted to withdrawal of any current their normal bowel flora causing no harm. antibiotic therapy which the doctor wil assess. Note: If a stool specimen identifies the The drugs of choice are usual y ORAL presence of C.difficile and the individual has no metronidazole initial y then if the individual diarrhoea, in these circumstances the C.difficile does not respond ORAL vancomycin. is of no significance. Nursing management:
When does clostridium difficile cause a
Careful hand decontamination is required to prevent transmission of C.difficile spores.
When the normal bowel flora is disturbed most Ensure al staff wear gloves and aprons if commonly fol owing treatment with antibiotics, handling infected material. C.difficile has the opportunity to multiply producing a toxin that causes colitis. Symptomatic residents should be nursed in a single room if practical. Ensure thorough What are the symptoms of the illness?
environmental cleaning is undertaken at least The il nesses range from mild diarrhoea and on a daily basis. colitis to life threatening pseudo membranous Precautionary measures may be lifted when the resident has had a normal bowel pattern The symptoms of the milder forms of this il ness are usual y diarrhoea, abdominal pain and sometimes dehydration. More severe If the resident requires antibiotics in the future forms of the il ness wil require hospital for an infection such as a chest infection, urinary tract infection etc, it may be useful to inform the prescribing doctor of any previous is clostridium difficile a cross infection
episodes of Clostridium difficile diarrhoea the resident has had and observe for any loose YES - Outbreaks of cross infection have been stool. If loose stools occur send a sample for reported from symptomatic individuals, that is, those who have C.difficile and have associated Testing of stool specimens for presence of C.difficile after recovery is not indicted. Transmission to other susceptible individuals is likely to occur from two sources, firstly on the relapse:
hands of health care workers and secondly Relapse in a significant proportion of cases wil from a heavily contaminated environment and occur within one week of completion of treatment. It is therefore important to monitor the bowel pattern of the individual during this maNagEmENT Of CaSES aNd
OUTbrEakS Of SCabiES
Scabies is an al ergic response to the excreta and saliva of the parasitic mite, Sarcoptes • Itching, particularly at night scabiei that burrows in the skin. Transmission • A symmetrical unexplained rash of mites is usual y by direct skin-to-skin contact • Burrows and other lesions on the sites lasting at least a couple of minutes. The environment is not usual y a route of transmission as the mites do not survive away A doctor must make the diagnosis of scabies, from the body therefore, normal cleaning of the decision to treat any skin-to-skin contacts furnishings and carpets is sufficient. of the case wil depend if the diagnosis is a possible or definite (probable) case of scabies Signs and symptoms of scabies may take and the type of contact with the case. several weeks to develop but during this period asymptomatic individuals can transmit mites to other people. Typical presentations of scabies Sites of infection
include an itch, which intensifies at night, and a The most common areas affected are between bi-lateral rash affecting fingers, wrists, the fingers, wrists, elbows, armpits, waist, forearms, axil ary folds, around the waist, lower thighs, genitalia, nipples, breasts and lower quadrants of the buttocks or around the ankles.
buttocks. In infants, the elderly and those who It may also be possible to observe tracking are chronical y il , the mites can be found on marks (burrows) between the fingers. the face, ears and scalp. It should be recognised that scabies causes an al ergic It must be stressed that individuals with scabies reaction, and the itch and the rash may not do not always present with "typical" signs and always coincide with the site of the mite.
symptoms and diagnosis is often difficult. Appropriately trained professionals who wil look for burrows and/or mites can make a clinical diagnosis. Usual y there are fewer than ten mites on the entire body and therefore evidence of infection can easily be missed.
Recovering the mite from its burrow by taking skin scrapings and identifying it microscopical y may establish diagnosis. However scabies should always be suspected in the presence of the fol owing symptoms: maNagEmENT Of CaSES aNd
OUTbrEakS Of SCabiES
Note: It is necessary to report suspected The rash is an al ergic reaction of the body to outbreaks of infectious il ness (two or more the mite, its waste products and the eggs cases) to the relevant organisations and deposited by the mite under the skin. The individuals (see section: reporting of infection).
appearance and severity of symptoms varies from person to person and as with al al ergies, the symptoms and their severity are strongly Al staff and residents having close contact with influenced by the immune status of the a diagnosed outbreak of scabies affected individuals. may require treatment even in the absence of symptoms. In many homes this wil involve al if scabies is diagnosed in your care home:
residents, staff and family members of the symptomatic resident that provide direct client When a single case of scabies is diagnosed
care being treated simultaneously in a co- (resident or staff)
ordinated way.
Treat the case and observe for symptoms in al It is recommended that the management of the other residents and staff for the next 4-6 care home facilities takes responsibility for weeks. Under take body mapping of al purchasing the scabicidal treatments for their residents to record any suspicious rashes. If staff. By doing this the home management can further possible or definite cases develop refer ensure that treatment is undertaken at the to "When more than one case is diagnosed same time and wil reduce the risk of prolonged (resident and/or staff)". When more than one case of scabies is
There is no evidence to support the spread of diagnosed (resident and/or staff)
scabies by fomites such as towels, bedding, soft If there is more than one person diagnosed as a furnishings or equipment. However, such items possible or definite case of scabies in a care may play a part in the dissemination of the home setting it is usual y necessary to treat al more unusual form of scabies infection known residents and staff whether they have as hyperkeratotic scabies (also known as symptoms or not. crusted, Norwegian or atypical scabies). Please contact your Infection Prevention and Control To assess who requires treatment the fol owing Team or Health Protection Agency if this is information has to be considered: being considered.
• Are the cases possible or definite? Normal washing temperatures for linen can be • For each case the duration and location of used and should be fol owed by thorough the symptoms on the body. • Have any of the cases received treatment for scabies or any other skin condition? Care home staff do not need to stay off duty • Location of affected residents in the care provided that they have observed the minimum contact time for their initial • Area of work in the care home if a member Where staff have responsibility for applying the Please contact your Infection Prevention and liquids/cream to residents, they should wear Control Team or Health Protection Agency if disposable non-sterile CE marked gloves and necessary to assess individuals who should be aprons to do so.
considered for treatment. maNagEmENT Of CaSES aNd
OUTbrEakS Of SCabiES
Co-ordination of treatment
Treatment should be applied to the whole
To minimise treatment failure it is necessary to body including the scalp, neck, face and ears.
be aware of the fol owing: • Staff should wear personal protective It is the responsibility of the owner, manager or equipment when applying treatment for nominated lead of a care facility to: • It is important not to wash off treatment • Identify a day when application of treatment during the recommended contact time. is given to al residents and staff Therefore, if the hands are washed or • To make sure that there are additional staff incontinence occurs treatment must be available to administer treatment for • The day fol owing treatment, used • To make sure that there are additional staff nightclothes and bed linen should be to undertake laundry and cleaning duties laundered on a hot wash, not for any • To make sure that al symptomatic residents infection control purpose but to ensure al are given a second application 7 days later traces of treatment are removed from • To make sure that al treatment is nightclothes/bed linen. Al other articles of documented in residents care record.
clothing or bedding should be cleaned in the • Post a notice in a public area of the home to inform visitors that an outbreak of infection is currently being experienced • Management should consider the need to • It is normal for symptoms (itch and/or rash) temporarily close to admissions/respite to persist for some weeks after successful treatment. These may be al eviated with treatments prescribed by the General application of treatment
• However, any individual with persistent • Everyone should be treated on the same symptoms 6 weeks after the second treatment requires medical assessment to • do not have a bath or shower before
exclude treatment failure or re-infection. applying treatment as the skin should be admissions and transfers to and from the care
• Leave treatment on for the recommended contact time, which wil vary from overnight During an outbreak of scabies it is advisable not (8-12 hours) up to 24 hours, depending on to admit or transfer residents until treatment is treatment prescribed. successful. If a resident requires hospital • Current recommendations are that
admission, the Care Home must inform the malathion and permethrin treatments are
admitting ward of the situation in the care applied twice one week apart
home (this applies to al residents regardless of • Apply treatment to the whole body not only
symptoms). Use the Assessment/hospital where the rash is present. Pay particular transfer form Appendix 7.
attention to the webs of the fingers and toes and under the nails. maNagEmENT Of CaSES aNd OUTbrEakS Of
diarrHOEa aNd VOmiTiNg
fOllOW THE NOrOVirUS TOOl kiT (SaNdWEll pCT)
general information
Care of residents
1. Diarrhoea in elderly people is common and If possible al ocate the same staff to either does not always have an infectious origin. symptomatic residents or asymptomatic Infectious diarrhoea in the elderly can cause residents. Al staff who may have direct contact considerable morbidity and mortality and with symptomatic residents must be ful y informed and fol ow the precautions listed 2. Al cases must be presumed to be infectious until advised otherwise. 1. Al symptomatic residents should be cared for in their room whenever possible until 3. The residents' General Practitioner should asymptomatic for 48 hours. If diarrhoea is be notified. If infection is suspected, the prolonged it may be unreasonable to keep General Practitioner may arrange for faecal the resident isolated for an extended period specimens to be sent to the laboratory. and individual circumstances may need to be considered, or advice sought. 4. If more than two cases which are known or 2. Single use disposable aprons and gloves suspected to be infectious occur within a must be used by staff administering care to few days, the HPA must be notified. They in symptomatic residents. Aprons and gloves turn wil notify the Environmental Health should be disposed of into a clinical waste Department of the Local Authority if 3. Soap dispensers and disposable hand towels must be used in each of the symptomatic 5. If admission to hospital is required the staff residents' rooms and in al communal member in charge should inform the ward resident toilets. or area within the hospital of the suspected or definite diagnosis and complete a transfer 4. alcohol hand rubs should not be used and
staff should be encouraged to wash hands with soap and water. 6. Staff must wear disposable gloves and aprons to handle soiled linen which should be placed within a water soluble bag, then washed in a washing machine on a hot wash. Delicates should be washed separately on a normal wash cycle. After placing the washing in the machine staff should remove gloves and apron and wash 7. Cleaning of hard surfaces, toilets and wash hand basins including door handles and taps must be increased to three times a day using a dilute solution of hypochlorite/bleach maNagEmENT Of CaSES aNd OUTbrEakS Of
diarrHOEa aNd VOmiTiNg
5. Emptying and cleaning of commodes and
(c) Homes that have minimum toilet facilities:
bed pans from symptomatic residents:
Where homes are unable to designate a separate toilet for the disposal of excreta and (a) Sluice facilities available:
cleaning of the commode pan/bed pan, it is When disposing of excreta disposable gloves vital that cleaning and disinfection of the area and aprons must be worn. Cover the is thorough to reduce the risk of cross bedpan/commode pan and remove to sluice infection. Immediately after each disposal of area immediately. Commode pots and bedpans excreta the toilet bowl, sink and surrounding should be washed using a washer disinfector. If surfaces in the area (including taps) should be excreta is disposed of manual y take care to cleaned with hot water and general-purpose avoid splashing. If the bedpan/commode pan detergent, then wiped with a 1000ppm dilution has to be cleaned manual y it should be of bleach. The use of protective clothing and washed in hot water and general-purpose hand washing should be adhered to as detergent and then disinfected in a previously discussed. hypochlorite/bleach solution (1000ppm). After cleaning the bedpan/ commode pan remove gloves and apron then wash hands thoroughly, but not in the sink in which the cleaning of the 1. Staff with diarrhoea or vomiting should be bedpan/commode pan has been carried out.
off work until they have been free of Return the bedpan/commode pan to the symptoms (diarrhoea or vomiting) for residents' room. (b) Sluice facilities not available:
2. Staff should not cross over from care giving Designate an area for the disposal of excreta to catering duties during a shift. If a cross and cleaning of bed pans/commode pans. This over from one duty to another is intended area should be reserved for this use only and then complete change of clothing/uniform is should consist of a toilet and sink as minimum necessary and thorough hand hygiene Disposal of the faeces should be into the toilet For organisations where there are more than and cleaning/ disinfection of the bed one home and staff move between these pan/commode pan should be carried out in the homes during the course of their duty staff sink. The sink should be cleaned with hot water must avoid moving and working between and general-purpose detergent and disinfected homes during and outbreak with a hypochlorite/bleach solution Staff must wear disposable gloves and aprons whilst dealing with excreta and cleaning the bed pan/commode pan. Hand washing must be thorough and should not take place in the sink in which the bed pan/commode pan has been cleaned. maNagEmENT Of CaSES aNd OUTbrEakS Of
diarrHOEa aNd VOmiTiNg
8. Incidents of vomiting or incontinence in a An outbreak of gastroenteritis is defined as communal area should be cleaned up more cases of diarrhoea and vomiting than immediately and the area wel ventilated to would normal y be expected among residents.
reduce possible airborne spread of viruses. Report two or more cases to the Health If carpeted areas are contaminated the Protection Agency (HPA) and the Infection affected area should be cleaned, Prevention and Control Team as soon as shampooed and if, a steam cleaner should 1. Faecal specimens should be obtained from al symptomatic staff or residents. Request forms marked clearly "OUTBREAk" ensuring the name of the care home is clearly shown. 2. An ongoing record should be kept of al cases including name, date of birth, date of onset, symptoms and if a specimen has been obtained. Any investigation wil require a list of al residents and staff, and these should be prepared in advance if possible. 3. If food poisoning is suspected, Environmental Health Officers wil wish to obtain a food history from residents and staff. Diet sheets and menus wil be 4. One or more toilets must be designated for the sole use of symptomatic residents. 5. Admissions to, or transfers from, the care home should be suspended until al cases have been asymptomatic (no diarrhoea or vomiting) for 48 hours. This may be varied fol owing discussion with the HPA.
6. Events, functions and parties serving food and drink to outside visitors should be cancel ed or postponed until clearance is given by the HPA. 7. Consideration should be given to the safety of visitors of residents with infections, particularly the elderly and very young visitors. In addition to verbal advice consider the provision of written advice on the nature of the infection and how to prevent cross infection for relatives of affected blOOd bOrNE VirUSES
Hepatitis b - what is Hepatitis b?
Hepatitis C - What is Hepatitis C?
It is a virus that affects the liver and may cause it is a virus that affects the liver and may
cause liver damage
What are the symptoms?
The symptoms of an acute il ness may include: What are the symptoms?
Acute infection is usual y mild, if symptoms • A flu like il ness occur they may include: • Nausea and vomiting • Nausea and vomiting • Jaundice (yel ow discolouration of the skin and eyes) • Mild jaundice - though this is uncommon Some people may not develop any symptoms The majority of people (between 50-80%) with at al and may never know they have been Hepatitis C wil become long-term carriers and infected. The majority of people (over 90%), if of these around half wil develop liver damage.
infected with the Hepatitis B virus in Approximately 20% of infected people wil adolescence or adulthood wil recover recover completely without significant medical completely without any medical intervention.
Only a few (less that 10%) wil become long- term carriers of the virus and a smal How is the virus transmitted?
percentage of these wil develop significant • Blood to blood contact with an infected person. This can include using dirty/shared How is the virus transmitted?
needles or equipment for injecting drug use, • Blood to blood contact with an infected accidents with used needles/blood stained person. This can include using dirty/shared sharp objects, blood splashes to the mucous needles or equipment for injecting drug use, membranes e.g. eyes and very rarely sharps injuries, blood splashes to the mucous membranes e.g. eyes and very • The main group of people affected are intra rarely through biting. venous drug users who share injecting • Unprotected sexual intercourse with an equipment e.g. needles, syringes, filters, infected person. water, tourniquets etc. • An infected mother can pass the virus to her • People who had a blood transfusion before 1991 are possibly at risk of acquiring • The sharing of toothbrushes/razors. hepatitis C. The virus was identified for the • You cannot get hepatitis B from normal first time in 1989 and blood has been social contact e.g. hugging, kissing, sharing screened in the United kingdom from 1991. cups, crockery, cutlery etc. • The virus has been found in sexual fluids, but it is not thought to be a significant method of transmission. There is a vaccine available against Hepatitis B.
• An infected mother can pass the virus to her A risk assessment is always carried out prior to unborn baby – thought to be a low risk immunisation as the vaccine is only offered to (approximately 6%). certain at risk groups, including workers who are classed as being at a high risk of acquiring Vaccination - There is no vaccine available
Hepatitis B occupational y. Hepatitis B against Hepatitis C immunisation is not a substitute for good infection control practices. blOOd bOrNE VirUSES
Human immunodeficiency Virus (HiV)
What is HiV?
It is a virus that affects the immune system. An individual diagnosed with HIV can live a healthy and symptom-free life for many years. A diagnosis of AIDS (auto-immune deficiency syndrome) may be made only if the individual is suffering from one or more of a predetermined list of il nesses e.g.
tuberculosis, kaposi's sarcoma, Pneumocystis carini pneumonia. What are the symptoms?
Approximately three weeks after exposure to the virus, the individual may develop sero- conversion il ness. The symptoms may include: • A mild flu like il ness • Painful joints and muscles • Loss of weight How is the virus transmitted?
• Blood to blood contact with an infected person. This can include using dirty/shared needles or equipment for injecting drug use, accidents with used needles/blood stained sharp objects, blood splashes to the mucous membranes e.g. eyes, and very rarely • Unprotected sexual intercourse with an infected person. • Mother to baby before, during or after birth (approximately 14%). Vaccination - There is no vaccine available
against HIV.
Shingles is caused by the same virus which What is the treatment for shingles?
causes chicken pox, the varicel a zoster virus.
The aim of treatment is to lessen tissue Only those individuals who have previously had damage, reduce pain and resolve the rash.
chicken pox can develop shingles. Antiviral treatment if given in the early stages of the il ness (within 48 hours of the rash After infection with chicken pox the virus appearing), can reduce the severity of the remains dormant in the body causing no harm il ness and prevent further blisters erupting. In but may be reactivated at a later date (up to addition to topical cream/ointments oral many years) resulting in shingles. It is not medication is usual y prescribed. Therefore it is known what causes the virus to reactivate but important to contact the General Practitioner reactivation is usual y associated with as soon as possible if you suspect a resident conditions that depress the immune system, may have shingles. such as old age, stress, and immunosuppression. Shingles can affect any Pain associated with shingles is often severe age group but it is most commonly found in the therefore, pain relief wil be required. If dressings have to be used to cover affected areas due to their location then non-adherent People with shingles are contagious to those dressings must be used to reduce discomfort. who have not had chicken pox. There is a risk of contracting chicken pox from contact (direct are there any complications associated with
or indirect) with the blister fluid of the shingles The shingles blisters may become infected therefore, it is important to keep the affected Therefore, carers who have not had chicken
areas as clean as possible i.e. avoid pox (or been immunised against it) or are
unnecessary touching. pregnant should be excluded from caring for a
resident with shingles. a risk assessment
additional information
should be undertaken for residents with
The Department of Health now recommends shingles sharing a room with others. please
varicel a immunisation for non-immune seek advice if you are concerned.
healthcare workers who work in primary care and hospitals and who have direct patient N.B. It is not possible to get shingles from a person who has chicken pox. NB Staff who have previously had chicken pox What are the signs and symptoms of shingles?
are deemed to be immune.
The first sign of shingles is usual y pain in the affected area. A rash of fluid-fil ed blisters then appears which is usual y present for about 7 days but the pain may persist for longer.
Persistent pain is more common in the elderly and is termed "post-herpetic neuralgia". aSEpTiC TECHNiqUE/NONE TOUCH
Aseptic technique is one of a number of Hand washing
procedures that contributes to preventing ‘Arms must be bare below the elbow', rings Health Care Associated Infections (HCAI). This jewel ery wrist watches must not be worn.
guideline provides the principles of asepsis and Hands must be cleaned before and after every should be considered whenever an aseptic patient contact and before a non touch aseptic technique is undertaken. technique is performed.
principles of asepsis (royal marsden
Damp or poorly dried hands wil increase the numbers of micro organisms on the skin which can then be easily transferred to other Infection is caused by organisms which invade surfaces. Dry hands wel using paper towels.
the host's immunological defence mechanisms; A dispenser of alcohol hand rub should be although susceptibility to infection may vary placed on the lower shelf of the trol ey used for from person to person. The risk of infection is aseptic techniques, to al ow hands to be increased if the patient is cleaned during the aseptic procedure. When immunocompromised by: undertaking a procedure in a patient's own • Age. Neonates and the elderly are more at home staff must ensure they have access the risk because their immune systems are less hand rub. A nurse with 'social y clean' hands wil not need to wash them during the aseptic • Underlying disease. For example, those procedure, but should use a bactericidal patients with severe debilitating or alcoholic hand rub whenever disinfection is malignant disease.
required, e.g. after opening the outer wrappers • Prior drug therapy, such as the use of of dressings. The use of a hand rub wil also immunosuppressive drugs or the use of remove the need for the nurse to leave the resident during the procedure to wash the • Patients undergoing surgery or hands at the nearest basin, during which time contamination may occur.
For those patients who are most susceptible to infection. The most usual means for N.B. However, alcohol hand rub must not be spread of infection include: used during procedures on patients with C.diff • Hands of the staff involved or viral gastroenteritis.
• Inanimate objects, e.g. instruments and Non touch technique
• Dust particles or droplet nuclei suspended in A non-touch technique is essential to ensure that hands, even though they have been • Patients own skin flora washed, do not contaminate the sterile equipment or the resident. This can be achieved by the use of either forceps or sterile Gloves can become contaminated during use with firm touching of the skin rather than light touching without any skin contact, leading to increased contamination. Hands must be washed after removal of gloves.
inanimate objects
Single use equipment
Al instruments, fluids and materials that come Single-use – The expression ‘single-use' means
into contact with the site must be sterile if the that the medical device is intended to be used risk of contamination is to be reduced. on an individual resident during a single Maintain these four principles of asepsis: procedure and then discarded. It is not • Identify what is sterile intended to be reprocessed and used on • Identify what is not sterile another resident.
• keep these two types of items separate • Replace contaminated items immediately.
The symbol below is used on medical device packaging indicating ‘do not reuse' and may replace any wording.
Sterile packs must be checked prior to opening.
key points to remember:
Packaging must be, dry intact and within the • A device designated for ‘single-use' must expiry date. Care must also be taken to ensure not be reused. It should only be used on an that equipment and lotions are sterile and that individual resident during a single procedure packaging is undamaged before use.
and then discarded. It is not intended to be reprocessed (washed or decontaminated in Al medical devices must carry the CE any way) and used again, even on the same (Conformité Europèene) marking which al ows residents, clinicians and other users to be confident that the medical device wil perform • The reuse of single-use devices can affect as the manufacturer intends and is safe when their safety, performance and effectiveness, used as instructed. Any faults or incidents with exposing residents and staff to unnecessary medical devices must be reported to the Medicines and Healthcare products Regulatory Agency (MHRA).
• The reuse of single-use devices has legal implications .Anyone that reprocesses or The manufacturer's recommendations for al reuses a device intended by the clinical supplies must be fol owed at al times.
manufacturer for use on a single occasion The reuse of single-use items must not occur bears ful responsibility for its safety and and could result in legal, economic and ethical effectiveness MHRA DB (2006).
consequences (MHRA 2006).
Remember reprocessing can mean anything Any equipment that becomes contaminated from sterilisation undertaken in an accredited during a procedure must be discarded. On no facility to washing a piece of equipment under account should contaminated equipment be returned to the sterile field. Additional supplies of equipment should be available, in case of contamination.
The dressing trolley
Waste that is generated from aseptic technique It is essential that equipment such as trol eys procedures i.e. used dressings, swabs, PPE etc are cleaned daily and, when they become must be disposed of in an orange clinical waste contaminated, with a detergent solution and bag if considered infectious. A risk assessment dried careful y with paper towels. This wil of the hazard must be undertaken on an remove a high proportion of micro-organisms, individual patient basis. including bacterial spores. Prior to use for aseptic technique, trol eys should be wiped Used sharps must be disposed of in a yel ow over with 70% ethanol alcohol using a wipe. lidded sharps bin unless contaminated with cytotoxic contaminated products when a Trol eys used for aseptic procedures must not purple lidded bin must be used.
be used for any other purpose.
personal protective Equipment (ppE)
A clean disposable plastic apron should be worn when undertaking a non touch technique. Plastic aprons are single use and must be worn for one procedure or episode of residents care and then removed. With the exception of removing the old dressings, sterile gloves must be worn for undertaking aseptic technique.
Boxed, clean, non-sterile, powder-free gloves made from materials other than latex are safe for routine use in particular to protect hands from contamination with organic matter and micro-organisms. However, boxed, clean, non- sterile gloves should not be used for aseptic HTM 07-01(2012) place a duty on healthcare workers to segregate hazardous and non hazardous waste at source. Al clinical waste must be segregated so it can be disposed of appropriately, on the basis of the hazard it appENdiCES &
appendix 1: HaNd dECONTamiNaTiON TECHNiqUE
appENdiCES &
appendix 2
HaNdliNg Of EqUipmENT priOr TO iNSpECTiON, SErViCE, rEpair, rETUrN TO lENdiNg
Note: it is illegal to send contaminated items through the post.
Decontaminate Item Can the equipment be decontaminated without • Label with contamination status removing evidence • Note fault/defect important to a repair or • Off site: pack and despatch for
an investigation? • On site: store in preparation for
Inform repairorganistion orinvestigating body Repair organisation or • Label with contamination status investigating body agrees • Note fault/defect • Pack and despatch for Arrange visit by service/repairorganisation or investigating body NBI don't quite understand this chart, not • Label with contamination status sure if some of the arrows have moved • Note fault/defect on the word doc provided?? • Quarantine in preparation for appENdiCES &
appENdiCES &
appendix 3
appENdiCES &
appendix 4
appENdiCES &
appendix 5
mattress audit Tool for Care Homes
Name of home:
S &

The aim of this audit it to identify mattresses, pil ows and duvets in poor condition where In some care settings a local risk assessment soiling and staining has occurred as these have may indicate that the resident uses their own been shown to be a known source of personal mattress and does not warrant a healthcare associate infection.
waterproof cover. In this situation this must be clearly documented and regular documented The mattress audit tool has been developed in reassessments undertaken to ensure that an response to the Care Quality Commission's appropriate mattress suitable for the residents ‘Practice Alert September 2009 – Mattresses' needs is always used.
Clinical and non clinical mattresses/pillows and duvets in care homes
• Mattresses and pil ows should be enclosed in a waterproof cover • Mattresses in care homes should be numbered. It may not be possible to label some mattress covers (i.e. special mattresses) However, an appropriate system must be put in place to identify these mattresses • Each mattress, cover, pil ow and duvet should be reviewed on a regular basis i.e. quarterly; however, the frequency should be agreed local y depending on the home and based upon a local risk assessment.
• Completed audit tools must be retained in a central location in order to provide evidence for external and internal inspections and retained for a period of two years.
in the event of a mattress, cover, pillow or duvet failing the audit an action plan must be drawn
up for the replacement of the item.
appENdiCES &
the boxeswereoverlappingwould you likethis chart tobe redrawn? appENdiCES &
appendix 6
bristol Stool Chart
Please commence on al residents presenting with known or suspected infectious diarrhoea date symptoms commenced:
date chart commenced:
appENdiCES &
appendix 6
Type ( i.e. 1-7)
appendix 7
infection prevention and control risk assessment/transfer form
(To be completed for al residents on arrival at the home and incorporated into residents care plan or when being transferred to other health facilities) Transferred from: Date of transfer: Date of admission: Reason for transfer: Transfer contact: Date of assessment: appENdiCES &
mrSa risk assessment
known History of MRSA Y N Date swab taken: ………………………………………………………… Site of colonisation/infection i.e. Skin/Wound Urine Sputum Nose Groin Other
Resident currently on decolonisation treatment (skin washes and nasal ointment) Y N
diarrhoea and or vomiting/c.diff risk assessment
Diarrhoea and or vomiting/c.diff risk assessment Is the client currently having diarrhoea and or vomiting (D&V) where infection has not been ruled out? Y N If yes has specimen been obtained Y N Result……………………………………………………….……….
Has the client been exposed to diarrhoea and or vomiting in the past 72 hours (i.e. other cases of D&V in thehome, hospital or by family member/carer? Y N Has the client a history of clostridium difficile? Y N Date of diagnosis………………….……….
Is client currently symptomatic (i.e. having active diarrhoea)? Y N Has a stool specimen been taken Y N Date…………….……. Result…………………………………… Other relevant information: i.e. current antibiotics, contact with infection: Has the client received a seasonal influenza vaccine within the past twelve months? Y N Date:…………………………….…. If no please give reason: ………………………………………………………….
appENdiCES &
Is the resident at risk from If yes suggested risks reduction (to be completed in care plan by Urinary Catheter insitu
Fol ow the essential steps for urinary Strict hand hygiene Wear clean gloves and aprons when emptying or accessing system Empty urine into clean urinal or directly down toilet Maintain a closed system, attach night drainage bag to leg bag tap.
Undertake assessment for the need for catheterisation. Record in residents care plan/record.
Suspected or confirmed wound
Fol ow essential steps programme Take wound swab if signs of infection (pus, heat, temperature, pain) Chronic wounds (pressure
Refer to Tissue Viability sores, venous ulcers, burns etc
Nurse/GP/District Nurse blood borne viruses
Fol ow Standard Infection Prevention (known or suspected) Hep b, C
and Control Precautions i.e. gloves and aprons when in contact with blood and body fluids Treat any blood spil s with a solution of chlorine i.e. Milton or bleach.
Skin risks, evidence of weeping
Fol ow Infection Prevention and vesicles shingles or chicken pox
Control policy. Fol ow Standard Suspected or confirmed scabies
Infection Prevention and Control or lice, itchy skin rash or skin
Fol ow Infection Prevention and known or suspected
Control policy. Fol ow Standard Infection Prevention and Control On chemotherapy or
high doses of steroids
Does the resident require isolation from others? Y N
Has the Community Infection Prevention and Control Nurse been informed Y N
Date: ………………………. Name of person who made contact: …………………………………………………
Telephone no. 0121 612 1627
Referral to other professionals (state which) ……………………….……………………. Date……………………….…
If risks identified ensure risk reduction strategy is incorporated in residents care plan appENdiCES &
appendix 8: What's this form called?
How to use this form:
1. keep it in a place which wil help you remember to fil it in e.g. diary, drugs cupboards, noticeboard. 2. Each time a resident is given flu vaccine, enter the details on the form. This should only take a few moments for each resident. 3. It is also advisable to keep a record of staff uptake of the influenza vaccination. This wil help staff al ocation should an outbreak of influenza occur.
appENdiCES &
Department of Health (2006) Infection Control Guidance for Care Homes. London, Department of Health. Department of Health (2010) Health and Social Care Act 2008: Code of practice for the prevention and control of infections and related guidance.
infection – its causes and spread (introduction)
Great Britain (1984) Public Health (Control of Disease) Act. London, HMSO. Horton, R. and Parker, L. (2002) Informed Infection Control Practice (2nd ed.), London, Churchil Livingstone. Lawrence, J. & May, D. (2003) Infection Control in the Community, London, Churchil Livingstone. Hand Hygiene
Ayliffe, G.A.J. Fraise, A.P. Mitchel , k. (2000) Control of Hospital Infection –A practical handbook (4th ed.).
Infection Control Nurse Association (2002) Hand Decontamination Guidelines. Huntington, ICNA. Wilson J. (2001) Infection Control in Clinical Practice (2nd ed.), London, Bal iere Tindal . Standard precautions
Advisory Committee on Dangerous Pathogens (1995) Protection Against Blood Borne Infections in the Workplace: HIV and Hepatitis. London, HMSO. Ayliffe, G. A. J. H. et al. (1993) Chemical Disinfection in Hospitals. London, Public Health Laboratory Service. Centres for Disease Control (1987) ‘Recommendations for the prevention of HIV transmission in health care settings.' MMWR, Aug 21, 36, 2S, 1S–18S. Centres for Disease Control (1996) ‘Guidelines for isolation precautions in hospitals hospital infection control advisory committee.' available from [Accessed 28th September 2000]. Great Britain (1974) Health and Safety at Work Act. London, HMSO. Health and Safety Commission (1992) The Management of Health and Safety at Work Regulations. London, Health and Safety Commission (1994) A Guide to the Health and Safety at Work Act 1974. Sudbury, HSE.
appENdiCES &
National Public Health Service for Wales Infection Control Guidelines for Care Homes Health and Safety Executive (1988) Control of Substances Hazardous to Health (COSHH) Regulations. London, Health and Safety Executive (1992) Personal Protective Equipment at Work Regulations. London, HMSO. Health And Safety Executive (1996) A Guide to reporting of injuries, diseases and dangerous occurrences Regulations. London, HMSO. Infection Control Nurse Association (2002) A comprehensive glove choice, Huntington, Infection Control Nurse Infection Control Nurses Association (2003) Reducing Sharps Injury, prevention and risk management.
Huntington, Infection Control Nurses Association. National Institute for Health and Clinical Excel ence (NICE) (2012) Infection: Prevention and Control of healthcare Associated Infections in Primary and Community Care.
management of sharps and the prevention of Sharps injuries
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Medical Biotechnology Achievements, Prospects and Perceptions Medical biotechnology:Achievements, prospects andperceptions TOKYO u NEW YORK u PARIS 1 Introduction: Biotechnology, bio-industry and bio-economy . . 2 Medical and pharmaceutical biotechnology: Current achievements and innovation prospects . . . . . . . . . . . . . . 4 The economics of pharmaceutical biotechnology and bio-


Journal of Controlled Release 94 (2004) 323 – 335 Incorporation and release behavior of hydrophobic drug in functionalized poly(D,L-lactide)-block–poly(ethylene oxide) Jaeyoung Lee, Eun Chul Cho, Kilwon Cho* Department of Chemical Engineering, School of Environmental Engineering, Pohang University of Science and Technology, 790-784 Pohang, South Korea Received 22 May 2003; accepted 9 October 2003