Guidelines for Infection Prevention and Control in Primary Care Medical Premises (Resource Pack) (Adapted with kind permission from NHS Ashton, Leigh & Wigan) Name of author: NHS Cumbria Health Protection Team Name of responsible committee: NHS Cumbria Infection Prevention and Control Committee Date issued for publication: May 2011 Date last Reviewed: Review Date May 2013 Expiry date: Main Author Clinical Specialist: Infection Prevention Target audience: Healthcare personnel involved in the provision and delivery of care in Primary Medical and Dental Premises CHANGE HISTORY Version Date Description Author 1.0 25/05/2011 Initial draft Nicola Holland, Clinical Specialist: Infection Prevention 2 PREFACE As you are aware the Care Quality Commission (CQC) are making plans to introduce the registration process for General Practice and it is not too early to begin to assess how you will meet the requirements of registration in your practice. The actual registration process will begin in October 2011 with an online enrolment form. This will request the basic details of the practice including how it is structured (partnership, Ltd company etc), together with the details of practice locations and person to contact. All providers must be registered by 1 April 2012 The second phase will require that you validate the details and ensure that they reflect the correct information. The third phase will be completion of the application including full details of regulated activities provided, practice locations and details of the Registered Managers for each location from which the practice operates. You will also be required to declare compliance with the Essential Standards of Quality and Safety (ESQS). It is important that Practices understand fully what declaring compliance means. If you make this declaration then you are stating in a legal document that you meet all of the ESQS. Care should be taken when making this declaration because if in reality you do not, then when the CQC visits you can be found to be in breach of the regulations. If however you do not comply fully then you must state this and put in place an action plan to demonstrate how you will become compliant in a reasonable time frame. The main areas which are most likely to be tested initially by the CQC during the first few months of the registration programme are: Outcome 4: Care and welfare of the people who use services. Outcome 8: Cleanliness and infection control. Outcome 9: Management of medicines. Outcome 11: Safety, availability and suitability of equipment. Outcome 16: Assessing and monitoring the quality of service provision General Practices are required to have systems in place to ensure compliance with good infection control practice. This Guidance document is based on current legislation, DOH guidelines and best practice (expected standard) and has been provided by NHSALW Health Protection Team to support Practices in meeting Outcome 8 and help prepare Practices for CQC visits. 3 INDEX PAGE 1. Introduction Aims 5 2. Aims 5 3. Hand hygiene 6 4. Personal Protective Equipment 8 5. Disposable gloves 9 6. Disposable plastic aprons 10 7. Surgical face masks and respirators 10 8. Laundry 11 9. Uniform 11 10. Waste Management 12 11. Safe use and disposal of sharps 13 12. Inoculation incidents and human bites 14 13. Spillages 14 14. Clean environment 15 15. Surgical instruments 17 16. MRSA 18 17. Clostridium difficile 19 18. Notification of infectious diseases 21 19. TB referral and management 22 Appendices Appendix 1 Useful contacts Appendix 2 Registered medical practitioner notification form template 23 Appendix 3 Colour coding of waste 24 Appendix 4 A to Z cleaning/disinfection for the environment & facilities 25 Appendix 5 National Patient Safety Agencies colour coding Scheme for cleaning materials and equipment 27 Appendix 6 MRSA decolonisation/eradication procedure 28 Appendix 7 HPA – Guidelines on infection control in schools & other childcare settings Appendix 8 30 HPA - Sharps injury/splash – First aid for healthcare workers 31 Appendix 9 Risk assessment – glove usage 32 Appendix 10 Glove selection guidance 33 Appendix 11 Handwashing poster 34 Appendix 12 Infection Prevention & Control Audit 36 Appendix 13 Fact sheet: Diagnosis of UTI in adults 43 Appendix 14 NHS Cumbria antibiotic guidelines 45 4 1. INTRODUCTION Infection prevention and control in all healthcare settings has attracted heightened interest in recent years. Because of the throughput of large numbers of patients the possibility of cross-infection is substantial. Public confidence in general and dental practices relies upon being, and being seen to be safe places for treatment, and safe places to work. The need for safe infection prevention and control in primary care is now more urgent than ever. Primary care for the first time has been made subject to the same infection prevention and control regulations as other parts of the Health Service; it therefore needs to ensure that procedures are compliant with the extensive agenda of legislation and regulations governing safe practice. Finally we hope the users of this resource pack will find both the content and the format suitable for their needs. We are aware that, frequently, the material in guidance such as this is superseded by new information between writing and publication. The Health Protection Team will review the resource pack every 2 years or if new national guidelines are published. 2. AIMS A diverse range of documents provides the foundation on which communicable disease and infection prevention and control procedures are built. No single publication considers all of the issues relating to infection prevention and control in primary care. This resource pack document will be particularly useful to GP’S, practice/dental nurses and practice managers, as well as other healthcare professionals working in general and dental practices. It seeks to review all relevant issues, and provide a framework upon which, audit can be undertaken to improve infection prevention and control. It will help healthcare professionals identify and minimise risks to staff and patients and create a safer working environment. The information contained within this document addresses the issues that are most likely to impact on health and communicable disease control in primary care which are: Standard (Universal) Precautions Hand hygiene Protective clothing and Equipment (PPE) Laundry management, uniform. Waste management and spillages Clean clinical environment Decontamination of equipment Management of exposure to blood or body fluids DH (2001) EPIC project: Developing national evidence based guidelines for preventing healthcare-associated infection. Journal of Hospital Infection 47 (Supplement) National Institute for Clinical Excellence (NICE): Prevention of healthcare-associated infection in Primary and Community Care. Clinical Guideline2 (2003) suppliment1 5 3. HAND HYGIENE Good hand hygiene is essential to reduce the transmission of infection in healthcare settings and is a critical element of standard infection prevention and control precautions. 3.1 WHO 5 moments hand hygiene The World Health Organisations publication 5 moments for hand hygiene is now the global benchmark of WHEN to perform Hand Hygiene It is your professional responsibility to follow this guidance. See also appendix 12 for poster 3.2 Choice of handwashing method In the community and home setting, choosing a method of hand decontamination will be heavily influenced by the assessment of what is practically possible, the available resources in the care setting (particularly patients own homes), what is appropriate for the episode of care, and, to some degree, personal preferences based on the acceptability of preparations or materials. Soap and Water - Effective handwashing with a non-medicated liquid soap will remove transient micro-organisms and render the hands socially clean. This level of decontamination is sufficient for general social contact and most clinical care activities. Surgical hand disinfection - Using an antiseptic soap preparation such as ‘hibiscrub’ will reduce both transient organisms and resident flora, and result in hand antisepsis. This should be reserved for operating theatres or before invasive procedures. Hygienic handrubs (alcohol) – eliminate transient micro-organisms and have the advantage that a source of water is not required for their use, Hygienic hand rubs offer a practical and highly acceptable alternative to 6 handwashing when hands are not grossly soiled and are recommended for routine use. 3.3 Hand decontamination using liquid soap An effective handwashing technique involves three stages: preparation, washing and rinsing and drying. Preparation requires wetting hands under tepid running water before applying liquid soap. The hand wash solution must come into contact with all of the surfaces of the hand. The hands must be rubbed vigorously together for a minimum of 10 – 15 seconds, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers (See below & appendix 11) as these are the areas most commonly missed. Hand drying has been shown to be a critical factor in the hand hygiene process, in particular removing any remaining residual moisture that may facilitate transmission of microorganisms. Hands that are not dried properly can become dry and cracked, leading to an increased risk of harbouring microorganisms on the hands that might be transmitted to others Handwashing 1 2 3 Palm to palm. 4 Backs of fingers to opposing palms with fingers interlocked. Right palm over left dorsum and left palm over right dorsum. 5 Palm to palm fingers interlaced. 6 Rotational rubbing of right thumb clasped in left palm and vice versa. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa. 5.3 3.4 Hand decontamination using hygienic handrubs (alcohol) When decontaminating hands using an alcohol hand rub, hands should be free of dirt and organic material. The amount/volume used to provide adequate coverage of the hands should be indicated in the manufacturers’ instructions. This is normally around 3 ml. The steps to perform hand hygiene using alcohol based hand rub are the same as when performing hand washing (see Appendix 11) The time taken to perform hand hygiene using alcohol based hand rub is at least 20seconds (20-30 seconds is adequate). Manufacturers’ instructions should be followed (a number of these recommend rubbing for 30 seconds) If the solution has not dried by the end of this process allow hands to dry fully before any patient/client procedures are undertaken. NB. The use of antimicrobial impregnated wipes has been considered for use in the hand hygiene process, however, it has been shown that such wipes are not as effective as hand washing or the use of alcohol based hand rub, therefore these are not considered a substitute. However as a last resort in the absence of appropriate 7 hand hygiene facilities in the home environment they may be used followed by the application of a alcohol hand rub prior to undertaking any care procedures. 3.5 Hand cream An emollient hand cream should be applied regularly to protect the skin from the drying effects of regular hand decontamination. If a particular soap or alcohol product causes skin irritation the Occupational Health Team should be consulted. 3.6 Nails It has been shown that nails, including chipped nail polish, can harbour potentially harmful bacteria. Caring for nails helps prevent the harbouring of microorganisms, which could then be transmitted to those who are receiving care. Nails must be natural, kept short and clean. Nail polish should not be worn Artificial fingernails/extensions should not be worn when providing care Nail brushes should not be used The steps included in the hand hygiene process must be followed in order to ensure nail areas are cleaned properly (Appendix 11) 3.7 Jewellery It has been shown that jewellery, particularly rings with stones and/or jewellery of intricate detail, can be contaminated with microorganisms, which could then spread via touch contact and potentially cause infection. Wrist and hand jewellery should be removed before care is provided. Where there will be close personal contact with patients/clients this is essential. 3.8 Occupational health Any member of staff experiencing a skin problem should refer themselves to the Occupational Health Department, where a full history will be taken and a discussion will take place to agree a suitable care plan. The manager may need to be informed of the outcome where changes in work practice are required, in line with health and safety requirements. References and sources of Information National Institute for Clinical Excellence (NICE): Prevention of healthcare-associated infection in Primary and Community Care. Clinical Guideline2 (2003) suppliment1 World Health Organisation (WHO): Your 5 moments for hand hygiene. May 2009 Department of Health: Uniforms & workwear: Guidance on uniform and workwear policies for NHS employers (2010) 4. PERSONAL PROTECTIVE EQUIPMENT (PPE) Personal protective equipment is used to protect both the patient and the healthcare worker from the potential risks of cross infection. Uniform is not classed as PPE. Gloves, aprons, masks goggles/visors, and in certain situations hats and footwear are classed as PPE. Practices should base their selection of PPE on an assessment of the risk of transmission of micro-organisms to the patient, and the risk of contamination of the healthcare practitioners clothing and skin by contact with the patient. If there is a risk of contact with blood, body fluids, secretions or excretions, additional precautions may be required. 8 Following a risk assessment, staff may also require PPE for contact with hazardous chemicals and certain pharmaceuticals. 5. DISPOSABLE GLOVES Hands have a key role in the transmission of infection and gloves can reduce the number of micro-organisms acquired. However hands should still be washed when gloves are removed. Gloves must be worn for invasive procedures, contact with sterile sites and non-intact skin or mucous membranes, and all activities that have been assessed as carrying a risk of exposure to blood, body fluids, secretions or excretions, or sharp or contaminated instruments. Gloves that are acceptable to healthcare personnel and conform to European Community (CE) standards on safety and performance must be available. Neither powdered gloves nor polythene gloves should be used in healthcare activities. Gloves must be worn as single-use items and should never be washed, disinfected or re-sterilised. They must be put on immediately before an episode of patient contact or treatment and removed as soon as the activity is completed. Gloves must be changed between caring for different patients, and between different care or treatment activities for the same patient. Gloves must be disposed of as clinical waste and hands decontaminated after the gloves have been removed. Non-latex hypo-allergenic gloves must be available for use by staff with latex allergy. Sensitivity to natural rubber latex in patients, carers and healthcare personnel must be documented, and alternatives to natural rubber latex gloves must be available. (nitrile or neoprene gloves) Oil can weaken and degrade latex, reducing the glove's protection. Avoid using oil-based lotions and moisturisers (e.g. those that contain lanolin, mineral oil, petroleum, coconut oil or palm oil as main ingredients). If you are uncertain about compatibility, check with the lotion manufacturer. Gloved hands should not be washed or alcohol applied in order to decontaminate them, they must be removed after single use. For glove selection also see appendix 10 Copolymer gloves Vinyl gloves Latex gloves Are more likely to burst under pressure because of weakness in the welded seams. Are more permeable to viruses than latex products and are more likely to split than latex. They are not the product of choice when exposure to blood or body fluids is a risk or when high levels of manual dexterity are required. Are made from natural products & contain proteins. Frequent users may develop allergies, which can be severe. The cornstarch powder picks up allergens in the rubber and distributes them via the skin or into the air. This increases the risk of sensitisation to patients as well as staff. Low protein powder-free 9 latex gloves provide the best protection. Latex free In cases of latex allergy, latex free gloves without allergenic hypo-allergenic gloves additives can be used. (nitrile or neoprene gloves) 6. DISPOSABLE PLASTIC APRONS Disposable plastic aprons should be worn when there is a risk that clothing may be exposed to blood, body fluids, secretions or excretions, with the exception of sweat. Plastic aprons should be worn as single-use items, for one procedure or episode of patient care, and then discarded and disposed of as clinical waste. Full-body fluid repellent gowns must be worn where there is a risk of extensive splashing of blood, body fluids, secretions, with the exception of sweat, onto the skin or clothing of healthcare practitioners. 7. SURGICAL FACE MASKS Should be worn when there is a risk of blood, body fluids, secretions, excretions or chemicals splashing into the face. During an outbreak of Pandemic Influenza surgical masks may also be worn to protect the wearer from the transmission of influenza by respiratory droplets. The mask should be fluid repellent and should be worn by the healthcare workers for any close contact with patients with influenza symptoms (i.e. within approximately one metre). The mask will provide a physical barrier and minimise contamination of the nose and mouth by droplets. When pandemic influenza patients are cohorted in one area and several patients must be visited over a short time or in rapid sequence, it may be more practical for staff to put on a surgical mask on entry to the area and to keep it on for the duration of the activity or until the surgical mask requires replacement (i.e. when it becomes wet or damaged). Surgical masks should: Cover both nose and mouth Not be allowed to dangle around the neck after or between each use Not be touched once put on Be changed when they become moist or damaged Be worn once and then discarded as clinical waste – hand hygiene must be performed after disposal. Respirator masks During an outbreak of Pandemic Influenza a disposable respirator providing the highest possible protection factor available (i.e. an EN149:2001 FFP3 disposable respirator) should be worn by healthcare workers when performing procedures that have the potential to generate infectious aerosols Fitting the respirator correctly is critically important for it to provide proper protection. Every user should be fit tested and trained in the use of the respirator. In addition to the initial fit test carried out by a trained fitter, a fit check should be carried out each time a respirator is worn. 10 A good fit can only be achieved if the area where the respirator seals against the skin is clean shaven. Beards, long moustaches and stubble may cause leaks around the respirator. Disposable respirators should be replaced after each use and changed if breathing becomes difficult, the respirator is damaged or distorted, the respirator becomes obviously contaminated by respiratory secretions or other body fluids, or if a proper face fit cannot be maintained. References and Sources of Information National Institute for Clinical Excellence (NICE): Prevention of healthcare-associated infection in Primary and Community Care. Clinical Guideline 2 (2003) suppliment1 The Personal Protective Equipment at Work Regulations, 1992 (Statutory Instrument 1992 no2966) London HMSO DoH. The epic project: Developing national evidence-based guidelines for preventing healthcare associated infections. Journal of Hospital Infection (2001); 47: S1 – S82. NHS Ashton, Leigh and Wigan. Handwashing Policy April 2010 DoH. Pandemic (H1N1) 2009 Influenza: A summary of guidance for infection prevention & control in healthcare settings 8. LAUNDRY If used linen should be laundered after every patient contact. Curtains should be washed at least every 6 months or when visibly soiled. 9. UNIFORM Not all staff need to wear uniforms, and it seems unlikely that uniforms are a significant source of cross-infection. Nevertheless, the way staff dress will send messages to the patients they care for, and to the public. It is sensible for Practices to consider what messages they are trying to convey, and to advise on dress codes accordingly. Both infection prevention and control and public confidence should underpin a Practices uniform policy, but the two are not necessarily interchangeable. Examples of expected standards as described by the Department of Health Include Dress in a manner which is likely to inspire public confidence Change into a clean uniform at the start of each shift Change immediately if uniform or clothes become visibly soiled or contaminated Wear short-sleeved shirts/blouses and avoid wearing white coats when providing patient care Cover uniform completely when travelling to and from work Wear clear identifiers (uniform and/or name badge) Tie long hair back off the collar Wash uniforms at the hottest temperature suitable for the fabric. (Practices may also wish to take in to account the ‘washable’ nature of clothing when making purchasing decisions e.g. are items which are ONLY capable of being washed at low temperatures or which are ‘dry-clean’ only suitable?). Keep finger nails short and clean References and Sources of Information Department of Health: Uniforms & workwear: Guidance on uniform and workwear policies for NHS employers (2010 11 National Institute for Clinical Excellence (NICE): Prevention of healthcare-associated infection in Primary and Community Care. Clinical Guideline2 (2003) suppliment1 10. WASTE MANAGEMENT Health care organisations and the individuals that work within these organisations, have a legal and moral duty to dispose of waste properly in accordance with statutory ‘duty of care’ requirements. Changes to legislation governing the management of waste, its storage, carriage, treatment and disposal meant previous guidance on clinical waste provided in the Health Service Advisory Committee (HSAC) publication Safe disposal of clinical waste (1999) required revision, and in December 2006 it was replaced by the Department of Health’s Health technical memorandum 07-01: Safe management of health care waste. The Safe management of health care waste memorandum 2006 introduces some key changes, specifically: The removal of the old ‘clinical waste group A to E’ definitions The introduction and definition of new identification terms (health care waste, infectious waste, medicinal waste and offensive waste) A revised colour-coded system for the disposal of waste. While the advice and courses of action contained within the memorandum aren’t mandatory, the memorandum advises that health care organisations must take steps to ensure compliance with relevant legislation, to ensure compliance with all regulatory requirements – from production through to transport and finally disposal. Employers are responsible for developing and making available an appropriate health care waste management policy which clearly outlines written instructions on the way waste should be managed. NHS Cumbria’s waste management policy covers the production, handling, movement and disposal of healthcare waste produced by its staff. Those independent contractors providing services on behalf of the PCT may if they wish use this document which is available on the intranet to form the basis for developing their own waste management policies and procedures. However national guidance clearly states that the existence of a policy should not be assumed to be an indication of good practice and that employers are responsible for monitoring practice within their organisation through the implementation of robust audit procedures. 10.1 Waste segregation Segregating waste at the point of production is critical to the safe management of health care waste. Segregation not only helps control the management costs associated with waste, but ensures the correct pathways are adopted for the storage, transport and ultimate disposal of waste. For segregation to work effectively the Safe management of health care waste (2006) advises that staff must be provided with colour-coded and labelled waste receptacles and sack holders. These should be positioned in locations as close to the point of production as possible and replaced when three-quarters full, securely tied and 12 appropriately labelled. Liquid or solidified waste should be placed in a rigid, leakproof container. 10.2 The national colour-coding system (appendix 3) The (2006) Safe management of health care waste memorandum recommends adopting the national, colour-coded waste segregation system with immediate effect. A new national colour-coded system for waste streaming is now recommended for the segregation of health care waste into streams that are linked to an appropriate disposal path. This means that waste should be identified and segregated on the basis of its waste classification, which in turn determines its waste management option. Adopting this new best practice segregation system will ensure standardisation across the UK. 10.3 Waste audits Waste auditing is a legal requirement, and not just best practice. Waste audits play an essential role in demonstrating compliance with regulatory standards and should be undertaken by the waste producer at least every year Environment Agency – Safe Management of Healthcare Waste March 2011) 11. SAFE USE AND DISPOSAL OF SHARPS All sharps must be disposed of safely and correctly immediately after use. Discard sharps personally – do not rely on others to do this for you. Sharps must not be passed from hand to hand, and handling should be kept to a minimum. Needles must not be recapped, bent, broken or disassembled before use or disposal. Discard needle & syringe as one unit directly into sharps container. Used sharps must be discarded into a sharps container (conforming to UN3291 and BS7320 standards) at the point of use by the user. These must not be filled above the mark that indicates that they are full. Containers must be assembled correctly according to manufacturer’s instructions i.e. ensuring that the lid is secure. Containers should be kept in a safe location out of the reach of children e.g. on a flat surface, below eye level, but not on the floor (free wall and trolley brackets are available from sharps bin manufacturers). This will reduce the risk of injury to patients, visitors and staff. When not in use the temporary closing mechanism on sharps containers must be activated Full containers should not be allowed to accumulate. They must be sealed and labelled/identification tag attached before disposal by the licensed route. Needle safety devices must be used where there are clear indications that they will provide safer systems of working for healthcare personnel. Under no circumstances should items be retrieved from a sharps box. Under no circumstances should sharps or sharps boxes be put in yellow bags for disposal. Under the Health and Safety Act (1974) it is the personal responsibility of the individual using a sharp to dispose of it safely, the exception being in 13 situations where it may be necessary to delegate this responsibility to another named person (e.g. during surgical procedures) 12. INOCULATION ACCIDENTS include: Skin prick or laceration by a sharp instrument or needle contaminated with blood. Blood splashes onto an abrasion or cut. Contamination of mucous membranes of eyes or mouth with blood. Human bites. Treatment of inoculation accidents: If it is a small wound, encourage bleeding by squeezing area, do not suck wound. Wash area thoroughly with soap and running water, and then cover with a waterproof dressing if necessary. If the eyes/mouth are involved irrigate with copious amounts of clean water. Following skin exposure, wash the affected area thoroughly with soap and water. Report the incident immediately to your manager. (Appendix 8 for poster/flow chart) Arrange with your manager for immediate referral either to Occupational Health (or A&E if Occupational Health is closed); Take with you a completed accident/incident form – so that an urgent risk assessment can be undertaken. Human Bites: If a bite does not break the skin, clean with soap and water and record incident no medical intervention necessary. If a bite does break the skin, clean immediately with soap and water and arrange with your manager for immediate referral to Occupational Health (or A&E if Occupational Health is closed); take with you a completed accident/incident form. 13. SPILLAGES Treating spills of blood or body fluid may expose the healthcare worker to bloodborne viruses or other pathogens. The task can be carried out more safely if any pathogens in the spill are first destroyed by disinfectant. Disposable gloves should always be worn when cleaning possible contaminated spills. If there is a risk of contaminating clothing, a disposable plastic apron should also be worn. 13.1 Methods of treating body fluid spills Chlorine-releasing granules* Put on disposable gloves and apron Cover fluid completely with chlorine granules Leave for 2 minutes Remove granules and discard into infectious waste stream Wash the area with detergent and water Hypochlorite solution* 14 Put on disposable gloves and apron Cover spill with disposable paper towels Pour hypochlorite (10,000 ppm available chlorine) over the towels i.e. half strength Milton 2 diluted with water, HAZ Tabs or other propriety product sufficiently diluted. Leave for 2 minutes Remove towels and discard into infectious waste stream Wash the area with detergent and water Detergent and water Put on disposable gloves and apron Soak up spill with disposable towels Discard towels into infectious waste stream Wash the area with detergent and water * Do not use for large spills of urine References and Sources of Information Health Technical Memorandum 07-01: Safe Management of Healthcare Waste 2006 Fraise, A.P. Bradley, C. (2009) Ayliffe’s Control of healthcare-Associated Infection. 5th ed, London, Hodder Arbnold, National Institute for Clinical Excellence (NICE): Prevention of healthcare-associated infection in Primary and Community Care. Clinical Guideline 2 (2003) suppliment1 14. CLEAN ENVIRONMENT The cleanliness of any health care environment is important to support infection prevention and control and ensure patient confidence. In August 2010 the National Patient Safety Agency (NPSA) published ‘The national specifications for cleanliness in the NHS: A framework for setting and measuring performance outcomes in primary medical and dental care premises ’along with a self audit tool. It is recommended that this audit tool and guidance is adopted by care providers where it is applicable to the services provided as this would contribute to demonstrating how they ensure they meet the registration requirement to maintain appropriate standards. NPSA guidance is available at: tp://www.nrls.npsa.nhs.uk/resources/type/guidance/?entryid45=75241 The Revised Healthcare Cleaning Manual is available at: www.nrls.npsa.nhs.uk/resources/?Entryld45=61830 14.1 Cleaning Cleaning is a process that removes contaminates including dust, soil large numbers of micro-organisms and the organic matter that shields them. Disinfection kills some micro-organisms but does not leave surfaces and equipment completely free of contamination and is only effective if the equipment or surface is thoroughly cleaned with detergent solution before hand. In most situations, thorough cleaning and rinsing with a freshly prepared solution of detergent and water is adequate and additional disinfection is wasteful. (appendix 4) 14.2 Colour coding of cleaning materials (appendix 5) Most healthcare organisations already have a colour coding scheme for cleaning materials and equipment. However, there is presently no consistency across the NHS. It has been estimated that there are as many as 50 different schemes currently in use, mostly revolving around the same core colours but with their specific meaning 15 varying. Sometimes, for historical reasons (for example, as a result of mergers), even hospitals within the same trust have different schemes in place. This presents a potential risk when domestic staff move from organisation to organisation, or even in some cases from practice to practice within the same consortium. A standardised code will mitigate the risk of possible crosscontamination. The National Patient Safety Agency (NPSA) has developed a National Colour Coding Scheme for cleaning materials (appendix 5). The recommendation is that all NHS organisations adopt this code as standard in order to improve the safety of cleaning, ensure consistency and provide clarity for staff. 14.3 Choice of cleaning products Select and use a good quality detergent. Detergents classed as anionic and non-ionic have the best detergent activity (e.g. good quality washing up liquid). Detergents classed as cationic (e.g. quaternary ammonium compounds (QACs) such as Roccal, Dettol ED and Cetavalon have some antimicrobial properties, but they are usually less efficient detergents. Check product labels before use. 14.4 Cleaning Practices should have a regular planned and written cleaning schedule available that details items and environments to be cleaned; Before and after each clinic session Daily Weekly Monthly Annually 14.5 Cleaning Equipment Cleaning equipment should be stored clean and dry in a designated lockable area Use different colour-coded equipment for cleaning different areas. This avoids any risk of cleaning equipment being used inappropriately, for example in both toilet and clinical areas. Do not use brooms as they raise dust. Cleaning cloths must be single-use. After cleaning, surfaces should be dried using paper towels. 14.6 Domestic cleaning staff Cleaning staff should receive induction and ongoing training in the following: Basic cleaning skills and schedules Cleaning blood and body fluid spills (if included in job description) Safe handling of sharps bins and waste bags Care of cleaning equipment Safe and correct storage of consumables including disinfectants Standard precautions including hand hygiene and use of personal protective equipment Actions to be taken as a result of a sharps injury All staff should know and understand the importance of thorough cleaning. A clean environment reduces the cumulative risk of cross-infection posed by micro-organisms 16 in the environment. Hands are in contact with surfaces all the time and, if unwashed, will transfer any organisms present. This risk is always present but will increase if cleaning is neglected. 15. SURGICAL INSTRUMENTS Practices must comply with current national legislation and regulatory requirements for the sterilisation and decontamination of medical devices. If they have not done so already, practices will need to take steps to ensure that they are in compliance. Ultimately, it is the responsibility of individual practices to ensure that they are compliant with current legislation. There has been a change in legislation affecting PCTs, who are now obliged to ensure that organisations from which they commission healthcare services are in compliance with current legislation – hence in recent years, letters to practices informing them of “new decontamination regulations”. Full compliance with current national decontamination standards which would enable practices to continue to use in-house facilities is not a practical or cost effective use of resources. However, a number of alternative options are available. These include: Switch to single use instruments Send instruments for sterilisation to an off-site location that is compliant with current standards (for example, a local hospital CSSD or super-CSSD site). Use a combination of the above options Each option has its advantages and disadvantages, and practices will need to carefully consider which approach will be the most suitable for their needs. 15.1 Single-use items If an item is marked for single-use, it means that you must only use it on a single occasion and then discard it. You should never use a single-use device on multiple occasions on a single patient or on different patients. Equipment marked with the following with must not be re-used If a medical device is marked for single patient use, you can use the item for multiple uses on one patient and then you must discard it. Examples of single patient use devices include nebulizer masks and suction tubing. Some form of reprocessing may be necessary between uses on the same patient. Always make sure you follow the manufacturer’s instructions. 17 16. MRSA (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS 16.1 Control of MRSA in community settings The risk of MRSA transmission in residential care homes, where residents are generally more healthy and have fewer invasive devices than hospital patients, is much lower. Spread of MRSA between residents may occur but is associated with colonisation rather than infection. Isolation of residents with MRSA is not necessary and they should be able to use communal areas with other residents. They may share a bedroom, provided neither occupant has open lesion, invasive devices or catheters. Standard (universal) precautions such as hand hygiene and the use of disposable gloves and apron for contact with body fluids, dealing with wounds or invasive procedures as described earlier should be sufficient to prevent spread. Advice to the home is available from the Infection Prevention and Control Team (See contact list appendix 1 for Infection Prevention and Control) 16.2 Control of MRSA in hospitals Attempts to control the spread of MRSA are essential to both retain options for antimicrobial therapy and protect vulnerable patients. Current guidelines for the control of MRSA in hospitals recommend targeting the approach to infection prevention and control according to level of risk and clinical area affected. 16.3 Decolonisation Since Staphylococcus aureus commonly colonises the skin, it is an important cause of post operative surgical wound infection. Decolonisation prior to elective surgery is therefore performed as recommended by the DH and is mandatory for all emergency admissions by 2011. For your information the full decolonisation regime used by Community Healthcare on colonised patients is included in the appendices of this document See contact list appendix 1 for advice/referral and Appendix 6 for decolonisation regime 18 17. CLOSTRIDIUM DIFFICILE INFECTION (CDI) Clostridium difficile infection (CDI) is associated with antimicrobial use. Prescribing antimicrobials wisely can reduce the incidence. Clostridium difficile infection (CDI) C. difficile is a bacterium present in the gut flora in some people. Antimicrobials disturb the balance of the gut flora, allowing C. difficile to multiply and cause infection. Symptoms of CDI can vary from mild diarrhoea to fatal bowel inflammation. C. difficile spores are shed in the faeces. The spores can survive for long periods in the environment. If ingested, they can transmit infection to others. 17.1 Prudent antimicrobial prescribing Only prescribe antimicrobials when indicated by the clinical condition of the patient or the results of microbiological investigation. Do not prescribe antimicrobials for sore throat, coughs and colds in patients at low risk of complications. Consider delayed prescriptions in case symptoms worsen or become prolonged. If an antimicrobial is required, follow local guidelines. Choose a narrow-spectrum agent where possible and prescribe a short course. Generally, no more than 5-7 days’ treatment is required. Three-day courses are appropriate in some cases. Broad-spectrum antimicrobials should be reserved for the treatment of serious infections when the pathogen is not known. 17.2 Which patients are most at risk of CDI? Patients are more at risk of CDI if they are: Elderly Suffering from severe underlying diseases Immunocompromised In an environment where they are in close contact with one another (e.g. in a care home), particularly if hygiene is lacking. Other factors that increase the risk of CDI are: Use of antimicrobials Recent gastrointestinal procedures Presence of a nasogastric tube The use of proton pump inhibitors (PPIs) might increase the risk of CDI. Only prescribe PPIs when indicated. 17.3 Antimicrobials to avoid where possible The antimicrobials most strongly associated with CDI are: Second and third generation cephalosporins: cefaclor, cefuroxime, cefixime and cefpodoxime are examples for oral use Clindamycin Quinolones (associated with the virulent 027 strain of C. difficile): ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin, norfloxacin. Long courses of amoxicillin, ampicillin, co-amoxiclav or co-fluampicil. 19 17.4 Antimicrobials to choose All antimicrobials are associated with CDI, but those with lower risk are trimethoprim, penicillin V, tetracyclines and aminoglycosides. If antimicrobials are required, prescribe a short course and follow the local formulary. Where therapy has failed or there are special circumstances, obtain advice from a local microbiologist. See contact details page 4 17.5 CDI and primary care CDI has commonly been associated with hospital stay but it is being recognised that many cases originate in the community, due to indiscriminate use of antibiotics. Patients most at risk are the elderly, particularly if they have medical conditions and are in close contact with others, e.g. in a care home, residential treatment centre or hospital. 17.6 When can broad-spectrum antibiotics be recommended? There are few indications for broad-spectrum cephalosporins or quinolones in primary care please refer to the PCT antimicrobial formulary. (see appendix 14) When using broad spectrum antimicrobials, counsel patients at risk to be alert for signs of CDI and to stop their antimicrobial and seek medical help if diarrhoea develops. 17.7 Diagnosis of Urinary Tract Infection in Adults For advice with regards to diagnosis of urinary tract infection and information about asymptomatic bacteriuria please refer to appendix 13: Factsheet: Diagnosis of UTI in Adults 20 18. NOTIFICATION OF INFECTIOUS DISEASES Health protection legislation in England has been updated to give public authorities new powers and duties to prevent and control risks to human health from infection or contamination, including by chemicals and radiation. The new Regulations for clinical notifications came into force on 6 April 2010. The new legislation adopts an all hazards approach, and, in addition to the specified list of infectious diseases, there is a requirement to notify cases of other infections or contamination which could present a significant risk to human health. Under the new Notification Regulations, there are no provisions for Registered Medical Practitioners (RMPs) to be paid fees for notifications. RMPs are expected to provide information that is a requirement of legislation needed to protect public health as part of their professional duties. The prime purpose of the notifications system is speed in detecting possible outbreaks and epidemics. Accuracy of diagnosis is secondary, and since 1968 clinical suspicion of a notifiable infection is all that is required. 18.1 Diseases notifiable under the Health Protection Regulations 2010: Acute encephalitis Acute meningitis (All types) Acute poliomyelitis Acute infectious hepatitis (All types) Anthrax Botulism Brucellosis Cholera Diphtheria Enteric fever (typhoid or paratyphoid fever) Food poisoning Haemolytic uraemic syndrome (HUS) Infectious bloody diarrhoea Invasive group A streptococcal disease and scarlet fever Legionnaires’ Disease Leprosy Malaria Measles Meningococcal septicaemia (without meningitis) Mumps Plague Rabies Rubella SARS Smallpox Tetanus Tuberculosis Typhus Viral haemorrhagic fever (VHF) Whooping cough Yellow fever 21 Examples of other infections which could present a significant risk to human health. Parvovirus B19 in a contact of a pregnant woman Chickenpox in a healthcare worker Cryptosporidiosis Giardiasis Campylobacter Salmonella Rotavirus Diarrhoea Enteropathogenic ‘E-coli’ Haemophilus Influenza type B Health Protection Agency (Cumbria & Lancashire Unit) contact details 01257 246450 19. TB REFERRAL AND MANAGEMENT All cases of TB should be managed by, or in consultation with, a Chest Physician specialising in this disease. Cumbria & Lancashire Health Protection Unit are responsible for local surveillance, for maintaining a register/database of cases, and for contributing to national surveillance by weekly reporting to the Office for National Statistics and participating in enhanced surveillance and research. Contact Tracing Contact tracing is an essential part of the routine management of patients with tuberculosis and should be carried out according to the protocol within current National Guidelines. In Cumbria, local contact tracing is undertaken by the TB Team See appendix 1 for TB Team contact details 22 Appendix 1 1. USEFUL CONTACTS NUMBERS NHS Cumbria Health Protection and Infection Prevention and Control Team Clinical Specialist: Health Protection Lead Lyn Murphy, Tel: 01228 603753 07920 467372 Clinical Specialist: Infection Prevention Nicola Holland, Tel: 01539 797895 07879 808305 TB Specialist Nurses for referral or patient advice South Cumbria/ Furness: Eileen Adamson, Tel: 01229 484034 West Cumbria: Louise Sullivan, Tel: 01946 693660 North/ East Cumbria, Mairi Black, Tel: 07500121125 Consultant Microbiologists and Microbiology Medical advice North Cumbria: CIC: 0122881 4648/ 4640 WCH: 01946 543422 South Cumbria: RLI: 01524 583770 FGH: 01229 491022 Health Protection Agency (Cumbria & Lancashire Unit) Tel. 01257 246450 Occupational Health (Team Prevent) Tel: 01768 213082 Fax: 01768 213083 23 Appendix 2 Registered medical practitioner notification form template Health Protection (Notification) Regulations 2010: notification to the proper officer of the local authority Registered Medical Practitioner reporting the disease Name Address Post code Contact number Date of notification Notifiable disease Disease, infection or contamination Date of onset of symptoms Date of diagnosis Date of death (if patient died) Index case details First name Surname Gender (M/F) DOB Ethnicity NHS number Home address Post code Current residence if not home address Post code Contact number Occupation (if relevant) Work/education address (if relevant) Post code Contact number Overseas travel, if relevant (Destinations & dates) 24 Appendix 3 Colour coding of waste Colour stream Description of waste Example Waste which requires disposal by incineration Indicative treatment/disposal is incineration in a suitably permitted or licensed facility Anatomical waste, Infectious waste requiring INCINERATION ONLY Waste which may be “treated” Indicative treatment/disposal required is to be “rendered safe” in a suitably permitted or licensed facilities, usually alternative treatment plans. However this waste may also be disposed of by incineration Infectious swabs, dressings, wipes, protective clothing and sharps (with no medicine contamination) Offensive/hygiene waste Indicative treatment/disposal required is landfill in a suitably permitted or licensed site. This waste should not be compacted in unlicensed/permitted facilities. Domestic (municipal) waste Minimum treatment/disposal required is landfill in a suitably permitted or licensed site. Recyclable components should be removed through segregation. Clear/opaque receptacles may also be used for domestic waste. Non-infectious swabs, dressings, wipes, protective clothing, nappies, human hygiene waste, sanitary waste. Clean packaging, food paper etc Cytotoxic and Cytostatic waste Indicative treatment/disposal required is incineration in a suitably permitted or licensed facility. Sharps contaminated with cytotoxic/static medicines, i.e. sharps used for injections of cytotoxic/static drugs. Medicines used for chemotherapy, certain antivirals, immuno-suppressants and hormonal drugs Waste which may be “treated” Sharps not contaminated with any medicines, i.e. sharps used for bloods, glucose, saline, etc. Also suitable for blades and razor blades. Sharps used for bloods, glucose, saline, etc, and blades Waste which requires disposal by incineration Sharps contaminated with medicines (noncytotoxic/static), Sharps used for injecting medicines 25 Appendix 4 A-Z Cleaning & Disinfectant Policy For The Environment & Facilities Equipment Routine decontamination method Acceptable alternative if required Additional information Electrical items including computer equipment and waiting room televisions/radios Telephones Dust Daily. Bowls/buckets including those used for patients with leg ulcers. Wash, dry, store inverted between patient use (always use with plastic liner for patient use). If patient is infected, wash and then disinfect using a phenolic or chlorine-based product. Badly scratched buckets and bowls used in leg ulcer treatment should be replaced Carpets Vacuum daily. Steam clean 6 monthly or if significantly stained. For contamination spills, clean with detergent & water then dry (most disinfectants will damage carpets) Ensure vacuum filters are changed frequently. Carpets should be visibly clean with no blood or body substances, dust, dirt, debris or spillages. Floors should have a uniform appearance and an even colour with no stains or water marks. Phones and keyboards cleaned with detergent wipe or equivalent daily. Do not use brooms in clinical areas. Drains Clean regularly. Chemical disinfection is not advised. Equipment surfaces Damp dust contact points between patient use with one full clean weekly. Use freshly prepared detergent solution, and dry. Clean and wipe with alcohol to disinfect. All parts (including underneath) should be visibly clean, with no blood,body substances, dust, dirt, debris or spillages. Floors (hard) Disinfection of floors is not required routinely. Wash daily with freshly prepared detergent solution. Rinse with water weekly to remove detergent residues and help maintain anti-static properties, if required. (It is good practice to do this anyway. It prevents slipping when floors get wet, eg, people coming in from the rain.) For known contaminated surfaces, use a phenolic or chlorine-based solution. The complete floor (including all edges, corners and main floor spaces) should have a uniform finish or shine and be visibly clean with no blood or body substances, dust, dirt, debris, spillages or scuff marks. Furniture and fittings Daily damp dust using a freshly prepared detergent solution. For know contaminated surfaces, clean then use phenolic or chlorine-based solution. Frequent use of disinfectants will damage cover. Mattresses Couch Pillows Use water impermeable cover. Wash using a freshly prepared detergent solution and dry twice daily, with additional spot clean as required. For know contamination, clean and disinfect with phenolic or chlorine-based solution. Refer to manufacturer. Frequent use of disinfectant will damage cover. Mops (dry and dust attracting) Vacuum after each use. Wash and clean every other day. Vacuuming between uses prolongs the life of mops. Mops (wet) Wash in washing machine daily if available. Wash and rinse after each use, wring and store dry. Disinfect by boiling or soak clean mop in chlorine-based product (solution 1000ppm available chlorine) for 30 minutes, rinse and store dry. Mops should not be left to soak overnight. Fluid will become a growing medium for bacteria. Rooms Wash surfaces with freshly prepared If infected patients have 26 (clean/dirty/clinical) detergent solution at end of clinic session. been treated, wash surfaces and then wipe down with phenolic or chlorine-based products. Toilet seats Wash with a freshly prepared detergent solution and dry. After use by infected patient or if grossly contaminated, use phenolic or chlorinebased product, rinse and dry. Clean toilet areas at least once a day. Toys Clean with a freshly prepared detergent and water solution. Machine wash soft toys. Clean toys on a regular basis and more frequently during ‘winter virus’ period. All toys should be wipeable. Soft toys are not recommended. Trolley tops (clinical) Clean with freshly prepared detergent solution at beginning & end of dressing clinic. Use alcohol spray between dressings. If contaminated, or patient has a known infection, clean when dressing finished and then disinfect. All parts (including wheels/castors and underneath) should be visibly clean with no blood or body substances, dust, dirt, debris, spillages. Wash basins/sinks Clean at least once daily using a proprietary cleaner to remove stains. Disinfection is not normally required. Clean and then disinfect if contaminated. Many products contain both a cleaner (ie, detergent) and a disinfectant. Hand wash containers/hand rub dispensers One full daily clean using detergent Walls and ceilings Clean using detergent every six months in treatment/minor surgery room. Clean annually elsewhere. Curtains Launder at least every 6 months or when visibly dirty Baby changing areas Clean daily and in between patient use using a freshly prepared detergent solution and dry. Waste receptacles Clean daily using a freshly prepared detergent solution and dry. Clean and disinfect if blood or body fluids splash onto walls or ceiling. 27 Appendix 5 28 Appendix 6 MRSA Decolonisation / Eradication Procedure Decolonisation therapy should be prescribed as per local arrangements. Directions for patient use supplied with the decolonisation product supplied should be followed. If further advice is required please contact the microbiologist or infection prevention team. *Contact infection prevention and control nurse if patient has psoriasis or very dry skin. The process for the application of Mupirocin (Bactroban) nasal ointment The nasal ointment should be applied three times a day to each nostril for five days (for example, 08:00, 14:00 and 20:00 hours. Use of nasal ointment: Put a small amount of Bactroban (matchstick head size) on a cotton bud and apply to the inside of each nostril. Close the nostrils by pinching the sides of the nose together to spread the ointment inside the nose. Wash your hands under running water using hand soap and warm water. Dry with a clean towel. During the eradication process it is advisable to change bed linen at home. The Infection Prevention and Control Team would advise to change bed linen on: Day 1 (commencement of the eradication process) Day 3 (mid way through the eradication) Day 5 (on completion of the eradication process and before re-screening) If swab report indicates resistance to Mupirocin, Naseptin nasal ointment will be prescribed as an alternative. The procedure for application remains the same Other site involvement Contact infection prevention and control lead and/or specialist clinical nurse for management of other site 29 Appendix 7 30 Appendix 8 31 Appendix 9 Risk Assessment – Glove Usage ARE GLOVES REALLY NECESSARY? Gloves are NOT required for procedures where there is minimal risk of cross infection between patients and staff, eg: Basic care procedures without contact with blood or body fluids Transferring food from food trolleys to patient bedside Making uncontaminated beds/changing or removing patients’ uncontaminated clothing Taking recordings (BP, Temp, Pulse) Closed Entrotracheal Suction Gloves ARE required for procedures where there is a risk of cross infection between patients and staff and further risk assessment should be carried out. IS THERE A HIGH RISK OF EXPSOURE TO BLOOD AND BODY FLUIDS NO NON-STERILE VINYL DON’T WEAR GLOVES YES IS A STERILE FIELD REQUIRED YES NON-THEATRE ENVIRONMENT: STERILE LATEX OR NITRILE THEATRE ENVIRONMENT: ELASTRYN NEOPRENE NITRILE NON-POWDERED LOW PROTEIN LATEX SYNTHETIC POLYISOPRENE TACTYLON No NON-STERILE LATEX OR SYNTHETIC NITRILE GLOVE WITH EQUIVALENT BARRIER PROPERTIES 32 Appendix 10 Glove selection guidance ALL GLOVE SELECTION MUST BE PRECEDED BY RISK ASSESSMENT Cleaning General cleaning ‘Colour coded’ marigolds Blood borne virus exposure/ spillage Food Handling, Preparation, Serving Polythene Tasks where there is a low risk of contamination, non-invasive clinical care, or environmental cleaning, eg: Procedures involving high risk of exposure to BBVs and where high barrier protection is needed, eg: Oral care Emptying catheter drainage bags Emptying urinals/bedpans and suction jars Handling low risk specimens Clinical cleaning Dressing wounds when contact with blood/body fluids is unlikely, eg, gastrostomy dressings Endotracheal suction Applying creams Touching patients with unknown skin rash/scabies/shingles Making beds/changing clothing of patients in isolation Non-Sterile Vinyl Non-Sterile latex/Nitrile TYPE OF ACTIVITY Potential exposure to blood/body fluids, eg, blood spillages, faecal incontinence, blood glucose monitoring, administering enemas/suppositories and rectal examinations Handing cytotoxic material Handling disinfectants Venepuncture/cannulation Vaginal examination Basic care and specimen collection procedures on patients known or suspected to be high risk of BBV Procedures which require a sterile field and high barrier protection for example: Lumbar punctures Liver biopsies Clinical care to surgical wounds/drain sites Procedures for neutropenic patients Insertion of urinary catheters Vaginal examination in obstetrics Non Surgical dentistry/podiatry Handling dirty/used instruments Processing specimens in a laboratory All Surgery and Invasive Radiological procedures STERILE SURGICAL GLOVES: Elastryn Neoprene Nitrile Non-powdered low protein Latex Synthetic polyisoprene Tactylon Sterile Latex or Synthetic alternative Nitrile Examination Gloves Non-Sterile latex or Synthetic alternative Nitrile 33 Appendix 11 Handwashing 1 2 3 Palm to palm. 4 Backs of fingers to opposing palms with fingers interlocked. Right palm over left dorsum and left palm over right dorsum. 5 Palm to palm fingers interlaced. 6 Rotational rubbing of right thumb clasped in left palm and vice versa. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa. 5.3 34 Appendix 12 GP Surgery Infection Prevention & Control Audit Tool This audit tool has been adapted for use by NHS Cumbria General Practitioners (from the ICNA ‘audit tools for monitoring infection control guidelines within the community setting, 2005’) It is intended for use by Infection Prevention and Control Link Practitioners and/ or GPs/ Practice Managers. Scoring All criteria should be marked ‘Yes’, ‘No’ or ‘N/A’ (not applicable). To work out a ‘percentage’ the number of N/A answers must first be deducted from the overall number of criteria in the section to give a ‘potential’ score. That number is divided in to the overall number of ‘yes’ scores and the answer multiplied by 100. Following the audit an action plan should be formulated to address any areas which do not meet the required criteria. This should be shared with the Infection Prevention and Control Team and updated at least quarterly. Part 1: Hand Hygiene Standard statement: Hands will be decontaminated correctly and in a timely manner using a cleansing agent to reduce risk of cross infection. Ref 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 1.10 1.11 1.12 1.13 1.14 1.15 1.16 . Yes Staff have received training in hand hygiene procedures (ask member of staff) Clinical staff nails are short, clean & free from nail extensions & varnish No wrist watches, stoned rings or other wrist jewellery are worn during clinical procedures Hand hygiene is encouraged and alcohol hand rubs are made available for visitors Posters promoting hand hygiene are on display (including ‘how to’ posters by sinks) There is a hand wash basin in each treatment/ clinical area Hand washing facilities are clean and intact (check sinks, taps, splash backs, soap & towel dispensers) Hand wash basins are dedicated for that use only and are free from equipment & inappropriate items There is easy access to the hand wash basin The hand wash basin complies with HTM64 (ie; no plugs, no overflow, water from taps not directly over plughole) Elbow or non-touch taps are available at all hand wash basins in clinical areas Liquid soap (in the form of single use cartridge dispensers is available at each hand wash basin There is no bar soap at hand washing basins in treatment/ clinical areas Alcohol hand rub is available at entrances/ exits as appropriate Alcohol hand rub is available at the point of care as per local & national standards Clinical staff are encourage to use moisturisers that are pump operated or personal use only No N/A 1.17 1.18 1.19 1.20 Soft absorbent paper towels are available at all hand wash sinks There are no reusable cotton towels used to dry hands There are no reusable nail brushes used or present at hand wash sinks There is a foot operated bin for waste towels in close proximity to hand wash sinks which are fully operational Overall Scoring: Potential score: (Overall number of questions less any N/A) Percentage: (‘overall’ divided by ‘potential’ score X 100) Date of next audit: Part 2: Environment Standard statement: The environment will be maintained appropriately to reduce the risk of cross infection Ref 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 2.11 2.12 2.13 2.14 . Yes Overall appearance of the environment is tidy & uncluttered with only appropriate, clean and well maintained furniture used Fabric of the environment and equipment smells clean, fresh & pleasant The allocation of rooms for clinical practice is fit for purpose Rooms where clinical practice takes place are not carpeted Floor coverings are washable, impervious to moisture and sealed regularly The complete floor, including edges and corners are visibly clean with no dust, body substances, dirt or debris Furniture, fixtures &fittings are visibly clean with no body substances, dirt, dust, debris or adhesive tape All dispensers, holders (couch roll, toilet paper, soap & alcohol gel) are visibly clean with no dirt, dust, debris, body substances or adhesive tape Toilets are visibly clean with no body substances, dust, lime scale stains, deposits or smears- including beneath toilet seat and raised toilet seats Waste receptacles are clean, including lid & pedal Foot pedals of clinical waste bins are in good working order There is a procedure in place for regular decontamination of curtains and blinds Furniture in patient areas (eg. chairs & couches) are made of impermeable and washable materials Chairs are free from rips and tears No N/A 2.15 Couches are free from rips and tears 2.16 Pillows are enclosed in a washable and impervious cover Furniture that cannot be cleaned is condemned 2.17 2.18 2.19 Tables are tidy and free from clutter to enable cleaning Medical equipment is cleaned, maintained and stored appropriately 2.20 Water coolers are mains supplied (not bottled water), visibly clean and on a planned maintenance programme Animals used for pet therapy have evidence that all appropriate worming & vaccinations are up to date and have a flea management programme Hand hygiene is actively encouraged after handling animals in healthcare environment- must apply to staff, patients & visitors 2.21 2.22 Overall score: Potential score: (Overall number of questions less any N/A) Percentage: (‘overall’ divided by ‘potential’ score X 100) Date of next audit: Part 3: Ward (beverage) Kitchen Standard statement: Kitchens will be maintained in accordance with current legislation to reduce the risk of cross infection Ref 3.1 The floor is clean and dry 3.2 There is no evidence of infestation in the kitchen 3.3 3.5 Cleaning materials used in the kitchen are clearly identifiable and stored away from food There is a separate hand wash sink and liquid soap and paper towels are available Fixtures and fittings are in a good state of repair 3.6 Fixtures, surfaces & appliances are clean & dry 3.7 Shelves, cupboards & drawers are clean & dry, free from dust and in a good state of repair All cooking appliances are visibly clean (look inside the microwave) Refrigerators are clean and free from ice build up 3.4 3.8 3.9 Yes 3.10 There is a thermometer in the fridge and there is evidence that daily temperatures are recorded and . No N/A appropriate action taken if standards are not met (ie; if fridge temp rises above 80C) 3.11 Patient & staff food is labelled & there is a system in place to determine when it was opened &/ or when it should be used by 3.12 There are no inappropriate items(eg. Specimens/ medication) in the refrigerator 3.13 All milk is stored in the refrigerator 3.14 Bread is stored in a clean, dry container 3.15 All food products are within their expiry dates 3.16 All opened food is stored in containers (eg. Tea, sugar) 3.17 There is a satisfactory system for cleaning crockery and cutlery (eg. Dishwasher) which is clean & well maintained 3.18 Disposable paper roll is available for dying equipment & surfaces 3.19 There are no fabric tea towels or dishcloths in use 3.20 There are no inappropriate items or equipment stored in the kitchen Overall score: Potential score: (Overall number of questions less any N/A) Percentage: (‘overall’ divided by ‘potential’ score X 100) Date of next audit: Part 4: Waste Management Standard statement: Waste is disposed of safely without the risk of contamination or injury Ref 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 . Yes Staff have attended a training session which includes information about the correct & safe disposal of waste There is evidence that staff are segregating waste correctly (look in some bins) Staff are aware of the waste segregation procedures (randomly question a member of staff) There are clinical waste signage posters identifying waste segregation available The waste storage area is clean & dry Clinical waste sacks are secured and labelled prior to disposal There is no storage of waste in corridors or other inappropriate areas whilst awaiting collection All plastic waste sacks are fully enclosed within bins to minimise the risk of injury All waste bins used are lidded, foot operated and in good working order No N/A 4.10 Waste bags are removed from clinical areas daily 4.11 There is no emptying of clinical waste from one bag to another There are no overfilled bags- bags are no more than 2/3 full 4.12 Overall score: Potential score: (Overall number of questions less any N/A) Percentage: (‘overall’ divided by ‘potential’ score X 100) Date of next audit: Part 5: Spillage/ contamination with blood/ body fluids Standard statement: Body fluid spillage/ contamination is dealt with appropriately to reduce the risk of cross infection. Ref 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 Yes Staff have received training in dealing with body fluids 9ask member of staff) Staff are aware of how to contact the occupational health dept in the event of an inoculation injury Dedicated spillage kits are available for decontaminating and cleaning body fluid spillages Personal Protective equipment is available (aprons, gloves, masks, eye protection) Equipment used to clear up body fluid spillages is disposable or able to be decontaminated Sodium hypochlorite solution in the strength 1:10,000 ppm (1%) or NaDCC (sodium dichloroisocyanurate) is available Medical equipment which has been contaminated with body fluids is cleaned appropriately and a permit to work document completed (eg. Decontamination certificate/ label) Furniture which has been contaminated with body substances and cannot be cleaned is condemned Overall score: Potential score: (Overall number of questions less any N/A) Percentage: (‘overall’ divided by ‘potential’ score X 100) Date of next audit: . No N/A Part 6: Personal Protective Equipment Standard statement: Personal protective equipment is available and used appropriately to reduce the risk of cross infection Ref 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 6.10 6.11 Yes Staff are trained in the use of personal protective equipment as part of local departmental induction GLOVES Sterile & non sterile gloves (powder free, not polythene and conforming to EC standards) are available in all clinical areas There is an appropriate range of sizes available An alternative (eg. Nitrile) to natural latex rubber is available for practitioners/ patients with NRL sensitivity Gloves are worn as single use items for each clinical procedure or episode of patient care Hand are decontaminated following removal of gloves Gloves are stored appropriately APRONS Disposable plastic aprons are worn when teher is a risk that clothing or uniform may become exposed to body fluids or become wet Disposable plastic aprons are worn as part of food hygiene practices (ie; food prep/ serving of meals) Aprons are stored appropriately FACE/ EYE PROTECTION Clean face masks & eye protection is worn when there is a risk of body fluids splashing in to the face/ eyes (COSHH) Overall score: Potential score: (Overall number of questions less any N/A) Percentage: (‘overall’ divided by ‘potential’ score X 100) Date of next audit: . No N/A Part 7: Prevention of sharp injuries Standard statement: inoculation injuries & splashes involving blood/ other body fluids are managed in a way which reduces the risk of injury or infection Ref 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 7.9 7.10 7.11 7.12 7.13 Yes There are arrangements in place which ensure staff are dealt with appropriately in the event of an inoculation injury All staff receive training in sharps/ splash/ bite injury management and are aware of the actions to take following an injury All inoculation/ sharp injuries are recorded There are appropriate devices used for exposure prone procedures There is signage (eg;poster) displayed for management of inoculation/ splash injuries Sharps bins comply with BS 7320 (1990)/ UN 3291 Sharps containers are correctly assembled, labelled with date, locality & signed Sharps containers are available at the point of use When full & ready for disposal all sharps containers are dated & signed Sharps containers are store safely away from the public and out of reach of children Sharps containers are not filled beyond the indicator mark (ie; not more than 2/3 full The are no inappropriate items (eg; swabs/ packaging/ gloves) in the sharps container Needles & syringes are disposed of as a single unit 7.14 Syringes with a residue of prescription medication are disposed of according to current legislation 7.15 The temporary closure mechanism is used when the bin is not in use 7.16 Full sharps containers are sealed with the bin’s integral lock (tape or stickers are not used) 7.17 Sharps containers are not put in waste bags prior to disposal 7.18 Sharps containers are available for use & located within easy reach 7.19 Sharps containers are visibly clean with no bodt substances, dust, dirt or debris 7.20 Inappropriate re-sheathing does not occur (ask member of staff) Overall score: Potential score: (Overall number of questions less any N/A) Percentage: (‘overall’ divided by ‘potential’ score X 100) Date of next audit: . No N/A Part 8: Specimen Handling Standard statement: Specimens are handled in an appropriate manner which reduces the potential risk of cross infection to all staff. Ref 8.1 8.2 8.3 8.4 8.5 8.6 8.7 8.8 8.9 8.10 8.11 8.12 Yes Specimens are sent to the microbiology laboratory in appropriate containers Patients are provided with an appropriate specimen container if required to produce specimens at home Specimens are sealed in appropriate plastic transit bags Request forms are not in the same part of the transit bag as the specimen Transit bags are not sealed with staples or paper clips Specimens awaiting transit are stored away from the public/ staff rest areas Refrigeration) for specimens away from food) is available if required Specimens are transported in leak resistant boxes with lids which can be fastened Specimen transport boxes are visibly clean with no body substances, dust, dirt or debris visible Specimen testing on the ward is undertaken in an appropriate designated area The test area is cleaned after use Samples tested on site are disposed of down a toilet or sluice Overall score: Potential score: (Overall number of questions less any N/A) Percentage: (‘overall’ divided by ‘potential’ score X 100) Date of next audit: . No N/A Appendix 13: UTI factsheet . . . . . Appendix 14: Abbreviated Antibiotic Guidelines Condition UPPER RESPIRATORY TRACT/ENT Tonsillitis/ pharyngitis/ sore throat Acute sinusitis Otitis media (acute) – child doses Comments Drug and dose (listed in order of preference) Avoid antibiotics as 90% resolve in 7 days without and pain only reduced by 16 hours. Antibiotics to prevent quinsy, NNT >4000 Antibiotics to prevent otitis media, NNT 200 Most episodes are viral. Symptomatic benefit from antibiotics small – 69% resolve in 7-10 days without antibiotics; and 84% resolve with antibiotics; reserve antibiotics for: persistent symptoms (e.g. lasting more than 10 days), severe symptoms (e.g., profuse purulent nasal discharge, facial pain, systemic symptoms), symptoms that are deteriorating significantly Intranasal decongestants may be useful for short-term use. Steam inhalations, antihistamines, mucolytics and intranasal corticosteroids not recommended. Antibiotics do not reduce pain in first 24 hours, subsequent attacks or deafness. Use paracetamol or NSAID. Illness resolves in 4 days in 80% without antibiotics. Need to treat 20 children > 2 years and seven 6-24 months old to get pain relief in one at 2-7 days. If antibiotic is required, Phenoxymethylpenicillin 500mg QDS (severe), or Clarithromycin 250-500mg BD Antibiotic treatment not routinely recommended Use antibiotics if: < 3 months of age (consider admission) > 4 days symptoms and not improving Systemically unwell or patient at high risk of complication due to underlying medical condition Immediate prescribing may be appropriate for the following groups: otorrhoea <2 years with bilateral acute otitis media LOWER RESPIRATORY TRACT Lower respiratory tract infection (including acute bronchitis) in otherwise healthy individuals Exacerbations of COPD Community acquired pneumonia . Antibiotics are not routinely indicated. Consider prescribing an antibiotic if the person has a significantly impaired ability to fight infection or if acute bronchitis is likely to worsen an existing condition. Alternative antibiotics may be used on the basis of sputum results. 30% viral, 30-50% bacterial, remainder undetermined. Sending sputum samples for culture not recommended in primary care. Use antibiotics if: exacerbation of COPD AND increased purulence of sputum Assess the person's need for admission by determining respiratory rate, blood pressure, age (65 years and older), and whether they are confused (the 'CRB-65' scale). If admission is not indicated, arrange a chest X-ray for people over the age of 50 years that smoke, and give advice on self-care such as using analgesia and keeping hydrated. If antibiotic is required, Amoxicillin 500mg TDS, or Doxycycline 200mg stat, then 100mg daily, or Clarithromycin 250mg BD Antibiotic treatment not routinely recommended If antibiotic is required, Amoxicillin 40-90mg/kg/day in 3 divided doses up to 1 gram TDS,or Clarithromycin <8kg - 7.5mg/kg BD 8-11kg – 62.5mg BD 12-19kg – 125mg BD 20-29kg – 187.5mg BD 30-40kg – 250mg BD 2nd line Co-amoxiclav 1-6yrs - 156mg TDS 6-12yrs - 312mg TDS If antibiotics are required, Amoxicillin 500mg TDS, or Doxycycline 200mg stat, then 100mg daily Amoxicillin 500mg TDS, or Doxycycline 200mg stat, then 100mg daily, or Clarithromycin 500mg BD Amoxicillin 500mg to 1 gram TDS, or Doxycycline 200mg stat, then 100mg daily, or Clarithromycin 500mg BD If no response after 48 hours or atypical pathogen is suspected give Amoxicillin + Clarithromycin Duration (days) 10 5 7 7 7 5 5 5 5 5 5 5 5 5 to 10 5 to 10 5 to 10 NICE CLINICAL GUIDELINE 69: ANTIBIOTIC PRESCRIBING FOR RESPIRATORY TRACT INFECTIONS No antibiotic (or delayed prescription) for: Acute otitis media Acute sore throat/acute pharyngitis/acute tonsillitis Common cold Acute rhinosinusitis Acute cough/acute bronchitis Consider immediate antibiotic prescribing strategy, depending on clinical assessment of severity for: Bilateral acute otitis media in children under 2 years Acute otitis media in children with otorrhea Acute sore throat/acute pharyngitis/acute tonsillitis when 3 or more Centor criteria are present: Temperature >38°C Absence of cough Swollen anterior cervical nodes Tonsillar swelling or exudate Immediate antibiotic prescription should only be offered if: Patient is systemically unwell The patient has signs/symptoms of serious illness and/or complications (pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis, intraorbital and intracranial complications) Patient is at high risk of serious complications because of pre-existing co-morbidity (heart, lung, renal, liver, neuromuscular disease, immunosuppression, cystic fibrosis and young children born prematurely) The patient is >65 years with acute cough + 2 or more of the following or >80 years with acute cough + 1 or more of the following: Hospitalisation in last year Type 1 or type 2 diabetes History of congestive heart failure Current use of oral glucocorticoids This guidance does not override the individual responsibility of health professionals to make decisions in the exercise of their clinical judgement in the circumstances of the individual patient. Abbreviated antibiotic choices overleaf Date of preparation January 2011 The FULL antibiotic guidelines can be found at: http://www.cumbria.nhs.uk/ProfessionalZone/MedicinesManagement/Guidelines/antibioticguidelin es.pdf . The NW SHA has one of the highest rates for C difficile in England Best practice in antimicrobial drug prescribing CUMBRIA has the 2nd highest rate for C difficile infection in the NW SHA Clostridium difficile infection (CDI) is associated with antimicrobial use. Prescribing antimicrobials wisely can reduce the incidence Clostridium difficile infection (CDI) C. difficile is a bacterium present in the gut flora in some people. Antimicrobials disturb the balance of the gut flora, allowing C. difficile to multiply and cause infection. Symptoms of CDI can vary from mild diarrhoea to fatal bowel inflammation. C. difficile spores are shed in the faeces. The spores can survive for long periods in the environment. If ingested, they can transmit infection to others. CDI and primary care CDI has commonly been associated with hospital stay but it is now recognised that many cases originate in the community, due to indiscriminate use of antibiotics. Patients most at risk are the elderly, particularly if they have medical conditions and are in close contact with others, e.g. in a care home, residential treatment centre or hospital. Which patients are most at risk of CDI? Prudent antimicrobial prescribing Patients are more at risk of CDI if they are: Elderly Suffering from severe underlying diseases Immunocompromised In an environment where they are in close contact with one another (e.g. in a care home), particularly if hygiene is lacking. Other factors that increase the risk of CDI are: Use of antimicrobials History of CDI (ie. risk of relapse) Recent gastrointestinal procedures Presence of a nasogastric tube The use of proton pump inhibitors (PPIs) might increase the risk of CDI. Only prescribe PPIs when indicated. . Only prescribe antimicrobials when indicated by the clinical condition of the patient or the results of microbiological investigation. Do not prescribe antimicrobials for sore throat, coughs and colds in patients at low risk of complications. Consider delayed prescriptions in case symptoms worsen or become prolonged. If an antimicrobial is required, follow Cumbria antibiotic guidelines. Choose a narrow-spectrum agent where possible and prescribe a short course. Generally, no more than 5-7 days treatment is required. Three-day courses are appropriate in some cases. Broad-spectrum antimicrobials should be reserved for the treatment of serious infections when the pathogen is not known. How we use antimicrobials affects the whole community. CUMBRIA has the 4th highest rate of CIPROFLOXACIN use in the NW SHA Please avoid using CIPROFLOXACIN & other antibiotics ass.with C.Diff unless indicated When can broad-spectrum antibiotics be recommended? Please refer to Cumbria Antibiotic guidelines April 2010 http://www.cumbria.nhs.uk/ProfessionalZone/MedicinesManagement/Guidelines/antibioticguidelines.pdf The following are examples of indications for 1 st line use of broad spectrum antibiotics Comments from the Consultant microbiologists Antimicrobials to avoid where possible High Risk of CDI “The four Cs” The antimicrobials most strongly associated with CDI are: Cephalosporins: cefaclor, cefuroxime, cefixime (2nd and 3rd generation) Clindamycin Ciprofloxacin and other Quinolones, levofloxacin, moxifloxacin, ofloxacin, norfloxacin. Co-amoxiclav and Co-fluampicil. Also long courses of amoxicillin and ampicillin Antimicrobials to choose Low to intermediate risk Trimethoprim, penicillin V, tetracyclines and macrolides have a lower associated risk; however, all antimicrobials are associated with CDI. Follow the Cumbria antibiotic guidelines If antimicrobials are required, prescribe a short course. Obtain advice from a microbiologist. Where “best guess” therapy has failed or there are special circumstances microbiological advice can be obtained from the Consultant Microbiologists at: West Cumberland Hospital 01946 693181 Cumberland Infirmary 01228 814641 Furness Hospital 01229 491022 This guidance does notGeneral override the individual responsibility of health professionals to make . decisions in the exercise of their clinical judgement in the circumstances of the individual patient. Exacerbations of COPD Community acquired pneumonia Acute pyelonephritis Acute prostatitis Simple gonorrhoea Animal bite or human bite If indicated: Amoxicillin or Doxycycline or Clarithromycin Amoxicillin or Doxycyline or Clarithromycin Ciprofloxacin or Co-amoxiclav Ciprofloxacin &/or Doxycycline Cefixime Co-amoxiclav There are few indications for broad-spectrum cephalosporins or quinolones in primary care. Counsel patients at risk of CDI to stop their antimicrobial and seek medical advice if diarrhoea develops. If prescribing antimicrobials to patients with a history and/or relapse of CDI, refer to the microbiologist Bottom line Ciprofloxacin, Cephalosporins, Clindamycin, Co-amoxiclav and other broad spectrum antimicrobials are associated with CDI. Don’t prescribe antimicrobials when they’re not needed. If an antimicrobial is indicated, prescribe a short course of a narrow-spectrum agent at the appropriate dose, as outlined in the PCT antimicrobial formulary. Supporting Medicines Q&A documents are available: Date of preparation January 2011 www.nelm.nhs.uk/en/NeLM-Area/Evidence/Medicines-Q--A/ Which antimicrobials are implicated? Are acid-suppressant medicines a risk factor? Are probiotics useful? .