Hand Hygiene · Web viewThe practice must have the following policies and documents in place which...

Template Policies for General Practice

Please be aware that these are example policies/guidelines suitable for the General Practice environment.

It is an expectation that you review these documents to ensure they are suitable for your location.

It is also your responsibility to ensure you review these policies on a 3 yearly basis or sooner if there is a change in evidence to satisfy yourself that they remain pertinent to your location.

If you have any queries or would like further advice or information, please do not hesitate to contact the Infection Prevention and Control Team.

Kind regards

Infection Prevention and Control TeamBirch HouseRansom Wood Business ParkSouthwell Road WestRainworthMansfieldNottinghamshireNG21 0HJ

Tel: 01623 673081Email: [email protected]

mailto:[email protected]


Table of Contents

Hand Hygiene.........................................................................................................................3Appendix 1a: 5 Moments of Hand Hygiene (Bed)................................................................8Appendix 1b: 5 Moments of Hand Hygiene (Chair)..............................................................9

Appendix 2: Hand Cleaning Techniques............................................................................10Personal Protective Equipment..........................................................................................11Management of Healthcare Waste and Sharps/Splash Injuries......................................15Cleaning and Decontamination..........................................................................................20Management of Spillages of Blood, Body Fluids and Vaccines......................................25Minor Surgery.......................................................................................................................29

Appendix 1: Surgical Site Audit..........................................................................................34Management of Vaccines and the Cold Chain..................................................................35

Appendix 1: Refrigerator Temperature Log........................................................................37Handling of Specimens.......................................................................................................38Management of Seasonal Influenza Outbreaks in Care Homes......................................41

Table 1: Selection of antivirals for severely immunosuppressed patients..........................45

Oseltamivir doses for weight and renal dysfunction...........................................................46Policy for the Management of.............................................................................................47Meticillin Resistant Staphylococcus Aureus (MRSA).......................................................47

MRSA protocol for screening and decolonisation ..............................................................54

How to apply Chlorhexidine/Octenisan bodywash and Mupiricin (Bactroban) ointment....55Management of Panton Valentine Leukocidin (PVL) Staphylococcus aureus Infections in General Practice...............................................................................................................57

Appendix 1: PVL Management: Quick Reference Guide...................................................61

Appendix 2: How to apply Chlorhexidine/Octenisan bodywash and Mupiricin (Bactroban) ointment..............................................................................................................................62

Appendix 3: Patient Information PVL – Staphylococcus aureus........................................63Management of Clostridium difficile..................................................................................65

Appendix 1: The Bristol Stool Form Scale..........................................................................69Appendix 2: Treatment of residents with positive C. difficile result....................................70

Scabies..................................................................................................................................72


Hand Hygiene

Introduction Under the terms of The Health and Social Care Act (DH 2015) (Practice) has a duty to ensure that the risk of healthcare associated infection (HCAI) is kept as low as possible. The National Patient Safety Agency (NPSA) recognises that improving the hand hygiene of healthcare staff at the point of patient care will reduce the risk of Healthcare Associated Infections (HCAI). Not all infections are preventable but evidence shows that improving hand hygiene contributes significantly to the reduction of HCAI (NPSA 2008).

AimThis policy has been written for all staff within (Practice) in order to:

Promote the optimal techniques for decontaminating hands. Help staff to understand the precise moments when they need to clean their hands

and why. Protect patients and staff from cross infection and therefore reduce incidents of

HCAI.

Risk Management

Indications All staff have an individual responsibility to assess the need for hand hygiene in their daily practice. The point of care refers to the patient’s immediate environment in which staff to resident contact or treatment is taking place (NPSA 2008). There are 5 recognised crucial points of care for hand hygiene, representing the time and place at which there is the highest likelihood of transmission of infection via the hands of healthcare staff (World Health Organisation 2009):

Before patient contact Before an aseptic task After body fluid exposure risk After patient contact After contact with patient surroundings

(Refer to Appendices 1a and 1b)

Contraindications There should be no contraindications preventing staff from carrying out effective hand hygiene practice within the practice. The practice must provide adequate hand hygiene facilities at the point of care, with designated hand wash basins, wall mounted single cartridge dispensed liquid soap, wall mounted dispenser paper towels and alcohol hand rub.

Hazards (Practice) endorses the ‘Bare Below the Elbows’ initiative for all staff working within the practice who are delivering care or cleaning. Staff must have short sleeves and wear no hand or wrist jewellery other than a plain wedding band. Nails should be clean, short and free from polish/nail art, artificial nails or gel wraps. The hand hygiene technique will be compromised by failing to adhere to this initiative.

Hand Hygiene

of 78


Evidence provided by The World Health Organisation in 2009 stated that 'Healthcare workers who wear artificial nails are more likely to harbour gram negative pathogens on their fingertips than those who have natural nails, both before and after hand washing or the use of alcohol gel' therefore healthcare workers who provide direct care to patients must not wear artificial nails including gel wraps. The World Health Organisation also went on to state that long sharp fingernails, either natural or artificial, can puncture gloves easily. They may also limit the staff performance in hand hygiene practices. The NICE clinical guideline in 2012 also states that 'healthcare workers should ensure that their hands can be decontaminated throughout the duration of clinical work by: making sure that fingernails are short, clean and free of nail polish'. There are hazards associated with hand hygiene such as dry, sore or irritated skin, which may be due to a variety of reasons, including:

Poor hand hygiene technique Poor hand drying technique Sensitivity to hand hygiene products Existing allergies and skin conditions, e.g. eczema and psoriasis. These conditions

may be exacerbated by some products and poor technique. If this occurs then staff should seek advice from the practice manager or their GP.

Risks associated with alcohol hand rub All alcohol based hand hygiene products purchased and supplied to staff must comply with the European Committee for Standardisation (CEN 1997) standard EN1500.

Placement of alcohol gel dispensers at sites other than the point of care should be based on a risk assessment. NPSA (2008) suggests that the following factors should be taken into consideration when undertaking the risk assessment:

Accessibility to alcohol hand rub by high risk groups e.g. patients with alcohol use disorders

Accidental splashes to the eyes Storage considerations Fire Risk

Equipment List Access to a hand wash basin and running water Liquid soap Paper towels Alcohol Hand Rub

Liquid soap will be provided in a wall-mounted dispenser using single use cartridge systems. Alcohol gel can either be provided in a wall mounted dispenser using single use cartridges, pocket size containers for individual use or free standing pump dispensers.

Hand wash basins should be compliant and designated for hand hygiene purposes only (DH 2011).

Hand Hygiene

of 78


Describing the Care Required

Micro-organisms Micro-organisms on the skin can be classified into two groups – resident and transient.

Resident micro-organisms are part of the normal human flora and live deep-seated within the epidermis. They protect the skin from invasion by more harmful organisms. They do not easily cause infections and are not easily removed.

Transient micro-organisms are located on the surface of the skin. They are described as ‘transient’ because they are easily transferred to other people, equipment and the environment, via the hands following direct contact. They have the potential to cause infections and can be easily removed or destroyed by good hand hygiene techniques.

Routine Hand Hygiene - this is achieved using liquid soap and running water following the NPSA hand washing technique, refer to Appendix 2. This method is sufficient to remove visible dirt and most transient micro-organisms. Visibly clean hands can be decontaminated with an application of alcohol hand rub following the NPSA recommended technique, refer to appendix 2. Aseptic Hand Hygiene - should be carried out prior to undertaking any procedure requiring an aseptic technique. It is achieved by washing with soap and water prior to preparation of equipment, following the NPSA recommended technique (refer to appendix 2). Subsequent hand decontamination, during the procedure, can then be achieved by the application of alcohol hand rub, using the NPSA recommended technique, refer to appendix 2.

Antiseptic Hand Wash - should be carried out prior to undertaking minor surgery. Antiseptic hand wash solutions used with water will remove and destroy micro-organisms on the hands. Some antiseptic agents have residual activity and provide continued anti-microbial activity. The first choice agent is Hibiscrub 4%.

Alcohol Hand Rub Alcohol hand rub should be used only on visibly clean hands or as part of aseptic hand hygiene. It must not be used when patients are known to have Clostridium difficile, norovirus, or are experiencing diarrhoea and/or vomiting. Refer to appendix 2 for how to apply alcohol hand rub.

Hand Drying Hands should be dried thoroughly using disposable paper towels. Poorly dried hands can more easily transfer micro-organisms to other surfaces than dry hands (Gould 2000), the damper the hands, the greater the number of micro-organisms (Taylor et al. 2000).

Skin Care Excoriated hands are associated with increased colonisation of potentially pathogenic micro-organisms and therefore increase the risk of infection. (Pratt et al, 2001; Boyce and Pittet, 2002) The appropriate use of hand cream is an important factor in maintaining skin integrity and staff are advised to use an emollient hand cream regularly, e.g after washing hands, before a break or when going off duty to maintain the integrity of the skin (Pratt et al, 2001). Pump dispenser or wall mounted single cartridge hand creams are recommended.

User Involvement In order to comply with the Health and Social Care Act (DH 2015) staff should encourage the involvement of patients in Infection Prevention and Control. Hand Hygiene notices and posters should be displayed in areas that are visible to patients and hand hygiene information leaflets should be made available.Hand Hygiene

of 78


Staff should be encouraged to challenge colleagues who have poor hand hygiene skills.

Education and Training Program The Health and Social Care Act (DH 2015) stipulates that infection prevention and control training is included for all staff at induction. Hand hygiene training is included in the induction programme. Hand hygiene training is mandatory and is offered to staff annually. Infection prevention and control updates are mandatory and are offered every 2 years. All members of staff have an individual responsibility to ensure that they access mandatory training.

‘Glow and Tell’ machines which are used to demonstrate the effectiveness of hand hygiene techniques are available for loan from the Infection Prevention and Control Team for the use of practices who wish to carry out hand hygiene training in house. The Infection Prevention and Control Team can be contacted on 01623 673081.

Review and Revision arrangements This Policy shall be reviewed every 3 years or sooner if the base of evidence indicates an earlier review.

References Boyce, J M, Pittet, D. (2002) Guidelines for Hand Hygiene in Healthcare Settings. Recommendations of the Healthcare Infection Control Practice Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hygiene Task Force

Department of Health (2007) Essential Steps to Safe, clean care.

Department of Health (2011) Performance requirements for building elements used in healthcare facilities 8941:0.6:England

Department of Health. (2015) The Health and Social Care Act 2008:Code of Practice for the NHS on the Prevention and Control of HCAI and related guidance

Gould, D. (2000) Innovations in hand hygiene: manual from SSL International. British Journal of Nursing. 9. (20). 2175-80

NICE (2012) Prevention and Control of Healthcare Associated Infections in Primary and Community Care National Patient Safety Agency. (2008) Clean Hands Save Lives Patient Safety Alert. Second Edition

Pratt, R, J, et al (2001) The Epic Project. Developing National Evidence-based Guidelines for Preventing Healthcare associated Infections Phase 1: Guidelines for preventing Hospital-acquired Infections. Journal of Hospital Infection; 47 (supplement). S1-S82 Standardization ECF Chemical disinfectants and antiseptics-hygienic handrub-test method and requirements: European Committee for Standardization Brussels 1997 Taylor, J.H. et al (2000) A microbiological evaluation of warm air hand driers with respect to hand hygiene and the washroom environment. Journal of Applied Microbiology. 89(6). 910-19

Hand Hygiene

of 78


Debbie Weston (2008) Infection Prevention and Control – Theory and Practice for Healthcare Professionals. John Wiley and Sons

World Health Organisation. (2009) WHO Guidelines on Hand Hygiene in Health Care (Advance Draft)

Hand Hygiene

of 78


Appendix 1a: 5 Moments of Hand Hygiene (Bed)

Hand Hygiene

of 78


Appendix 1b: 5 Moments of Hand Hygiene (Chair)

Hand Hygiene

of 78


Appendix 2: Hand Cleaning Techniques

Hand Hygiene of 78


Personal Protective Equipment

Introduction (Practice) is committed to and obliged legally to ensure that all staff employed are trained in the appropriate use of personal protective equipment and provided with the correct equipment to work safely (Health and Safety Executive1974). The practice should in relation to preventing, reducing and controlling the risks of infections have in place appropriate policies including personal protective clothing (Department of Health, 2015).

Aims of the policy The policy aims to:

Provide staff with information relating to the importance of PPE. Provide staff with sufficient information which will encourage staff to use a risk

assessment approach when deciding when and what type of PPE to use. Reduce the risks of staff and patients acquiring HCAI including blood borne viruses.

Risk Management The main purpose of PPE is to protect staff and the patient from the risk of exposure to blood and other body fluids, and reduce the opportunities for transmission of micro-organisms from staff to patient and vice versa. The decision to use or wear PPE must be based upon an assessment of the level of risk associated with the specific procedure/patient care activity or intervention and take account of good practice standards and current health and safety legislation.A risk assessment must be carried out by all staff in order to decide which PPE is the most appropriate for the task/intervention depending on what risks the wearer may be exposed to. The risk assessment process requires the member of staff to assess if there are any potential risks of exposure to the skin or mucous membranes of blood, body fluids or any other potential source of infection. If there are none then PPE would not be necessary.

Risk assessment and glove use Choosing the type of glove to use requires assessment of the following:

What is the nature of the task? Are sterile or non-sterile gloves required? Is there a possibility of exposure to blood or body fluids or any other potential source

of infection? Is the resident or member of staff allergic to natural rubber latex?

Glove ChoiceGloves used for direct patient care must conform to current EU legislation (CE marked as medical gloves for single use) and should be appropriate for the task (NICE, 2012). Gloves are available in a variety of materials. Risk assessment must ensure that the physical characteristics and barrier properties are acceptable, and provide protection against the risks encountered.

Natural rubber latex remains superior in protecting against blood borne viruses. However, latex gloves that contain powder should never be used due to the risks associated with aerosolisation and an increased risk of latex allergies. When a risk assessment indicates latex glove use they must be non-powdered and be low protein.

The problem of patient or health care worker sensitivity to natural rubber latex must be considered when deciding on glove materials and alternatives must be available in a variety of sizes. Nitrile gloves should be considered as the most acceptable alternative to latex.

Personal Protective Equipment of 78


However, any other alternative glove choice must provide the same level of safety and protection against HCAI.

Gloves reduce the risk of contamination but do not eliminate it; therefore gloves must not be used as a substitute for hand hygiene. Hands must always be decontaminated following removal of gloves as the integrity of gloves is not guaranteed and hands may become contaminated during their removal (DH and HPA, 2013).

CE Marking PPE must be CE Marked and comply with the requirements of the Personal Protective Equipment Regulations (1992). The CE mark signifies that the PPE satisfies basic safety requirements and in some cases will have been tested by an independent body. Gloves must also comply with the Medical Devices Directive 93/42 EEC and the Personal Protective Equipment Directive 89/686/EEC. Sterile Gloves Sterile gloves should be used for all aseptic and surgical procedures and also for the preparation of sterile pharmaceutical products.

Non-sterile GlovesNon-sterile gloves should be used when there is a risk of contact with blood, bodily fluids and non-intact skin.

Disposable Plastic Aprons Disposable plastic aprons are worn for two reasons:

To protect the wearer’s clothing/uniform from contamination from the resident. To protect the patient from contamination from the wearer’s clothing/uniform.

A disposable plastic apron must not be re-used, for example it should be changed in between if a patient has two wound dressings or bilateral leg ulcers (Loveday HP, Wilson JA, Pratt RJ et al 2014).

A disposable plastic apron must not come into contact with more than one patient. Micro-organisms will survive for a sufficient time to allow cross infection to occur if the apron is worn in caring for more than one resident (Loveday HP, Wilson JA, Pratt RJ et al 2014).

Masks, Eye Protection and Face Visors Masks, eye protection or face visors should be worn during procedures likely to cause splashing of body substances into the face. Face shields/visors should be considered in place of a surgical mask and goggles where there is a higher risk of splashing/aerosolisation of blood or body fluids. Face protection should be available during procedures where splashing/production of aerosols is possible (DH 1998).

The following procedures require risk assessment to determine the type of face protection required:

Cleaning of equipment when there is a risk of splashing and spraying When there is a risk of splashing and spraying of blood and / or body fluids Use of cleaning products



A disposable particulate filtration FFP3 MASK (“tight facial seal”) must be worn in the following situations:

When performing procedures that have the potential to generate aerosols on patients known or suspected of having Pandemic Influenza.

For procedures, which directly expose staff to respiratory secretions, which may contain multi-resistant – smear positive pulmonary tuberculosis strains.

When caring for a patient with suspected or known Severe Acute Respiratory Syndrome.

All staff requiring FFP3 masks must be fit tested by a suitably qualified health care professional who has been specifically trained.

If the mask becomes contaminated with body fluids it must be changed immediately.

Correct removal and disposal of Personal Protective Equipment The order for removing PPE is important to reduce cross contamination. The order for removal of PPE always applies, even if not all items of PPE have been used. The Department of Health (2008) state that order for removal of PPE is as follows:

Gloves Apron Eye protection Surgical mask or respirator

Re-usable items of protective equipment, such as visors or eye safety goggles should be decontaminated according to manufacturer’s instructions. Other items must be placed into the appropriate waste stream, infected items into infectious waste (orange bag), non-infected items into offensive waste (yellow with a black stripe).




References Department of Health (1974), Health and Safety at Work Act. Department of Health (2008) Pandemic Influenza Guidance for Dental Practice.

Department of Health and Health Protection Agency (2013) Prevention and Control of infection in care homes – an information resource.



Department of Health (2015) The Health and Social Care Act 2008. London. Department of Health.

NICE (2012) Prevention and Control of Healthcare Associated Infections in Primary and Community Care – NICE clinical guideline 139

Loveday HP, Wilson JA, Pratt RJ, Golsorkhi M, Tingle A, Bak, A, Browne J, Prieto J and Wilcox M (2014) Epic 3: National Evidence Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England. Journal of Hospital Infection 86S1 S1-S70

Health and Safety Executive (1992) Guidance on Personal Protective Equipment at Work Regulations (PPE) London Health and Safety Executive.



Management of Healthcare Waste and Sharps/Splash Injuries

Introduction The successful management of healthcare waste is essential in ensuring that healthcare activities do not pose a risk of infection and healthcare organisations need to fulfil legislative requirements for the safe management of healthcare waste.

Good infection prevention and control are essential to ensure that people who use health and social care services receive safe and effective care. Effective prevention and control of infection must be part of everyday practice and be applied consistently by everyone (Department of Health, 2015).

(Practice) aims to minimise and control risks caused by waste generated by its activities and will dispose of waste in a safe and efficient manner.(Practice) recognises its duties and legal responsibilities to ensure, as far as reasonably practicable, the health, safety and welfare of its employee’s and other people who may be affected by its activities and its duty to the environment in which it operates.

The purpose of this procedure is to describe the arrangements for the correct segregation, collection and disposal of all types of waste in order to:

Ensure that waste is managed safely and legally Ensure that waste is managed with minimum impact on the environment. Inform and assist staff to apply correct and safe procedures at all times and

comply with the law Inform contractors of their obligation and good practice Minimise the risk to the health and safety of staff and of anyone else who may be

affected Minimise the cost of waste collection and disposal Fully comply with the large body of law and official guidance concerning both

health and safety and environmental protection.

The practice uses (waste company) for the disposal of offensive, infectious, sharps and instrument waste. The practice has a collection: (enter frequency). Waste consignment notes are kept for a minimum period of 2 years.

Definitions of Waste Streams

Colour DescriptionDomestic Waste (Black)Domestic waste includes uncontaminated items such as paper towels and food waste, those items generally found in household waste.

Offensive Waste (Yellow with a black stripe)Offensive waste includes those items contaminated but not deemed infectious, such as soiled continence pads, used gloves and aprons.

Healthcare Waste and Sharps/Splash Injuries of 78


Infectious Waste (Orange)Waste is classified as infectious waste where:

It arises from a patient known or suspected to have an infection, whether or not the causal agent is known, and where the waste may contain the pathogen; or

Where an infection is not known or suspected, but a potential risk of infection is considered to exist.

Sharps – yellow with a purple lidSharps including those contaminated with cytotoxic and cytostatic medicines

Sharps – yellow with a yellow lidPartially discharged sharps including those contaminated with medicines other than those that are cytotoxic and cytostatic

Sharps – yellow with an orange lidSharps not contaminated with medicinal products i.e. fully discharged syringes

Importance of waste segregation Segregation of waste at the point of production into suitable colour-coded packaging is vital to good waste management. Health and safety, carriage and waste regulations require that waste is handled, transported and disposed of in a safe and effective manner.

The segregation of the different waste streams is necessary for the following reasons:

In England and Wales, mixing is prohibited by law – the different categories of waste must be segregated.

Health and Safety: reducing the risk of exposure and injury (for example needle-stick) for all staff handling these waste streams.

NoteIt is not acceptable practice to take any action to intentionally discharge syringes etc containing residual medicines in order to dispose of them in the “fully discharged” sharps receptacle (that is, the orange-lidded receptacle). If the syringe is partially discharged and contaminated with residual medicines, it should be disposed of in the yellow-lidded sharps receptacle.

Waste containersWaste bins will be a rigid container with a lid and pedal and a waste sack fully enclosed within. Offensive waste such as continence products must be placed in a plastic bag prior to placing in the correct waste stream to reduce odour. Waste bins must be cleaned thoroughly on a regular basis.

Boxes used for the disposal of sharps will be leak-proof, rigid, assembled correctly and labelled on opening and closing with the date, location and signature. They must be stored in a safe and secure manner.



Waste bags and full sharps bins are stored in a locked room whilst awaiting collection. (delete if not appropriate)

Waste bags are placed into a large storage bin outside whilst awaiting collection; the bin is kept locked and secure. Full sharps bins are stored in a locked room whilst awaiting collection. (delete if not appropriate)

SharpsA ‘sharp’ is defined as any object, which can pierce or puncture the skin, which is potentially contaminated with blood or body fluids.

A sharp includes any item, which has the potential to cause penetration injury i.e.

Needles Stitch cutters Clip removers and wound closure clips Razor blades and disposable razorsScalpels Glass vials/ampoules Specimen containers Lancets Wound closure clips Disposable scissors Probes

Equipment Select the size of sharps bin most appropriate to your needs to avoid prolonged use Discard of sharps directly into a sharps container immediately after and at the

point of use NEVER re-sheath a needle. Dispose of needle and syringe as a complete unit.

Never detach needle by hand The person using the sharp is responsible for disposal Place sharps containers wherever sharps are handled on a level, stable surface Apertures MUST be in the closed position when the sharps bin is not in use NEVER try to retrieve items from a sharps container NEVER overfill; sharps bins should be no more than two thirds full prior to disposal Sharps containers must not be in use for more than 3 months Always locate containers in a secure position out of reach of others to prevent injury

to patients, public and other Health Care Workers NEVER wear open footwear in situations where sharp instruments or needles are

handled

Sharps injuries pose a real risk to health, particularly from blood borne virus transmission, such as Hepatitis B and C viruses and HIV. Immunisation is available for Hepatitis B, the need for workers to be immunised should be determined by a risk assessment and it should be seen as a supplement to reinforce other control measures. The employer should make vaccines available free of charge to employees (HSE, 2018). Any exposure to blood and body fluids through a sharp object, bite or splashing into the eyes or mouth must be followed up immediately to prevent the risk of infection from blood borne viruses (Lawrence and May 2003).



The risk of infection following a percutaneous injury especially deep penetrating injuries involving a needle or a device visibly contaminated with blood has been estimated at;

1 in 3 for Hepatitis B 1 in 30 for Hepatitis C 1 in 300 for HIV

Many incidents of occupational exposure have been described as preventable providing there is proper adherence to standard precautions for the safe handling and disposal of clinical waste. Needle safety devices must be used where there are clear indications that they will provide safer systems of working for healthcare personnel. Safety devices not only minimise the risk of operator injury but also reduce ‘downstream’ injuries following the disposal of sharps (NICE, 2003). However; their use is not regarded as a complete solution to reducing sharps related injuries amongst healthcare workers, therefore safer sharps devices should be introduced alongside appropriate educational programmes to ensure they are used correctly (HSE, 2012). It is important that all members of staff report incidents of occupational exposure and complete and incident form.

Guidance for staff following a needle stick/sharps injury, human bite/scratch injury, body fluid splash to the eyes. A sharps injury only includes injury where there is a risk of infection; an injury from a sterile sharp instrument is not a sharps injury for the purposes of this policy, although first-aid treatment may be necessary.

1. Allow the wound to bleed – do not suck or lick the wound. For eye and mucous membrane contamination wash with water only, if contact lenses in place wash with copious amounts of water first with lenses in place and then with them removed.

2. Wash and clean the wound using soap and water only. For eye and mucous membrane contamination wash with water only, if contact lenses in place wash with copious amounts of water first with lenses in place and then with them removed.

3. Report it to your manager or the person in charge, who will complete a risk assessment on the need for blood testing and prophylaxis treatment.

4. Contact occupational health.






ReferencesDepartment of Health (2013) Environment and Sustainability Health Technical Memorandum 07-01: Safe management of healthcare waste

Department of Health (2015) The Health and Social Care Act 2008 – Code of Practice on the Prevention and Control of Infections and related guidance

Health and Safety Executive (2012) An evaluation of the efficacy of safer sharps devices.

Health and Safety Executive downloaded 4/01/18 Blood borne viruses in the workplace http://www.hse.gov.uk/pubns/indg342.pdf

Lawrence, J. May, D. (2003) Infection Control in the Community. Edinburgh. Churchill Livingstone.

National Institute for Clinical Excellence (2003) Prevention of Healthcare Associated Infections in Primary and Community Care


http://www.hse.gov.uk/pubns/indg342.pdf


Cleaning and Decontamination

Introduction It is essential to ensure that people who use health and social care services receive safe and effective care. Having effective infection prevention and control and cleanliness measures in place contributes to the quality and safety of patients, staff and visitors. Therefore this must be part of everyday practice and be applied consistently by everyone (Department of Health 2015). Cleanliness is intrinsically linked to infection prevention and control. A clean, well ordered environment provides the foundation for excellent infection control practice to flourish.

The National Patient Safety Agency National Specifications for Cleanliness: Guidance on setting and measuring performance outcomes in primary care medical and dental premises (2010) is designed to assist providers in ensuring their cleaning services address and minimise infection control risks.

Aim This policy aims to:

Provide staff with information relating to the importance of the delivery of high quality safe and effective cleaning techniques and best practice advice

Provide staff with sufficient information on which to base a risk assessment approach when deciding on the appropriate cleaning and decontamination method to use

Reduce the risks to staff and residents of acquiring a Health Care Acquired Infection (HCAI)

Risk ManagementPractice managers will assure themselves that the practice meets its obligation to deliver high-quality, effective, safe and clean premises that support the control of health care associated infections and make a positive contribution to healthcare outcomes.

The practice manager is responsible for the cleanliness of the practice and for ensuring all staff are aware of their responsibilities. The cleaning team are responsible for adhering to written cleaning schedules and clinicians are responsible for ensuring that equipment used is cleaned afterwards.

Introduction to Cleaning Micro-organisms are always present in the environment and all staff have a responsibility to ensure that equipment used is decontaminated properly to minimise the risk of cross infection to patients, staff and visitors. Decontamination is a general term for the destruction or removal of microbial contamination to render an item safe. Cleaning methods include:

Cleaning Disinfection Sterilisation

Cleaning Cleaning is a process, using general-purpose detergent and hot water (<35°C), to physically remove contaminants, including dust, soil, large numbers of micro-organisms (germs) and the organic matter (e.g. faeces, blood) that protects them.

Cleaning and Decontamination of 78


Cleaning remains the single most effective way of reducing the risk of infection from the environment and is usually the first stage before disinfection or sterilisation is attempted. The value of cleaning cannot be overemphasised. Without cleaning an item first, it may not be possible to disinfect or sterilise it properly.

Disinfection Environmental disinfection is a process used to reduce the number of micro-organisms, but not usually of bacterial spores. The process does not necessarily kill or remove all micro-organisms, but reduces their number to a level which is not harmful.

Sterilisation Sterilisation is a process used to render an object free from all microorganisms. For practices it is recommended that sterile equipment is obtained pre-sterilised from a manufacturer supplies and or via a Central Sterile Supplies Department (CSSD). Sterile equipment must be single use.

Colour Coding for Cleaning Adopting the national colour coding for cleaning to reflect the different areas within the establishment is considered best practice. This includes disposable cloths, mops and buckets.

Colour AreaRed Toilets and basinsBlue General areas including offices, waiting areaGreen Kitchen areasYellow Isolation areas

Equipment List Disposable well-fitting gloves Disposable aprons Eye protection including goggles and face visors Colour coded cloths Colour coded mops and buckets General purpose detergent or general surface cleaner Chlorine based product for use with Clostridium difficile, norovirus, diarrhoea and

vomiting Lime scale remover (care must be taken when choosing product to ensure that it

does not contain Hydrochloric acid, which will discolour chromed items). Cleaning Trolley Use this policy in conjunction with other policies such as PPE, hand washing,

cleaning of blood and body fluid spillages Detailed cleaning schedule

What Cleaning Product to Use and When?

For routine day-to-day cleaning of the environment and equipment activities:General cleaning of the environment can be achieved by using neutral general purpose detergent and warm water.

Cream cleaner or a hard surface cleaner is usually suitable for cleaning toilets and hand wash basins.

A neutral general purpose detergent is recommended for other environmental cleaning.

Detergent wipes for example, can be used for those items that cannot be immersed



For known infections resulting in isolation at the practice: A chlorine releasing agent to a concentration of at least 1:1000ppm must be used. Cleaning products such as, Household thick bleach; Milton; Chlor Clean; Haz Tabs; Difficile S; Milton are recognised as acceptable cleaning products for designated isolation rooms.

Storage of cleaning productsAll cleaning products must be accessible, prepared, stored, applied and disposed of in line with manufacturing instructions, local and health and safety COSHH regulations. A COSHH assessment is required for any cleaning material used. Cleaning cupboards must be kept locked at all times.

Cleaning SchedulesCleaning schedules must be specific and contain sufficient detail to prompt cleaning of all surfaces and equipment in all areas. Cleaning schedules must include cleaning frequencies and cleaning staff should sign on completion of a task.

Compliance and Audit Cleaning audits must take place on a regular basis to provide assurance that cleaning schedules are being adhered to.

Outsourced Cleaning (delete if not required) The practice has a contract with (name), an external cleaning company to carry out cleaning within the practice, the practice manager will gain regular assurance that cleaning schedules meet the needs of the environment, that they are being adhered to and that the correct equipment and products are available along with correct use of products eg: cleaning cloths being changed after each room, gloves and aprons being used and changed between room. The practice will not rely on external auditing completed by the cleaning company and will complete a regular in-house cleaning audit to monitor standards.

Equipment Cleaning List

ITEM METHOD FREQUENCY

Otoscope ear piece Single use Dispose of after useOpthalmoscope/otoscope handheld device

Clean with detergent wipe

After use

Blood glucose monitoring device Refer to manufacturer’s guidance

After each use

Blood pressure machine/sphygmomanometer/cuff


After each use

Curtains - disposable Replace 6 monthly or when visibly soiled

Doppler ultrasound probe Remove gel and clean with detergent wipe

After each use

Dressings trolleys Clean with detergent wipe

Before and after each use

Ear irrigation equipment Single use tips

Clean and disinfect reusable equipment with Propulse chlor-clean tablets, following manufacturer’s

Dispose of after use

At the end of each ear irrigation session



instructions.ECG electrodes Single use Dispose of after useECG machine/leads Clean and disinfect with

detergent wipeAfter use

Examination couch Cover with paper roll (store paper roll off the floor)


Change paper roll between each patient

After each use

Foot stool Cover with paper roll (store paper roll off the floor)


Change paper roll between each patient

After each use

Height scale Clean with detergent wipe

After each use

Hyfracator tips Single use Dispose of after useHyfracator Clean with detergent

wipeBefore and after each session

Monofilament probe Clean with detergent wipe

After each use

Nebuliser Single use mask

Clean nebuliser box with detergent wipe

Dispose of after use

After each use

Peak flow/spirometer mouth piece

Single use Dispose of after use

Peak flow meter hand held device when using disposable one-waycardboard mouthpieces


Refer to manufacturers guidance

After each use


Peak flow meter hand held device when using disposable cardboardmouthpieces



Pillows – vinyl covered Cover with paper roll


Change after each use

After each use

Pulse oximeter Clean with detergent wipe

After each use

Scissors for clinical/dressings use Single use Dispose of after useSpecula (vaginal) Single use Dispose of after useSpirometer flowhead Wipe flowhead with

detergent wipe

Wash in hot water and Hospec solution. Disinfect in 1000ppm sodium dichlorsocyanurate solution for 15 minutes

After each patient

At least monthly/or after every 100 patients (500 blows)



and replace meshes



Stethoscope diaphragm/bell Clean with detergent wipe

After each patient

Tourniquets Single use Dispose of after useTourniquets Clean with detergent

wipeAfter each use

Tympanic thermometer ear pieces

Single use Dispose of after use

Tympanic thermometer handheld device


At the end of each session and after patient use if contaminated

Weighing scales Clean with detergent wipe

After each use

Wheelchair Clean with detergent wipe

After each use

Education and Training All staff will receive appropriate training prior to being allocated specific cleaning tasks.

The Health and Social Care Act (DH 2015) stipulates that infection prevention and control training is included for all staff at induction. Hand hygiene training is included in the induction programme. Hand hygiene training is mandatory and is offered to staff annually. Infection prevention and control updates are mandatory and are offered every 2 years. All members of staff have an individual responsibility to ensure that they access mandatory training.



References DH (2009) The Health and Social Care Act 2008: Code of Practice for Health and adult social care on the prevention and control of infections and relating guidance

NICE (2010) Infection control: prevention of healthcare associated infection in primary and community care

NPSA (2010) National Specifications for Cleanliness: Guidance on Setting and Measuring Performance Outcomes in Primary Care Medical and Dental Premises

NPSA (2009) The Revised Healthcare Cleaning Manual



Management of Spillages of Blood, Body Fluids and Vaccines

Introduction The management of blood or body fluid spillage is a procedure which has potential infection risks. Blood spillages, if not managed appropriately, increase the risk to the health care worker of exposure to blood borne viruses. Vaccine spillages must be cleared quickly as all vaccines are chemicals which need to be cleared up appropriately and some vaccines are live and may be a potential source of infection. The aim of this policy is to:-

Aid in reducing the potential risk of cross infection from the spillages of blood and body fluids.

Ensure all staff are aware of the correct management of a blood or body fluid spillage.

Ensure all staff are aware of the correct management of a vaccine spillage.

Risk Management It is a legal requirement that all employers ensure that all employees are appropriately trained and proficient in procedures necessary for working safely (Health and Safety Executive 1974).

The Department of Health (1998) states that procedures should be reviewed in line with the Control of Substances Hazardous to Health Regulations (1994 COSHH). These procedures include any activities that involve contact with a substance hazardous to health including micro-organisms.

It is recommended that high risk body fluids as in blood are disinfected with sodium hypochlorite at strength of 10,000 ppm before disposal.

Spill Kits are recommended where there is an increased risk of spillages from blood, body fluids and vaccine spillages. Spill Kits contain granules and tablets. The granules can be used to soak up most spills and the tablets provide the correct strength of chlorine to disinfect the spillage area. The practices spill kit is stored: (enter).

Contraindications Due to the bleaching effects of chlorine, the Spill Kit should only be used on surfaces or equipment that can tolerate a hypochlorite solution. Always check the manufacturers cleaning and decontamination guidance before use.

Hazards The Spill kits contain chemicals which are harmful to health; therefore before using the product the individual must be aware of the potential risks and the necessary Health and Safety actions required to use it safely. COSHH 2002 regulations require that potential risks and safety data are provided. This data should be contained in the spill kit or be documented on the packaging of the chemical container.

Urine, Vomit and Faeces Spill Safety Granules used on urine and vomit spills may cause unpleasant fumes and give off extra chlorine gas therefore Spill Kits should NOT BE USED for urine and non-blood stained body fluids.

If the urine or vomit spill is blood stained, staff must ensure that the room is well ventilated and that the spill is cleaned up with paper towels and detergent and water before using

Spillages of Blood, Body Fluids and Vaccines of 78


sodium hypochlorite. A risk assessment should be carried out in relation to the comfort and safety of patients before urine and blood stained vomit spills are cleaned using the spill kit. It may be necessary if practicably possible to move the patient(s) before carrying out the procedure.

Equipment Spill Kit or Sodium hypochlorite Paper towels Detergent & water or detergent wipes Protective clothing: disposable gloves and apron; face visors or goggles when a risk

of splashing or spraying is present Infectious waste bag (orange) Carpet cleaning equipment and steam cleaner

Non-blood stained urine: Gather equipment Wash hands Apply PPE Soak up urine with paper towels and place in infectious waste Wipe with detergent and water and then dry with paper towels Remove all PPE and dispose of into infectious waste Place wet safety sign Wash hands If carpet arrange for the carpet to be shampooed If soft furnishings arrange for this to be steam cleaned

Non-blood stained vomit and faeces: Gather equipment Wash hands Apply PPE Remove matter with paper towels or scoop and scraper if using the spill kit and place

in infectious waste Wipe with detergent and water and then dry with paper towels Remove all PPE and dispose of into infectious waste Place wet safety sign Wash hands If carpet arrange for the carpet to be shampooed If soft furnishings arrange for this to be steam cleaned

Blood stained urine: Gather equipment Wash hands Apply PPE Soak up urine with paper towels and place in infectious waste Wipe with detergent and water followed by a solution of sodium hypochlorite strength

10,000ppm and then dry with paper towels Remove all PPE and dispose of into infectious waste Place wet safety sign Wash hands If carpet arrange for the carpet to be shampooed If soft furnishings arrange for this to be steam cleaned

Blood stained vomit and faeces:



Gather equipment Wash hands Apply PPE Remove vomit and faeces matter with paper towels or scoop and scraper if using a

spill kit and place in infectious waste Wipe with detergent and water followed by a solution of sodium hypochlorite strength

10,000ppm and then dry with paper towels Remove all PPE and dispose of into infectious waste Place wet safety sign Wash hands If carpet arrange for the carpet to be shampooed If soft furnishings arrange for this to be steam cleaned

Blood (on surfaces that tolerate sodium hypochlorite): Gather equipment Wash hands Apply PPE Sprinkle sodium hypochlorite granules onto the spill and allow to solidify Using the scoop and scraper pick up the matter and place in the infectious waste bag Wipe with a solution of sodium hypochlorite strength 10,000ppm and then dry with

paper towels Remove all PPE and dispose of into infectious waste Place wet safety sign Wash hands If carpet arrange for the carpet to be shampooed If soft furnishings arrange for this to be steam cleaned

Blood (on surfaces that CANNOT tolerate sodium hypochlorite): Gather equipment Wash hands Apply PPE Soak up blood spill with paper towels and place in infectious waste Wipe with detergent and water and then dry with paper towels Remove all PPE and dispose of into infectious waste Place wet safety sign Wash hands If carpet arrange for the carpet to be shampooed If soft furnishings arrange for this to be steam cleaned Any furniture, equipment left with residual staining should be taken out of use as

soon as is practicably possible

Vaccine Spillage: Spillages should be cleaned immediately and PPE should be used. The spillage should be soaked up with paper towels, taking care to avoid skin

puncture from glass or needles. The area should then be cleaned according to COSHH data sheets supplied with the

vaccine. Spillages on skin should be washed with soap and water. If a vaccine is splashed in the eyes, they should be washed with sterile 0.9% sodium

chloride solution and medical advice should be sought.

Roles and Responsibilities



It is the responsibility of all staff to take reasonable precautions to protect themselves and patients from accidental exposure to blood and body fluids. The staff member needs to anticipate where spills are likely to occur and to take action to reduce or eliminate the risk. In clinical areas it is the responsibility of the staff to ensure that spillages of blood, vomit, urine, faeces, body fluids and vaccine spills are cleaned up promptly and safely. The cleaning procedure must only be delegated to staff who have received training and are competent; this may include domestic staff.

Education and Training Program The Health and Social Care Act (Department of Health 2015) stipulates that infection prevention and control training is included for all staff at induction. Hand hygiene training is included in the induction programme. Hand hygiene training is mandatory and is offered to staff annually. Infection prevention and control updates are mandatory and are offered every 2 years. All members of staff have an individual responsibility to ensure that they access mandatory training.



References Department of Health (1998) Guidance for Clinical Health Care Workers: Protection against Infection with Blood Borne Viruses. Recommendations of the Expert Advisory Group on AIDS and the Advisory Group on Hepatitis

Health and Safety Executive (1974) Health and Safety at Work Act Health and Safety Executive (1994) The Control of Substances Hazardous to Health

Health and Safety Executive (2002) The Control of Substances Hazardous to Health Regulations. Approved codes of practice and guidance

PHE and DH (2013) The Green Book - Immunisation against infectious disease



Minor Surgery

AimGood infection prevention is essential to ensure that people who use health and social care services receive safe and effective care. Good management and organisational processes are crucial to make sure that high standards of infection prevention and control are developed and maintained (Department of Health, 2015). Research and investigation have consistently confirmed that the healthcare environment can be a reservoir for organisms with the potential for infecting patients, therefore the environment must facilitate good infection prevention and control practices in that fixtures and fittings enable thorough access, cleaning and maintenance to take place (DH, 2013).

NHS commissioners must satisfy themselves that the General Practice setting in which minor surgery takes place is of a requisite high standard for Infection Prevention and Control. The Health and Social Care Act 2008 and regulations are law and must be complied with and the Care Quality Commission has enforcement powers that it may use if registered providers do not comply with the law (DH, 2015).

Policies, protocols and guidelinesThe practice must have the following policies and documents in place which are compliant with national guidelines:

Hand Hygiene Personal Protective Equipment Management of Waste Equipment Policy (CSSD or single use) Handling of Specimens Cleaning and Decontamination Cleaning Schedules Evidence of quarterly Infection Prevention and Control audits Surgical site audits

The Minor Surgery/Treatment RoomThe clinical area will be organised to ensure that dirty and clean procedures and processes are clearly separated to reduce the risk of cross contamination.

Room SizeThe room will be of a sufficient size to enable staff to move around freely and to accommodate the GP, patient and assistant with access to three sides of the operating couch.

Clinical Hand Hygiene BasinThere will be a designated hand wash basin that is large enough to contain splashing and enables the correct hand hygiene technique to take place. The clinical hand hygiene basin is compliant with relevant guidance and fitted with elbow operated taps, has no overflow or plug and the taps should not be fitted directly over the aperture.

The following will be available at the hand hygiene sink:

Wall mounted single cartridge liquid soap dispenser Wall mounted paper towel dispenser Surgical hand scrub must be available in a pump dispenser, preferably wall mounted Foot operated domestic waste bin for the disposal of paper towels Splash backs will be smooth and impermeable, without joints

Minor Surgery of 78


Pipework will be concealed; any boxing in of pipes is with a PVC washable material or in new and refurbished builds an IPS unit (integrated plumbing system). (delete as appropriate)

Furniture, fixtures and fittings The room contains the minimum amount of equipment to reduce the risk of dust

accumulation and to allow for easy cleaning There is no open shelving to reduce the risk of dust accumulating and cupboards

must be boxed to the ceiling or sloping top All equipment and consumables unless floor standing are stored off the floor and

wherever possible stored in a cupboard to reduce the risk of environmental contamination

Radiators are accessible and cleanable with supply pipework concealed Finishes are impervious, smooth and seamless There are no dead legs and blind ends in the water systems Pipework is concealed; any boxing in of pipes should be a PVC washable material Metal framed couches are intact and covered in a washable vinyl fabric

Flooring Flooring is sheet vinyl, seamless and smooth, slip resistant, easily cleaned and runs

up the wall to form a coved skirting that has a minimum height of 100mm to allow for easy cleaning

Work surfaces Work surfaces are impermeable, intact, with all joints sealed and coved up the wall to

facilitate cleaning and to reduce the build-up of harmful micro-organisms

Walls Walls are smooth, hard and impervious to moisture. Posters are kept to a minimum,

those that are required are laminated to facilitate cleaning

Windows / Blinds / Curtains Window blinds are vertical and made of washable PVC fabric or integral to the

window (delete as appropriate) Privacy curtains are disposable

Ventilation Mechanical extract ventilation (extractor fan) is fitted to an outside wall or window as

operations on the superficial structures of the body takes place and odour producing procedures take place

If more invasive surgical procedures take place for example vasectomies where instruments are entering a sterile body, then mechanical ventilation providing at least 10 air changes per hour should be installed

Lighting Lighting is flush to the ceiling, easy to clean and unlikely to accumulate dust

Surgical Instruments Surgical instruments are stored safely to prevent damage and contamination and are

sterile at the point of use The practice uses single use instruments or contract with their local CSSD

department (delete as appropriate) Single use instruments are disposed of into an instrument disposal bin supplied by

the waste contractor (delete as appropriate)

Minor Surgery of 78


Environmental CleaningIn addition to the routine daily clean that takes place, the room is cleaned before and after each minor operation session and includes specified areas in between each patient using the following:

All surfaces are cleaned with detergent and warm water or disposable detergent wipes. In addition to this some surfaces require enhanced cleaning with sodium hypochlorite 1000ppm or Milton, surfaces must be allowed to air dry or have a minimum contact time of 5 minutes before rinsing and drying. Specified areas to be cleaned with sodium hypochlorite 1000ppm or ‘Milton’ between each patient include: work surfaces, patient couch and stainless steel trolley

The practice has a spillage kit to manage blood and bodily fluid spillages effectively, this is located in (enter room)

Antiseptic Skin Preparation and Hair Removal Skin sites are prepared immediately prior to surgery with either povidone-iodine 10%

or chlorhexidine 0.5% Hair must not be removed routinely to prevent the risk of surgical site infection.

However, if this is required, the use of electric clippers with disposable heads are recommended as the use of disposable razors increases the risk of infection

Waste Disposal A domestic bin is in close proximity to the hand wash sink for the disposal of paper

towels, the bin is rigid with a working lid and pedal and a waste sack fully enclosed within

An offensive and infectious waste bin is available, bins are rigid with a working lid and pedal and a waste sack fully enclosed within

A sharps bin is available for the disposal of sharp items. The sharps bin will be fitted correctly and labelled on opening and closing with the location, date and signature

An instrument bin is available for the disposal of single use instruments and is fitted correctly and labelled on opening and closing with the location, date and signature

Supporting Rooms (where applicable)

Dirty Utility Room The dirty utility room is located near to the minor surgery room. A slop hopper, deep

sink with drainer and a clinical hand hygiene basin is available

Clean Utility Room The clean utility room is located near to the minor surgery room for the storage of

clean and sterile products. A clinical hand hygiene basin is available

Patient ConsentAdequate patient consent is essential; this is always recorded in the medical records. The GP will:

Discuss the nature and purpose of the procedure Explain the risks involved Hand out a leaflet (if appropriate) Discuss alternatives

Minor Surgery of 78


Antiseptic Hand WashPrior to undertaking minor surgery an antiseptic hand wash takes place. Antiseptic hand wash solutions used with water will remove and destroy micro-organisms on the hands. Some antiseptic agents have residual activity and provide continued anti-microbial activity. The first choice agent for antiseptic hand wash is Hibiscrub 4%.

Aseptic TechniqueAsepsis is defined as the absence of pathogenic (harmful) organisms. An aseptic technique is used to carry out a procedure in a way that minimises the risk of contamination. Only staff trained and competent in an aseptic technique should undertake this procedure. Adherence to the principles of asepsis plays a vital role in preventing the transmission of infection in any environment. It is the responsibility of each member of staff who undertakes an aseptic technique to understand the meaning of these principles and to incorporate them into their everyday practice.

The principles of aseptic technique: Reducing activity in the immediate vicinity of the area in which the procedure is to be

performed Keeping the exposure of a susceptible site to a minimum Checking all sterile packs to be used for evidence of damage or moisture penetration Ensuring all fluids and materials to be used are in date Not re-using single use items Ensuring contaminated/non-sterile items are not placed in the sterile field Ensuring appropriate hand decontamination prior to the procedure Protecting uniform/clothing with a disposable apron Using sterile gloves

Uniform and WorkwearNeck ties will not be worn as they are rarely laundered but worn daily and perform no beneficial function in patient care and have been shown to be colonised by pathogens.

Staff will be ‘bare below the elbows’ and avoid wearing white coats as cuffs become heavily contaminated and are more likely to come into contact with patients.

Personal Protective EquipmentGloves, aprons and facial protection must be available and staff undertake individual risk assessment to identify what personal protective clothing is required for each procedure (this is not a written risk assessment)

Surgical site auditsClinical audit is a process that has been defined as a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Surgical site audits monitor infection rates following minor surgery. See appendix 1 for surgical site audit.


Minor Surgery of 78




ReferencesDepartment of Health (2005). National Decontamination Strategy. London.

Department of Health (2006). Health Technical Memorandum 07-01: Environment and Sustainability: Safe Management of Healthcare Waste. London.

Department of Health (2007) Uniforms and Workwear: an evidence base for developing local policy. London.

Department of Health (2007). Health Technical Memorandum 03-01: Heating and Ventilation Systems: Specialist Ventilation for Healthcare Premises. London.

Department of Health (2015). Health and Social Care Act 2008: Code of Practice on the Prevention and Control of Infections and related guidance. London.

Department of Health (2013). Health Building Note 00-09: Infection Control in the Built Environment. London.

Department of Health (2013). Health Building Note 00-10 Part B: Walls and Ceilings. London.

Department of Health (2013). Health Building Note 00-10 Part A: Flooring. London.

National Institute for Clinical Excellence (2003). Infection Control: Prevention of Healthcare Associated Infection in Primary and Community Care. London.

Minor Surgery of 78


Appendix 1: Surgical Site Audit

PATIENT PROCEDURE PERFORMED

GP PERFORMING PROCEDURE

DATE AND TIME

POST INFECTION

YES/NO

CULTURE OBTAINED

YES/NO

CAUSATIVE MICRO-ORGANISM

ANTIBIOTICS YES/NO

OUTCOME

Minor Surgery of 78

Management of Vaccines and the Cold Chain

IntroductionVaccines are biological substances that may lose their effectiveness if not transported and stored appropriately. The cold chain is the term used to describe the cold temperature conditions that vaccines need to be stored. Maintaining the cold chain ensures that vaccines are stored and transported according to the manufacturers recommended temperature of between 2 -8°c until the point of administration.

Receipt The named individual responsible for the receipt and storage of vaccines is (name). The named deputy in times of absence is (name).

A stock control book or database with suitable back-up (delete as appropriate) is kept to help maintain the cold chain, as the information will be available without having to open the fridge door for long periods to examine stock. This record should:

Keep track of orders, expiry dates and running totals of vaccines. Incorporate the refrigerator temperature monitoring chart so that all the

information is kept in one place. Be dedicated to one fridge – there should be a book for each fridge.

On receipt of delivery the designated person(s) will check against the order for discrepancies and for leakage or damage before signing for them. The following information is recorded in the stock control book:

Vaccine type and brand Quantity Batch number and expiry date Date and time of receipt Signature of person receiving goods

Vaccines must be kept in their original packaging and refrigerated immediately on receipt.

Storage Make regular stock-checks to remove expired vaccines Rotate stock so that those with the shortest expiry date are moved to the front of the

refrigerator and used first Do not store in the drawer or doors of the refrigerator The refrigerator will be no more than 50% full and contents will be evenly distributed

to allow air to circulate, they should not be stored up to the sides and back of the refrigerator

Vaccines are stored in their original packaging to prevent damage from light

For vaccine sessions/visits being carried out off site, vaccines are transported in an appropriate validated cool box (with minimum and maximum thermometer). Vaccines are placed quickly into the validated cool boxes and opening must be kept to a minimum. If there are any unused vaccines left over at the end of a vaccination session, providing there is evidence from the temperature monitoring that the cold chain has been maintained, the vaccines can be returned to the vaccine refrigerator. Returned vaccines should be marked so that they can be used at the earliest opportunity.

Refrigerator

Vaccines and the Cold Chain of 78

The vaccine refrigerator: Is not a domestic fridge but a commercially purchased refrigerator specifically for the

storage of vaccines The refrigerator is not placed near to a radiator or other heat source and air is

allowed to circulate around all sides Is serviced annually in line with manufacturers guidance and is checked, defrosted

and cleaned monthly to prevent ice build up Has an uninterrupted electrical supply The thermometer is calibrated yearly Has a data logger in place and this is downloaded on a weekly basis The refrigerator is kept locked at all times A backup refrigerator is available in the event of failure

Temperatures The refrigerator has a digital thermometer The data logger is downloaded on a weekly basis Daily temperatures are obtained and include minimum, maximum and actual

temperatures (see appendix 1 for template temperature chart) Maximum and minimum functions are reset after each temperature reading

Disruption of the cold chainIn the event of a cold chain incident refer to NHS England Policy and Procedure for Maintaining the Vaccine Cold Chain (2017).

Education and Training Program Practice nurses receive annual vaccination and immunisation training including management of the cold chain.

The Health and Social Care Act (DH 2015) stipulates that infection prevention and control training is included for all staff at induction. Hand hygiene training is included in the induction programme. Hand hygiene training is mandatory and is offered to staff annually. Infection prevention and control updates are mandatory and are offered every 2 years. All members of staff have an individual responsibility to ensure that they access mandatory training.



ReferencesDH (2006). Immunisation Against Infectious Disease (The Green Book, current edition)

NHS England (2015) Policy and Procedure for Maintaining the Vaccine Cold Chain

Appendix 1: Refrigerator Temperature Log


Temperatures must be within 2-8°. Check each working day. If the temperature is outside the recommended range, take appropriate action.

REMEMBER: READ, RECORD, RESET, REACT

MONTH AND YEAR:

DATE MINIMUM MAXIMUM ACTUAL RESET COMMENTS SIGNATURE


Handling of Specimens

IntroductionSpecimens if not handled safely can pose a risk of infection. Accurate analysis is crucial in determining the correct diagnosis, or detecting an infectious agent, so that appropriate and timely treatment can be given. A clinical specimen can be defined as any bodily substance, solid or liquid, that is obtained for the purpose of analysis (Weston, 2008).

AimTo ensure that staff handle specimens in a safe manner to allow any relevant treatment required given in a timely manner.

To ensure that the practice complies with current Health and Safety at Work and Control of Substances Hazardous to Health legislation.

Collection of Specimens Follow standard precautions when collecting specimens Write the patient details on the container immediately after collecting the specimen When taking the specimen ensure that the outside of the container is free from

contamination of bodily fluids When taking swabs from a dry area i.e. nasal screening, the tip should be

moistened in sterile normal saline Do not over fill containers Ensure the lid is immediately secured to prevent spillage in transport Place in a clear plastic bag and request relevant test on ‘ICE’, apply barcode label

and place in box for delivery to the laboratory Ensure that a designated specimen fridge is available for when a sample requires

refrigeration.

Specimens brought in by patient A box is available on reception Reception staff pass the box and the patient places the specimen in the box Practice nurse collects the box and requests relevant tests on ‘ICE’, apply barcodes

and places in box for delivery to the laboratory Reception staff have access to alcohol gel to decontaminate hands

Or: (delete as appropriate)

A box is available on reception Reception staff apply gloves and place the specimen in the box, reception staff

remove gloves and use alcohol gel provided to decontaminate hands Practice nurse collects the box and requests relevant tests on ‘ICE’, apply barcodes

and places in box for delivery to the laboratory

Collection of SpecimensIdeally all specimens should be obtained as near to the time of collection for delivery to the laboratory.

Blood samples: Should be sent straight to the laboratory

Urine samples for MC&S: Specimens should be taken before antimicrobial therapy is started.

Handling of Specimens of 78

Specimens should be transported to the laboratory as soon as possible. Delays of more than 4 hours; refrigerate sample.

Wound swab: Specimens should be taken before antimicrobial therapy is started. Specimens should be transported and processed as soon as possible. If processing is delayed refrigeration is preferable to storage at ambient temperature.

Delays of over 48 hours are undesirable. Ensure that the specific wound site is listed.

MRSA screen: Nose and perineum swab, any open wounds, any manipulated sites e.g. lines, drain

sites. Specimens should be transported and processed as soon as possible. If processing is delayed refrigeration is preferable to storage at ambient temperature.

Delays of over 2 days are undesirable.

PVL screen: Screen consists of nose, perineum and any lesions patient currently has. Specimens should be transported and processed as soon as possible. If processing is delayed refrigeration is preferable to storage at ambient temperature.

Delays of over 48 hours are undesirable.

Throat swab: Sample should be collected before antimicrobial therapy where possible. Throat swab taken from the tonsillar area and/or posterior pharynx, should be taken

avoiding the tongue and uvula. Specimens should be transported and processed as soon as possible. If processing is delayed refrigeration is preferable to storage at ambient temperature.

Delays of over 48 hours are undesirable.

Norovirus: Deliver to laboratory as soon as possible or refrigerate at 4-8oC before sending. Ensure that request is for virology.

Sputum: Specimens should be taken before antimicrobial therapy is started. For sputum

specimens the material required is from the lower respiratory tract, expectorated by deep coughing.

Specimens should be transported to the laboratory as soon as possible. If processing is delayed refrigeration is preferable to storage at ambient temperature.

Sputum may be refrigerated for up to 2-3 days without an appreciable loss of pathogens. Any delay beyond this time may allow overgrowth of Gram-negative bacilli, and Haemophilus species and S. pneumoniae may be rendered non-viable.

Clostridium difficile: At a minimum to the bottom of the label. Formed stools not suitable and will not be tested. Sample must be type 5-7 on Bristol stool chart and patient over 2 years of age. GP samples from patients <65 years of age are not automatically tested. The test

must be specifically requested in this age group. Toxin degrades at room temperature, therefore send to laboratory as soon as

possible or refrigerate until delivery to laboratory. Clostridium difficile testing not routinely performed on <2 year olds, and <65 year olds from General Practice.





ReferencesNUH A to Z of tests and investigations www.nuh.nhs.uk

D Weston (2008) Infection Prevention and Control: Theory and Practice for Healthcare Professionals. John Wiley and Sons Ltd


http://www.nuh.nhs.uk/

Management of Seasonal Influenza Outbreaks in Care Homes

Introduction Influenza and other respiratory infections are a major cause of hospitalisation, morbidity and death among the elderly due to underlying health conditions. Respiratory infections can spread quickly in the care home setting. The Public Health England definition of an outbreak of influenza like illness is ‘two or more cases which meet the clinical case definition of influenza like illness or alternatively two or more cases of laboratory confirmed influenza arising in the same 48 hour period with an epidemiological link to the care home (PHE, 2016). This policy has been written to assist GP’s to contribute to the recognition, management and safe control of an outbreak of respiratory infection within the care home setting.

Risk Management Indications Outbreaks of infection must be carefully managed to bring about a safe conclusion as soon as clinically and practicably possible.

This policy will assist staff to achieve this by: Verifying that there is an outbreak of infection Investigating the extent Identifying possible causes and/or source Bringing the outbreak under control and reducing further spread

Hazards The Health and Safety Executive states that hazardous substances at work can put people’s health at risk. Micro-organisms such as bacteria and viruses are classed as hazardous substances (COSHH 2002). Therefore, in an outbreak situation, employers and employees need to be aware of the potential risk of infection to patients, visitors and themselves and put into place the appropriate actions to reduce the risk of further spread as indicated within the policy. It is important that residents and staff receive annual influenza vaccination as this limits the risk of flu outbreaks and/or severe illness.

Definition of influenza like illnessThe Public Health England influenza like illness case definition for use in care homes is as follows:

Oral or tympanic temperature ≥37.8°c

AND one of the following:

Acute onset of at least one of the following respiratory symptoms: cough (with or without sputum), hoarseness, nasal discharge or congestion, shortness of breath, sore throat, wheezing or sneezing

OR

An acute deterioration in physical or mental ability without other known cause

(PHE, 2016)

Seasonal Influenza Outbreaks in Care Homes of 78

Definitions of Influenza

Uncomplicated influenza: Influenza presenting with fever, coryza, generalised symptoms (headache, malaise, myalgia, arthralgia) and sometimes gastrointestinal symptoms, but without any features of complicated influenza.

Complicated influenza: Influenza requiring hospital admission and/or with symptoms and signs of lower respiratory tract infection (hypoxaemia, dyspnoea, lung infiltrate), central nervous system involvement and/or a significant exacerbation of an underlying medical condition.

Risk factors for complicated influenza: a. Neurological, hepatic, renal, pulmonary and chronic cardiac disease. b. Diabetes mellitus. c. Severe immunosuppression. d. Age over 65 years. e. Pregnancy (including up to two weeks post-partum). f. Children under 6 months of age. g. Morbid obesity (BMI ≥40).

For full details refer to Immunisation Against Infectious Disease, known as the Green Book.

Severe immunosuppression: Degrees of immunosuppression are difficult to quantify and individual variation exists, therefore this list is not comprehensive.

a. Severe primary immunodeficiency. b. Current or recent (within six months) chemotherapy or radiotherapy for

malignancy. c. Solid organ transplant recipients on immunosuppressive therapy. d. Bone marrow transplant recipients currently receiving immunosuppressive treatment,

or within 12 months of receiving immunosuppression. e. Patients with current graft-versus-host disease. f. Patients currently receiving high dose systemic corticosteroids (equivalent to ≥40 mg

prednisolone per day for >1 week in an adult, or ≥ 2mg/kg/day for ≥1 week in a child), and for at least three months after treatment has stopped.

g. HIV infected patients with severe immunosuppression (CD4<200/μl or <15% of total lymphocytes in an adult or child over five; CD4< 500/μl or <15% of total lymphocytes in a child aged one to five; expert clinical opinion in a child aged under one).

h. Patients currently or recently (within six months) on other types of highly immunosuppressive therapy or where the patient’s specialist regards them as severely immunosuppressed.

PHE (2017)


Obtaining Specimens Viral throat swabs should be obtained within 48 hours of symptoms developing to eliminate influenza. In an outbreak situation these should be labelled respiratory outbreak and a maximum of 5 swabs should be taken.

South and North swabs (red)

The taking of swabs only applies before receipt of the chief medical officers letter (CMO letter) in GP practice, confirming we are in official flu season – once this has been received, viral swabs are not required, however; they can be obtained to allow the care home to re-open where influenza has not been detected

Outbreak Management within the Care Home: prescribing of antiviralsAs appropriate, the practice will ensure consent has been obtained by the care home from the patient, or patient's relative, for antiviral to be administered, or that the Care Home has undertaken a best interest assessment.

When an outbreak has been declared antiviral medication will be required for all patients with or without symptoms. For patients exhibiting symptoms this will be commenced within 48 hours of onset and will be given whether the case is vaccinated or not.

Prophylaxis is recommended for those close contacts aged >65yr OR in an at risk group OR pregnant, where this can be started within 36 hours (Zanamivir) or 48 hours (Oseltamivir) of last contact with a case.

Prophylaxis can be given >48 hours if there are any concerns about high attack or high fatality rates (though unlicensed).

The GP may need to convert prophylactic doses to treatment doses if patients on prophylaxis become symptomatic or consider stopping prophylaxis if swab results are negative.


Treatment of Suspected or Confirmed Influenza


Suspected or confirmed Influenza

Uncomplicated Complicated

Previous healthy At risk group

NO TREATMENT

OrOseltamivir PO

If physician feels patient is at serious risk of developing complications

No Yes

Severely immunocompromised?

No Yes

Oseltamivir PO within 48hrs of onset, or later at clinical

discretion

See table 1 1st line

oseltamivir PO/NG2nd line

zamamivir INH NEB or

IV

See table 1

Table 1: Selection of antivirals for severely immunosuppressed patients

Dominant circulating strain has a lower risk of oseltamivir resistance, e.g. A(H3N2), influenza B *

Dominant circulating strain has a higher risk of oseltamivir resistance, e.g. A(H1N1) *

Uncomplicated influenza oseltamivir PO and clinical follow up.Commence therapy within 48 hours of onset (or later at clinical discretion)

zanamivir INH (Diskhaler®)Commence therapy within 36 hours of onset (or later at clinical discretion)OR if unable to take inhaled preparation useoseltamivir PO and clinical follow up.Commence therapy within 48 hours of onset (or later at clinical discretion)

Complicated influenza 1st line: oseltamivir PO/NG2nd line: zanamivir INH, NEB or IV Consider switching to zanamivir if:- Poor clinical response- Subtype testing confirms a strain with potential oseltamivir resistance, e.g. A(H1N1)

zanamivir INH, NEB or IVCommence therapy within 48 hours of onset (36 for children) or later at clinical discretion(if there are delays in obtaining aqueous zanamivir, use oseltamivir as a bridging treatment until zanamivir is available)

* = (also applicable if this is the strain known to be infecting patient; treatment however, should not be delayed while waiting for test results).

Dosage in adults for treatment of uncomplicated influenza

Oseltamivir 75mg PO twice daily for 5 days Zanamivir 10mg INH twice daily for 5 days

Note: dose adjustments for obesity and renal dysfunction are provided later in this document.

Treatment of adults in complicated influenzaAll patients with complicated influenza should receive treatment, this often occurs in hospital. Treatment should be started as soon as possible; there is no need to wait for a result.

1st line treatment: oseltamivir2nd line treatment: zanamivir if there is a poor response to oseltamivir or if there is evidence of gastrointestinal dysfunction

For further detail see PHE guidelines on use of antiviral agents for the treatment and prophylaxis of seasonal influenza.


Oseltamivir doses for weight and renal dysfunction

Weight Renal function Treatment dose Post exposure prophylaxis dose

>40 kg NormalCr Cl >60 ml/min

75 mg twice a dayfor 5 days

75 mg once a dayfor 10 days

23-40 kg NormalCr Cl >60 ml/min



Allpatients

Moderate impairmentCr Cl 30-60 ml/min



Allpatients

Severe impairmentCr Cl 10-30 ml/min


30 mg every 48 hoursfor 10 days

Allpatients

Established renal impairmentCr Cl <10 ml/min

30 mg once only 30 mg once, repeatedafter 7 days

Education and Training Program The Health and Social Care Act (Department of Health 2015) stipulates that infection prevention and control training is included for all staff at induction. Hand hygiene training is included in the induction programme. Hand hygiene training is mandatory and is offered to staff annually. Infection prevention and control updates are mandatory and are offered every 2 years. All members of staff have an individual responsibility to ensure that they access mandatory training.



ReferencesDepartment of Health (2015) The Health and Social Care Act 2008. London

PHE (2016) PHE guidelines on the management of outbreaks of influenza-like illness (ILI) in care homes. Crown Copyright

PHE (2017) PHE guidance on use of antiviral agents for the treatment and prophylaxis of seasonal influenza. Crown Copyright


Policy for the Management of Meticillin Resistant Staphylococcus Aureus (MRSA)

IntroductionThe aim of this policy is to provide information to staff working within Primary Care organisations within Nottinghamshire Clinical Commissioning Groups (CCG) (excluding Bassetlaw) to ensure that people with MRSA (Meticillin Resistant Staphylococcus Aureus) are managed appropriately and effectively in order to limit the spread within primary care. The Department of Health have stated that all Organisations are directly accountable for reducing the rate of MRSA bacteraemia in their local population. Each organisation has been given a zero tolerance target for avoidable MRSA bacteraemia infections.

Aim Explain what MRSA is and to highlight the standard infection prevention and control

principles that should be applied by staff to minimise the spread. Ensure that patients who are found to be MRSA positive are informed of their

diagnosis, given the correct information about MRSA, its treatment and any follow up required.

Ensure that patients who are found to be positive for MRSA are offered decolonisation treatment in accordance with this policy.

Ensure that all patients who require screening for MRSA are screened according to this policy

PurposeThe Health and Social Care Act 2008, states the need for health and social care providers to have policies in place that will help to prevent and control infections. The purpose of this policy is to ensure that staff, working within Primary Care in Nottinghamshire CCGs, have sufficient information to effectively care for and manage patients with MRSA.

Definitions

MRSA - Staphylococcus aureus (SA) is a common bacteria, which may be found on the skin of around one third of healthy adults. Meticillin Resistant Staphylococcus aureus (MRSA) is a strain of SA that is resistant to many antibiotics, in particular flucloxacillin, which is the standard treatment for many staphylococcal infections. Although MRSA is no more likely to cause an infection than sensitive SA, the infection can be more difficult to treat due to a limited choice of antibiotics. It can be carried on the skin or in the nose of healthy people (colonisation) without causing any adverse effects. However, colonisation is considered to be a major risk factor for infections, which may range from mild to life threatening.

Panton Valentine Leukocidin (PVL) - Staphylococcus aureus (SA) is a bacterium that commonly lives on healthy skin. About one third of healthy people carry it quite harmlessly, usually on moist surfaces such as the nostrils, armpits and groin. Some types of SA produce a toxin called Panton Valentine Leukocidin and they are known as PVL-SAs. (Panton and Valentine were the two doctors who first found the toxin which can kill white blood cells called leukocytes – hence leukocidin).

MRSA of 78

PVL-SAs can cause skin and soft tissue infections e.g. boils and abscesses. They can also cause invasive infections affecting the lungs, blood, joints and bones.

The PVL toxin can be produced by both meticillin-sensitive Staphylococcus aureus (MSSA) and meticillin-resistant Staphylococcus aureus (MRSA). (Refer to the CityCare Policy for Managing and Treating Patients in Primary Care available on the POD).If patients attends with recurrent boils or skin abscesses please consider additional testing for PVL infection. This will need to be specifically requested on the laboratory form

Colonisation- occurs when a microbe establishes itself in a particular environment such as a body surface, without producing disease or symptoms. This is sometimes referred to as asymptomatic carriage and can be identified by screening. Around 30% of the general population are colonised with Staphylococcus aureus. It may be present on the skin, in the nose, axillae, groin or perineum. It can also colonise wounds and other areas of non-intact skin without causing harm.

Decolonisation – refers to the application of antimicrobial products to body surfaces cavities in order to eradicate colonising micro-organisms (e.g. MRSA)

Infection - occurs when the bacteria gain access to the body tissues and multiply, causing a host reaction and clinical signs of infection, which may include redness, swelling, pain or discharge in a wound or invasive device site. Depending on the properties of the infecting micro-organism and the capacity for resistance of the infected host, there may be other effects in the body, including toxin production and spread to other sites.

Bacteraemia – occurs when there is evidence of spread of infection into the blood stream.

Responsibilities

Infection Control Lead in the practice Insert Name____________________________The Infection Control Lead has overall responsibility for ensuring that there are effective arrangements for infection prevention and control within the practice and for meeting all statutory requirements.

The Practice Manager Insert Name______________________________The Practice Manager is responsible for ensuring that there are the necessary policies and training to reduce the risk of infections being transmitted and for ensuring that appropriate governance arrangements are in place to provide effective care and management of patients with MRSA in accordance with this policy. The infection Prevention and Control Team (IPC):Receive laboratory reports which provide information about the positive MRSA screens and samples from primary care and receive discharge information on patients requiring further follow up and treatment interventions from hospital.

The Infection Prevention and Control team will receive the results from the source laboratory and will provide clinical expertise and advice and support clinicians with the choice of treatment and management appropriate for the patient.

MRSA of 78

The IPC team provide support and leadership for providers in implementing the Post Infection Review process (PIR) for all pre-48 hour MRSA bacteraemia cases in line with the criteria in the NHS England PIR process and policy for serious incidents.

https://www.england.nhs.uk/patientsafety/wp-content/uploads/sites/32/2015/04/serious-incidnt-framwrk-upd2.pdf

http://www.england.nhs.uk/wp-content/uploads/2014/04/mrsa-pir-guid-april14.pdf

The team will disseminate the findings to the clinicians involved and the wider lessons for all clinicians.

Line managers Line Managers have responsibility to ensure staff are aware of this policy, have read and signed to say they have read it and for ensuring their staff adhere to the policy.

All staff Ensure all staff that have contact with a patient with MRSA adhere to the relevant

policy and guidelines Take screens in accordance with the policy and communicate screen results to the

patients Inform the patient of their diagnosis and document this within the patients’ medical

/care records. Explain and document treatment regimens. Implement standard infection prevention and control principles (see section 7

Control of MRSA). Ensure when care is transferred to another provider, that the diagnosis is

communicated to the provider after consultation with the patient.

Delivery of Care

TransmissionMRSA infections occur in all types of healthcare settings, however it is well known that controlling the spread of MRSA outside of the acute hospital environment has often been overlooked or deemed to be unnecessary. The recent trends towards earlier discharge from hospital, day surgery, minor surgery and interventions in community settings, along with the increased need for the use of indwelling devices significantly increases the risk of patients developing infections in the community. The often continuous and repeated movement of patients between different healthcare settings also increases the risks of HCAI to patients, as well as the emergence of Community Associated strains of MRSA e.g. Panton- Valentine Leukocidin (PVL) which is also a significant factor. Routes of Transmission MRSA can be transmitted either:

Endogenously - this occurs when a person already colonised with MRSA spreads the organism from one part of their body to another.

Exogenously - this occurs when MRSA is spread from one person to another. This can happen in a variety of ways including:

Direct spread via the hands of healthcare workers Indirect spread through equipment that has not been appropriately decontaminated Via transfer of micro-organisms from the environment, where contamination is highly

significant, as staphylococci can survive for long periods in dust

Screening

MRSA of 78




A new diagnosis of MRSA is often made from a clinical specimen (e.g. wound swab) and not from an MRSA screen. In this instance, please contact the Infection Prevention and Control team for advice on the correct management of the patient.

A screen consists of swabs/samples being taken from the following sites:

Nose swab– one swab from both nostrils, pre-moisten the swab with saline if needed and roll around both nostrils

Perineum or groin swab Wound swab- swab all wounds and other lesions or breaks in the skin Swabs from manipulated sites- lines, cannulae, drains, PEG sites etc Urine specimen from patients with a catheter in situ only or mid-stream urine (MSU) if

MRSA has been isolated in a urine specimen previously. If the patient has a supra pubic catheter in situ then the entry site should also be swabbed

Sputum sample if patient has a productive cough Swabs from invasive medical devices such as PEG tubes, tracheostomies and

supra-pubic catheter sites. The laboratory request form should be clearly request an MRSA screen and give

details of why the screen is being performed, the clinician requesting the screen should ensure the site of the screen is documented on each individual swab and on the laboratory request form.

The clinician should ensure that the individual is fully aware of the screens to be taken and ensure consent to the procedure, documenting in their records.

Re-screening A patient should be re-screened one month after completion of decolonisation treatment. A negative screen will suggest that the decolonisation treatment has been effective. If the screen results identify a positive MRSA result a second decolonisation treatment can be offered.

Sometimes a third might be attempted if the patient has increased risk factors, but this will need to be reviewed with the Infection Prevention and Control Team (after discussion with Infection control doctor/medical microbiologist) and assessed on an individual patient basis.

Further re screening is not recommended Some patients in primary care will remain colonised with MRSA, it is important that this is documented in the patient’s records and communicated effectively to the patient and when transferring care to another provider or out of hours provider. Further advice should be sought from the Infection Prevention and Control Team.

Treatment

Decolonisation MRSA decolonisation refers to the use of topical agents such as nasal ointment and

body wash/shampoo to eradicate or reduce nasal and skin carriage. Complete eradication is not always possible but a decrease of carriage may reduce

the risk of transmission into the healthcare setting and therefore the risk to other patients. It will also reduce the risk of transmission into any wounds or indwelling devices that the patient may have.

Compliance with the treatment is important and once commenced should be completed for the full 5 days.

Decolonisation treatment should not be implemented for prolonged periods or repeatedly i.e. more than 2 courses for 5 days, as resistance may be encouraged.

MRSA of 78

In cases of repeated colonisation the advice of a medical microbiologist should be sought.

For patients with eczema, dermatitis or other skin conditions, attempts should be made to treat the underlying skin condition. Advice on suitable eradication protocols for these individuals should be sought from the consultant Dermatologist/Microbiologist

Nasal decolonisation Currently the treatment is 2% Mupiricin (bactroban) nasal ointment (or other

Microbiological approved product) which should be applied to the inner surface of each nostril (anterior nares) three times daily for five days. Nasal decolonisation should always be used in conjunction with skin decolonisation.

Whilst Mupiricin (bactroban) nasal ointment is the treatment of choice, Naseptin cream can be prescribed and applied to both nostrils four times daily in the event of a supply problem with Mupiricin (bactroban), the treatment period is 10 days. Naseptin should be prescribed with caution as it contains arachis oil so should be avoided in those with peanut allergies

Skin decolonisation Skin decolonisation is useful for eradicating or suppressing skin colonisation for short

periods, particularly pre-operatively. Patients should bathe/shower daily for five days using the prescribed antiseptic detergent as below

The current recommended agents are either Chlorhexadine 4% or Octenisan. For neonates and children under the age of 5, Octenisan should be used. The body wash should be applied neat to wet skin and left on the skin for 3 minutes (refer to product instructions). Applying a diluted solution to the skin will affect its efficacy. Special attention should be paid to all carriage sites, such as the axilla, groin and perineal area. The patient should be advised not to use normal soap or shower gels following the treatment being applied.

Hair should also be washed on days 2 and 4 within the five-day treatment using the same product. Clean clothing, bedding, wash cloths and towels should be provided after each bath/shower/bed bath and hair wash.

Octenillin wound irrigation solution can be prescribed for wounds with MRSA growth.

Peg Sites If Peg site is positive on screening, and site is dry, 2% Mupiricin (bactroban) nasal

ointment should be prescribed and applied around the site three times daily for five days.

If Peg site is positive on screening and site is moist or sticky seek advice from Nutrition team or Tissue Viability team.

Antibiotic Therapy As antimicrobial use is a recognised risk factor for MRSA acquisition, all patients with

MRSA should have their current antibiotic therapy reviewed. Any unnecessary agent should be stopped.

Antibiotics are not indicated unless there are clinical signs suggestive of infection. Prescribers should refer to the Antimicrobial Prescribing Guidelines (2015) and discuss with the duty Microbiologist for further advice if needed. www.nottsapc.nhs.uk

MRSA of 78

If antibiotics are required they should be in line with the given sensitivities and antimicrobial prescribing guidance. If uncertain then contact the Medical Microbiologist for advice:

NUHT - 0115 9249924 ext. 61163SFHT – 01623 622515

Consider the temporary use of an antimicrobial dressing for wounds where there are signs of clinical infection, refer to the Wound Care Formulary for wound care products or the Tissue Viability team on 01623 784759.

Control of MRSA

Basic Principles Standard IPC precautions must be implemented at all times in all settings to reduce the risks and should include all of the following:-

Hand Hygiene –Compliance with hand hygiene is essential and will significantly reduce the risk of transmission and cross infection. Decontamination of hands should be carried out before and after every episode of direct patient care or contact with the patient’s environment and equipment. Effective hand hygiene can be achieved using soap and water or alcohol gel (on visibly clean hands), using the National Patient Safety Agency (NPSA) recommended technique.(NPSA 2008) http://www.npsa.nhs.uk/corporate/news/cleaning-up-at-the-awards/

The Correct use of Personal Protective Equipment (PPE) Decontamination of Equipment according to manufacturer’s guidance. Single Use

equipment should always be considered where possible.

Advice for Patients in their own Home MRSA does not present a risk to other healthy individuals and colonisation should

not prevent an individual from continuing with normal unrestricted activities Wherever possible, patients with a known MRSA infection should be seen at the end

of the healthcare professionals visiting list. Good hand hygiene and standard basic precautions should be employed by all staff

involved in the care of a patient at home Avoid taking non-essential equipment in to the home. Encourage patients and carers to undertake good hand washing. Family members should be advised to cover any skin lesions they may have with an

impermeable dressing and to maintain good hand hygiene. Advise the patient/family that regular environmental cleaning using detergent and

water is an effective method of reducing levels of MRSA. Patients should be advised that their laundry should be washed at the hottest

temperature suitable for the fabric and that it can be washed with other household laundry. Laundered garments should be dried thoroughly before re-use. Drying in a hot air dryer or ironing will help further reduce the amount of MRSA present.

Patients should be encouraged to continue with their normal activities/routines.

Advice to parents about school aged children Children should not normally be excluded from school as a result of MRSA Wounds must be kept covered to reduce the risks of transmission. Encourage and promote good hand washing and the use of liquid soap, rather than

bar soap which will reduce to risk of transmission. An alert should be added to the patient’s records to highlight that the patient is at risk

of acquiring MRSA again in the future.

MRSA of 78

http://www.npsa.nhs.uk/corporate/news/cleaning-up-at-the-awards/




ReferencesDepartment of Health (2015) The Health and Social Care Act 2008 –code of practice for health and adult social care on the prevention and control of infections and related guidance Crown copyright 2009 London UK. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_115045.pdfDepartment of Health (2010) MRSA Screening Operational Guidance 3 Gateway Reference Number 13482 Department of Health Crown Copyright. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_115045.pdf

NHS England (2014) Guidance on the reporting and monitoring arrangements and post infection review process for MRSA bloodstream infections from April2014 (version 2)http://www.england.nhs.uk/wp-content/uploads/2014/04/mrsa-pir-guid-april14.pdf

MRSA of 78



http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_115045.pdf




MRSA protocol for screening and decolonisation

MRSA of 78

YesIs the wound expected to heal?

If positive – prescribe 2nd

course of decolonisation using 2% Nasal Mupirocin,

Octenisan or Chlorhexadine

Reinforce hygiene measures

If negative – no further action required unless 3

negative screens requested by acute trust -

action one week apart

Rescreen in 1 month – nose/perineum, wound

and any invasive devices

Consider referral to Tissue Viability and

decolonise using 2% Nasal Mupirocin,

Octenisan or Chlorhexadine

No

Rescreen in 1 month – wound, nose,

perineum and any invasive devices

Yes

Decolonise after wound has healed. Using 2%

Nasal Mupirocin, Octenisan or

Chlorhexadine

Rescreen in 1 month – nose/perineum, and any invasive devices

Decolonise using 2% Nasal Mupirocin, Octenisan or

ChlorhexadineGive advice/leaflet on hygiene

whilst using decolonisation

No

Add alert to record Send Special Note to OOH

Does the patient have an existing wound?

No history

Rescreen in 1 month – nose/perineum, and any

invasive devices

No - Decolonise using 2% Nasal Mupirocin, Octenisan or

Chlorhexadine

Yes – ring Infection Prevention and Control

team

Has the patient been treated before?

Previous history of MRSA

MRSA positive swab

Check history

How to apply Chlorhexidine/Octenisan bodywash and Mupiricin (Bactroban) ointment

1.

Ensure that your hair and body are wet

2.

Put the lotion onto a damp washcloth

3.

Apply all over body paying particular attention to the areas highlighted in red. Hair must be washed on day 2 and 4.

4.

Rinse off thoroughly

5.

Dry with a clean, dry towel

6.

Put on clean underwear and nightwear every day

Night clothes and bedding must be changed daily throughout the treatment and vacuuming and damp dusting completed daily during treatment.

MRSA of 78

Mupiricin (Bactroban) ointment applicationApply a matchstick head sized amount (less for a small child) on the end of cotton bud to inner surface of each nostril and massage gently upwards for 3 times a day for 5 days

Management of Panton Valentine Leukocidin (PVL) Staphylococcus aureus Infections in General Practice

IntroductionThis guidance has been developed for use by healthcare staff in the primary care setting when a patient presents with suspected or diagnosed Panton Valentine Leukocidin – Staphylococcus aureus (PVL-SA). Staff should have access to appropriate guidance that will help effectively prevent and control infections.

PurposeThe purpose of this guidance is to ensure that primary care staff within the practice; have sufficient information to effectively treat and manage patients with PVL-SA.

Aim Explain what PVL-SA is, how it is treated and what actions are necessary to minimise

spread. Ensure that patients found to have PVL-SA are informed of their diagnosis and given

information about their treatment and any follow up actions required.

Responsibilities

Practice Manager ………..insert name…………………….The Practice Manager has overall responsibility for ensuring that there are effective arrangements for Infection Prevention and Control within the practice and for meeting all statutory requirements. They will ensure that appropriate governance arrangements are in place to provide effective care and management of patients with PVL in accordance with this guidance.

Infection Control Lead in the Practice…………….insert name……………………The Infection Control Lead is responsible for ensuring that necessary policies and training to reduce the risk of infections being transmitted is in place.

Infection Prevention and Control TeamThe Infection Prevention and Control Team receive laboratory reports which provide information about the positive PVL samples from primary care. The clinician will receive the results from the source laboratory. The team will provide clinical expertise and advice and support clinicians with the choice of treatment and management appropriate for the patient.

Clinicians Clinicians that have contact with a patient with PVL have a responsibility to ensure

that they adhere to relevant guidance. Inform the patient of their diagnosis and documenting this within the patient’s medical

record. Explaining and documenting treatment regimes. Ensuring when care is transferred to another provider; that the diagnosis is

communicated to the provider after consultation with the patient.

DefinitionsStaphylococcus aureus (SA) is a bacterium that commonly lives on healthy skin. About one third of healthy people carry it quite harmlessly, usually on moist surfaces such as the nostrils, armpits and groin. Some types of SA produce a toxin called Panton Valentine Leukocidin and they are known as PVL-SA’s (Panton and Valentine were the two doctors who first found the toxin which can kill white blood cells called leukocytes – hence

PVL of 78

leukocidin). PVL-SA’s can cause skin and soft tissue infections such as boils and abscesses.

They can also cause invasive infections affecting the lungs, blood, joints and bones. The PVL toxin can be produced by both meticillin-sensitive Staphylococcus aureus (MSSA) and meticillin-resistant Staphylococcus aureus (MRSA).

Risk ManagementPatients with PVL-SA are at risk of transmitting the infection to others. Risk factors for PVL-SA include compromised skin integrity such as wounds, existing skin conditions (psoriasis, eczema), skin to skin contact and sharing of contaminated items (towels, razors) and poor hand hygiene. Public Health England have identified the following groups as high risk for acquiring PVL-SA: healthcare workers, care home staff, individuals who play close contact sports such as rugby, wrestling or those that attend a gym and use shared equipment. Environments such as prisons, nurseries and schools are also identified as high risk in terms of spread if infection is identified.

Describing the Care Required

SymptomsPVL-SA mainly causes skin and soft tissue infections but can cause serious illness such as necrotising haemorrhagic pneumonia this is associated with a high mortality rate.

Skin and soft tissue infections Boils, carbuncles, folliculitis, cellulitis, purulent eyelid infection Cutaneous lesions Pain and erythema out of proportion to visual symptoms Necrosis

Invasive infections Necrotising pneumonia Necrotising fasciitis Osteomyelitis, septic arthritis and pyomyositis Purpura fulminans

Patients who develop necrotising pneumonia commonly have a flu like illness prior to the more serious disease. Therefore it is important to investigate respiratory infections with bacterial co-infection.

Management of skin and soft tissue infections Minor skin infections do not require systemic antibiotic treatment unless the patient is

an infant, immuno-compromised or is deteriorating clinically. The treatment required is incision and drainage, as for normal abscesses.

Moderate skin and soft tissue infections (larger than 5cms) should be treated with oral antibiotics, antibiotic therapy must be in line with sensitivities and antimicrobial prescribing guidance and in addition to this incision and drainage. If clinically not responding second line treatment with agents that help reduce toxin production may be indicated, seek advice from local microbiologist.

As PVL–SA is associated with recurrent infections, topical decolonisation of individuals with confirmed infection and assessing if close contacts require treatment is one of the most important aspects of its management.

Decolonisation treatment should be offered once the initial infection has been treated and the skin is intact. The aim of the decolonisation treatment is to reduce the chances of the

PVL of 78

individual getting repeated infections and to minimise the risk of the PVL-SA spreading to others. A decolonisation treatment consists of using either Chlorhexidine bodywash 4% (north of the county) or Octenisan bodywash (south of the county, children under the age of 5 and those with sensitive skin/skin conditions). Both are skin disinfectant solutions and are used daily for 5 days in place of usual toiletries. The hair has to be washed with the skin disinfectant solution on days 2 and 4 of the 5 day treatment period (See appendix 1: How to apply Chlorhexidine / Octenisan). A nasal cream Mupirocin 2% is also used; this is applied three times a day into each nostril for 5 days. (See Appendix 1: How to apply Chlorhexidine/Octenisan).

A risk assessment should also be made to decide if household / close contacts require decolonisation treatment. Public Health England (2013) define a household / close contact as someone who has had prolonged close contact with the case in a household type setting during the five days before onset of the illness.

Other risk factors to be considered are: Has the household / close contact had a history of any skin infections within the last

year? If the household / close contact/s are within the high risk group (healthcare worker,

care home worker, nursery worker, food handler, take part in close contact sports/attends a gym etc) and have had a positive screen.

If the household / close contact requires decolonisation treatment then they should be treated at the same time as the person with the PVL result.

ScreeningFor all MRSA cases the patient and those identified as high risk household/close contacts will require screening a month after the decolonisation treatment has been completed. If the screen is negative no further action is necessary. If the screen is positive a second decolonisation treatment should be offered but no further screening is necessary following this second decolonisation. MSSA cases do not require re-screening. If further acute infections occur the infection should be treated following advice from microbiology. Only undertake repeat screening for MSSA PVL if the patient is immunosuppressed, is in the high risk group or the spread of infection is ongoing in close contacts

A PVL screen should include the following sites: Nose Perineum

The laboratory request must state PVL screen.

Reducing the risk of spread

The patient Practice good hand hygiene. Cover the nose and mouth with a tissue when coughing or sneezing particularly if

they have a cold as PVL can live in the nose. Throw any used tissues in the bin and then wash hands.

Infected areas should be kept covered and occluded with a clean dressing as fluid or pus from infected skin may have large numbers of PVL-SA that can spread to others.

Do not share towels, flannels and razors. Do not share bar soap, liquid soap reduces the risk of harbouring and spreading the

infection Clean the sink and bath after each use with a disposable cloth, detergent and then

rinse.

PVL of 78

Regular vacuuming and dusting with a damp cloth of the home environment. Washing clothing and bedding regularly. Seek medical advice if boils / abscesses re-occur. (See appendix 2: Patient Information Leaflet)

Primary Care Staff Good hand hygiene; refer to the organisations Hand Hygiene Policy. Use an aseptic non touch technique when redressing wounds. Where there is a risk of contact with non-intact skin, blood and/or bodily fluids; gloves

and an apron must be worn and disposed of into the correct waste stream, refer to the organisations PPE and waste policies.

Equipment used when performing dressing changes must be single use. Good communication is essential in ensuring a safe discharge/transfer of care of

patients with PVL-SA




ReferencesHealth Protection Agency (2008) Guidance on the diagnosis and management of PVL associated Staphylococcus aureus infections (PVL-SA) in England.

Health Protection Scotland (2014) Interim Advice for the Diagnosis and Management of PVL associated Staphylococcus aureus infections (PVL-S aureus).

Public Health England (2013) Assessment of risk to close contacts of patients with lower respiratory tract infection due to Panton Valentine Leukocidin-positive staphylococcus aureus in England. Enhanced case and household contact protocol. Version 1.3

PVL of 78

Appendix 1: PVL Management: Quick Reference Guide

PVL of 78

If further acute infection, seek

specialist advice on management

No repeat screening

NoYes

Screen 1 month following completion of decolonisation

If patient remains positive offer 2nd decolonisation. No need for re-screen

Does the patient belong to a high risk group, is there ongoing family spread or

they have MRSA PVL

Offer decolonisation * when the wound has healed. Give

patient leaflet

Treat in line with sensitivities if required

PVL POSITIVE

*Decolonisation

North of the County:Chlorhexidine bodywash daily

for 5 daysMupiricin nasal ointment TDS

for 5 daysBabies and those with sensitive skin Octenisan bodywash for 5

days

South of the County:Octenisan bodywash daily for 5

daysMupiricin nasal ointment TDS

for 5 days If unable to source Mupiricin,

use Naseptin QDS for 10 days (NOTE: do not use if patient

suffers with nut allergy)

Treat in line with sensitivities if required

PVL NEGATIVE

Consider the need for incision and drainage and refer if necessary

Obtain swab and request PVL testing

Patient presents with infected boil(s) / recurring boil(s)

Appendix 2: How to apply Chlorhexidine/Octenisan bodywash and Mupiricin (Bactroban) ointment

1.

Ensure that your hair and body are wet

2.

Put the lotion onto a damp washcloth

3.

Apply all over body paying particular attention to the areas highlighted in red. Hair must be washed on day 2 and 4.

4.

Rinse off thoroughly

5.

Dry with a clean, dry towel

6.

Put on clean underwear and nightwear every day

Night clothes and bedding must be changed daily throughout the treatment and vacuuming and damp dusting completed daily during treatment.

PVL of 78

Mupiricin (Bactroban) ointment applicationApply a matchstick head sized amount (less for a small child) on the end of cotton bud to inner surface of each nostril and massage gently upwards for 3 times a day for 5 days

Appendix 3: Patient Information PVL – Staphylococcus aureus

What is PVL Staphylococcus aureus?Staphylococcus aureus is a bacterium (germ) that commonly lives on healthy skin. About one third of the population carry it harmlessly usually on moist surfaces such as the nose, throat and groin. This is known as colonisation.

Some types of Staphylococcus aureus produce a toxin called Panton-Valentine Leukocidin, these are known as PVL-SA.

What type of illness does it cause?PVL-SA can cause harm if it has an opportunity to enter the body. They can cause boils or skin abscesses and are occasionally associated with more serious infections such as pneumonia and septicaemia (blood poisoning).

How do you catch PVL-SA?Anyone can catch PVL and it may cause an infection or you may just carry it on your skin. PVL can be picked up by having skin to skin contact with someone who is already infected or carrying the bacteria on the skin, for example close family or during contact sports. It can also be picked up by contact with an item or surface that has PVL on it from someone else, for example sharing towels and equipment.

How is PVL-SA treated?Boils and abscesses would normally be drained by incision and you may then require treatment with antibiotics. If tests show that you have an infection caused by PVL or you are carrying PVL, you will be offered further treatment consisting of a skin body wash and a nasal cream used over 5 days. This reduces the chances of you getting repeated infections and from passing it on to others. If you have a PVL infection that has not yet healed you should not work in a nursery, hospital, care home or the food industry. Children may go to school but only if they are old enough to keep the wound infection covered and they can wash their hands well. Individuals with PVL should not use gym equipment or take part in contact sports until the infection has gone.

What can me and my family do to reduce potential spread? Keep infected areas of your body covered with a clean dry dressing or plaster. Change plasters / dressings regularly and as soon as discharge seeps to the surface.

It is important that fluid or pus from infected skin is contained, because it has large numbers of the PVL bacteria that can easily be spread to other people through skin contact.

Do not touch, poke or squeeze infected skin. This could make the infection worse and you will be likely to pass it on to others.

Regularly wash your hands. Encourage others in your household to regularly wash their hands. Do not share towels or wash cloths Do not share razors and make up Do not share bar soap, liquid soap is recommended Frequently wash towels and bed linen on a hot wash. Regularly dust and vacuum your home. Closely following the instructions for the five day skin treatment as prescribed by your

GP.

If you are worried that a person you live with has this infection, discuss this with your GP. All the people you live with may need treating at the same time to prevent re-infection.

PVL of 78

Can PVL-SA return? PVL is a strain of Staphylococcus aureus that can live on our bodies and can sometimes be difficult to clear. Some people may persistently carry PVL in their nose or on their skin but it may not cause any problems.

If you have any repeat infections or are admitted to hospital as an emergency or for an operation, always tell the doctor or nurse looking after you that you have had a PVL infection. This will help you to have the right treatment and avoid spreading the infection.

ReferenceHealth Protection Agency (2008). Guidance on the diagnosis and management of PVL-associated Staphylococcus aureus infections (PVL-SA) in England, 2nd edition.

PVL of 78

Management of Clostridium difficile

Introduction Clostridium difficile (C.difficile) is a spore forming bacterial infection of the gastrointestinal tract capable of causing toxin related mild, moderate or severe diarrhoea, liquid stool type 5 – 7 (Department of Health 2008) as per Bristol Stool Chart (Heaton 1999) (see Appendix 1 and 4). In extreme cases C. difficile may cause pseudomembranous colitis. This type of infection is related to the use of broad spectrum antibiotics, which disrupts the protective normal bacterial flora of the gut, allowing the multiplication of large numbers of C. difficile bacteria. The diarrhoea and colitis occur as a consequence of toxins secreted by C. difficile. Symptoms may start as early as day one of antibiotic use or even up to four weeks after discontinuation of antibiotics.

Risk Management The information and treatment recommended within this policy relates specifically to C. difficile. Therefore, it should only be applied when this infection is suspected or confirmed.

Symptoms of C. difficile infection vary, from mild diarrhoea to severe illness and potentially death. In elderly persons it has a mortality of 10-15% and prolongs hospital stays by an average of 20 days. Up to 20% of persons suffer a relapse of diarrhoea following successful treatment (Teasley et al 1983, Bartlett 1985, Wenisch et al 1996). After a first recurrence, the risk of another infection increases to 45-60% (McFarland et al 1999). There are over 100 strains of C. difficile. Type 027 a more virulent strain was first detected in Canada in 2000. This has since caused outbreaks in hospitals in the United Kingdom (UK) and has been identified locally within Nottinghamshire as the cause of some C. difficile infection. Type 027 produces more toxins than other types, causing severe disease and has a higher mortality rate. It also has the ability to spread between residents more easily. Treatment of 027 is the same as other C. difficile strains (see Appendix 2).

C. difficile spreads by the faecal-oral route (ingestion). Affected patients with diarrhoea secrete large numbers of C. difficile and its spores (a protective state in which the bacteria can survive) leading to contamination of the surrounding environment. The spores can survive within the environment for months and are resistant to most commonly used disinfectants (Wilcox et al 2002). The transmission of infection is generally thought to occur via contaminated hands of staff, direct contact with affected patients, or contaminated surfaces e.g. bathrooms, furniture, bed sheets (Fawley et al 2007). Enteric precautions (see Appendix 3) are therefore essential in the prevention or spread of Clostridium difficile and the Infection Prevention and Control Team should be consulted for further advice.

Describing the Care required

Identification of C. difficile infection The Department of Health and ARHAI (Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection) advises that organisations adhere to a two stage testing approach which consists of a GDH (glutamate dehydrogenase) or PCR (toxin gene) test to screen samples for potential C. difficile excretors followed by a sensitive toxin EIA test. Patients who pass a stool loose enough to take the shape of a container used to sample it or a type 5-7 stool, which is not attributable to any other cause, should have a stool sample sent promptly to Microbiology, specifically requesting examination for C. difficile. Relevant history and details of the antibiotics the patient has taken should be given on the request form. All type 5-7 stool samples sent to the laboratory from patients over the age of 65 years are routinely tested for C. difficile, formed stools will not be tested in the laboratory.

Clostridium difficile of 78

NB. Some symptomatic patients may have no C. difficile detected, due for example to fast gut transit times. In this case the toxin assay is not 100% reliable and a repeat sample should be sent to the laboratory. Treatment should be commenced according to severity of symptoms and continue regardless of further negative results.

The toxin may also biodegrade at room temperature, increasing the possibility of false negative results. Stool samples must therefore be placed in a specimen fridge if there is to be any delay in transportation. Clinicians should apply the following protocol (SIGHT) when managing suspected potentially infectious diarrhoea (Public Health England, 2013)

S Suspect that a case may be infective where there is no clear alternative cause for diarrhoea

I Isolate the resident and consult with the Infection Control Team while determining the cause of the diarrhoea

G Gloves and aprons must be used for all contacts with the Resident and their environment

H Hand washing with soap and water should be carried out before and after each contact with the Resident and the Residents environment

T Test the stool for toxin by sending a sample immediately

Assessing the severity of Clostridium difficile (CDI)Mild CDI: <3 stools type 5-7 per day

Moderate CDI: WCC <15 109/L and 3-5 stools type 5-7 per day

Severe CDI: if any evidence of severe disease, the patient should be referred for urgent admission and gastroenterology review. WCC >15 109: or an acute rising serum creatinine (>50% increase above baseline) or a temperature of >38.5°c or tachycardia >100 beats per minute or evidence of severe colitis

Life threatening CDI: in life threatening CDI the patient should already have been referred for urgent admission. This includes hypotension, partial or complete ileus or toxic megacolon or CT evidence of severe disease.

Treatment of residents with positive CDI result (appendix 2)In all cases review the following:

PPI treatment, can this be stopped during the treatment period or changed to ranitidine to re-establish normal flora

Anti-motility agents, this MUST NOT be prescribed where there is a risk of CDI or on a positive result and ensure that the patient is not self-medicating with anti-motility agents

Review current medication, stop any unnecessary antibiotics to re-establish normal flora

Mild Disease: residents with mild disease may not require specific C. difficile antibiotic treatment, if treatment is required, oral metronidazole is recommended 400mg three times a day for 10 days.

Moderate Disease: residents with moderate disease should also be treated with oral metronidazole 400mg three times a day for 10 days.


Severe Disease: residents with severe disease should be treated with oral vancomycin 125mg four times a day for 10-14 days. Fidaxomicin should be considered for residents with severe C. difficile who are at increased risk of recurrence; these include elderly residents with multiple co-morbidities who are receiving concomitant antibiotics (Hu et al 2009, Wilcox 2012).

Life threatening CDI: oral vancomycin 500mg QDS for 10-14 days via naso-gastric tube or rectal installation plus IV metronidazole 500mgs TDS. In life threatening CDI the patient should be admitted to acute.

Up to 20% of patients will have a recurrence which is more common in elderly patients, with a risk of further recurrence of nearly 50%. These should be investigated with repeat samples and treated as follows:

First recurrence (not confirmed CDI): repeat same antibiotic regimen the original infection responded to

First recurrence (confirmed CDI): discuss with microbiology if fidaxomicin naïve fidaxomicin 200mg BD for 10 days (amber 2 microbiologist recommendation only)

Subsequent recurrences: discuss with microbiology/gastroenterolgy

Clearance samples are NOT necessary, formed stools WILL NOT be tested.

Surveillance and Reporting C. difficile is part of the mandatory surveillance data collected by Public Health England. Acute NHS Trusts in England are required to report all C. difficile cases in persons aged 2 years and over (HPA 2005). These cases include hospital and community cases that may be in care homes or in their own homes. From this data Public Health England produce an annual report on C. difficile, which is accessible via their website www.gov.uk/government/organisations/public-health-england .

Root Cause AnalysisOutbreaks of C. difficile, deaths caused by C. difficile (reported on part 1 of the death certificate) or where C. difficile results in the person requiring a colectomy should be reported as serious untoward incidents. This request is from NHS England. These instances will be reported by the Infection Prevention and Control Team.

Following the reporting of a serious untoward incident a process known as ‘root cause analysis’ is undertaken to review why the incident happened and if there are lessons to be learned to prevent further occurrences and cases. This process is normally clinician led however it is currently led by the Infection Prevention and Control Team. Where a resident resides in a care home, the care home will be asked to participate in the ‘root cause analysis’ process.



http://www.gov.uk/government/organisations/public-health-england



References Fawley, W. Underwood, S. Freeman, J. Baines, S. Saxton, K. Stephenson, K. Owens, R. and Wilcox, M. (2007) Efficacy of hospital cleaning agents and germicides against epidemic Clostridium difficile strains. Infection Control Hospital Epidemiology. 28. 920-925

Heaton, K. (1999) The Bristol Stool Form Scale. Practical Procedures for Nurses. Nursing Times. June 30. 95. (25)

Health Protection Agency and Healthcare Commission (2005) Management, prevention and surveillance of clostridium difficile. Interim findings from a national survey of NHS acute trusts in England.

McFarland LV, Elmer GW, Rubin M et al (1999) Recurrent clostridium difficile disease: epidemiology and clinical characteristics. Infection control Hospital Epidemiol 20:43-50.

Public Health England (2013) Updated guidance on the management and treatment of Clostridium difficile infection

Wenisch C, Parschalk B, Hasendhundi M et al (1996) Comparison of vancomycin, teicoplanin, metronidazole and fusidic acid for the treatment of Clostridium difficile associated diarrhoea. Clinical Infectious Diseases 22:813-18. Wilcox, N. Fawley, W. Wigglesworth, N. Parnell, P. Verity, P. and Freeman, J (2002) Comparison of the effect of detergent versus hypochlorite cleaning on environmental contamination and incidence of Clostridium difficile. Journal of Hospital Infection 54.


Appendix 1: The Bristol Stool Form Scale

Heaton (1999)


Appendix 2: Treatment of residents with positive C. difficile result



Scabies

Introduction The incidence of scabies varies over time, records show that epidemics occur at approximately 30-year intervals and persist for about 15 years.

Scabies is a common contagious skin infestation caused by the parasitic mite Sarcoptes Scabiei. It is transmitted by skin-to-skin contact that typically occurs within families, between sexual partners and between patients and care givers.

The Infection Control Team frequently assist with the management of scabies and there is a high incidence of cases within nursing and residential care homes, where there are highly dependent residents.

Life Cycle of ScabiesA scabies infestation starts when a female mite burrows into your skin; the mite is approximately 0.3-0.4mm in length.Male mites move between different burrow sites looking to mate. After mating, the male mite dies and the female begins to lay eggs, which hatch around three to four days later.After hatching, the young mites move to the surface of the skin, where they mature into adults after 10 to 15 days. Male mites stay on the surface of the skin, while female mites burrow back into the skin to create a new burrow. The life cycle is then repeated. Without effective treatment, the life cycle of the scabies mite can continue indefinitely.

Risk Management

IndicationsThis guidance is for use when an individual is being treated for scabies or it is suspected. It aims to provide information about what scabies is and how it is treated effectively.

Contraindications/hazardsScabies treatment requires the prescriber to be aware of the contraindications when considering treatments, e.g. pregnancy, asthma, ensuring that the correct products are then prescribed.

Signs and SymptomsThe scabies rash consists of tiny red spots. Scratching the rash may cause crusty sores to develop.

Burrow marks can be found anywhere on the body. They are short (1cm or less), wavy, silver-coloured lines on the skin, with a black dot at one end that can be seen with a magnifying glass.

In adults, burrow marks often appear in the following areas: the folds of skin between fingers and toes the palms of the hands the soles and sides of the feet the wrists the elbows around the nipples (in women) around the genital area (in men)

Scabies of 78


The rash usually affects the whole body, apart from the head. The following areas can be particularly affected:

the underarm area around the waist the inside of the elbow the lower buttocks the lower legs the soles of the feet the knees the shoulder blades the female genital area the groin around the ankles

Elderly people, young children and those with a low immune system (immunocompromised) may also develop a rash on their head and neck.

Men usually have one or more very itchy, lumpy, 3 to 10mm spots on the skin of the genitals (on the penis and scrotum).

The intense itching associated with scabies is thought to be caused by the immune system reacting to the mites, their saliva, eggs and faeces.

Itching does not occur until 2-4 weeks after the initial infestation. Itching is usually worse at night and may persist after successful treatment. Even after treatment the symptoms of itching may continue for up to a month.

Transmission Skin to skin contact through care by nurses and other carers (these staff may not

always show clinical signs). Skin to skin contact e.g. sleeping together, holding hands and sexual contact. The mite does not “jump” or “fly” from person to person, it walks, which can be up to

2.5cm per minute on warm skin. Good personal hygiene does not reduce the risk of transmission of the mite. Scabies mites can survive outside the human body for 24 to 36 hours, making

infection by coming into contact with contaminated clothes, towels or bed linen a possibility. However, it's rare for someone to be infected in this way.

It's unlikely that scabies will be transmitted through brief physical contact, such as shaking hands or hugging.

Identification An early diagnosis is essential in order to avoid resident to staff transmission in a

care home setting and patient to family. Diagnosis is usually made in the presence of intense itching with a follicular papular

rash, which is confined to certain body areas. See picture below:

Scabies of 78


The diagnosis can be confirmed by seeing mites under the microscope but this is usually done by an experienced practitioner.

If mis-diagnosis has occurred and there has been treatment failure, then an expert clinical diagnosis would be necessary by a dermatologist.

Crusted Norwegian ScabiesThis is caused by the same mite but is a form of Scabies, which can be seen in immunosuppressed individuals and in the elderly.

In this form many more mites are present and the skin presents as thickened with crusts, often mistaken for Psoriasis. Unlike classical scabies where intense itching is evident, with Crusted Norwegian Scabies patients are unlikely to experience itching. The condition affects all parts of the body including head, neck, nails and scalp. If crusted Norwegian scabies is suspected consult with / refer the patient to dermatology as oral treatment with Ivermectin may be required as well as topical treatment.

Treatment

For one diagnosed case of scabies Treat the patient and their close family contacts and/or carers who have had frequent

skin to skin contact with the individual affected.

For more than one case of scabies in a care home setting When more than one case of scabies is diagnosed at the same time and place, this

is defined as an outbreak and should be treated as such Prescribe treatment for all residents within the home, those with rashes require 2

treatments 7 days apart and refer the home to the Infection Prevention and Control Team (01623 673081) to discuss management of the outbreak

The infection control team will discuss with the care home treatment of all staff and managing the outbreak

Scabies of 78


Treatment Products

Permethrin (Lyclear 5%) Dermal Cream This is currently the agent of choice for the treatment of scabies and also for

prophylactic treatment for contacts. Permethrin is licensed for use in children over 2 months of age, but recommends

seeking specialist advice from a paediatric dermatologist as scabies is rare in the under 2’s. Permethrin is a cream, which should be applied and left for 8-12 hours before washing off.

Malathion (Derbac M) This should only be used if permethrin is inappropriate eg: the person has an allergy

to chrysanthemums. This medication is a lotion and should be left on the body for 24 hours. It should not be used more often than once a week for a maximum of three weeks. Avoid in children less than 6 months of age, seek medical advice. Can be used in pregnancy. Aqueous preparations are preferable to alcoholic lotions, as they are less of an

irritant to the skin and respiratory tract.

Pregnancy/Breastfeeding For women who are breastfeeding or pregnant, treat scabies with permethrin 5%

dermal cream. Alternatively use malathion 0.5% aqueous liquid if permethrin is not appropriate eg:

the person has an allergy to chrysanthemums. Breastfeeding mothers should remove the liquid or cream from the nipples before

breastfeeding and reapply treatment afterwards.

Ivermectin This is an oral medication that is only given on a named patient basis within the UK

and more commonly used in the treatment of Norwegian ‘Crusted’ Scabies. The decision to prescribe should only be undertaken after consultation with the Dermatology Department at the Queens Medical Centre or Sherwood Forest Hospitals Foundation Trust. Topical treatments may also be applied in conjunction with the oral medication being given.

User InvolvementScabies can be a distressing condition and the dignity of the patient / resident should be maintained throughout. Compliance is important with dealing with this condition and the patient / resident / carer should be given as much information as possible.



Scabies of 78



ReferencesNHS Choices website downloaded 04/2015. www.nhs.uk/Conditions/Scabies/Pages/Introduction.aspx

NICE Clinical Knowledge Summaries downloaded November 2017 https://cks.nice.org.uk/scabies

Nottinghamshire Antimicrobial Prescribing Guidelines (2015)

Scabies of 78

https://cks.nice.org.uk/scabies

http://www.nhs.uk/Conditions/Scabies/Pages/Introduction.aspx

Hand Hygiene · Web viewThe practice must have the following policies and documents in place which...

Documents

Transcript of Hand Hygiene · Web viewThe practice must have the following policies and documents in place which...