wensumvalleymedicalpractice.nhs.uk · Web viewClean and dirty areas in the surgery should be...

Wensum Valley Medical Practice Infection Prevention and Control Policy

A. Confidentiality Notice

This document and the information contained therein is the property of Wensum ValleyMedical Practice.

This document contains information that is privileged, confidential or otherwise protected from disclosure. It must not be used by, or its contents reproduced or otherwise copied or disclosed without the prior consent in writing from Wensum Valley Medical Practice.

B. Document Details

Classification: 1.1.2019Author and Role: Denise DavisonOrganisation: Wensum Valley Medical PracticeDocument Reference:Current Version Number:Current Document Approved By:Date Approved: 12.12.18

C. Document Revision and Approval History

Version Date Version Created By:

Version Reviewed By:

Comments Review Date Due

1 02.08.17 Denise Davison Jan Hardinge Aug 182 Updated AS

location of spillage kit

3 12.12.18 Denise Davison DD & JH Addition of Sepsis, Notification of communicable diseases added, and amalgamation of all infection control policies into one

Dec 19

4 04/01/2019

Denise Davison DD & JH Change re guidance on accepting used Sharps Bins by surgery staff

Dec 19

5 11/03/2019

DD & JH Important Contact numbers added – appendix 13

Dec 19

1


Contents Page

1. Infection Prevention and Control Policy 3

2. Appendix 1: Protocol for the decontamination of surfaces 6

3. Appendix 2: Clinical waste management 12

4. Appendix 3: Disposal of sharps 17

5. Appendix 4: Handwashing techniques 18

6. Appendix 5: Needle-stick injuries 21

7. Appendix 6 : Specimen handling 23

8. Appendix 7: Spillages 27

9. Appendix 8: Toys in the waiting room 29

10. Appendix 9: Notification of infection diseases 30

11. Appendix 10: Sepsis identification and management 34

12. Appendix 11: Aseptic technique 47

2


Infection prevention and control clinical lead: Dr Emmanuel Ighomereho. Persons responsible for day to day management: Denise Davison, IPC Lead and Jan Hardinge, Practice Manager, Gabrielle Rimbaut, IPC Link Nurse (BG), Julie Roche, IPC Link Nurse (AS) Purpose

The purpose of the policy is to set out the infection prevention and control procedures at Wensum Valley Medical Practice. This policy is relevant to anyone who works at Wensum Valley Medical Practice, including contractors and visitors.

This policy will be monitored and reviewed annually by the Infection Prevention and Control Lead.

Commitment of the practice

Wensum Valley Medical Practice is committed to minimising the risk of infection and to ensure the safety of patients and staff.

Standard Precautions

Hand washing procedures

Washbasins with elbow operated taps, liquid soap dispensers, alcohol rubs, paper towels and waste bins are provided in all clinical care areas. All clinical and some non-clinical areas have posters displayed containing hand washing and hand rub instructions. All clinicians and staff are trained in hand washing procedures.

Protective Clothing

Latex Free Gloves (non-sterile and sterile), aprons and goggles are available and should be worn for procedures with associated risk. Gloves and aprons are single use. All clinicians and staff are trained in the use of personal protective equipment. Protective equipment is audited monthly.

General Dress Code

The practice has a non- uniform policy and dress code. The code includes details of appropriate dress to manage infection control. Staff should wear clothes that are clean and fit for purpose. All Clinicians should adopt the “bare below the elbows” advice when in clinical settings.

3


Handling and disposal of healthcare waste including sharps and single use-devices

The practice has a sharps policy. All clinical areas have sharps bins in place. The practice has a contract to ensure the safe disposal of hazardous waste, including sharps. All staff and clinicians undertake annual online training in the use and disposal of sharp and disposable instruments and how to handle and dispose of clinical waste safely and correctly.

Handling specimens

The practice has a policy covering handling specimens and dealing with spillages of body fluids. All practice clinicians and staff undertake annual online training on handling samples and spillages. The practice has a dedicated spillage kit in place and signage indicating where this can be found. At West Earlham and Bates Green, the spillage kit is located in the cleaning cupboard at Adelaide Street it is available at reception.There are dedicated sample storage boxes and fridges at each site. Patients are required to label their own sample and place it in the sealed pathology bag, to reduce the risk of contamination and to keep handling to a minimum. Clinicians are required to label samples procured during consultation and place in sealed pathology bag and to transfer to relevant ISS receptacle.All blood or potentially infected matter such as urine or faeces for microbiological examination is treated as high risk and generic precautions are used.

Processing of medical instruments

The practice uses single use instruments for all its procedures. These are disposed of after each patient. There are no instruments that require sterilisation. NB: CJD/vCJD handling of instruments and devices – not applicable as all single use equipment.

Accidents

In the event of a needle stick injury, the practice follows the Protocol for the Management of Needle Stick Injuries. The practice has access to occupational health services and A & E at the local hospital.

The practice has a first aid kit and nominated first aiders. The first aid kit is located in reception. In the event of an incident, contact a manager. The first aid kit is checked monthly.

An accident log book is maintained.

4


Immunisation

Patient immunisation

The practice has a vaccine policy and procedure to ensure vaccines are stored and managed correctly.

The vaccine fridges are inspected daily. Cleaning plans are in place for vaccine fridges. Fridge temperatures are recorded daily and data logger information downloaded monthly.

All immunisers have received training on immunisation, vaccine storage and management of sharps.

Staff immunisation protection

All clinical and administrative staff are offered vaccination against hepatitis B. Blood titres are requested to be taken by staff’s own GP following initial course of vaccinations. This is to ensure immunity and there is a robust system for ensuring vaccinations are boosted.

A record of employees’ Hepatitis B and MMR status is to be kept and maintained by the practice.

All staff are offered annual influenza immunisation.

Training

Online infection control training is undertaken by all staff and clinicians as part of the practice induction and on an annual basis. The practice also provides online training on health and safety, management of sharps, management of samples and hazardous fluids/spillages, use of personal protective equipment, COSHH and hand hygiene (list not exhaustive).

Surgery Cleaning

The practice uses an external company for most of the cleaning requirements. There are contracts in place with Anglia Business Cleaning for West Earlham and Bates Green and G4S at Adelaide Street.There are robust cleaning plans in place, these are completed by each cleaner every shift. The plans contain a daily, weekly, and monthly cleaning specification in line with current guidance. The plans are audited for compliance and their content reviewed regularly. The entire practice is formally inspected every 6 months by the practice manager or site lead and regularly on an adhoc unannounced basis by the practice manager or senior administrator, IPC lead and an Anglia Business Cleaning manager/supervisor or G4S as appropriate.

5


A national colour coded cleaning system is in place to reduce cross contamination risk.

General practice staff are responsible for leaving their workspace clear and tidy to allow the contract cleaners to clean

effectively appropriate cleaning of clinical equipment and fixtures between individual

patients, a written policy for this is available in each room and each clinician has signed said policy to ensure adherence.

Keeping all staff areas clean and tidy Reporting any issues with cleanliness cleaning of spillages which arise during the day cleaning of bodily fluid spillages, there is a spillage kit for blood and vomit on each

site and its location clearly labelled

Audit and risk assessment

The practice manager performs an annual infection control audit and an infection control inspection of the entire practice every 6 months. Health and safety risk assessment/inspections are performed monthly. The practice manager meets with the Infection Control Lead to discuss policy reviews or any other issues relating to infection control.

The practice manager works closely with the contract cleaning manager to ensure cleaning is of a high standard and any issues are resolved swiftly. The practice manager also works closely with the senior practice nurse to monitor infection control and cleaning of clinical areas.

The practice engages with patients through feedback, complaints and patient participation group. The practice has not received any negative feedback indicating patients have concerns regarding infection control or cleanliness within the practice.

The practice actively participates in significant event analysis.

Notifiable Diseases

Any notifiable diseases will be reported to the appropriate authority in accordance with the Health Protection Notification Regulations 2010.

6


Relevant guidance:

The National Specifications for cleanliness in the NHS; Guidance on setting and measuring performance outcomes in primary care medical and dental premises; August 2010

National institute for clinical excellence, Prevention and control of health-care associated infections in primary and community care; April 2014.

World Health Organisation; Guidance on hand hygiene in health care:2009

The Health & Social Care Act 2008.

Code of Practice on the Prevention and Control of Infections and Related Guidance 2015

HSE Sharp Instruments in Healthcare Regulations 2013

Legionnaire’s Disease – The Control of Legionella Bacteria in Water Systems (ACOP) HSE 2013

Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 2013

The Hazardous Waste Regulations 2005

Health Protection Notification Regulations 2010.

7


Appendix 1: PROTOCOL FOR THE DECONTAMINATION OF SURFACES AND THE ENVIRONMENT

Introduction

This protocol provides guidance on the procedures for the decontamination of surfaces within the clinical area.

The aim of this protocol is to ensure that safe standards of cleanliness are maintained and to demonstrate that a clean and appropriate environment is provided, enabling the prevention and control of healthcare-associated infections

Dust, dirt and moisture will increase the risk of infection and should be kept to a minimum by regular cleaning. The environment should be clean, dry, well-lit and well ventilated.

The transfer of micro-organisms from environmental surfaces to patients is generally due to direct hand contact with these surfaces.

The term ‘environment’ refers to:

Any general surfaces in the patient’s surroundings. Any frequently touched surfaces in the environment. This also includes rooms such as store

rooms. Reception and waiting areas, including tables and chairs. Toilets. Sinks, basins and the items surrounding them, e.g. soap and paper towel dispensers. Floors. Doors and door handles, particularly those in the immediate environment that are

frequently touched by patients and workers. Paint work and surroundings, e.g. skirting and walls. Curtains and window blinds. Light fittings and light switches. Kitchen areas. Window ledges and surrounding frames.

This list is not exhaustive and an assessment and cleaning schedule should be drawn up for each specific setting.

Levels of Decontamination

Level 1This means the physical removal of soil, dust, dirt and organic matter, along with most pathogens to an acceptable level; using detergents and friction. This may be all that is required for certain items.

8


Level 2Disinfection – a process that inactivates or reduces the number of viable microorganisms but is not necessarily effective against bacterial spores or some viruses. Disinfection can be achieved through the use of heat or chemicals.

Level 3Sterilisation – the complete destruction of all microorganisms, including spores.

The Environment

Surfaces in clinical and decontamination areas should be impervious in order to enable adequate cleaning. Surfaces should be continuous and free from abrasion or damage wherever possible.

When choosing surfaces and cabinetry, thought should be given to the cleaning process. All fixtures and fittings should be easy to clean and maintain.

Floor coverings should also be impervious, non-slip and preferably seam free. Carpet is not advised in the clinical area because of the high risk of spillages. Clinical areas should have curved, integral skirting to aid cleaning and prevent dust, dirt and debris from collecting.

Walls should be impervious and easily cleanable. Clinical areas should be able to withstand any products used for decontamination of blood and body fluid splashes.

Using suspended, tiled ceilings is not advised as they can harbour dust and fungi. If tiles are used they should have a smooth, easily cleanable finish. Smooth, hard impervious surfaces are recommended.

Consideration should be given to ventilation and air quality. The manufacturer’s advice should be sought as to the compatibility of detergents and

disinfectants used for cleaning the environment. Any defects in surfaces or equipment discovered during the cleaning process should be

reported to the practice manager. There should be a dedicated cleaning protocol for each room, outlining the room-cleaning

schedules and a named person for each piece of equipment. Always store cleaning materials used for general areas separately from those used for

clinical and decontamination areas. Training for cleaning of clinical and decontamination areas should be included in the staff

induction. The use of alcohol should be avoided for cleaning surfaces and equipment as it fixes proteins

and biofilm. Detergents should always be CE marked and suitable for use in clinical areas. Monitoring of cleaning standards should be undertaken regularly, and written records kept.

Cleaning the Treatment Areas

Always wear the correct personal protective equipment (PPE) and maintain good personal hygiene.

Always comply with health and safety policies, and infection control policies and procedures. Always observe COSHH, referring to data/assessment sheets.

9


Clean and dirty areas in the surgery should be clearly identified in order to reduce the risk of cross-contamination between patients.

Avoid touching and contaminating objects such as drawer handles, pens, computer keyboards and door handles with gloved hands.

Surfaces and associated areas should be cleaned after every patient, using a recommended bactericidal agent and disposable cleaning cloths. Using alcohol should be avoided as it binds blood protein to surfaces and stainless steel.

Avoid electrical devices when cleaning. Surfaces should be immediately dried using disposable cloths. Clearing spillages of blood or bodily fluids may lead to exposure to infectious

microorganisms. Every care must be taken to ensure members of staff make appropriate use of the appropriate spillage kit, protective clothing, such as gloves, aprons and eye or face protection if there is a chance of splashing.

Blood spillages should be cleaned in line with the spillage protocol, using a 1% sodium hypochlorite solution. The affected area should be doused for a minimum of 5 minutes. The area should then be mopped with paper towels, cleaned and immediately dried.

Disposable clothing and materials used to clear up spillages of blood or bodily fluids should be disposed of in a clinical waste bag, and hands should be washed.

Apply a colour-coding policy based on the National Colour Coding Scheme for cleaning:

Sanitary areas, including sinks in sanitary areas

General areas, e.g. waiting rooms and consulting rooms (including sinks in general areas)

Treatment and minor operations rooms

10


Kitchens

All surfaces (including underneath) should be visibly clean, with no blood or body substances, dust, dirt, debris or spillages.

When area is clean remove gloves, wash hands and use disinfectant gel. Use fresh gloves and prepare for the next patient.

Cleaning at the End of Each Session To be read in liaison with the Infection Control Policy

Sinks, taps and splashbacks Cabinets, trolleys Floor

General Cleaning

Equipment used for cleaning the environment should be fit for purpose. Mops and buckets should be kept clean and dry, and mops should be stored head up and

buckets inverted. Mop head should be removable if re-usable, or single use. Different areas should house different equipment, and this should be colour coded so that it

is easy to see which equipment should be used. Cleaning equipment should be stored in a designated area, away from potential sources of

contamination, materials and equipment.

11


Appendix 2:- CLINICAL WASTE MANAGEMENT PROTOCOL

Introduction

The Practice has a general duty to ensure, so far as is reasonably practicable, the health and safety of employees and other persons who may be affected by the storage, handling or disposal of waste products.

It is essential that waste is disposed of in a proper manner and that the method of disposal, and the standard of record keeping, complies with both legislation and best practice.

The policy will be reviewed annually to ensure that it remains effective and complies with both best practice guidelines and current legislation. This will be done prior to completion of the annual pre-acceptance audit in respect of the collection of hazardous waste

The aim of this protocol is to increase awareness among staff who may be involved in the handling of clinical waste, ensuring that safe procedures are maintained. Waste handling risk assessments should be carried out for all employees handling clinical waste and for any third-party contractor who has responsibility for handling practice hazardous waste to the point of its collection (i.e. cleaning companies) and its storage prior to collection (i.e. facilities management staff). Known hazards must be advised to any company or individual contracted to the practice under Health & Safety legislation.

The colour-coding arrangements for waste containers contained in this protocol are best practice compliant, however it should be noted that they are not mandatory. The principle resource in this respect is the DoH Technical Memorandum accessed from the Resources section below. Practice staff should be familiar with the relevant principles.

The regulations regarding the categorisation, packaging, storage and disposal of waste are complex. The practice will ensure staff accurately identify the types of waste produced on the premises and discuss their requirements for disposal with their licensed waste contractor.

Clinical Waste

Defined as any waste which consists wholly or partly of human tissue, blood or other body fluids, excretions, drugs or other pharmaceutical products, swabs or dressings or syringes, needles or other sharp instruments, being waste which unless rendered safe may prove hazardous to any person coming into contact with it. This includes other waste arising from the provision of treatment such as disposable clothing, towels, or any other waste which may cause infection to any person coming into contact with it.

12


Clinical waste is classed as hazardous, as it has properties which may be harmful to persons or the environment.

Segregation

Waste will be segregated into appropriate colour-coded containers at the point of use, which will determine the storage, transportation, and disposal methods. Clinical staff will have appropriate receptacles available and will be responsible for the most suitable choice of receptacle for the material being disposed of, with due regard to the type of receptacle (bin, bag etc.) and the colour coding requirements. Hazardous waste will not be mixed with any other waste produced at the practice and the recommended segregation should cover: • cytotoxic and cytostatic waste;• other medicines;• medicinally-contaminated sharps;• non-medicinally-contaminated sharps;• clinical waste (orange bag);• clinical waste (yellow bag);• offensive waste e.g. faecal material such as used nappies (yellow/black bag);• domestic waste (black/clear or other appropriate bag);

Each waste receptacle must be sealed (not to be more than three-quarters full) before being removed from the room where it was filled and then placed in a secure area to which there is no unsupervised or general access. The disposal method will then become the responsibility of the authorised and licensed contractor, who will dispose of the containers according to their colour-coded and correctly segregated contents.

Key Colour - Codes for hazardous waste bags and sharps containers Yellow - medicine contaminated infectious clinical waste

In a rigid container labelled “sharps”, includes needles/syringes, blades, scissors and disposable instruments

In an impervious bag, includes all contaminated soft material (swabs used with chemicals etc.)

Orange – infectious clinical waste or non-medicine contaminated sharps

In an impervious bag, includes items that may be contaminated with body fluids such as protective equipment (aprons/gloves etc.), plain dressings and bandages

In a rigid container labelled “sharps”, includes syringes/ blades etc. used in the treatment of infectious patients but with no contamination by medicines

13


Purple – cytotoxic or cytostatic waste

In a rigid container labelled “sharps”, includes needles, blades etc. Contaminated with cytotoxic or cytostatic material.

Blue – Medicine waste (none at present in surgery as drugs returned to onsite pharmacy)

In a blue-lidded container (usually rigid), includes unused, out-of-date tablets, creams and liquid medicines. NB – NOT FOR CONTROLLED DRUGS which must be destroyed by de-naturing and under strict conditions and supervision

Yellow with Black stripe – offensive or hygiene waste

In an impervious bag, includes nappy and sanitary waste

General Procedures for Handling Waste

All staff handling waste must wear appropriate and suitable protection (gloves, aprons) and be trained in Infection Control and Control of Substances Hazardous to Health (COSHH) risk mitigation procedures at least on an annual basis. All bags of waste must not be more than three-quarters full.

All waste must be placed into an “appropriate” container, which must clearly indicate the nature of its contents, and must be secure in relation to its nature. As a minimum, externally stored containers must be lockable and preferably stored in a secure and dedicated area. There may be a need to segregate waste, especially chemical waste which may interact.

All waste is to be handled and disposed of only by the practice-authorised contractor, who will provide certified waste transfer notices and be responsible for disposal of the waste using registered disposal sites. Waste must be collected at intervals not exceeding one week.

Liquid waste or solidified liquid waste must be in a leak-proof container and placed in a properly colour-coded receptacle. Liquid waste cannot be sent for disposal to landfill. Guidance should be obtained from the licensed contractor.

14


All transfer of waste from the practice to an authorised contractor must be supported by a Waste Transfer Note (WTN). This may be a note issued for the purpose of one transfer of waste only, or it may be in the form of a certificate (perhaps annual) stating the nature of the waste and its collection arrangements. These must be retained for at least two years.

When hazardous waste is moved, it must be accompanied by correctly completed paperwork called a consignment note. These must be retained for at least three years.

The contractors may require a declaration from the practice stating the composite nature of the waste in advance of a contract year, and require the practice to limit the waste to the previous stated items, or advise them of any extra waste types which may be included from time to time. Contractors may also offer a special disposal collection for certain waste types.

Waste, including unused medicines are not accepted from patients or members of the public as the practice is not a licensed waste contractor. Patients are to be directed to community pharmacies for safe disposal of medicines. The local council at present does not offer a sharps collection service, so sharps can be accepted on reception as long as bins are labelled , visually clean and sealed securely, if this is not adhered to staff can decline to accept. Practices sharing premises with producers employed by other organisations should be careful that others` waste is not mixed with theirs, as unknown hazardous content or incorrectly handled waste may be attributed to the practice and result in prosecution and significant fines.

Sharps

Sharps are any items which may cause a puncture, including needles, syringes with attached needles, broken glass, ampoules, scalpel blades etc.

Syringes containing residual products should not be intentionally discharged fully in order to dispose of them in a “fully discharged” sharps bin (i.e. the orange – lidded bin). If the syringe is only partially discharged and contaminated it must be disposed of in the yellow-lidded sharps bin. Sharps waste excludes syringe bodies where no needle is attached.

Training

All staff required to handle clinical waste must be given adequate instruction about the risks associated with, and the procedures to be used, in order to ensure the safe handling, segregation and storage of clinical waste. In addition to this all staff must be made aware of the procedures to be used following a spillage and receive online COSHH training at least annually, or as relevant to their role.

Staff handling cytotoxic drugs must be specifically trained to do so. Members of staff at any stage of pregnancy are not permitted to handle or dispose of these drugs or products.

15


Personal Protective Equipment (PPE) must be worn at all times to include PVC disposable apron, Non-latex gloves or similar, eye protection, as appropriate.

Training will include:

Risk assessment Use of PPE First aid on exposure Waste handling and segregation Spillage Needlestick injury Personal and equipment hygiene

Principal References

Health Technical Memorandum 07-01: Safe management of healthcare wastewww.gov.uk/government/publications/guidance-on-the-safe-management-of-healthcare-waste

Hazardous Waste Regulations 2005 (amended 2009) www.gov.uk/government/uploads/system/uploads/attachment_data/file/218704/haz-waste-regs-guide.pdf

Safe Handling of Cytotoxic etc. drugs - HSEwww.hse.gov.uk/healthservices/safe-use-cytotoxic-drugs.htm

16


Appendix 3: Safe handling and disposal of sharps

Introduction

Effective safe management of sharps, across all sectors, flows from existing health and safety legislation. In particular, the needs to assess the risks, provide appropriate information and training, and consult with employees. The Sharps Regulations build on the existing law and provide specific detail on requirements that must be taken by healthcare employers and their contractors.

The main principles of safe handling and disposal of sharps are:

The use of sharps will be avoided wherever possible. Where sharps must be used, injuries will be prevented. Where the use of a sharp cannot be avoided, substituted for a “safer sharp” when it

is practicable to do so ie medical sharps that incorporate features or mechanisms to prevent or minimise the risk of accidental injury, e.g syringes with shields or covers

In the event of a penetrating sharps injury all staff will take the appropriate actions including the reporting of sharps injuries to the appropriate persons via the approved system

Sharps disposal practices will comply with HTM 07-01 – Safe Management of Health Care Waste (2013).

All systems and equipment will conform to the EU Directive 2010/32/EU on the prevention of sharps injuries in the health care sector

Hierarchy of controls applied to sharps injury prevention

Elimination or substitution (for example, eliminate unnecessary injections) Most effective

Engineering controls (for example, safer needle devices, sharps containers)

Administrative (policies and training programmes)

Work practices (standard precautions, no recapping)

Personal protective equipment (gloves, masks, gowns etc.) Least effective

17


Appendix 4: Hand Hygiene

Hand Hygiene is the single most important measure for preventing the transmission of infection.

Hands readily pick up and transfer micro-organisms and must be decontaminated between activities that result in direct contact with the service user or their environment.

The aim of Hand Hygiene is to remove or destroy potentially pathogenic transient micro-organisms, dirt and organic material from the hands and wrists.

The acquisition of a healthcare acquired infection (HCAI) increases the cost of care by three times.

In addition to the direct costs to providers of healthcare, HCAIs also have intangible costs to both the service user and their families.

Hand hygiene can protect the service user, the healthcare worker and their families.

The principles of hand hygiene apply equally to where-ever care is given.

The technique, timing and duration of hand hygiene practice needs to be correct to be an effective means of preventing infection spread.

Research has revealed that when hand washing is carried out in a hasty manner, certain areas will not be effectively decontaminated.

The diagram below shows the areas of skin which were typically not decontaminated during a poor hand washing procedure.

The “6 step” technique is a research based process which, if undertaken correctly, will ensure all surfaces of the hands are effectively decontaminated.

18


The sequence of movements is important and should be identical to the diagram below. The process should last for 20-30 seconds. Counting to “2” for each step will ensure the correct time is spent on the procedure.

The Six Step Technique

The process

a) W a shing h ands w ith soap and w ater

Wet hands with water before applying soap

Use sufficient amounts of soap to cover all areas of skin. Liquid soap dispensers are designed to deliver the right amount of soap in one or two push/pull movements of the dispenser bar. Excessive application of soap will result in irritation and dehydration of the skin.

19

Don’t forget your

wrists!

Alcohol gel does not kill norovirus or C.diff spores


Using the six step technique above, work soap and water onto all areas of the skin. This should be done energetically to achieve gentle friction.

Rinse under running water.

Dry skin thoroughly us ing disposable p a p e r towels. Poor drying can lead to skin becoming chapped and sore

b) Using hand sanitisers (alcohol or non-alcohol)

A local risk assessment must be conducted to ascertain safety of providing alcohol based hand sanitiser dispensers in areas accessible to service users and the general public. Responsibility for this rests with the clinical manager responsible for the area.

Hand sanitizers will continue to reduce the microbial load on skin for many minutes after application. Alcohol based products are effective on bacterial microorganisms like MRSA, but does not work on some viruses e.g. Norovirus, Blood Borne viruses or bacterial spores e.g. Clostridium difficile.

Some non-alcohol based products can be effective on Norovirus and Clostridium difficile

The six step technique must be used to apply the gel, the product must be rubbed onto skin for 20-30 seconds and until totally evaporated and the skin feels dry. This will permit sufficient skin contact time for the chemical to destroy micro-organisms.

c) Hand Cream

An emollient hand cream should be applied regularly to help protect skin integrity.

Communal pots must not be used – only use pumps action dispensers.

Only apply before a refreshment break or at the end of a shift. Over liberal use of hand cream combined with frequent washing can provoke chapped skin and dermatological problems.

d) When to perform hand hygiene The “5” moments

The World Health Organisation (WHO 2009) defined the ‘5 moments for hand hygiene’. The five moments serve as defined critical control points for hands decontamination and preventing the spread of infection.

20


Appendix 5: PROTOCOL FOR NEEDLESTICK INJURIES

INTRODUCTION

The purpose of this protocol is to provide guidance for the urgent treatment and attention to injuries by sharps. It should be readily available in the event of an incident. Practices should research local arrangements and follow procedures in place as recommended by their own Health Protection unit and must also refer to the Health and safety Regulations for Sharps under the HSE website (see below).

PROCEDURE

The following action is recommended in the event of an inoculation injury.

1. IMMEDIATELY:(a) Make the wound bleed, if possible.(b) Clean well with copious amounts of soap and running water.(c) Apply occlusive dressing.(d) Identify the source of the sharp.

2. Refer to Occupational health - Workplace Health & Wellbeing (Tel. 01603 287035) who can advise what further action is necessary.

Out of Hours Contact (A&E at Norfolk and Norwich University Hospital-Tel: 01603 286286)

Recommended Action may then be:

3. Obtain sufficient information to identify the patient and the member of staff. Take a focused and impartial history to identify risk of HIV, HEP B (HBV) and HEP C (HCV).

4. If at high risk for HIV start Post Exposure Prophylaxis preferably within an hour, but worthwhile up to 36 hours post-exposure. Find HBV status of “recipient” and consider booster even if good immunity, consider HEP B immunoglobulins.

5. Note the type of injury, depth, gauge of needle, if used for injecting or aspiration, and if hollow bore or bloodstained.

6. Counsel and consent “donor” to take blood for immediate testing regardless of history.

7. Counsel and consent “recipient” for bloods to be taken and stored for HIV, HBV and HCV.

21


Appropriate clotted blood specimens from the member of staff involved and the source patient may be requested immediately and in three months time, and should be sent with request forms and details of the accident. HIV testing is not routine and will not be undertaken without full counselling.

If immunoglobulin is required the member of staff will be contacted and treated by the Accident and Emergency Unit. Immunoglobulin must be given within 48 hours to be of most benefit.

8. An accident report should be completed.

The Accident Report Book is held at reception. The following should be recorded:

The source of the sharp and description of the accident. Include the place, date, time

and any witnesses.

The name of the source patient.

The action taken.

Any persons who gave advice and the advice given.

The advice given to the patient and/or staff member concerned.

The action taken to prevent recurrence.

The incident should be discussed at the next staff/clinical meeting and lessons learnt should be highlighted through the Practice Learning Point reporting system(PLP).

Sharps should be kept in the appropriate "Sharps" box, out of the reach of children and with the lid closed - except when disposing of the sharp.

Sharps should be disposed of by the person using them. Never leave sharps to be disposed of by someone else.

It is the responsibility of staff suffering injury to ensure that advice on first aid is sought and to ensure completion of the appropriate documentation in accordance with the Health and Safety Regulations.

Resources

www.europeanbiosafetynetwork.eu

http://www.hse.gov.uk/healthservices/needlesticks/

www.nhsemployers.org

22


Appendix 6: SPECIMEN HANDLING PROTOCOL

Introduction

A specimen is defined as:“Any bodily substance taken from a person for the purpose of analysis, such as blood or urine”.

Specimens can therefore pose a risk to all staff handling them, from Reception Staff to Laboratory Staff.

To minimise these risks, the Practice will ensure that staff who handle specimens will be appropriately trained.

Collection and Storage

For accurate results to be obtained, specimens should be received by the laboratory within 24 hours maximum, as after this period, the environmental organisms (such as e.coli) will form and flourish, whilst the weaker organisms (e.g. anaerobes), will die off. Consequently a false result will be obtained. Blood samples which include U & Es should not be kept overnight.

Request Forms and Containers

Specimens sent to the laboratory often cause concern for laboratory staff by either being sent in the incorrect packaging, or by not including the correct information.

The patient / service users’ details must be placed on both the specimen container and the specimen request form.

The specimen must be placed in a plastic bag with the request form in the separate pouch which is attached.

Specimen containers should include the patient/service users' name, date of birth and or NHS Number.

The request for analysis form must be generated using ICE and will include: Patient’s name date of birth and / or NHS number; Patient’s GP and requesting Practitioner; The location, to enable correct reporting of results; Relevant clinical details, including planned or previous antibiotic therapy, date of onset

of symptoms and specimen type; Date and time the specimen was taken.

Failure to provide this information may result in specimens not being processed, delay specimen processing or lead to inappropriate tests being performed.

23


Specimens known or suspected to contain high risk pathogens, (e.g. blood borne viruses, tuberculosis, salmonella typhi), should be marked ‘Risk of Infection’ using the facility on ICE.

Patient Information Within the Practice environment patients need to be advised on appropriate specimen collection and should always be given the appropriate container.

Ideally, a designated specimen return area should be available, such as a plastic box that can be easily cleaned in case of spillage or contamination.

The patient should be encouraged to place the specimen in the container, or sample bag to reduce potential staff contact; leaking and broken specimens should be placed into the clinical waste system and any spillage cleaned up promptly.

Specimens must not be stored near food or drink.

Hand Alcohol Gel will be available for staff at all times and must be utilised after each sample collection taken, to avoid infection.

Blood All samples of blood are to be in the approved sample tubes provided, which are sealed by a top. Should leakage of blood occur, due to imperfections in the bottle or incorrect fitting of the top, the sample must not be transported out of the Practice in the container.

All sample tubes containing blood are to be inserted into an approved plastic bag, which is sealed to minimise the risk of contamination of personnel, should leakage occur.

If there is leakage or a spillage, subsequent action will depend on its extent.

If the leak is contained within the plastic bag, the bag is not to be opened and is to be insertedwithin another plastic bag, which is then sealed.

A suitable person (doctor / nurse) is to be informed when a leak occurs and will decide whether to dispose of the sample, or to transfer the remains of the sample into another bottleSuch a transfer of blood must only be undertaken when the risk of contamination of personnel is minimal and when gloves are used; otherwise the sample is to be disposed of as above in a plastic bag and inserted into the sharps box.If the leak is not contained within the bag and therefore contaminates either the outside of the bag or external objects, the following action is to be taken:Avoid any further contamination by containing the sample within another plastic bag - if possible without undoing the bag. Tighten the top of the tube as this may be loose.Dispose of the sample within an approved sharps box.

24


Ensure that hands are washed thoroughly with hot water and / or alcohol gel or soap. Any cut or open wound that comes into contact with the patient's blood must be thoroughly washed to ensure that none of the patient's blood remains in contact with the wound.Any contaminated objects should be cleaned and disinfected.All blood should be treated as high risk and universal precautions applied.

Urine

Although Urine, whether non-infected or infected, poses less of a risk than blood, sensible precautions should still be taken to avoid contamination of personnel or their clothing.

Gloves should be worn when handling urine containers as it is impossible to tell whether or not the container is contaminated with blood or faeces.

Urine Samples in Sealed ContainersSamples of urine in sealed containers should pose no health risk, provided that the bottle is adequately sealed and no urine contaminates the outside of the bottle.

Pregnancy tests and dipstick testing make necessary the opening of urine bottles and exposure of personnel to urine. Gloves are always to be worn whilst testing urine and hands must always be washed after handling and testing urine.

Disposal of UrineUrine is to be disposed of in its container in the appropriate sharps box.

Disposal of DipsticksDipsticks should be disposed of in a clinical waste bag.

Faeces

Faeces pose a risk to medical personnel. Through faeces, a number of diseases are transmitted that can be serious (though they are rarely as serious as blood diseases). It is important to handle faeces specimens correctly to avoid the risk of disease. As far as possible the patient is responsible for correct labelling and will be asked to label the sample themselves if presented unlabelled.

Faeces SamplesPatients must provide their faeces sample(s) inside a specimen pot - No other container is acceptable.

Before defecation, the Patient should label their specimen container with their name, date of birth and date and time of production.

The specimen must then be placed inside a specimen pot and sealed by the Patient.

25


The Patient will be advised to wash their hands thoroughly after defecation, but before touching the specimen pot, and again after inserting the specimen pot into the bag.

Microbiological Swabs

Because swabs are taken of many infected areas of the body to assess the cause of the infection, a swab by definition therefore contains an unknown hazard.

Provided the swab is not removed from the transport medium, no risk of transmission of infection exists, unless there has been contamination of the outside of the container.

The following guidelines are to be implemented:The top of the bottle must be sealed adequately before insertion into a sealed plastic hazard bag.The form that accompanies the swab is to be placed in the appropriate pocket of the bag and not in the same compartment as the swab.In the event of the top becoming loose and parting from the container whilst in the bag, the top is to be re-sealed either through the bag, or by opening the bag.The transport medium is solid and unlikely to leak out of the bag. However, in the unlikely event of such an occurrence, it has to be assumed that microbiological material has also leaked. Therefore the specimen is to be disposed of and re-taken.

26


Appendix 7: SPILLAGES

Purpose

The purpose of this policy is to direct staff on the appropriate management of blood and body fluid spillages to reduce the risk of cross infection. The policy aims to provide guidance for staff to safely manage spillages in a variety of care settings including a patient’s homes, healthcare environments and the transport of specimens’ service. The policy content is based on sound infection prevention and control principles and national guidance on the appropriate management of blood and body fluid spillages.

Background

Dealing with spillages of blood and body fluids may carry a risk of exposure to blood borne virus or other pathogens. This risk will be minimised by following the precautions in this policy including the correct use of personal protective equipment (PPE) and disinfectant products.

Responsibilities

Spillages of blood/body fluids must be cleaned up as quickly as possible by a member of staff. For safety reasons all patients and staff not involved in clearing the spill must be kept away from the spillage area until it has been dealt with effectively.

General Precautions

If there is any blood or other body fluid spillage outside the workplace then it can be rinsed away with a 2% bleach / water solution.

If there is spillage within the workplace a spillage kit is available as follows:-

West Earlham - Cleaning Cupboard

Adelaide Street – Reception

Bates Green – Cleaning Cupboard

These kits contain antiseptic granules which may be poured onto blood spills, leave for 2 minutes, and removed using paper towels. The kit also contains gloves (to be replaced if used once) and goggles to prevent splashes into the eyes. Disposable aprons should also be used.

27


Block off spillage areas from patients and staff until the spillage has been removed. Always use Personal Protective Equipment (PPE), and note the following general guidelines:

Paper towels etc, once used, should be placed in clinical waste

Non-disposable items such as buckets etc should be disinfected using a suitable bleach / disinfectant solution

All used PPE should be disposed of as clinical waste

Furniture affected by spillages should be removed immediately and isolated in order for the cleaners to deep clean. The items of furniture must not be used until this process has been undertaken.

Always wash your hands using thorough techniques immediately after the event – POSTERS OF THE HAND WASHING PROCESS CAN BE FOUND AT EACH HAND WASHING POINT.

Notes:

HIV is much less infectious than Hep B. HIV will not live long outside the human body but Hep B will survive for over a week in a drop of dried up blood. Consequently everyone in the practice will receive a Hep B vaccination shortly after recruitment, and everyone will receive training on infection control on an annual basis.

In the case of possible acute infection by a HIV+ patient, drugs are available which, if administered within 1 hour will give an 80%+ chance of killing the HIV infection. In such cases, the A&E department is to be contacted immediately for advice on obtaining this treatment (which is called Post Exposure Prophylaxis - PEP for short).

Always report a spillage as a Practice Learning Point (PLP)

28


APPENDIX 8: WAITING ROOM TOYS PROCEDURE

Introduction

Most surgeries provide toys for children either in the waiting room or in consulting rooms. These can harbour germs if not cleaned on a regular basis, and these can be passed on via mouth contact. During periods of pandemic or health alerts it may be prudent to remove these altogether with a suitable sign advising parents of the precaution.

This document sets out the practice procedure designed to minimise infection risk.

Requirements

Numbers of toys will be kept to a minimum Toys will be removed in the event of pandemic flu or other major similar outbreak No soft toys will be available – any donated or left on the premises should be disposed

of Hard toys (wood, plastic) will be accepted and must be in a good state of repair, of

good quality, and specifically designed for small children Toys generally must be of a sufficient size to prevent them being inserted into a child’s

mouth in its entirety. Toys deemed to be smaller than this should be disposed of. Toys which become contaminated with blood or body fluid will be cleaned immediately

or disposed of. The designated person responsible for the hygiene and maintenance of toys is Brenda

Scott at West Earlham, Susan Carter at Bates Green and Kathryn Pye at Adelaide Street.

Toys will be washed in hot water with a general purpose detergent and dried with disposable towels

Interim cleaning will be carried out using anti-bacterial wipes and / or spray. Where books are available they will preferably have washable / wipeable covers and

will be in good condition. Books which appear old or soiled will be disposed of. Identify any toys left as donations in the toy area, and ensure any new ones comply

with the above.

29


Appendix 9: NOTIFICATION OF INFECTIOUS DISEASES

Introduction

The Health Protection (Notification) Regulations (England) 2010 came into effect from 6th April 2010 and changed the basis of the notification of communicable disease. The purpose of this document is to provide GP practices summary information relating to the guidance.

The term “Registered Medical Practitioner” (RMP) has been used rather than “GP” in this document to be consistent with the format of the official guidance.

Basics

An RMP attending a patient is required to notify the ‘proper officer’ at their local council or local health protection unit (HPU) when they have “reasonable grounds for suspecting” that the patient:

• Has a notifiable disease as listed in Schedule 1 (See Appendix A below) of the Notification Regulations; or

• Has an infection not included in Schedule 1 which in the view of the RMP presents, or could present, significant harm to human health (e.g. emerging or new infections); or

• Is contaminated (such as with chemicals or radiation) in a manner which, in the view of the doctor presents, or could present, significant harm to human health; or

• Has died with, but not necessarily because of, a notifiable disease, or other infectious disease or contamination that presents or could present, or that presented or could have presented significant harm to human health.

It is expected that the notification of cases of infection not included in Schedule 1 and of contamination are likely to be exceptional occurrences.

RMPs should not wait for laboratory confirmation or results of other investigations in order to notify a case. Complete a notification form immediately on diagnosis of a suspected notifiable disease. A link to the form can be found in Resources, below.

This will ensure prompt notification so that health protection interventions and control measures can be initiated as soon as possible. The guidance describes how such notifications should be made and the time limits for making them, including provision for urgent oral reporting.

Send the form to the proper officer within 3 days, or notify them verbally within 24 hours if the case is urgent, securely by:

Phone / letter / encrypted email

30


Factors to Consider For Non-Schedule 1 Notifications

Notification of infections not included in Schedule 1 and contamination are expected to be exceptional occurrences. The RMP may wish to consider the following in deciding whether to notify a case of infection that is not included in Schedule 1 or a case of contamination:

• The risk of transmission or spread to others • The potential to cause significant harm to human health.

RMPs should not wait for laboratory confirmation of the suspected infection or contamination before notification. They must notify cases if they have reasonable clinical suspicion that their patient is suffering from a notifiable disease or other relevant infection or contamination. If an RMP has good reason to believe that another RMP has already notified the case, they are not required to notify.

The examples in the following sections are not exhaustive, and further scenario descriptions relating to these examples are provided within the official guidelines, accessed via the link in the Resources section below.

Notification of Contamination

There is now a requirement for RMPs to notify suspected cases of contamination that they believe present, or could present, significant harm to human health.

In deciding whether there could be significant harm to human health from the contaminated case, the attending RMP should consider morbidity and mortality already caused, or likely to be caused, by such contamination and the risk to public health from the spread of the contamination.

In making a judgement, the RMP may consider the clinical presentation of the case(s) and/or available evidence on the effects of such contamination. If in doubt, the RMP may seek advice from the proper officer, the HPA locally or another appropriate person. It is recommended that the RMP should also contact the proper officer or the local HPA office, if they become aware of a possible source of contamination associated with a suspected case that presents or could present a risk to others – even if there is no risk of spread of contamination from the case. This will ensure that appropriate investigation and control measures can take place. The RMP should send a written notification to the proper officer of the local authority so that it is received within three days, beginning with the day on which the RMP forms the clinical suspicion or makes the clinical diagnosis. If the RMP considers the case requires urgent notification, they need to notify it orally – usually by telephone – as soon as reasonably practicable and follow this up with written notification within three days. It is recommended that urgent notifications are made as soon as possible after the RMP forms the clinical suspicion or makes the clinical diagnosis, and always within 24 hours.

31


Other Changes

The legislation also changed:

Removal of fee for notification Under the Notification Regulations, there is no longer a provision for RMPs to be paid fees for notifications. RMPs are expected to provide information that is a requirement of the legislation to protect public health as part of their professional duties.

Removal of Offence for RMPs There is no longer an offence in the Notification Regulations for failure by an RMP to notify because there are other mechanisms for dealing with non-compliance with legal requirements.

RMPs in England are regulated by the General Medical Council and RMPs in employment are also subject to the clinical governance requirements that safeguard standards of care in the NHS. Contracts for general medical services and personal medical services require adherence by providers to relevant legislative requirements such as those in the Notification Regulations

RESOURCES

Notifiable diseases: Form for registered medical practitioners

https://www.gov.uk/government/collections/notifications-of-infectious-diseases-noids

Health protection legislation guidance 2010: Department of Health - Publications

Health Protection Regulations Toolkit

32


APPENDIX A

Notifiable Diseases (Schedule 1)

Acute encephalitisAcute infectious hepatitis *Acute meningitis *Acute poliomyelitis *Anthrax *Botulism *BrucellosisCholera *Diphtheria *Enteric fever (typhoid or paratyphoid fever) *Food poisoningHaemolytic Uraemic Syndrome (HUS) *Infectious bloody diarrhoeaInvasive group A streptococcal disease *Legionnaires’ disease *LeprosyMalaria Measles *Meningococcal septicaemia *MumpsPlagueRabies *RubellaSevere Acute Respiratory Syndrome (SARS) *Scarlet feverSmallpox *TetanusTuberculosisTyphus Viral haemorrhagic fever (VHF) *Whooping coughYellow fever

* The asterisk indicates diseases that an RMP must notify urgently.

www.legislation.gov.uk/uksi/2010/659/schedule/1/made

33


Appendix 10: SEPSIS IDENTIFICATION & MANAGEMENT PROTOCOL

Introduction

Good hygiene procedures and effective infection prevention and control are of paramount importance in protecting patient health, as well as upholding the reputation of primary care providers and, ultimately, our Practice.

Sepsis, also referred to as blood poisoning or septicaemia, is a potentially life-threatening condition triggered by an infection or injury which causes the body’s immune system to go into overdrive. If it is treated quickly, most patients will have a full recovery with no lasting health issues, but if not treated it can lead to septic shock, loss of limbs, organ failure and even death. Studies indicate that one in three people with sepsis will die; the condition kills more people than breast, bowel and prostate cancer combined.

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 sets out the key activities that should be undertaken by all NHS organisations with respect to good practice.

Additionally, there are substantial long-term physical and psychological health problems associated with sepsis which significantly reduce patients’ independence and increase their contact with the healthcare profession.

Sepsis – early response from Practices

A report by Health Education England ('Getting it right - the current state of sepsis education and training for healthcare staff across England'), highlights numerous examples of good practice in relation to sepsis education and training. It also identifies gaps in the provision of sepsis education and training, particularly for healthcare professionals who work in community and primary care settings.

34


Staff TrainingThe Practice must conduct staff training in recognising and responding to acutely unwell or deteriorating patients who may have sepsis. This can be co-ordinated by the Lead GP or Nurse, or in conjunction with any area-wide training organised by the CCG, Federation or other primary care organisation.

The Practice also discusses sepsis management at internal practice meetings, which are minuted and any relevant actions carried out and recorded. Clinicians attend relevant training/study as part of their ongoing professional development, which are listed in their records of training.

Treatment and Triage ProcessThe Practice must have a triage process in place which can identify and quickly respond to identified or suspected cases of sepsis. CCGs should be able to provide a clinically safe triage system, or there is a triage tool available from the UK Sepsis Trust included here;

Guidance from NHS England and NICE recommends that people with suspected sepsis are assessed for risk factors and then clinically using a structured set of observations (temperature, heart rate, respiratory rate, level of consciousness, oxygen saturation) to stratify risk of severe illness or death.

Equipment and diagnosisThe Practice has access to the appropriate equipment to assess possible instances of sepsis infection – this includes blood pressure monitors, temperature monitors, and pulse oximetry for adults and children.

Vaccination ProgrammeInfluenza vaccination programmes should have a high coverage of the practice population, especially patients over 65, pregnant women and patients with long-term conditions.

Patient informationThe Practice will provide information and guidance on sepsis for higher-risk patients and their carers, e.g. patients with long-term conditions, patients who have been prescribed immune-suppressive medication. The UK Sepsis Trust has a series of support material including a patients’ guide, booklets etc. https://sepsistrust.org/get-support/resources/

35


Sepsis ScreeningThe Practice uses appropriate sepsis clinical screening, assessment and audit tools to help in identifying any sepsis infections.

NB: It is the responsibility of the individual(s) undertaking sepsis screening to ensure they have the knowledge and understanding that is required.

Hand HygieneThe Practice has a Hand Hygiene Procedure in place to reduce the spread of infection. This is available to all staff and is reviewed annually.

Symptoms(Guidance taken from NHS Choices and NHS Inform and NICE)

There are three stages of sepsis; Sepsis

Severe sepsis

Septic shock.

Sepsis can occur while recovering from a procedure, but this isn’t always the case. Because it can begin in different parts of the body, it can have many different symptoms - early signs in older children and adults include a fever or low body temperature, as well chills, shivering, increased heartbeat and rapid breathing.

Symptoms of sepsis include:

A fever above 38ºC or a temperature below 36ºC

Heart rate higher than 90 beats/min

Breathing rate higher than 20 breaths per minute

Probable or confirmed infection

They must have two of these symptoms before a doctor can diagnose sepsis.

Sepsis symptoms in older children and adultsIn some cases, symptoms of more severe sepsis or septic shock (when your blood pressure drops to a dangerously low level) develop soon after. These can include:

feeling dizzy or faint

36


a change in mental state – such as confusion or disorientation

diarrhoea

nausea and vomiting

slurred speech

severe muscle pain

severe breathlessness

less urine production than normal (e.g. not urinating for a day)

cold, clammy and pale or mottled skin (purple or reddish patches)

loss of consciousness

Sepsis symptoms in children under 5

Parents should be advised to go straight to A&E or call 999 if their child displays any of these symptoms;

looks mottled (purple or reddish patches), bluish or pale

Lethargic or difficult to wake

Abnormally cold to touch

Rapid breathing

A rash that does not fade when you press it

Fits or convulsions

Temperature Over 38C in babies under three months

Over 39C in babies aged three to six months

High temperature in a child who cannot be encouraged to show interest in anything

Low temperature (below 36C – check three times in a 10-minute period)

Breathing

37


Finds it much harder to breathe than normal

Makes "grunting" noises with every breath

Can't say more than a few words at once (for older children who normally talk)

Breathing that obviously "pauses"

Toilet/nappies Has not had a wee or wet nappy for 12 hours

Eating and drinking New baby under one month old with no interest in feeding

Not drinking for more than eight hours (when awake)

Bile-stained (green), bloody or black vomit/sick

Activity and body Soft spot on a baby's head is bulging

Eyes look "sunken"

Child cannot be encouraged to show interest in anything

Baby is floppy

Weak, "whining" or continuous crying in a younger child

Older child who appears confused

Not responding or very irritable

Stiff neck, especially when trying to look up and down

Severe sepsisSevere sepsis occurs when there’s organ failure. You must have one or more of the following signs to be diagnosed with severe sepsis:

patches of discoloured skin

decreased urination

38


changes in mental ability

low platelet (blood clotting cells) count

problems breathing

abnormal heart functions

chills due to fall in body temperature

unconsciousness

extreme weakness

Septic shockSymptoms of septic shock include the symptoms of severe sepsis, plus a significant drop in blood pressure that can lead to respiratory or heart failure, stroke, failure of other organs, and death.

Possible complications include:

Heart failure

Abnormal blood clotting

Kidney failure

Respiratory failure

Stroke

Liver failure

Loss of a portion of the bowel

Loss of all or parts of limbs

Sepsis Causes and Risk Factors

Bacterial infections are most often the cause of infection, however sepsis can also result from other infections. It can begin anywhere bacteria or viruses enter the body; it could be something as minor as a scratch, or a more serious medical problem such as appendicitis, pneumonia, meningitis, or a urinary tract infection. An infection of the bone (osteomyelitis) could lead to sepsis. In people who are hospitalised, the bacteria that trigger sepsis can

39


enter the body through IV lines, surgical incisions, urinary catheters, and in the case of poor hygiene, even bed sores.

There are certain groups of people at greater risk of infection;

People with impaired immune systems due to illness e.g. HIV/AIDS or cancer

People taking immuno-suppressive drugs e.g. steroids and those used to prevent rejection of transplanted organs

Very young babies

The elderly, especially those with health problems

People recently hospitalised and/or had major surgeries

Patients with diabetes

It is also important to note that a septic patient is not like an accident victim or heart attack patient, where the diagnosis and the need for urgent treatment can be immediately obvious. Sepsis in patients can present itself in many ways, with vague symptoms, and may be elderly with several illnesses (called co-morbidities) which could disguise and complicate an accurate diagnosis.

Types of infections associated with sepsis include;

lung infection (pneumonia)

appendicitis

Peritonitis (infection of the thin layer of tissue that lines the inside of the abdomen)

urinary tract infection (infection of the bladder, urethra or kidneys)

cholecystitis (an infection of the gallbladder) or cholangitis (bile ducts)

skin infections like cellulitis – this can be caused by an intravenous catheter that's been inserted through the skin to give fluids or medication

infections after surgery

infections of the brain and nervous system – such as meningitis or encephalitis

flu (in some cases)

osteomyelitis (bone infection)

40


endocarditis (heart infection)

Sepsis treatment

Sepsis can quickly progress to septic shock and death if left untreated. There are a number of medications to treat sepsis, including:

antibiotics via IV to fight infection

vasoactive medications to increase blood pressure

insulin to stabilise blood sugar

corticosteroids to reduce inflammation

painkillers

Severe sepsis may also require large amounts of IV fluids and a respirator for breathing. Dialysis might be necessary if the kidneys are affected.

In some cases, surgery may be needed to remove the source of an infection. This includes draining a pus-filled abscess or removing infected tissue.

Recognising sepsis in primary care

Many patients are seen and managed for infections in primary care, but only a very small proportion will have sepsis. The skills and judgment of primary care clinicians will be crucial and must be adequately supported.

NICE recommends that people with suspected sepsis are assessed for risk factors and then clinically using a structured set of observations (temperature, heart rate, respiratory rate, level of consciousness, oxygen saturation) to stratify risk of severe illness or death.

In non-face-to-face assessments, if a clinician suspects sepsis and has no access to physiological measurements they should arrange for the patient to attend a facility where these measurements can be recorded without delay.

Where a primary care clinician suspects sepsis and the results of physiological observations suggest a risk of severe illness or death then the clinician should arrange urgent referral and transfer of the patient to an acute hospital for further assessment and treatment immediately.

“Safety Netting” in Primary Care

41


The NICE Quality Standards on sepsis published in September 2017 include a requirement for “safety netting”. This means that where a patient with an infection has been clinically assessed and thought not to have sepsis, the patient/carer is given information on what to look out for to prompt them to seek further clinical assessment.

The GP software providers have been asked to include sepsis safety-netting resources that GPs can pass on to patients/carers, especially the parents of children with infections.

Where a primary care clinician has considered and discounted a diagnosis of sepsis, they should provide appropriate safety-netting information to the patient/carer in case of later deterioration.

Assessment

People with suspected sepsis require face-to-face assessment to determine whether they need urgent intervention. Using a structured set of observations for assessing physiological symptoms should ensure that people at risk of severe illness or death from sepsis receive timely and appropriate treatment.

See Appendix 2 for a receptionists’ guide to Sepsis awareness

Sepsis – preventing infectionTaking steps to prevent the spread of infection can reduce your risk of developing sepsis. These include:

Patients should stay up to date on vaccinations (flu, pneumonia, and other infections)

Practicing good hygiene - proper wound care, handwashing, and bathing regularly.

Getting immediate care if they develop signs of infection.

Identifying people with suspected Sepsis

The following guidance provides links to the recommendations from the National Institute for Health and Care Excellence (NICE);

42


children under 5 out of hospital

children under 5 in hospital

children aged 5 to 11 years out of hospital

children aged 5 to 11 years in hospital

children and young people aged 12 to 17 out of hospital

children and young people aged 12 to 17 in hospital

adults aged 18 and over out of hospital

adults aged 18 and over in hospital

See Appendix 1 for a Risk stratification tool for adults, children and young people aged 12 yrs and over with suspected sepsis

Further information

Sepsis: recognition, diagnosis and early management: Resources sectionNational Institute for Health and Care Excellence

Sepsis Guidance Implementation Advice for Adults (NHS England)https://www.england.nhs.uk/wp-content/uploads/2017/09/sepsis-guidance-implementation-advice-for-adults.pdf

The UK Sepsis Trust : A UK charity raising awareness among patients and healthcare professionals that developed the ‘Sepsis Six’ practical tool to help healthcare professionals deliver basics of Sepsis carehttps://sepsistrust.org

NHS SAM (Sepsis Assessment & Management) What to look for if your child has a temperature and you are concerned.

This quick assessment guide can be downloaded here:

43


APPENDIX A: RISK STRATIFICATION FOR ADULTS, CHILDREN & YOUNG PEOPLE (12 AND OVER)

This document has been created using NICE guidance and recommendationsNICE guideline NG51 : https://www.nice.org.uk/guidance/ng51

Category High-Risk Criteria Moderate to high-risk criteria Low-Risk criteria

HistoryObjective evidence of new altered mental state

History from patient, friend or relative of new onset of altered behaviour or mental stateHistory of acute deterioration of functional ability Impaired immune system (illness or drugs including oral steroids)Trauma, surgery or invasive procedures in the last 6 weeks

Normal behaviour

Respiratory

Raised respiratory rate: 25 breaths per minute or more New need for oxygen (40% FiO2 or more) to maintain saturation more than 92% (or more than 88% in known chronic obstructive pulmonary disease)

Raised respiratory rate: 21–24 breaths per minute

No high risk or moderate to high risk criteria met

Blood Pressure

Systolic blood pressure 90 mmHg or less or systolic blood pressure more than 40 mmHg below normal

Systolic blood pressure 91–100 mmHgNo high risk or moderate to high risk criteria met

Circulation and hydration

Raised heart rate: more than 130 beats per minuteNot passed urine in previous 18 hours.For catheterised patients, passed less than 0.5 ml/kg of urine per hour

Raised heart rate: 91–130 beats per minute (for pregnant women 100–130 beats per minute) or new onset arrhythmiaNot passed urine in the past 12–18 hoursFor catheterised patients, passed 0.5–1 ml/kg of urine per hour

No high risk or moderate to high risk criteria met

Temperature Tympanic temperature less than 36°C

Skin

Mottled or ashen appearance

Cyanosis of skin, lips or tongue

Non-blanching rash of skin

Signs of potential infection, including redness,swelling or discharge at surgical site orbreakdown of wound

No non-blanching rash

44


APPENDIX B: SEPSIS AWARENESS FOR RECEPTIONISTS

The following page is a guide for receptionists to recognise any possible symptoms of sepsis.

The image file can be downloaded and used as a separate image, or you can download the following page and provide a copy to reception staff.

45


46


Appendix 11: Aseptic Technique

1. Introduction

2. When should an aseptic technique be used?

3. Who should undertake and aseptic technique?

4. The principles of asepsis/aseptic technique

5. Good practice

6. The procedure for dressing a wound using an aseptic technique

7. Non- touch technique (clean technique)

8. Symbols and their meanings

9. Additional IPC resources

10. References

11. Appendices

47


1. IntroductionAn aseptic technique is used to carry out a procedure in a way that minimises the risk of contaminating an invasive device, e.g., a urinary catheter or a susceptible body site such as the bladder or a wound.

2. When should an aseptic technique be used?The following are some examples of when an aseptic technique should be used, but is not an exhaustive list:

When infusing sterile fluids and medication When dressing wounds healing by primary intention, e.g., surgical wounds,

burns Dressing deep wounds that lead to a cavity or sinus Minor Surgery procedures Vaginal examination using instruments, e.g. smear taking, high vaginal swab,

insertion of IUCD If the patient is immunosuppressed, diabetic or at high risk of infection

3. Who should undertake an aseptic technique? Only staff trained and competent in an aseptic technique should undertake

this procedure. Adherence to the principles of asepsis (as described below) plays a vital role in preventing the transmission of infection in any environment. It is the responsibility of each member of staff who undertake an aseptic technique to understand the meaning of these principles and to incorporate them into their everyday practice.

Education, training and assessment of aseptic technique should be provided for all persons before undertaking such procedures.

It is good practice to undertake peer audits to monitor competency and a record of training and audit should be available.

Staff undertaking an aseptic technique should be free from infection, e.g., colds, sore throats, septic lesions.

4. The principles of asepsis/aseptic technique.Asepsis is defined as the absence of pathogenic (harmful) organisms. The principles of asepsis/aseptic technique are:

Reducing the 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

48


5. Good Practice Use standard precautions Dispose of single use items after use. Do not re-use Dispose of single patient use items after the patient’s treatment (single

patient use items can be decontaminated and re-used again on the same patient, but cannot be used on another patient).

Store sterile equipment in clean, dry conditions, off the floor and away from potential damage

Dispose of waste as per local policy

6. The procedure for dressing a wound using an aseptic technique Avoid exposing or dressing wounds or performing an aseptic procedure for at

least 30 minutes after domestic cleaning to allow dust particles to settle Staff should be “Bare Below the Elbows” (see hand hygiene guidance) Maintain a sterile field throughout the procedure Decontaminate hands by washing with liquid soap and warm water or by

applying alcohol handrub, using the recommended technique. (see Appendix 4 above).

Decontaminate the trolley (or working surface to be used if trolley not available, e.g., in a patient’s home) with detergent and warm water of detergent wipes and dry.

Assemble sterile procedure packs, e.g., dressing packs and equipment, check all items are in date and packaging is intact.

Ensure any windows are closed and fans switched off Explain and discuss the procedure with the patient Ensure that the patient is positioned both comfortably and so the area to be

exposed is accessible without undue exposure Put on disposable apron If an old dressing is in place, loosen the tape/adhesive security it, but leave in

place. Decontaminate hands with alcohol handrub Open sterile procedure pack outer packaging, sliding the contents onto the

top shelf of the trolley (or work surface) Open the sterile field by using the corners of the paper Add any extra items without compromising the sterile field Decontaminate hands with alcohol handrub Lift the plastic waste disposal bag from the sterile field carefully but its open

end and holding one edge of the opening end, place the other hand into bag, hence covering the hand with a sterile “glove”. Using the sterile “glove” arrange sterile items on the sterile field

With sterile “glove” in place, remove the old dressing from wound. Invert the “glove” removing it from hand ensuring the old dressing is left inside it. Attach the bag to the trolley, below the top shelf of on a nearby surface

Avoid exposing the wound for longer than the minimum time to prevent air borne contamination and to maintain optimal wound temperature

49


Apply alcohol handrub and put on sterile gloves ensuring hands do not contaminate outer surface of the glove

Perform the procedure, including cleaning of the skin where applicable Ensure equipment is discarded if it becomes contaminated Dispose of all used items, including soiled dressings, into the plastic waste

disposal bag and seal Discard waste bag into infection waste bag Decontaminate hands with alcohol handrub Decontaminate the working surface with detergent and warm water of

detergent wipe Decontaminate hands with liquid soap and warm water or apply alcohol

handrub Complete appropriate documentation on the computer

7. Non-touch technique (clean technique)This is a modified aseptic technique that can be used for undertaking procedures on vulnerable sites that are not sterile, but there is a need to avoid the introduction of micro-organisms to the site.

A non-touch technique (clean technique) should be used for the following:

Dressing open wounds that are healing by secondary intention, e.g., pressure sores, leg ulcers, dehisced wounds, dry wounds, simple grazes and removing sutures

Vaginal examination (in the absence of instrumentation)

The aim is to avoid contamination by not touching key elements e.g., the inside surface of a sterile dressing, end of a sterile connection or other item that will be in contact with a susceptible site.

A disposable apron should be worn. Non- sterile gloves can be worn as they are usually for the protection of the staff rather than the patient. Tap water rather than sterile saline can be used for the cleaning of the wounds.

Please note: if wounds enter deeper sterile body areas, then an ASEPTIC TECHNIQUE must be used. If the risk assessment shows the patient to be high risk, then an aseptic technique must be used.

If two procedures are being undertaken, e.g., suction and a wound dressing, change gloves and decontaminate hands between each procedure.

Summary for wound dressingsAseptic Technique Clean Technique

Gloves Sterile Non-sterileDressings Sterile Sterile

50


Cleansing solution Sterile water/saline/antiseptic

Tap water

Technique for Commonly Performed ProceduresProcedure Technique CommentsCervical Smear Clean Use a sterile disposable

(single use) speculumIUD Insertion Aseptic Sterile

8. ReferencesDepartment of Health (2010) The Health and Social Act 2008. Code of Practice for the prevention and control of infections and related guidanceDepartment of Health (2006) Essential steps to safe, clean careDoughty L, Lister S (Eds) (2008) The Royal Marsden Hospital Manual of Clinical Nursing Procedures 7th Edition

51


APPENDIX 13NCHC Infection Prevention and Control team. 01603 272767

Infectious Disease – Anglia Health Protection 03442253546

PHE Headquarters 02076548000

52

wensumvalleymedicalpractice.nhs.uk · Web viewClean and dirty areas in the surgery should be...

Documents

Transcript of wensumvalleymedicalpractice.nhs.uk · Web viewClean and dirty areas in the surgery should be...