INFECTION PREVENTION AND CONTROL POLICY

Transcription

1 Document title: Infection Prevention and Control Policy CCG document ref: Author / originator: Date of approval: Tanya Kidson 29 th Approving committee: Quality Committee Responsible director: Category: Dawn Clarke Clinical Sub category: Date policy is due for review: Target audience: Infection Prevention and Control November 2020 All Staff INFECTION PREVENTION AND CONTROL POLICY

2 VERSION CONTROL Document Location This document is only valid on the day it was printed. The current version of this document will be found at Revision History Date of this revision: Date of next revision: November 2020 Version Date Author Change Description Tanya Kidson New Policy /11/17 Tanya Kidson Policy review & update to reflect changes in Occupational Health Provider and Mandatory Training System Approvals This document requires initial approval at the Quality Directorate Team and formal approval by the Quality Committee. For subsequent changes approval is required as follows: Type of Change Name of Committee Title (if individual) Major revision Quality Committee Minor revision Infection Prevention and Control Lead Nurse Distribution This document has been distributed to: Name and job title / External organisation / All staff Date of Issue Version All staff 29/11/ Website 29/11/ Infection Prevention and Control Policy Version 2.0

3 Title Contents Page 1 Purpose 1 2 Scope 1 3 Responsibilities 1 4 Hand Hygiene 1 5 Personal Protective Equipment 4 6 Inoculation Incident 5 7 Immunisation of Staff 7 8 Dress Code for Staff Visiting Clinical Areas of Providers of Health and Social Care 7 9 Infectious Diseases 8 10 Implementation 8 11 Equality Impact Assessment 9 12 References 9 Appendix 1 - Hand Decontamination Techniques Appendix 2 - Glove Selection Flowchart Appendix 3 - Management of Occupational Exposure to Blood Borne Viruses Algorithm Infection Prevention and Control Policy Version 2.0

4 1. Purpose Shropshire Clinical Commissioning Group (CCG) is responsible for ensuring that appropriate systems and processes are in place within the organisation to protect staff, minimise the risk of infection and reduce the risk of cross infection. This policy exists to help protect CCG staff, the public and other stakeholders from the risks of infection and for Shropshire CCG to comply with national guidance and legislation including Health and Safety at Work Act 1974 and the Control of Substances Hazardous to Health Regulations It is recognised this policy will be relevant to some members of CCG staff more than others i.e. clinical staff vising providers of health and social care. 2. Scope This policy applies to all Shropshire CCG employees irrespective of age, sex, gender reassignment, sexual orientation, race, religion or belief, disability, marriage and civil partnership or pregnancy and maternity, provided that the matter at issue is within the control of the organisation. This policy applies to CCG bank employees and those employed on temporary, honorary and fixed term contracts. Individuals employed by agencies and other contractors will be expected to adhere to the standards contained in this policy when undertaking work for the CCG. Standard infection prevention and control (IPC) precautions underpin safe practice, offering protection to both staff and patients from healthcare related infections. This policy will cover the following specific areas of standard infection prevention and control precautions: a) Hand Hygiene b) Personal Protective Equipment c) Inoculation Incident It also provides guidance on immunisation and advice for Staff when visiting clinical areas that are experiencing incidents of infectious disease including gastrointestinal and influenza. 3. Responsibilities The Board has a responsibility to oversee the implementation of this policy and to ensure that managers take action to meet the organisation s obligations to minimise the risks of infections and comply with national guidance and legislation. Managers have a responsibility to follow this policy and to act on issues of poor conduct in an appropriate and timely manner, as well as assist and support employees to meet the required standards of conduct. Employees have a responsibility to familiarise themselves and act in accordance with this policy. The Infection Prevention and Control Team are responsible for the provision of advice and/or support to managers and employees in relation to the application of this policy. 4. Hand Hygiene Hands are the principal route by which cross-infection occurs and hand washing is one of the most important procedures for preventing the spread of infectious disease. Infection Prevention and Control Policy Version 2.0 1

5 Hand decontamination is a simple and effective way in which staff can prevent the transmission of infection and protect themselves. 4.1 Micro-organisms Found on the Skin Resident (Normal) Flora - forms part of the body s normal defence mechanisms and protects the skin from invasion by more harmful micro-organisms. They rarely cause disease and are of minor significance in routine clinical situations. Transient Flora - acquired by touch e.g. touching patients, from the environment, equipment, laundry, etc. They are located superficially on the skin, readily transmitted to the next thing touched, and are responsible for the majority of healthcareassociated infections. They are easily removed by hand decontamination. 4.2 Hand Care In order to achieve effective hand hygiene, it is important to look after the skin and fingernails. Damaged or dry skin leads to loss of smooth skin surface, and increases the risk of skin colonisation with resistant organisms such as Meticillin resistant Staphylococcus aureus (MRSA). Continuing damage to the skin may result in cracking and weeping, exposing staff to increased infection risk, which can lead to sickness absence. Clinical staff with acute or chronic skin lesions/conditions/reactions must seek advice from Team Prevent. Cover cuts and abrasions with water-impermeable dressing. Skin damage and dryness often results from frequent use of harsh soap products, application of soap to dry hands, or inadequate rinsing of soap from the hands. It is therefore essential that staff always wet hands before applying liquid soap and rinse and dry hands thoroughly. Regular use of hand cream may help to prevent skin damage. Communal pots of hand cream are not recommended due to the potential for contamination of the hand cream. Natural, artificial nails and nail extensions all harbour micro-organisms. Staff visiting clinical areas must keep fingernails short clean and free from nail varnish and art, not wear artificial nails or nail extensions. Rings, wristbands and other jewellery worn on the hands and wrists harbour microorganisms and prevent thorough hand procedures. Staff visiting clinical areas must remove wrist watches, wrist and fitness bands, bracelets and rings (except one plain banded ring). 4.3 When to Perform Hand Hygiene Both the decision to decontaminate hands and what type of cleaning agent to be used should be based on a risk assessment. This must include the likelihood that micro-organisms have been acquired or may be transmitted, whether the hands are visibly soiled, and what activity is about to take place. All staff must decontaminate their hands: Before preparing or eating food After using the toilet All staff visiting clinical areas of providers of health and social care must decontaminate their hands: Infection Prevention and Control Policy Version 2.0 2

6 Before contact with all patients, particularly susceptible sites e.g. wounds, burns, intravenous lines, catheters Before donning gloves Before clean/aseptic procedures After removing disposable gloves (gloves are not a substitute for effective hand washing they can develop holes whilst in use and hands can become contaminated on removal of gloves) After body fluid exposure/risk After direct patient contact After contact with patient surroundings After handling contaminated laundry and waste After contact with patients in isolation or during outbreaks, including those infected or colonised with resistant organisms e.g. MRSA. 4.4 Choice of Cleansing Agent Liquid Soap Washing the hands with plain liquid soap and water is adequate for most routine activities. Hand washing with soap lifts transient micro-organisms from the surface of the skin and allows them to be rinsed off. Alcohol Hand Rub/Gels (with emollients). These may be used in place of soap and water if hands are visibly clean. They are especially useful if hand washing and drying facilities are inadequate, or where there is a need for rapid or frequent hand washing. These agents have disinfectant activity, and destroy transient micro-organisms. If applied for an extended length of time, they will also destroy some resident flora. Alcohol hand rubs are recommended products for ensuring effective hand hygiene in all patient care situations except when: Hands are visibly soiled There is evidence of diarrhoeal illness including Norovirus and Clostridium difficile After removing disposable gloves There is direct hand contact with any body fluids i.e. failure to don gloves or gloves punctured In these instances, hands should always be washed with liquid soap and water. 4.5 Performing Hand Hygiene Routine Hand Washing Use liquid soap and water, and follow this procedure: Wet hands under running water Dispense one dose of liquid soap into a cupped hand Wash hands vigorously cover all surfaces as per hand hygiene technique (see Appendix 1) Rinse hands thoroughly under running water Turn off taps using elbows (or paper towel if taps are not elbow-operated) Infection Prevention and Control Policy Version 2.0 3

7 Dry hands with disposable paper towels Alcohol Hand Rub/gels (with emollients) Dispense required amount of product onto visibly clean, dry hands Ensure enough product is dispensed to cover surfaces of hands as per hand hygiene technique (see Appendix 2) Rub vigorously until dry 4.6 Hand Drying Effective drying of hands after washing is important because wet surfaces transfer micro-organisms more effectively than dry ones and inadequately dried hands are prone to skin damage. Disposable paper towels are the preferred option for use in communal settings. These should be conveniently placed in relation to hand washing facilities in a wall-mounted dispenser. Foot operated bins should be used to dispose of paper towels to reduce the risk of re-contamination of hands. 5. Personal Protective Equipment 5.1 Selecting Personal Protective Equipment The choice of personal protective equipment (PPE) selected depends on the anticipated risk of exposure to blood and body fluid during the particular activity. Many clinical activities involve no direct contact with body fluid and do not require the use of protective clothing, e.g. taking a pulse, blood pressure or temperature. Other procedures may result in contamination of the hands or clothing and require the use of gloves, a plastic apron, goggles or face visor, e.g. wound care, handling specimens or during specific treatments. 5.2 Gloves Gloves are not a substitute for hand washing. Hands should be decontaminated before donning gloves and washed with soap and water and dried after removal, as they may be punctured, and because hands are easily contaminated as the gloves removed. To prevent transmission of infection, disposable, single use gloves must be used only once and disposed of. Disposable gloves must be worn for invasive procedures, contact with sterile sites and with non-intact skin-mucous membranes and all activities that have been assessed as carrying a risk of exposure, or involve direct contact with blood, body fluids, secretions and excretions. Choice of Glove Refer to Appendix 3 Glove Selection Flowchart. The CCG has a duty of care to minimise the risk of Staff or patients developing a latex allergy and to manage Staff and patients who have a latex allergy. Staff with a known or suspected latex allergy must not use latex gloves and latex gloves must not be used if the patient has, or is suspected of having, a latex allergy. 5.3 Disposable Plastic Aprons Since the front of the body is the part most frequently contaminated by body fluid, disposable plastic aprons provide adequate protection in most circumstances. Disposable plastic aprons should be worn when contamination of clothing with blood Infection Prevention and Control Policy Version 2.0 4

8 and body fluids is anticipated. Disposable plastic aprons should be discarded after each procedure and between patients. 5.4 Eye and Facial Protection Eye and facial protection including disposable masks are used to protect health care staff from splashes of body fluid and should be worn for any activity where there is a risk of body fluid splashing the face or eyes. 5.5 Safe Removal of Personal Protective Equipment PPE should be removed in an order that minimises the potential for crosscontamination. Hand hygiene should be performed immediately after removing all PPE. Gloves Grasp the glove in the palm with the opposite gloved hand and slowly withdraw hand outside of the glove Hold the removed glove in the gloved hand Slide the fingers of the ungloved hand under the remaining glove at the wrist Peel the second glove off over the first glove Dispose of into appropriate waste stream Aprons Break ties at neck and allow apron to fold over Pull apron away from waist touching inside only and pull to break Fold or roll into a bundle Dispose of into appropriate waste stream Masks Unfasten the ties first the bottom, then the top Pull away from the face without touching the front of the mask/respirator Infection Prevention and Control Policy Version 2.0 5

9 Dispose of into appropriate waste stream 6. Inoculation Incident For the purposes of this section of the policy an inoculation incident refers to needlestick or sharps injury, or any other exposure to blood borne viruses. Accidents with blood and body fluids may occur within healthcare facilities. In certain circumstances, such accidents can be associated with a small, but significant, risk of transmission of one of the blood-borne viruses (BBV) such as hepatitis B (HBV), hepatitis C (HCV) or Human Immunodeficiency Virus (HIV). A great deal of anxiety can arise in someone who has been involved in an inoculation incident. Body fluids implicated in transmitting BBV include the following: Blood Cerebrospinal fluid Peritoneal fluid Pleural fluid Pericardial fluid Synovial fluid Amniotic fluid Semen Vaginal secretions Breast milk Any other body fluid containing visible blood, including saliva in association with dentistry Unfixed tissues and organs 6.1 Assessment of the Risk of Transmission of Infection Significant exposures include: Needlestick injury - involve needles, sharp-edged instruments, broken glassware and other items which are likely to be contaminated in use by blood or body fluids and which may cause laceration or puncture wounds. Sharp tissues such as shards of bone or teeth may also pose a risk of injury Injury with sharp object contaminated with blood or high risk body fluid - not urine or faeces unless they contain blood A significant bite or scratch where skin is broken The splashing of blood or body fluid onto mucous membrane or break in skin Contamination with urine, vomit, faeces, sweat or saliva is NOT a significant risk unless it is visibly blood stained. Spillage of blood or body fluids on to intact skin needs to be washed off with soap and water, but further action is not required. No further action will be needed if it is evident that the incident was not a risk for transmission of infection, for example if body fluids contaminated intact skin only or that the needle did not penetrate the subject's skin. 6.2 Managing Occupational Exposure to Blood Borne Viruses Almost all inoculation injuries can be avoided by safe working practices, but if an injury does happen, the following action must be taken immediately: Infection Prevention and Control Policy Version 2.0 6

10 Encourage bleeding of the sharp or bite injured area and gently squeeze the surrounding skin for a few seconds Do not suck on the wound Wash the affected skin area gently with plenty of soap and running water Cover the wound with a suitable dressing If mouth or eye(s) are exposed, irrigate with eyewash, sterile saline, or tap water for 1-2 minutes. If contact lenses are worn, irrigation should take place before and after removing the lenses. Clean lenses in normal manner before re-insertion Inform a manager and, during normal opening hours, telephone Occupational Health Provider, Team Prevent UK on If Team Prevent UK is closed, seek advice from the local A&E department at Shrewsbury and Telford Hospital Trust and contact Team Prevent UK on the next working day If the source is known and strongly suspected to be HIV positive, contact the consultant microbiologist URGENTLY (via radiopage or mobile phone, if necessary). Discuss whether prophylactic anti HIV drugs are needed. If necessary these should be given WITHIN one hour. Starter packs are located in the A&E departments at Shrewsbury and Telford Hospital Trust An incident report must be completed using the CCGs normal incident reporting procedures Where the source of the blood or body fluid is unknown Take 5ml clotted blood (red-top tube) from the injured person and send to Virology for measurement of Hepatitis B antibody levels and storage Undertake risk assessment Where the source of the blood or body fluid is known Take 5ml clotted blood (red-top tube) from the injured person and send to Virology for measurement of Hepatitis B antibody levels and storage Obtain the name, hospital/nhs number and location of the patient who was the source of the needle, blood or body fluid and write this on the request form. (This is important as, after testing, it enables the Occupational Health Adviser or Medical Microbiologist to assess the risk to which the staff member has been exposed) Contact the location to see if the doctor in charge can arrange for a blood sample to be taken from the patient. The blood sample may need to be taken promptly if the patient is only in the hospital for a short visit. If the patient has left the hospital, then useful information might be obtained from the clinical or nursing notes. The clinician caring for the source patient, or doctor independent of any medical staff injured, should undertake a pre-test discussion with the source patient to ensure informed consent is obtained prior to obtaining blood specimens. The patient has the right to refuse any tests and should not be tested without giving consent. Consent does not have to be written but should be documented in the patient s notes Take 5ml clotted blood (red topped bottle) from the source patient and request testing for Hepatitis B surface antigen, Hepatitis C antibody and HIV testing. Write the name of the injured staff member on the form from the patient Infection Prevention and Control Policy Version 2.0 7

11 It is the responsibility of the clinician or team caring for the source patient to inform the patient of the results of the blood tests when they become available Refer to Appendix 4 Algorithm Management of Occupational Exposure to Blood Borne Viruses. 7. Immunisation of Staff All CCG Staff are offered vaccination against seasonal flu free of charge. All clinical Staff should be immunised against hepatitis B. The hepatitis B status of all clinical and other relevant Staff is checked as part of the recruitment process. Where the member of Staff is not already immunised, immunisation is offered and is provided free of charge. A record of the vaccination status and hepatitis B status of all relevant Staff including dates of boosters due is held by Team Prevent. 8. Dress Code for Staff Visiting Clinical Areas of Providers of Health and Social Care All Staff issued with a uniform should refer to the CCG Uniform/Dress Code Policy. Staff visiting clinical areas must adopt bare below the elbows and wear short sleeves or sleeves that can be rolled up to the elbows. Staff visiting clinical areas must not wear artificial nails or nail extensions wrist watches, wrist and fitness bands, bracelets and rings (except one plain banded ring). Fingernails must be short and clean Neckties, necklaces, long hair and ID badges on lanyards are potential sources of cross infection and all Staff must tie them back, tuck them in or remove them during visits. 9. Infectious Diseases 9.1 Diarrhoeal Illness including Norovirus and Clostridium difficile If a provider of health and social care is experiencing an outbreak of diarrhoea or vomiting as a result of Norovirus, CCG Staff should refrain from visiting unless the visit is essential or the areas affected can be avoided. On the occasions when staff are required to visit the standard IPC precautions detailed in this policy must be adopted. Any member of staff who has diarrhoea or vomiting should refrain from work until clear of symptoms for 48 hours, and feel well. 9.2 Influenza Like Illness Staff and visitors should be encouraged to minimise potential influenza transmission through good respiratory hygiene measures: Hands should be kept away from the eyes, mouth and nose Disposable, single-use tissues should be used to cover the nose and mouth when sneezing, coughing or wiping and blowing noses. Used tissues should be disposed of promptly in the appropriate waste bin Tissues, waste bins (preferably lidded and foot operated) and hand hygiene facilities should be available for Staff and visitors Hands should be cleaned (using soap and water if possible, otherwise using alcohol hand rub) after coughing, sneezing, using tissues or after any contact with respiratory secretions and contaminated objects. Infection Prevention and Control Policy Version 2.0 8

12 If a provider of health and social care is experiencing an outbreak of influenza, CCG Staff should refrain from visiting unless the visit is essential or the areas affected can be avoided. On the occasions when Staff are required to visit the standard IPC precautions detailed in this policy must be adopted 10. Implementation 10.1 Training Requirements To support the successful implementation this policy training is available online via the MLCSU Learning Management System. The IPC Level 1 module is mandatory for all staff and should be undertaken annually. Additional advice and training associated with this policy is available from the CCG IPC Team Monitoring Compliance Compliance with the policy and on-going monitoring will be facilitated through the CCG Executive team Review and Revision This policy will be reviewed three years from the date of approval, or sooner if new relevant legislation is published Applying the Policy If any member of Staff experiences difficulties following this policy then one to one guidance may be given by the IPC Team together with their line manager. 11. Equality Impact Assessment This document has been subject to an Equality Impact Assessment and is not anticipated to have an adverse impact on any group. 12. References The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance (2015) DH publications, London. Infection Prevention and Control Policy Version 2.0 9

13 Appendix 1 - Hand washing technique Infection Prevention and Control Policy Version 2.0

14 Appendix 2 Alcohol hand rub technique Infection Prevention and Control Policy Version 2.0

15 Appendix 3 Glove Selection Flowchart Glove Selection Flowchart Surgical (Sterile) Examination Polythene Household Latex All Surgical Procedures Synthetic Alternative: Nitrile Sterile Latex Synthetic Alternative: Nitrile Non Sterile Sterile Vinyl Non Sterile Food Handling Not for clinical use Non Sterile Rubber Domestic & Cleaning Procedures Synthetic Aseptic procedures with potential exposure to blood, blood stained body fluids or vaginal secretions Handling cytotoxic materials Non aseptic procedures with potential exposure to blood, blood stained body fluids or vaginal secretions Handling cytotoxic materials Handling aldehydes/peracetic acid Aseptic procedures where contact with blood, heavily blood stained body fluids or vaginal secretions is unlikely Non aseptic where contact with blood, heavily blood stained body fluids or vaginal secretions is unlikely Infection Prevention and Control Policy Version 2.0

16 Appendix 4 - Management of Occupational Exposure to Blood Borne Viruses Needle stick/sharps injury or bite Blood splash on broken skin Blood/high-risk fluid splash in eyes or mouth (See section 6) Encourage bleeding Wash under running water Irrigate under running water Inform Line Manager/Supervisor Report to Occupational Health or Out of Hours A&E, MIU or Shropdoc Complete Datix Incident Form NO Was the exposure significant? No further action required Is there a high risk of transmission of HIV? NO Contact Microbiology Consultant urgently Is the source patient known? NO Is HIV PEP recommended? Does the staff member consent? Start PEP ASAP Take bloods for baseline serology, U+Es, LFTs Arrange follow-up NO May need immunoglobulin and hepatitis B vaccination. See section 8 Take blood from HCW for HBV antibodies and storage Has informed consent been obtained from the patient? Take 5ml clotted blood (red top) for HBV surface antigen, HCV antibodies and HIV Has the staff member been immunised against hepatitis B? Was there an adequate response to hepatitis B vaccine? Take blood from HCW for HBV antibodies and storage Arrange follow-up Consider hepatitis B booster Infection Prevention and Control Policy Version 2.0