Infection Prevention and Control (Level 2)€¦ · Waste Management All healthcare workers are responsible for the safe management and disposal of waste. Waste is potentially hazardous

Version:1

Infection Prevention and Control

(Level 2)

For all clinical staff

Please ensure you read the workbook thoroughly

and complete the assessment at the end

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Learning Outcomes

This work book is designed to help all staff play their part in the prevention of avoidable infection associated with health care by reinforcing the awareness and the delivery of safe, clean care. This information should be used in association with Milton Keynes Hospital Infection Prevention and Control and the Marsden Manuals. Both are available on the hospital intranet. You do not need a password to access the system. All staff must undertake infection prevention and control education in accordance with the learning and development framework. Guidance regarding education requirements is available through the Mandatory Training and Induction icon on the hospital main intra-net page. You must complete all sections of the work book before sending it to the Infection Prevention and Control Team, in the Pathology Department in the hospital. You must achieve a pass score of 75% to achieve this mandatory requirement. What is infection prevention and control? Success in the prevention of infection means doing everything possible in order to stop infection from developing and or spreading to others. This means following standard precautions, the basic principles being the appropriate use of personal protective equipment, hand hygiene and observing the bare below the elbow rule if working in a clinical environment. Healthcare associated infections (HCAI’s) can occur anywhere that services connected to health are delivered; hospitals, nursing and residential homes are just a few examples. It is the responsibility of each and every one of us to prevent the spread of infection; this includes staff, visitors and patients themselves. Why is infection prevention and control important? HCAIs pose a serious risk to patients, staff and visitors. They can incur significant costs for the NHS and cause considerable morbidity to those infected. Furthermore, infected patients cost 3 times more to treat than non-infected. Increasing antimicrobial resistance is resulting in infections that are very difficult to treat. Standard Precautions Standard precautions underpin safe practice, protecting both staff and patients from potential infection. The application of standard precautions at all times during your working day when caring for patients means that the risks of infection and spread of infection are greatly reduced. Standard precautions are the minimum standard of hygiene to be applied during all contact with blood or body fluids from any source. Use of appropriate personal protective equipment (PPE) e.g. gloves; single use plastic apron is paramount when undertaking ‘hands on’ tasks like mouth care or blood sampling. Standard infection control measures protect both staff and patients.

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Every patient has the potential to be at risk of infection, it is therefore essential that all healthcare staff use appropriate infection prevention and control measures when caring for all patients in order to protect from avoidable harm. Clean safe care underpins how we must care for all patients.

Hand Hygiene Is the single most important way in which we can protect patients, ourselves and others from infection starting, or the potential spread of infection. Hand hygiene prevents both staff and patients from acquiring pathogenic material. Pathogenic means it is capable of causing infection. It is sometimes referred to as micro-organisms, bacteria or bugs. The word micro means it is not visible to the naked eye and you need a microscope to view and identify it. All of us have bacteria on our skin, not all of it can cause harm as it forms part of our natural defence system. When to decontaminate your hands The 5 moments of hand hygiene below are a guide to enable you to see key moments where hand decontamination must be undertaken. Hand decontamination is determined by clinical tasks; those completed, and those intended to be performed.

Steps to reduce potential HCAI

1. Hand decontamination 6. Safe Sharps management

2. Use of PPE 7. Blood/body fluid spillages

3. Waste management 8. Medical device management

4. Decontamination of equipment 9. Antimicrobial prescribing

5. Laundry 10. Risk assessment

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Soap or Alcohol based products? For most instances hand washing with soap and water is sufficient. Alcohol based hand rubs are effective in most situations and kill the majority of bacteria (including MRSA), however alcohol does not kill spores- meaning it does not kill Clostridium difficile or Norovirus. In cases of exposure to patients or surroundings where contamination with spores may have occurred hand washing will kill and remove spores effectively. Hand washing with soap and water must always take place if hands are visibly dirty or you have cared for a patient or cleaned a piece of equipment that is deemed as high risk. Hand Care

Keep nails short, varnish free. False or acrylic nails are not permitted. Bare below the elbow to enable adequate hand hygiene. Always wet hands before applying liquid soap. Follow the hand hygiene technique displayed on all soap/alcohol dispensers. Ensure that hands are thoroughly rinsed under running water. Dry with paper towel, ensuring that you do not over rub, pat hands dry. Cover cuts or abrasions with a water proof dressing and change regularly. Ensure that you apply moisturiser regularly to prevent skin damage.

Remember to report any empty soap/alcohol/moisturiser dispensers to the domestic team in order for them to be refilled. If no domestic staff available, you should replace the cartridge. All wards and departments have access to supplies and keys to dispensers. Personal protective equipment Personal protective equipment (PPE), such as disposable plastic aprons/gloves are used to protect the healthcare worker and the patient from cross-contamination/infection. A risk assessment should be undertaken in order to ensure that the appropriate level of PPE is worn. This applies to all disciplines of staff.

Gloves Must be worn if there is potential for direct contact with blood or body fluids, or if caring for a patient in either source or protective isolation. Gloves must always be worn by staff when blood sampling or cannulation is undertaken. Gloves worn for routine tasks are latex and powder free- this is to reduce skin sensitivities for staff and patients. Sterile gloves are also latex and powder free. Only a few areas within the Trust use latex gloves e.g. Maxillo facial department.

Gloves must be removed and hands decontaminated after each patient contact, and between tasks where necessary e.g. after urinary or venous catheter care and before mouth care.

After removal of gloves, hands must be washed or alcohol based rub

used. Do not apply alcohol based rub to gloves or re-use gloves

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Aprons Single use disposable aprons must be worn if direct patient contact is anticipated e.g. assisting with patient bed bath, or if caring for a patient in either source or protective isolation. White aprons are used for patient care. Some departments use heavier duty green apron at times e.g. Resus area in ED or theatres. The Department of Critical Care also use different coloured aprons to indicate which staff are caring for patients within specific bays within the department. After completion of a task the apron must be removed and disposed of appropriately.

Face protection Appropriate facial protection must be worn when there is potential splash to the facial area, either blood, body fluids or when dealing with chemicals. There are different types of facial protection available and the appropriate form should be chosen depending on the task being undertaken. The three main types available include:

Goggles Mask Visor

Masks Masks are not necessary for routine patient management. Surgical face masks are usually only worn in the theatre environment. Fluid shield masks (TB masks/ FFP3) masks should be worn if caring for patients with open, untreated pulmonary tuberculosis. If caring for TB patients the member of staff should wear the mask, the patient would only be requested to wear the mask if transferring between wards/departments. A TB nurse specialist is available for support and education please access intranet phone directory for contact details. Masks are single use and should be disposed of after each episode of patient care, or immediately if contaminated. The TB masks (FFP3) have a fluid shield protection which protects the wearer for up to 7 hours exposure. For guidance in relation to mask use for Viral Haemorrhagic Fevers (VHF) including E bola and Influenza patient management please refer to the intra-net page for latest Department of Health and Public Health England (PHE) Guidance.

Note: BLUE aprons are worn by staff for patient meal/snack delivery

Protect yourself and your patients by always wearing the appropriate PPE

Dispose of all PPE appropriately- never re-use! Ensure that masks are well fitted and if a specialist mask such as FFP3

is needed a trained ‘fitter’ must assess the fit of the mask. All front line staff are now required to be FIT tested for pandemic flu

and E bola preparedness.

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Sharps This term refers to any needle or sharp instrument used within the hospital setting for patient treatment e.g. cannula needle/ scalpel. The person using the sharp is responsible for safe disposal of the sharp into the appropriate sharps container.

Always dispose of the sharp at the point of care. Never re-sheath needles, always use needles with integral guard Use integral sharps tray- take sharps container to the patient.

Sharps containers

Ensure that the lid of the sharps box is securely fastened all the way round. All containers must be signed and dated with the areas stated when assembled and on

closure. All sharps containers must be no more the 2/3 full at closure- Never fill above fill line. Ensure that all sharps containers are stored in secure area. Use wall mounted sharps containers where used in an area that they do not need to be

moved e.g. treatment or clinic rooms. Always leave the aperture (closure) in the temporary closed position when not in use or

moving from preparation area to patient and back. Do not place sharps containers in clinical waste bags- they are collected separately. Use correct size sharps container according to usage/ area.

In the event of sharps/needle stick injury

Splashes of blood or body fluids to the eyes or mouth must be treated as potential exposure to a blood borne virus. Rinse with copious amounts of water and follow procedure above.

Encourage wound to bleed by applying gentle pressure around wound - do not suck!

Wash under running water and dry Cover with waterproof dressing Report to manager Contact Occupational Health Department or Emergency Department

out of hours Datix/ incident form must be completed

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Blood/Body Fluid Spillages All spillages should be dealt with quickly to reduce potential contamination, transmission of infection and reduce the risk of slips/trips/falls. Clinical staff are responsible for the initial clean of blood or body fluids. It is not the responsibility of our domestic staff.

Wear appropriate PPE- apron/gloves/goggles Use presept granules directly onto the spillage- follow instruction on the container- Do not use

presept directly onto urine spill. Soak excess liquid up with disposable paper towel and dispose of as clinical waste. Clean the affected area with detergent and disposable cloth/mop. Use Tristel to clean following infectious spillages e.g. faeces from patient suspected or known

to have Clostridium difficile. Remove PPE when spill cleared and dispose of as clinical waste. Wash hands thoroughly. Use wet floor sign if indicated and remove once area is dry.

Waste Management

All healthcare workers are responsible for the safe management and disposal of waste. Waste

is potentially hazardous and if not disposed of correctly, can result in life altering injury or

infection. All waste must be segregated and the correct colour-coded containers and plastic

bags used.

Yellow bags for clinical, anatomical waste- disposed of by incineration Black bags for general/domestic waste- disposed of as landfill Tiger-stripe (yellow and black) bags for offensive, non-infected waste- disposed of as landfill Orange bags for infected waste- disposed of by incineration.

Make sure waste bags are securely sealed using a suitable plastic tie or secure knot.

Be careful when handling bags so they do not tear and keep at arm’s length to avoid injury.

Waste bags must be closed at 2/3 full or less.

All waste bags awaiting collection must be stored in a suitable, secure area, away from the general public.

Sharps bins awaiting disposal must never be placed inside clinical waste bags

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Remember-

When disposing of waste into a bin always use the foot pedal to raise the lid to avoid contamination of your hands

Always segregate waste correctly

Laundry Linen used in healthcare can become soiled with blood, urine, faeces or other body fluids containing bacteria. The way in which we transport and dispose of used linen must ensure that staff and patients are not placed at risk. All used linen must be segregated appropriately:

White bags= used linen, not contaminated with blood or body fluids Red bags= contaminated/infected linen

Remember

Red water soluble (alginate) bags must be used to bag infected linen prior to placing into an outer white bag. This reduces handling of this type of linen by laundry staff.

Decontamination of equipment Safe decontamination of equipment between patients is vital to prevent potential cross-infection and keep patients safe.

3 levels of decontamination

1 Cleaning The physical removal of dirt and organic material e.g. blood, faeces

2 Disinfection The removal or destruction of harmful micro-organisms

3 Sterilization The complete destruction/removal of all micro-organisms

Gloves and apron must be worn when handling used/soiled/infected linen. Aprons should be worn for bed making and disposed of after completion of

task. Bag the linen at the point of use. Laundry bags should be used for linen ONLY. Linen bags should be secured at 2/3 full. Do NOT hand sluice soiled linen as this could potentially result in splash

exposure. Clean linen must be stored separately to used linen. Staff uniforms/dress must be washed daily on a cycle recommended by the

manufacturer. All staff are expected to adhere to the dress code

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1. Cleaning Any non-electrical equipment that is in contact with intact skin, e.g. mattress, commode, crutches, etc. must be cleaned with detergent or detergent based wipe(s) and dried. 2. Disinfection Any equipment in contact with mucous membranes or body fluids, e.g. commodes that have been contaminated with faeces. This type of contaminated equipment should be cleaned with a chlorine based solution/wipe. Alcohol wipes should not be used as the first step to clean commodes or any equipment contaminated with faeces as alcohol is not effective against spores e.g. Clostridium difficile or Norovirus. 3. Sterilisation Any item requiring sterilisation must be returned to the Hospital Sterilising and Decontamination Unit (HSDU) for cleaning.

Single Use

Any item marked with this symbol must not be re-used as these are single use only e.g. syringes, urinary catheter, disposable scissors.

Single patient use Items marked ‘single patient use’ can be re-used on the same patient and disposed of when soiled or no longer required e.g. oxygen mask/nasal specs/tourniquets. Cleaning between uses still applies. Use disposable wipes and dry. Decontamination certificate If equipment requires servicing or repair a decontamination certificate must be completed. These certificates can be found on the intra-net. Remember

Before replacing/purchasing new equipment check with the manufacturer how the equipment should be cleaned and seek support from the Equipment Library and the Infection Prevention and Control Team prior to placing an order. Uniform and Dress Code Please refer to the Uniform/Dress Code Policy on the Intranet for full details.

Wear a clean uniform every day- change immediately if soiled. Wear appropriate PPE. Hand decontamination as per policy. Long hair should be tied back and up off the collar. Clinical staff should wear minimal hand jewellery

**Plain band only if wearing a ring and NO wrist watches. Bare below the elbow in all clinical areas. All wounds must be covered with waterproof dressing. Eating or drinking is prohibited in main ward/patient areas. Report any illness to line manager and Occupational Health Department. If symptomatic with diarrhoea +/or vomiting you should remain at home and

not return to work until 48hrs after your last symptoms.

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Disease Specific

MRSA- (Patient Information Leaflet available to download and print) MRSA stands for Meticillin Resistant Staphylococcus Aureus. It is a type of a common Staphylococcus aureus. The bacteria lives harmlessly on the skin and in the nose of many people (about 1/3 of us). MRSA is resistant to some commonly used antibiotics e.g. Flucloxacillin. Where is MRSA found? It prefers to live in dark, moist areas such as the nose, armpit and groin. Many people have MRSA as part of their own skin flora. This usually causes no harm. How is it spread? Usually person to person, direct skin contact, or by contaminated equipment or surfaces. What problem can it cause? People carrying MRSA on their skin are colonised, but not infected. MRSA can cause local infection and this is more likely to occur in people who are already unwell. MRSA can get into the body (e.g. through wounds or medical devices) and cause blood stream infection.

How is it treated? All adult patients admitted must be encouraged to have an MRSA swab/screen within 48hrs. If present on the skin a topical treatment will be offered (nasal ointment and body wash). This treatment lasts for 5 days only- the patient/staff must use the care plan. If the patient has bloodstream infection the topical treatment and an appropriate intra-venous antimicrobial will be prescribed. Patients are re-screened at day 8 and day 18. If second line treatment is indicated, this will be Consultant Microbiologist/IPC generated. Preventing spread? Hand hygiene and use of PPE is an essential part in reducing the potential spread of MRSA. MRSA is easily killed on hands/surfaces by soap/detergent. Patients who are colonised with MRSA are not always able to be isolated in single rooms, however standard precautions used for all patients will minimise the risk to others. Please report via Datix if you are unable to isolate. Who is at risk? MRSA is not usually a risk to healthy people, including children and pregnant women. Patient flag/alert notice? All patients known to have/have had MRSA are identified on EPR (Electronic Patient Record) with a ‘Biohazard’ alert- this also relates to C diff. Please ensure all staff are aware of the need to access EPR Power Chart icon for full details.

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Clostridium difficile (C.diff)- Patient information leaflet available

Clostridium difficile (C.diff) is a spore forming bacteria which can cause offensive, watery diarrhoea. C.diff is present in the gut of 3%-8% of healthy adults. This is known as gut carriage. Usually the normal gut flora (bugs) keep the C.diff bacteria in check, however if the gut flora is disturbed, e.g. by antimicrobials, the C. diff can multiply producing toxins which cause diarrhoea. Vulnerable people, children and adults with chronic conditions who need antimicrobials on a regular basis are more susceptible to C.diff diarrhoea. What does C.diff cause? Offensive, watery diarrhoea which can range from mild to severe symptoms. Abdominal pain or tenderness and fever may also be present in some cases. Patients with diarrhoea should be encouraged to maintain their fluid intake to avoid dehydration. Those that cannot drink will need intravenous fluids. Patients usually recover following appropriate treatment with antimicrobials, diet and fluid management and review by Gastro-intestinal (GI) Consultant Team. Some patients will require surgical intervention in severe cases. The Department of Health dictate that the patient must be isolated within 2 hours. Failure to achieve this will require a Datix entry. How is it spread?

Direct contact via contaminated hands. Environmental contamination- any surface may be contaminated by the C.diff spores Transmission to healthcare workers is uncommon

How do you prevent spread? The table below shows the mnemonic protocol to be used when managing potentially infective cases of diarrhoea. (Clostridium difficile infection: How to deal with the problem, DH & PHE, December 2008, revised 2011, Gateway ref: 9833)

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

I Isolate the patient and consult with IPCT while determining cause of diarrhoea

G Gloves and aprons must be worn for all contact with the patient or the patient’s environment.

H Hand washing with soap and water should be carried out before and after each contact with the patient or patient’s environment.

T Test stool for toxin by sending specimen immediately

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Treatment

Remember to ensure that the patient is always encouraged to wash hands after using

the toilet or commode

ESBL (Extended- Spectrum Beta-lactamase) Including Multi-Resistant Gram-negative Bacteria- Patient information leaflet available for download and print. Some bacteria have developed the resistance to some commonly used antimicrobials. Their ability to transfer this resistance to different species of bacteria can make them very difficult to eradicate and treat. The types of bacteria that can exhibit this resistance are: ✴ Escherichia coli (E coli) ✴ Klebsiella ✴ Proteus ✴ Pseudomonas ✴ Enterobacter ✴ Acinetobacter These bacteria are known as Gram- negative bacilli.

Where are these bacteria found? Commonly found in the gut where they can be part of our normal gut flora. Some of them can also be found in the environment e.g. water and soil Bacteria such as E coli are commonly found in urine specimens, How is ESBL spread? Usually by contact e.g. hands. Treatment The presenting condition of the patient will determine if antibiotic(s) are indicated. The presence of an ESBL often limits the choice and method of delivery of antibiotic.

Review current antimicrobials -prudent antimicrobial prescribing Antimicrobial treatment will be directed by the clinician/ Consultant

Microbiologist: usually 10-14 day treatment course. 1st line treatment = Oral Metronidazole (Mild cases) 2nd line treatment= Oral Vancomycin (Moderate cases) 3rd line treatment= IV Metronidazole +Oral Vancomycin (Severe cases) CDI recurrence = Fidaxomicin – on Consultant Microbiologist advice

only. Refer patient to GI team for review of symptoms/management. Refer to dietician for review of nutritional status. Monitor via stool chart. Monitor fluid balance. Liaise with IPCT for advice on patient management. Complete Route Cause Analysis (RCA) within 10 working days for hospital

cases.

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CPE- Carbapenemase Producing Enterobactericeae Carbapenems are broad spectrum antimicrobials, often used as the last line of treatment for hard to treat human infections caused by Gram negative bacteria. Carbapenemases- These are enzymes produced by bacteria that destroy Carbapenems and other beta-lactam antibiotics. CRE- Carbapenemase Resistant Enterobactericeae

Preventing Spread

References Public Health England (2015) Acute trust toolkit for the early detection, management and control of Carbapenemase-Producing Enterobactericeae. Department of Health, January 2008 Clean, Safe, Care, Reducing infections and saving lives. Department of Health, July 2008 Dear colleague letter Re: Introduction of MRSA screening for all elective patients by March2009. Department of Health, HPA, December 2009, Gateway ref: 9833 Clostridium difficile infection: How to deal with the problem. Department of Health, December 2008 Winning Ways: Working together to reduce healthcare associated infection in England. Milton Keynes University Foundation Hospital NHS Trust Infection Prevention and Control Manual 2017

Use staff handover to alert all HCW`s of the need to observe PPE/Hand hygiene/preventative measures

Hand decontamination- soap & water or alcohol based hand sanitiser (choice dependant on task)

Standard precautions- use of PPE. Isolation required for all patients with ESBL/CPE Environmental cleaning as per policy. Biohazard flag

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Frequently Asked Questions

Q How do I know if the patient has MRSA or CDI?

A All patients who have a history of MRSA or CDI have a ‘Biohazard’ alert visible on

CRS bed state and individual patient screen. All patients with this alert should have a

full MRSA screen and assessment of need to isolate.

Q How long does it take to find out if the patient has CDI after a stool sample has

been sent?

A If a diarrhoeal sample of greater than 4mls is received in the laboratory (in-hours) the

result will be available same day.

Q How do I decide if the patient needs isolation?

A All patients should have a risk assessment at the time of admission (continuing

throughout their stay) of best placement for the individual. Always think of mode of

transmission/spread e.g. if the patient presents with diarrhea and/or vomiting they should

be isolated until further assessment and results available.

Q How needs screening for CPE?

A All patients who have been transferred from another hospital should be isolated and

screened for CPE, as well as routine screening for MRSA/ESBL etc.

Q What swab do I use for CPE screening?

A A black (charcoal) swab should be used.

Q How long does it take for swab results to be available?

A Usually 3-5 days for results. Remember to check ICE for results.

Q Do patients or staff wear masks?

A Staff should wear the appropriate protective mask. For TB- patients are only asked to

wear the mask if necessary when transferring between wads/departments.

Q Who do we inform if staff member affected with diarrhea and/or vomiting?

A All staff sickness should be reported manager and to Occupational Health Department

for support/monitoring.

Please note Be aware of seasonal information issued by the Infection Prevention & Control Team via the Communications Team on Intranet page. To access Infection Prevention & Control polices please use the Intranet system.

Contact details for the Infection Prevention and Control team are: Extension: 85788 or via switchboard or on bleep: 1182.

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Assessment Paper – Infection Prevention & Control Level 2

(Please select only one answer for each question)

Questions

1) Standard precautions are only necessary if caring for a patient with a known

infection? True/False

2) Hand hygiene is the single most important measure for preventing the spread of

infection? True/False

3) You must decontaminate your hands after removal of gloves?

True/False

4) If a patient has suspected/confirmed TB they must wear a mask whilst in their

room? True/False

5) Gloves and aprons should be removed after you leave a single room?

True/False

6) You must always use sharps bin and tray to take to patient when using sharps?

True/False

7) Sharps containers must be closed at 2/3rd full/ by visible black line on the

container? True/False

8) Presept granules must not be used on urine spill?

True/False

9) Aprons must be worn when handling used linen?

True/False

10) The ‘Biohazard’ alert is to highlight all patients with infections?

True/False

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11) Stool samples must be at least 4mls to enable testing? True/False

12) Patients who have been transferred from another hospital should be isolated?

True/False

13) CPE screening is repeated twice following initial screen at admission?

True/False

14) The infection prevention and control team are responsible for informing the

ward/department of patients’ test results? True/false

15) All staff have a responsibility for infection prevention control to ensure safe, clean

care? True/False

Name (print): Office Use

Signature: Results

Job Title:

Ward/Department: Pass

Date Completed: Fail

Please return the assessment paper only to: Infection Prevention and Control Team Pathology Department