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Template Policies for Care Homes

Please be aware that these are example policies/guidelines suitable for the care/nursing home environment.

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

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

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

Kind regards

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

Tel: 01623 673081Email: [email protected]

mailto:[email protected]


Table of Contents

Management of Clostridium difficile....................................................................................3Appendix 1 – The Bristol Stool Form Scale..........................................................................9Appendix 2 - Treatment of residents with positive C. difficile result...................................10

Appendix 3 - Weekly Bowel Record...................................................................................12Cleaning and Decontamination..........................................................................................13Hand Hygiene.......................................................................................................................18

Appendix 1a – 5 Moments of Hand Hygiene (Bed)............................................................23

Appendix 1b - 5 Moments of Hand Hygiene (Chair)...........................................................24Appendix 2 – Hand Cleaning Techniques..........................................................................25

Management of Influenza-like Illness Outbreaks..............................................................26Management of Diarrhoea and Vomiting...........................................................................30Management of E coli..........................................................................................................34Management of Laundry......................................................................................................37Management of MRSA.........................................................................................................39Management of PVL-associated staphylococcus aureus................................................43

Appendix 1 - How to apply Chlorhexidine/Octenisan bodywash and Mupiricin (Bactroban) ointment..............................................................................................................................46

Appendix 2 - Patient Information for PVL Staphylococcus aureus.....................................47Personal Protective Equipment..........................................................................................49Scabies..................................................................................................................................53Management of Spillages of Blood and Body Fluids.......................................................59Management of Healthcare Waste and Sharps/Splash Injuries......................................63


Management of Clostridium difficile

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

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

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

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

Describing the Care required

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

Clostridium difficile Page 3 of 69


NB. Some symptomatic residents may have no C.difficile detected, due for example to fast gut transit times. In this case the toxin assay is not 100% reliable and a repeat sample should be sent to the laboratory. Treatment should be commenced according to severity of symptoms and continue regardless of further negative results. The toxin may also biodegrade at room temperature, increasing the possibility of false negative results. Stool samples must therefore be placed in a specimen fridge if there is to be any delay in transportation. Clinicians should apply the following protocol (SIGHT) when managing suspected potentially infectious diarrhoea (Public Health England, 2013)

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

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

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

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

T Test the stool for toxin by sending a sample immediately

Treatment of residents with positive C. difficile result (appendix 2)Mild Disease: residents with mild disease may not require specific C difficile antibiotic treatment, if treatment is required, oral metronidazole is recommended 400mg three times a day for 10 days.

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

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

Enteric Precautions for Clostridium difficile Infection

Environment & Personal Protective Equipment Care for the resident in a single room. Provide a designated toilet or commode for the affected residents use only. Wear gloves and a disposable apron when in contact with the infected resident or

the resident’s environment. These must be applied before entering the room. An infectious (orange bag) waste bin must be available for the disposal of all waste

and must be placed in the resident’s room. Remove gloves and apron and dispose of into infectious waste (orange bag) before

leaving the residents room/bed area. Before leaving the room staff must wash their hands with liquid soap and water and

then apply alcohol gel (if available). Alcohol gel MUST not be used alone as it is not effective against bacterial spores.

Residents must be encouraged to wash their hands after they have used the toilet/commode.



Keep equipment in the room to a minimum. If equipment is to be used between residents it MUST be cleaned in between use with detergent and water followed by a solution of sodium hypochlorite strength 1000ppm.

Keep charts and notes outside of the room.

Cleaning, Linen, Curtains Damp dust the resident’s room daily with detergent and water followed by a sodium

hypochlorite product made up to 1000ppm and steam clean the carpet daily. If carpets become soiled consider replacement of the carpet.

Designated commodes, including the underneath surfaces, and toilets must be cleaned after each use with detergent and water followed by sodium hypochlorite strength 1000ppm.

Bed linen must be changed daily. Use red soluble bags for all linen, ensuring that they are not overfilled and are sealed

and removed from the bed area immediately after use. Following 72 hours free of symptoms, the resident being discharged or admitted to

hospital or death occurs, complete a deep clean of the resident’s room with detergent and water followed by a solution of sodium hypochlorite strength 1000 ppm to all surfaces and equipment that will tolerate it. Steam clean the carpet or replace if soiled / stained with faeces and remove bedding and curtains and launder on a sluice wash placing in a red soluble bag before transportation to the laundry (see below for deep clean details).

Laundry Care must be taken to handle laundry safely by all staff to prevent cross contamination. It must be placed straight into a red alginate bag and then a red outer cloth laundry bag/skip. Staff must wear gloves and an apron and pay strict attention to hand hygiene.

All laundry from the affected resident must be washed separately from other laundry on a sluice wash. Hands must be washed with soap and water and dried thoroughly after handling.

Visitors Visitors should be advised to report to the nurse in charge before visiting. Visitors should wash their hands with liquid soap and water and dry with paper towels

before and after contact with affected individuals.

Discontinuation of Enteric Precautions Enteric precautions can be discontinued when the Resident has been 48 hours free from diarrhoea and they have passed a normal stool. The Infection Control Matrons will confirm when discontinuation of enteric precautions can take place.

Clearance samples are NOT necessary.

Deep CleanFollowing 72 hours free of symptoms, the resident being discharged or admitted to hospital or death occurs; complete a deep clean of the resident’s room. A deep clean includes:

Equipment required PER ROOM: Gloves and apron Disposable cloth Mop and bucket Solution of sodium hypochlorite 1000ppm/Milton 50:50 strength solution Detergent and water



Carpet shampooer Steam cleaner

MOP HEADS MUST BE CHANGED AFTER EACH ROOM, CLOTHS MUST BE DISPOSED OF AFTER EACH ROOM AND GLOVES AND APRONS CHANGED BETWEEN ROOMS

Resident Rooms Shampoo carpet Remove curtains and bedding and wash on a sluice wash Clean all surfaces with detergent and water followed by sodium hypochlorite/Milton

followed by a damp cloth (surfaces include tops of wardrobes, window ledges, TV’s, pictures, ornaments etc)

Steam clean soft furnishings, the steam cleaner must reach its temperature and the nozzle must touch the fabric as it is slowly moved over every section

Ensuites Clean all bathroom equipment with detergent and water followed by sodium

hypochlorite/Milton followed by a damp cloth Clean all surfaces including tiles and waste bins with detergent and water followed by

Milton followed by a damp cloth Mop flooring with Milton

Lounges/Dining Rooms Clean all surfaces with detergent and water followed by sodium hypochlorite/Milton

followed by a damp cloth Shampoo carpets Steam clean soft furnishings, the steam cleaner must reach its temperature and the

nozzle must touch the fabric as it is slowly moved over every section Remove and dispose of any ornaments that cannot be cleaned Remove and wash table cloths on a sluice wash Remove curtains and wash on a sluice wash

Bathrooms/Toilets Clean all surfaces including tiles with detergent and water followed by sodium

hypochlorite/Milton followed by a damp cloth Clean all bathroom equipment including commodes, raised toilet seats/surrounds and

waste bins with detergent and water followed by sodium hypochlorite/Milton followed by a damp cloth

Remove and dispose of any ornaments that cannot be cleaned Mop flooring with sodium hypochlorite/Milton solution Clean shower curtains

Sluice Clean all surfaces and waste bins with detergent and water followed by sodium

hypochlorite/Milton followed by a damp cloth Mop flooring with sodium hypochlorite/Milton solution



Treatment Room Clean all surfaces including tops of cupboards, shelves, waste bins and medication

trolley with detergent and water followed by sodium hypochlorite/Milton followed by a damp cloth

Mop flooring with sodium hypochlorite/Milton solutionCorridors

Clean all surfaces including pictures, hand rails and wall art with detergent and water followed by sodium hypochlorite/Milton followed by a damp cloth

Remove any ornaments that cannot be cleaned Shampoo carpets

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

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

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

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

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

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

References Bartlett JG (1985) Treatment of Clostridium difficile colitis. Gastroenterolgy 89:1192-5


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


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

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

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

Hu MY, Katachar K, Kyne L, Maroo S, Tummala S, Dreisbach V, Xu H, Leffler DA, Kelly CP (2009) Prospective derivation and validation of a clinical prediction rule for recurrent Clostridium difficile infection. Gastroenterology 136: 1206-14

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

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

Teasley DG, Gerding DN, Olson MM et al (1983) Prospective randomised trial of metronidazole versus vancomycin for Clostridium difficile associated diarrhoea and colitis. Lancet 2: 1043-6

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

Wilcox MH (2012) Progress with a difficult infection. Lancet Infec Dis 12: 256-7



Appendix 1 – The Bristol Stool Form Scale

Heaton (1999)



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





Appendix 3 - Weekly Bowel Record

NAME …………………………………………. ROOM…………………… WEEK COMMENCING………………….DATE TYPE 1 TYPE 2 TYPE 3 TYPE 4 TYPE 5 TYPE 6 TYPE 7

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

SUNDAY


http://upload.wikimedia.org/wikipedia/commons/2/21/Bristol_stool_chart.svg








Cleaning and Decontamination

Introduction It is essential to ensure that people who use health and social care services receive safe and effective care. Having effective infection prevention and control and cleanliness measures in place contributes to the quality and safety of service users, care workers and visitors. Therefore this must be part of everyday practice and be applied consistently by everyone (DH 2015). Cleanliness is intrinsically linked to infection prevention and control. A clean, well ordered environment provides the foundation for excellent infection control practice to flourish.The National Patient Safety Agency National Specifications for Cleanliness: Guidance on setting and measuring performance outcomes in care homes (2010) is designed to assist providers in ensuring their cleaning services address and minimise infection control risks.

Aims of the policy The policy aims to:

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

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

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

Risk ManagementCare Home Managers must assure themselves that the home meets its obligation to deliver high-quality, effective, safe and clean premises that support the control of health care associated infections and make a positive contribution to healthcare outcomes.

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

Introduction to Cleaning Micro-organisms are always present in the environment and all staff in care homes have a responsibility to ensure that items such as furniture, wheelchairs, commodes, shower chairs, and re-usable medical devices etc in the care home environment are decontaminated properly to minimise the risk of cross infection to residents, staff and visitors.

Decontamination is a general term for the destruction or removal of microbial contamination to render an item safe. Cleaning methods include:

Cleaning Disinfection Sterilisation

Cleaning and Documentation Page 13 of 69


Cleaning Cleaning is a process, using general-purpose detergent and hot water (<35°C), to physically remove contaminants, including dust, soil, large numbers of micro-organisms (germs) and the organic matter (e.g. faeces, blood) that protects them. Cleaning remains the single most effective way of reducing the risk of infection from the environment and is usually the first stage before disinfection or sterilisation is attempted. The value of cleaning cannot be overemphasised. Without cleaning an item first, it may not be possible to disinfect or sterilise it properly.

Disinfection Environmental disinfection is a process used to reduce the number of micro-organisms, but not usually of bacterial spores. The process does not necessarily kill or remove all micro-organisms, but reduces their number to a level which is not harmful. Heat disinfection methods (e.g. dishwashers, washing machines, bedpan washer’s disinfectors, steam cleaners etc.) are more reliable than chemical methods and should be chosen whenever practicable.

Sterilisation Sterilisation is a process used to render an object free from all microorganisms. For care homes it is recommended that sterile equipment is obtained pre-sterilised from a manufacturer supplies and or via a Central Sterile Supplies Department (CSSD). However; in the care home setting when sterile or disinfected items are required, sterile equipment must be single use.

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

Colour AreaRed Bathrooms, washrooms, showers, toilets, basins and bathroom floorsBlue General areas including wards, departments, offices and basins in public

areasGreen Catering departments, kitchen areas Yellow Isolation areas

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

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

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

cleaning of blood and body fluid spillages Detailed cleaning schedule



What Cleaning Product to Use and When?

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

Cream cleaner or a hard surface cleaner is usually suitable for cleaning baths, toilets and hand washbasins.

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

Detergent wipes for example, can be used for those items that cannot be immersed e.g. wheelchairs

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

Deep Clean

Equipment required PER ROOM: Disposable cloth Mop and bucket Milton 50:50 strength solution Detergent and water Carpet shampooer Steam cleaner


Resident Rooms Shampoo carpet Remove curtains and bedding and wash on a sluice wash Clean all surfaces with detergent and water followed by Milton followed by a damp

cloth (surfaces include tops of wardrobes, window ledges, TV’s, pictures, ornaments etc)


Ensuites Clean all bathroom equipment with detergent and water followed by Milton followed

by a damp cloth Clean all surfaces including tiles and waste bins with detergent and water followed by

Milton followed by a damp cloth Mop flooring with Milton

Lounges/Dining Rooms



Clean all surfaces with detergent and water followed by Milton followed by a damp cloth

Shampoo carpets Steam clean soft furnishings, the steam cleaner must reach its temperature and the


Bathrooms/Toilets Clean all surfaces including tiles with detergent and water followed by Milton followed

by a damp cloth Clean all bathroom equipment including commodes, raised toilet seats/surrounds and

waste bins with detergent and water followed by Milton followed by a damp cloth Remove and dispose of any ornaments that cannot be cleaned Mop flooring with Milton solution Clean shower curtains

Sluice Clean all surfaces and waste bins with detergent and water followed by Milton

followed by a damp cloth Mop flooring with Milton solution


trolley with detergent and water followed by Milton followed by a damp cloth Mop flooring with Milton solution

Corridors Clean all surfaces including pictures, hand rails and wall art with detergent and water

followed by Milton followed by a damp cloth Remove any ornaments that cannot be cleaned Shampoo carpets

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

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

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



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

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

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

References Department of Health (2006) Infection Control Guidance for Care Homes

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

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

NPSA (2010) National Specifications for Cleanliness: Guidance on Setting and Measuring Performance Outcomes in Care Homes

NPSA (2009) The Revised Healthcare Cleaning Manual



Hand Hygiene

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

Aims of the policy This policy has been written for all staff within (Name of Care Home) in order to:

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

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

HCAI.

Risk Management

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

Before resident contact

Before an aseptic task

After body fluid exposure risk

After resident contact

After contact with resident surroundings

(Refer to Appendices 1a and 1b)

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

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

Hand Hygiene Page 18 of 69


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

Poor hand hygiene technique

Poor hand drying technique

Sensitivity to hand hygiene products

Existing allergies and skin conditions, e.g. eczema and psoriasis. These conditions may be exacerbated by some products and poor technique. If this occurs then staff should seek advice from the home manager or their GP.

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

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

Accessibility to alcohol hand rub by high risk resident groups e.g. residents with dementia related illness and residents with alcohol use disorders

Accidental splashes to the eyes

Storage considerations

Fire Risk

Equipment List Access to a hand wash basin and running water

Liquid soap

Paper towels Alcohol Hand Rub

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



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

Describing the Care Required

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

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

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

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

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

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

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

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



Facilities will be made available for residents and visitors to carry out relevant hand hygiene. Residents should be encouraged and, where necessary, assisted to carry out hand hygiene.

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



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

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

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

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

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

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

National Patient Safety Agency (2008) Clean Hands Save Lives Patient Safety Alert. Second Edition

NICE (2012) Prevention and Control of Healthcare Associated Infections in Primary and Community Care Pratt, R, J, et al (2001) The Epic Project. Developing National Evidence-based Guidelines for Preventing Healthcare associated Infections Phase 1: Guidelines for preventing Hospital-acquired Infections. Journal of Hospital Infection 47 (supplement) S1-S82 Standardization ECF Chemical disinfectants and antiseptics-hygienic handrub-test method and requirements: European Committee for Standardization Brussels 1997



Taylor, J.H. et al (2000) A microbiological evaluation of warm air hand driers with respect to hand hygiene and the washroom environment. Journal of Applied Microbiology: 89(6). 910-19

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



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



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



Appendix 2 – Hand Cleaning Techniques



Management of Influenza-like Illness Outbreaks

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

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

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

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

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

Oral or tympanic temperature ≥37.8°c

AND one of the following:

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

OR

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

(PHE, 2016)

Management of Influenza-like Illness Outbreak Page 26 of 69


Immediate Actions Required by Staff for all Suspected Respiratory Outbreaks Any member of staff who considers there are individuals with unexpected signs of infection, or evidence of spread of infection must firstly:

1. Isolate or cohort any symptomatic patients

2. Inform the following individuals:

Office Hours Senior person on duty/immediate line manager Community Infection Prevention and Control Team – 01623 673081 GP - for the prescribing of antivirals only when the Chief Medical Officer has

announced that influenza is circulating in the community Care Quality Commission

Out of Hours Public Health England (PHE) - 0344 2254524 (option 1), ask for PHE on call person,

out of hours call handler will call the PHE on call person, PHE will call you back

The service must close to admissions and visitors. Any residents requiring emergency care must have access to this but clear communication with the emergency crew and admitting hospital must be in place and any transfer documentation must state possible outbreak in the care home.

Outbreak – What to Do Inform the relevant organisations as detailed above – advice will be given on

whether the home should close and on whether viral throat swabs are required Inform all staff of the outbreak and keep a running record of all new cases in each 24

hours so when you are contacted you have this information to hand and as the manager, delegate an individual to take phone calls from Public Health England or the Infection Control Team in the absence of the manager who has all the relevant information to hand

Isolate the symptomatic residents in their own room if possible. If not possible consider cohorting in one area and complete a risk assessment to detail how you are going to manage this to prevent spread to other residents

Ensure paper towels and liquid soap are available for staff to wash their hands ‘at the point of care’ in the residents room (not in plastic boxes and not alcohol gel)

Write a care plan for how the problem will be managed for each resident Use fluid balance chart to maintain hydration of the resident Ensure kitchen staff are not undertaking carers duties as well Restrict care staff and cleaners to cover designated areas to prevent them working

across areas Staff members who become unwell with influenza like illness symptoms should be

excluded from work until they have recovered Agency and temporary staff who have been exposed during the outbreak should be

advised not to work in any other healthcare settings until 2 days after last contact with the home

Inform cleaners that affected rooms need cleaning daily with a chlorine based product such as Milton and ensure they are using a separate cloth for each room

Ensure gloves and aprons are easily accessible around the home and are being used

Waste must be disposed of as per recent waste guidance



Put a sign up on the door advising visitors of the outbreak and discouraging them to visit. Symptomatic visitors should be excluded from the home until no longer symptomatic

Display messages promoting hand hygiene, good respiratory hygiene and cough etiquette eg. ‘catch it, bin it, kill it

Alert any visiting organisations for whom their visit is not a priority; for example visiting chaplains, musicians etc

Cancel any non-urgent hospital or other appointments

Obtaining Specimens Viral throat swabs should be obtained within 48 hours of symptoms developing to eliminate influenza. If obtained these should be labelled respiratory outbreak and should be viral swabs NOT charcoal. A maximum of 5 swabs should be taken.

South and North swabs (red)

THE TAKING OF SWABS ONLY APPLIES BEFORE RECIEPT OF THE CHIEF MEDICAL OFFICERS LETTER (CMO LETTER) IN GP PRACTICE, CONFIRMING WE ARE IN OFFICAL FLU SEASON – ONCE THIS HAS BEEN RECEIVED, VIRAL SWABS ARE NOT REQUIRED

Residential Homes: the Community Infection Control Team will advise on whom can take viral swabs in residential care homes.

Outbreak declared over Once the outbreak is declared over a full deep clean of resident rooms and communal areas with a systematic and co-ordinated approach is required.

Deep CleanEquipment required PER ROOM:

Gloves and apron Disposable cloth Mop and bucket Solution of sodium hypochlorite strength 1000ppm / Milton 50:50 strength solution Detergent and water Carpet shampooer Steam cleaner









sodium hypochlorite/Milton followed by a damp cloth Mop flooring with sodium hypochlorite/Milton




Bathrooms/Toilets Clean all surfaces including tiles with detergent and water followed by sodium

hypochlorite/Milton followed by a damp cloth Clean all bathroom equipment including commodes, raised toilet seats/surrounds and

waste bins with detergent and water followed by sodium hypochlorite/Milton followed by a damp cloth









ReferencesPublic Health England (2016) PHE guidelines on the management of outbreaks of influenza-like illness (ILI) in care homes



Management of Diarrhoea and Vomiting

IntroductionDiarrhoea in older people is common and not always caused by infection. The home should have a baseline of usual bowel habits so any changes can be identified, the Bristol stool chart is a useful tool in identifying different stool types. Diarrhoea can be caused by laxatives, change in diet or underlying bowel disease, however; all cases should be presumed infectious until this has been excluded. If the home has 2 or more cases linked in time and place, an outbreak will be declared. The majority of acute diarrhoea/gastroenteritis cases are caused by viruses such as norovirus.

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

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

Hazards The Health and Safety Executive states that hazardous substances at work can put people’s health at risk. Micro-organisms such as bacteria and viruses are classed as hazardous substances (COSHH 2002). Therefore, in an outbreak situation, employers and employees need to be aware of the potential risk of infection to patients, visitors and themselves and put into place the appropriate actions to reduce the risk of further spread as indicated within the policy.

NorovirusNorovirus is highly contagious, the incubation period ranges from 12-48 hours and the attack rate is often more than 50%. Symptoms of norovirus include:

Sudden abrupt onset of symptoms Watery profuse diarrhoea and/or projectile vomiting Nausea Painful stomach cramps Slight fever Headaches Aching limbs

It is estimated that more than 30million virus particles are released during vomiting and the infecting dose necessary to induce symptoms is relatively small at only 10-100 virus particles. Norovirus is spread via faecal – oral route and person to person spread following dispersal of virus particles through the air which causes widespread environmental contamination. Contaminated fingers can transfer norovirus onto as many as seven clean surfaces (Baker, Vipond and Bloomfield 2004). Norovirus can remain viable within the environment for up to 12 days and will start to be excreted in your stool a few hours before you have any symptoms, therefore you can be infectious and pass it on to other people before you feel ill. Norovirus will continue to be excreted for up to ten days.

Management of Diarrhoea and Vomiting Page 30 of 69


Immediate Actions Required by Staff for all Suspected Diarrhoea and/or Vomiting Outbreaks

If 2 or more cases of diarrhoea (type 6-7 on the Bristol Stool Chart) linked by time and place occur, this is identified as an outbreak. The home must contact the following professionals:

Office Hours Senior person on duty/immediate line manager Community Infection Prevention and Control Team – 01623 673081 GP Care Quality Commission

Out of Hours Public Health England (PHE) - 0344 2254524 (option 1), ask for PHE on call person, they will call PHE on call person, PHE will call you back

The service must close to admissions and visitors. Any residents requiring emergency care must have access to this but clear communication with the emergency crew and admitting hospital must be in place and any transfer documentation must state possible outbreak in the care home.

Outbreak – What to Do Inform the relevant organisations as detailed above Inform all staff of the outbreak and keep a running record of all new cases in each 24

hours so when you are contacted you have this information to hand and as the manager, delegate an individual to take phone calls from Public Health England or the Infection Control Team in the absence of the manager who has all the relevant information to hand

Isolate symptomatic residents in their own room with their own toilet facilities if possible. If not possible consider cohorting in one area and complete a risk assessment to detail how you are going to manage this to prevent spread to other residents

Ensure paper towels and liquid soap are available for staff to wash their hands ‘at the point of care’ in the residents room (not in plastic boxes and not alcohol gel). Alcohol gel is not effective against gastroenteritis/norovirus

Obtain samples from 10% of symptomatic residents and state ‘D&V outbreak’ and ‘Test for virology’ on the lab form

Write a care plan for how the problem will be managed for each resident Use fluid balance chart to maintain hydration of the resident Use the Bristol stool chart to monitor bowel movements Ensure kitchen staff are not undertaking carers duties as well Restrict care staff and cleaners to cover designated areas to prevent them working

across areas Staff members who become unwell with diarrhoea and/or vomiting should be

excluded from work until they are 48 hours clear of symptoms Agency and temporary staff who have been exposed during the outbreak should be

advised not to work in any other healthcare settings until 2 days after last contact with the home

Inform cleaners that affected rooms need cleaning daily with a chlorine based product such as Milton and ensure they are using a separate cloth, mop, gloves and apron for each room. Use cleaning equipment as per the appropriate colour coding and clean unaffected areas/rooms first

Ensure gloves and aprons are easily accessible around the home and are being used

Waste must be disposed of as per recent waste guidance



Put a sign up on the door advising visitors of the outbreak and discouraging them to visit. Symptomatic visitors should be excluded from the home until 48 hours clear of symptoms

Display messages promoting hand hygiene Alert any visiting organisations for whom their visit is not a priority; for example

visiting chaplains, musicians etc Cancel any non-urgent hospital or other appointments

Outbreak declared over Once the outbreak is declared over, when the home is 48 hours clear of symptoms, a full deep clean of resident rooms and communal areas with a systematic and co-ordinated approach is required.

Deep CleanEquipment required PER ROOM:

Gloves and apron Disposable cloth Mop and bucket Solution of sodium hypochlorite strength 1000ppm/Milton 50:50 strength solution Detergent and water Carpet shampooer Steam cleaner







sodium hypochlorite/Milton followed by a damp cloth Mop flooring with sodium hypochlorite/Milton




Bathrooms/Toilets



Clean all surfaces including tiles with detergent and water followed by sodium hypochlorite/Milton followed by a damp cloth

Clean all bathroom equipment including commodes, raised toilet seats/surrounds and waste bins with detergent and water followed by sodium hypochlorite/Milton followed by a damp cloth












ReferencesBaker. J, Vipond, IB and Bloomfield. SF (2004) Effects of cleaning and disinfection in reducing the spread of Norovirus contamination via environmental surfaces. Journal Hospital Infection 58 (1), 42-49

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

Department of Health (2013) Prevention and Control of Infection in Care Homes – an information resource



Health Protection Agency (2012) Guidelines for the Management of Norovirus Outbreaks in Acute and Community Health and Social Care Settings



Management of ESBL’s

IntroductionExtended spectrum beta-lactamases (ESBLs) are enzymes produced by certain bacteria e.g. E. coli. These enzymes break down antibiotics belonging to the beta-lactam group, making them ineffective. Bacteria that produce ESBLs are resistant to all ‘beta-lactam’ antibiotics e.g. Penicillin’s, Co-amoxiclav and Cephalosporin’s. These bacteria are also commonly resistant to other non-beta-lactam antibiotics e.g. trimethoprim, ciprofloxacin and gentamicin due to other related mechanisms.

ESBLs were first described in the mid-1980s and were mostly found in hospitals. However, since 2000, they have been increasingly found in patients in the community with no previous links with hospital.

Implications for treatmentThe resistance to the above groups of antibiotics makes any infection with ESBL-producing bacteria much more difficult to treat.

Infection or Colonisation?The main source of ESBL-producing organisms is in the lower gastrointestinal tract where they are found as part of the ‘normal’ gut bacteria and do not cause any illness (colonisation). However, they are also capable of causing infection e.g. urinary tract infection and wound infection.

Signs of infection

Skin infections: Inflammation in and/or around the wound Pain from the wound site Swelling around the wound Heat

Urinary tract infections: Pain or discomfort Frequency of passing urine Urgent need to pass urine If catheterised, urine may be discoloured, bloody and smell strongly (N.B. strong

smelling urine may also be an indicator of dehydration)

Risk factorsThe following are risk factors for infection with ESBL:

Previous history of ESBL colonisation or infection. Repeated courses of antibiotics particularly for urinary tract infection. Recent broad spectrum antibiotics such as cephalosporin’s or quinolones. Previous hospitalisation particularly involving specialist or intensive care. Contact with areas of the world where there is a higher prevalence of ESBL

organisms (e.g. Indian sub-continent, Southern Europe).

Management of E. coli Page 35 of 69


Cross infectionESBLs are mostly spread from person to person by faecal contamination of the hands (including from the hands of healthcare workers), transfer from the environment, from a wound infection or contaminated equipment.

SpecimensIt is important to send the appropriate clinical specimens for culture and sensitivity (ideally before commencing antibiotics) in any patient with a suspected infection.

If the patient is known to be colonised with ESBL or has had a previous ESBL infection this should be documented on the Microbiology laboratory request form. However, repeat specimens are not necessary unless there is an outbreak of ESBL.

Antibiotic treatment for ESBL infectionsTreatment of infection due to ESBL bacteria should be based on the results of antibiotic sensitivity testing, as well as clinical signs/symptoms. GPs may need to seek advice from the Duty Microbiologist when treating a patient with a confirmed or suspected ESBL infection, as the usual antibiotic treatment guidance may not always cover this type of infection.

NOTE: Patients who have had ESBL bacteria isolated in their specimens but do not have any symptoms of infection do not require antibiotic treatment (e.g. a clinically well patient who has grown ESBL E. coli from a catheter urine specimen).

Special precautionsThe following precautions should be followed:

Hand hygiene All staff must strictly adhere to the Hand Hygiene Policy. Staff must wash their hands with liquid soap and water before and after contact with patients, after removing gloves and before leaving the resident’s room. Alcohol gel is effective against ESBL- producing bacteria and can be used if hands are not visibly soiled or if there is no hand wash basin available.

Residents and visitors should be encouraged to clean their hands. A patient who is unable to effectively clean their hands must be given assistance where appropriate to ensure good hand hygiene is achieved.

Visitors to a care home should clean their hands on entering and before leaving the resident’s room and after contact with the resident.

Use of personal protective equipment Gloves and aprons should be worn for clinical tasks and assistance with personal hygiene. Visitors or relatives to a care home should wear gloves and aprons if they are assisting with any personal care of the patient. Remove gloves and aprons before leaving the room and dispose of them into clinical waste and then wash hands.

Waste disposal All waste from care home residents with symptoms to be disposed of in infectious (orange) waste bags e.g. catheters, catheter bags, incontinence pads and dressings if there is an infected wound.

Linen All soiled/urine-soaked linen should be placed in a red alginate bag and taken to the laundry as soon as possible, following Laundry Policy for infected linen. If the relatives of the resident are taking laundry home to wash, they should be advised to wash clothing separately and on the hottest wash.



Decontamination of spillages All spillages of blood and body fluids must be cleaned up as soon as possible using detergent and water for urine spillages and vomit or 10000ppm chlorine solution (e.g. Milton) for blood spillages. Chlorine solution can only be used on hard surfaces because it may stain carpets and soft furnishings.

General environmental decontamination In a care home setting thorough cleaning of the resident’s room and ensuite should be carried out daily to reduce the risk of spreading the bacteria, using detergent and water followed by a chlorine-containing cleaning agent containing 1000ppm available chlorine (e.g. Milton) on hard surfaces. The resident’s room should be kept tidy to promote thorough cleaning.

When the resident has recovered, the room and its contents must be scrupulously cleaned. Pillows and mattress covers should be thoroughly cleaned and replaced if ripped or damaged. Curtains should be laundered at the highest temperature the material will allow.

EquipmentEquipment in the resident’s room should be kept to a minimum. Where there are no ensuite facilities in the resident’s room, a commode should be designated (where appropriate) and cleaned after each use with detergent and water followed by a chlorine solution. Similarly a designated urinal (where appropriate) should be used by male residents and cleaned thoroughly after use. All other communal equipment should be cleaned thoroughly after each use.

Visitors to a care homeThere should be no restrictions on family and friends visiting the care home, but all visitors should wash their hands or use hand gel when arriving at the care home and before leaving the resident’s room. They should also clean hands after carrying out any personal care.

Transfer to other healthcare facilitiesESBL status should be communicated to any other healthcare providers (where appropriate) when other healthcare professionals are involved in the resident’s care.




ReferencesDH (2015) The Health and Social Care Act 2008 Code of Practice on the Prevention and Control of Infections and Related Guidance



Essex Health Protection Unit (2006) Factsheet on ESBL’s



Management of Laundry

IntroductionThe provision of clean linen is a fundamental requirement of care as incorrect handling, processing and storage presents an infection hazard. The Department of Health defines linen as ‘all reusable textile items requiring cleaning/disinfection via a laundry process. Laundry should be fit for purpose; it should look visibly clean, should be the right material, should be the correct type of linen for the intended purpose and should not be damaged or discoloured (DH, 2016).

Handling of Used, Soiled and/or Infected LinenAll should be handled with care to prevent the spread of infection. Personal protective equipment, an apron and gloves must be worn and linen should not be held close to the chest to prevent contamination of the uniform. Staff should never empty bags onto the floor to sort linen into categories; any segregation must take place prior to transport to the laundry. Bags must not be overfilled

Categorisation of Linen

Used linen: Place in a white sack

Soiled/Infected Linen: Place in a red soluble bag into a red sack; removing any solids prior to doing this

Laundry The laundry should be a separate room with clear segregated areas for dirty and clean. Care homes should work towards best practice where two separate rooms are available for dirty and clean with a way into dirty and a way out through clean. All used/soiled/infected linen should enter the laundry through the dirty entrance and should be processed as soon as possible. A designated hand hygiene sink must be available that is compliant with relevant guidance and has wall mounted single cartridge liquid soap dispenser, wall mounted paper towel dispenser and a domestic waste bin that is rigid with a working lid and pedal and a waste sack fully enclosed within. Gloves and aprons must be available for laundry handling.

The laundry floor should be sheet vinyl with a continuous run up the wall to form a coved skirting that is fully sealed at all edges. An industrial washing machine should be available that meets the disinfection requirements where the disinfection cycle in which the temperature load is either maintained at 65°c for not less than 10 minutes or 71°c for not less than three minutes when thermal disinfection is used. Heat labile items (fabrics damaged by the normal heat disinfection process and those likely to be damaged at thermal disinfection temperatures) should be washed at the highest temperature possible for the item or by chemical disinfection. All items (where compatible) are then transferred to the clean area where they enter the drying process.

Storage of Clean LinenLaundry should be stored in a clean area above floor level and not be kept in the laundry area. The storage area should be designed to prevent damage to linen and should be equipped with shelving that can easily be cleaned. The storage area should be included on the cleaning schedule and on a regular basis linen stocks removed to facilitate thorough cleaning of the area and shelving.

Management of Laundry Page 39 of 69


CleaningThe laundry must be included on the cleaning schedule for a daily clean. Cleaning should include:

Mopping of the floor Cleaning of all surfaces Cleaning of the hand wash sink Clean and check soap and paper towel dispensers and replenish if necessary De-fluff the tumble dryers




ReferencesDepartment of Health (2013) Prevention and Control of Infection in Care Homes - an information resource

Department of Health (2016) Health Technical Memorandum 01-04: Decontamination of Linen for Health and Social Care. Management and Provision

Department of Health (2016) Health Technical Memorandum 01-04: Decontamination of Linen for Health and Social Care. Social Care

Management of Laundry Page 40 of 69


Management of MRSA

Introduction In order to comply with The Health and Social Care Act (DH 2008) (Care Home) is required to have in place and operate effective management systems for the prevention and control of healthcare associated infections (HCAIs). Early identification and appropriate management of residents who are colonised with MRSA will significantly reduce the risk of transmission to other residents.

The purpose of this policy is to: Provide staff with evidence based information about MRSA. Ensure early identification of high risk colonised and infected residents in order to

reduce the risk of transmission and cross infection. Ensure that residents identified with MRSA are treated and managed appropriately

and do not have their care compromised due to their MRSA diagnosis.

Risk Management Compliance with this policy will ensure that (name of care home) identify those residents at high risk and manage them effectively to reduce the risk of exposure and subsequent cross infection to other residents.

The consequences of developing a serious infection with MRSA can be life threatening. Early identification and the appropriate management and treatment of MRSA will significantly reduce the risk of Healthcare Associated Infections.

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

Colonisation Means that MRSA is present on the body without causing an infection. Around 30%

of the general population are colonised with SA. It may be present on the skin, in the nose, axillae, groin or perineum. It can also colonise wounds and other areas of non intact skin without causing harm.

Infection Occurs when the bacteria gain access to the body tissues and multiply causing

clinical signs of infection, which may include redness, swelling, pain or discharge in a wound or invasive device site.

Bacteraemia Occurs when there is infection in the blood stream. All MRSA bacteraemia (blood

stream infections) are considered to be serious untoward incidents and therefore are reportable to NHS England. All MRSA bacteraemia are subject to a Post Infection Review (PIR) to identify how a case occurred and to identify actions that will prevent it reoccurring (NHS England 2014).

MRSA Page 41 of 69


Screening for MRSA Screening is testing for the presence of MRSA on the most common sites. A full routine screen consists of:

Nose swab, one swab can be used for both nostrils and swab should be pre-moistened with sterile saline

Perineum/Groin swab Wound swab, any surgical wounds, other lesions or breaks in the skin Swabs from invasive device sites e.g. cannulae, drains, PEG sites etc Urine sample if catheterised Sputum sample if a productive cough is present

Routine screening in community does not currently take place. Residents will be risk assessed on an individual basis through discussions with the Infection Control Team. Follow up screens following decolonisation will take place in community and include 1 screen, this should be 1 month after completing decolonisation (unless the resident is waiting for surgery and the consultant requires 3 negative screens when it would be 48 hours after completing decolonisation and screens 1 week apart).

Where wound infection is thought to be present, samples should ONLY be obtained where two or more signs and symptoms of infection are present. Clinical signs of infection include:

New or increased pain Swelling Erythema Puss production (or serous (clear) exudate with inflammation) Offensive smell Localised warmth around the site of the wound

The following residents are deemed high risk and should be risk assessed for screening for MRSA.

The resident has a known MRSA colonisation and one or more of the following: Chronic wounds grade 4 and above Any invasive device Diabetic foot wounds

Consent from the resident must be gained prior to performing an MRSA screen and where a resident lacks mental capacity a Best Interest Assessment and Mental Capacity Assessment must take place.

Decolonisation MRSA decolonisation refers mainly to the use of topical agents such as nasal ointment and body wash/shampoo to eradicate or reduce nasal and skin carriage. Complete eradication is not always possible but a decrease of carriage may reduce the risk of transmission and therefore the risk to other residents. It will also reduce the risk of transmission into any wounds or indwelling devices that the patient may have.

Nasal decolonisation Currently the treatment is 2% mupirocin (bactroban) nasal ointment which should be applied to the inner surface of each nostril three times daily for five days. Nasal decolonisation should always be used in conjunction with skin decolonisation.

If bactroban is unavailable naseptin nasal can be prescribed and should be applied to each nostril four times a day for 10 days. Note that patients with a nut allergy should not be prescribed naseptin and an alternative must be given.

MRSA Page 42 of 69


Apply a matchstick head sized amount on the end of a cotton bud to the inner surface of each nostril and massage gently upwards.

Skin decolonisation *Delete as appropriate

*Care homes in the North of the County:The current treatment for the north of the county is chlorhexidine 4% body wash unless the resident has sensitive skin then Octenisan body wash can be used.

*Care homes in the South of the County:The current treatment for the south of the county is Octenisan body wash.

Skin decolonisation is useful in eradicating or suppressing skin colonisation for short periods, particularly pre-operatively. Residents should bathe or shower daily for five days using the chosen antiseptic ointment and on two of the five days the hair must be washed. The skin should be moistened and the antiseptic ointment applied thoroughly to all areas before rinsing in the bath or shower. Special attention should be paid to all carriage sites, such as the axilla, groin and perineal area. The antiseptic can also be used for all other washing procedures such as bed bathing.

The product must not be diluted in water as this reduces efficacy The product must be applied directly to wet skin as soap on a disposable wipe or on

the hand Do not apply to dry skin The product must remain in contact with the skin for 3 minutes before being rinsed off Bedding, nightwear and towels must be changed daily during the treatment and the

residents room vacuumed and damp dusted daily.

Compliance with the above is important and, once commenced, should be completed for the full 5 days. Decolonisation treatment should not be implemented for prolonged periods or repeatedly i.e. more than two courses for five days, as resistance may be encouraged. In cases of repeated colonisation the advice of a medical microbiologist should be sought. For residents with eczema, dermatitis or other skin conditions, attempts should be made to treat the underlying skin condition. Advice on suitable eradication protocols for these individuals should be sought from the consultant dermatologist via the residents GP. Antibiotics are not indicated unless there are clinical signs suggestive of infection.

Staff screening The screening of staff for MRSA is not routinely performed and must only be undertaken at the request of the Infection Control Team. Where staff screening is advised, this will always be done on a voluntary basis with the consent of staff involved.

Routes of transmission MRSA can be transmitted in the following ways:- Direct spread via the hands of healthcare workers Equipment that has not been appropriately decontaminated after each use Environmental contamination is highly significant, as staphylococci can survive for

long periods in dust

CommunicationCommunication of a residents MRSA status between organisations facilitates the provision of optimum care. This is a requirement under the Health and Social Care Act 2008 where

MRSA Page 43 of 69


information is communicated in an appropriate manner and where possible accompanies the resident.




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

Department of Health (2008) MRSA screening operational guidance 2, Gateway reference 11123, December 2008 Department of Health. (2015) The Health and Social Care Act 2008: Code of Practice for the NHS on the Prevention and Control of HCAI and related guidance.

National Patient Safety Agency. (2008) Clean Hands Save Lives Patient Safety Alert. Second Edition. September 2008

NHS England (2014) Guidance on the reporting and monitoring arrangements and post infection review process for MRSA bloodstream infections from April 2014

Nottinghamshire Guidelines on the Management of Common Infections and Infestations in Primary Care (Antimicrobial Prescribing) (2015)

Addendum to MRSA Policy

MRSA Page 44 of 69


Management of PVL-associated staphylococcus aureus

IntroductionStaphylococcus aureus (SA) is a bacterium that commonly lives on healthy skin. About one third of healthy people carry it quite harmlessly, usually on moist surfaces such as the nostrils, armpits and groin. Some types of SA produce a toxin called Panton Valentine Leukocidin and they are known as PVL-SA’s (Panton and Valentine were the two doctors who first found the toxin which can kill white blood cells called leukocytes – hence leukocidin). PVL-SA’s can cause skin and soft tissue infections such as boils and abscesses. They can also cause invasive infections affecting the lungs, blood, joints and bones. The PVL toxin can be produced by both meticillin-sensitive Staphylococcus aureus (MSSA) and meticillin-resistant Staphylococcus aureus (MRSA).

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

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

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

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

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

Management of Cases Skin and soft tissue infectionsMinor skin infections do not require systemic antibiotic treatment unless the patient is an infant, immuno-compromised or is deteriorating clinically. The treatment required is incision and drainage, as for normal abscesses. Moderate skin and soft tissue infections (larger than 5cms) should be treated with oral antibiotics, antibiotic therapy must be in line with sensitivities and antimicrobial prescribing guidance and in addition to this incision and drainage. If clinically not responding second

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line treatment with agents that help reduce toxin production may be indicated, seek advice from local microbiologist.

Infection Prevention and Control

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

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

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

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

infection Residents should not use communal leisure facilities e.g. gym, saunas, swimming

pools or have a massage, manicure or other treatments until the lesion has healed. (See appendix 2: Patient Information Leaflet)

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

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

Equipment used when performing dressing changes must be single use. Clean the sink and bath after each use with a disposable cloth, detergent and then

rinse. Daily vacuuming and dusting with a damp cloth of the resident’s room. Washing clothing and bedding regularly, laundry and towels should be washed using

a hot wash (60C) where possible. Lesions should be covered and thorough daily personal hygiene should take place

i.e. daily bath or shower. Residents should be advised not to touch or squeeze lesions.

Seek medical advice if boils / abscesses re-occur. Good communication is essential in ensuring a safe discharge/transfer of care of

patients with PVL-SA Isolation and special precautions e.g. use of personal protective equipment should be

used in hospital.

Screening and decolonisationTopical decolonisation should be offered to primary cases and a leaflet should be given to the resident where appropriate, describing how to minimize cross-infection and when and how to use the topical agents. Decolonisation should last 5 days. Residents with dermatological conditions will require specialist dermatological advice.

Chlorhexidine is also unsuitable for infants or those with sensitive skin, Octenisan body wash can be used. During treatment, sheets, towels and bedding should be changed daily.

Repeated screening may be recommended.

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Close contacts should be risk-assessed for screening and decolonisation. Special consideration should be given to contacts who have had previous PVL-SA infection in the past year or who work in healthcare settings.

Close contacts that have been risk-assessed for decolonisation treatment should undergo decolonisation at the same time as the primary case, without prior screening.

If screening is carried out, it must include a swab of anterior nares, throat and skin lesions including broken skin.

Close household contacts of a patient diagnosed with necrotising pneumonia likely to be caused by PVL-SA should be offered a five-day topical decolonisation regimen starting immediately (to include a Chlorhexidine gargle if feasible).

Residents and their families should be made aware of the potential for recurrence of PVL-SA infection within the family/close contacts.

Care homes/residential homesWhere there is one case of PVL-SA related infection, enquiries should be made to find out if there have been other confirmed cases or recurrent infected lesions amongst residents or staff. Public Health England should be informed. A risk assessment will be made regarding the suitability of screening all staff and residents. Individual cases can be decolonised with the topical treatment. If 2 or more residents or members of staff are affected, an outbreak meeting should be arranged to discuss infection control issues and the feasibility of decolonising all staff and residents. Standard precautions should be used and all staff trained in standard infection control precautions.

Topical Decolonisation procedure Only use decolonisation treatment when lesions are dry. Treatment requires 5 days

use of Chlorhexidine 4% or Octenisan bodywash used once per day as soap in the bath, shower or bowl and as a shampoo on 2 of the 5 days. The treatment should not be diluted and should be applied directly to wet skin on the hand or on a clean disposable wipe.

Particular attention should be given to skin creases: under armpits and breasts, groins, hands and buttocks.

It should remain on the skin for at least 3 minutes and then should be rinsed off well, followed by thorough drying.

Sheets, towels and facecloths should be changed daily. Use individual personal towels and facecloths. Clean sink/bath with a disposable cloth and detergent after use, then rinse. Apply a matchstick-head size amount of Mupirocin (Bactroban nasal) 3 times a day

for 5 days on the end of a cotton bud to the inner surface of each nostril and press both side of the nostril together, spreading the ointment inside the nostrils.

An antiseptic gargle may also be prescribed.

ReferencesHPA (2008) Guidance on the diagnosis and management of PVL-associated Staphylococcus aureus infections in England

PVL-associated Staphylococcus aureus – frequently asked questions (Sep 2008) obtained from http://www.hpa.org.uk/

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http://www.hpa.org.uk/


Appendix 1 - How to apply Chlorhexidine/Octenisan bodywash and Mupiricin (Bactroban) ointment

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Appendix 2 - Patient Information for PVL Staphylococcus aureus

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

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

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

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

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

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

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

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

Regularly wash your hands. Encourage others in your household to regularly wash their hands. Do not share towels or wash cloths Do not share razors and make up Do not share bar soap, liquid soap is recommended Frequently wash towels and bed linen on a hot wash. Regularly dust and vacuum your home.

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Closely following the instructions for the five day skin treatment as prescribed by your GP.

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

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

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

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

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Personal Protective Equipment

Introduction (Name of Care Home) is committed to and obliged legally to ensure that all staff employed are trained in appropriate procedures necessary and provided with the correct equipment to work safely (Department of Health,1974). The care home should in relation to preventing, reducing and controlling the risks of infections have in place appropriate policies including personal protective clothing (DH, 2015).

Aims of the policy The policy aims to:

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

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

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

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

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

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

Glove ChoiceGloves used for direct patient care must conform to current EU legislation (CE marked as medical gloves for single use) and should be appropriate for the task NICE, 2012). Gloves are available in a variety of materials. Risk assessment must ensure that the physical characteristics and barrier properties are acceptable, and provide protection against the risks encountered. Natural rubber latex remains superior in protecting against blood borne viruses. However, latex gloves that contain powder should never be used due to the risks associated with aerosolisation and an increased risk of latex allergies. When a risk assessment indicates latex glove use they must be non-powdered and be low protein. The problem of resident or health care worker sensitivity to natural rubber latex must be considered when deciding on glove materials and alternatives must be available in a variety of sizes. Nitrile gloves should be considered as the most acceptable alternative to latex. However; any other alternative glove choice must provide the same level of safety and protection against HCAI.

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

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

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

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

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

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

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

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

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

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

Cleaning of equipment when there is a risk of splashing and spraying A resident with MRSA isolated in a sputum sample and has a productive cough

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

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



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

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

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

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

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

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

Gloves Apron Eye protection Surgical mask or respirator

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




References Department of Health (1974), Health and Safety at Work Act. Department of Health (1998) Guidance for Clinical Health Care Workers : Protection Against Infection with Blood Borne Viruses. Recommendations of the Export Advisory Group on Hepatitis. London HMSO.

Department of Health (2002) Personal Protective Equipment Regulations

Department of Health (2008) Pandemic Influenza Guidance for Dental Practice



Department of Health and Health Protection Agency (2013) Prevention and Control of Infection in Care Homes – an information resource

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

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

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

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



Scabies

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Identification An early diagnosis is essential in order to avoid resident to staff transmission. Diagnosis is usually made in the presence of intense itching with a follicular papular

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



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

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

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

In this form, many more mites are present and the skin presents as thickened with crusts, often mistaken for Psoriasis. Unlike classical scabies where intense itching is evident, with Crusted Norwegian Scabies residents are unlikely to experience itching. The condition affects all parts of the body including head, neck, nails and scalp.

Treatment

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

frequent skin to skin contact with the individual affected.

For more than one case of scabies Consult with the Infection Prevention and Control Team (01623 673081). A decision will be taken between the home manager and the Infection Prevention

and Control Team to treat all the residents, staff and visitors who have come into contact with the infected residents in the previous 24 hours.

Treat all at the same time. Those with a diagnosis of Scabies should be treated with a second treatment 7 days

later. It is the responsibility of the care home to provide and pay for treatment for staff.



Treatment Products

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

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

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

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

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

irritant to the skin and respiratory tract.

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

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

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

breastfeeding and reapply treatment afterwards.

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

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

Applying Treatment Ensure the skin is clean, dry and cool before application. Individuals must not have a

hot bath before treatment is applied. All those being treated should have the treatment at the same time, to ensure that individuals do not re-infect one another.

Remove bedding, nightwear and towels and place in a red soluble bag and wash on a sluice wash (above 50°c) before applying treatment, if items cannot withstand a sluice wash i.e. delicate items, place in a plastic bag and leave for 72 hours, after this time, the scabies mites will have died.

Apply the treatment to the whole body (including the scalp, face, neck and ears) paying special attention to the areas between the fingers and toes and under the nails. Applying the cream at night before going to bed is usually the best time because it can be left on overnight. Care staff applying the cream or lotion should wear gloves and an apron (protective clothing) with each individual they are treating. A second person is necessary when treating oneself, to ensure all the body is covered. Allow the lotion or cream to dry before dressing.

Nails should be trimmed and medication applied with cotton wool buds underneath the nails and around the nail bed area. If hands are subsequently washed, then further treatment needs to be applied.



The treatment should be left on for the recommended time period, permethrin 8-12 hours and malathion 24 hours. Reapply treatment if it is washed off during the treatment period.

Following the recommended time period for the cream/lotion to be left on, remove by thorough washing of all areas of the skin to which it has been applied.

Bedding, all clothing worn and towels should be placed in a red soluble bag and washed on a sluice wash (above 50°c) the same day the treatment has been washed off. Delicate items that cannot withstand a sluice wash must be placed in a plastic bag and left for 72 hours, after which time the mite will have died.

A second treatment of symptomatic residents is required seven days later, following the above application points.

Residents should be advised that itching will persist for a few weeks after treatment. Simple moisturisers such as aqueous cream may be applied to residual itchy areas. Use of emollients for washing the skin, rather than soap or bubble bath products can also provide some relief for dry itchy skin.

Review the resident in 4-6 weeks. There is potential for secondary skin infection by repeatedly scratching itching skin,

this may break the skins surface and allows the resident to become more vulnerable to bacterial skin infections such as impetigo. If this occurs refer the resident to the GP as a course of antibiotics may be required.

Infection Control Measures Residents who are being transferred between health care environments should

routinely have their skin examined for signs of rashes. If diagnosis is suspected but not medically confirmed wear aprons and gloves for

patient contact. Bedding and clothing should be treated as infected and placed into a red soluble bag before being transported to laundry and washed on a sluice wash (above 50°c), if items cannot withstand a sluice wash ie: delicate items, place in a plastic bag and leave for 72 hours, after this time, the scabies mites will have died.

In a case of Classical Scabies where skin shedding does not occur, there is no need to isolate the individual providing that they are able to understand the importance of not touching others. If skin shedding does occur it is recommended that the resident is isolated to prevent the risk of spread, cleaning and hoovering of their immediate environment should take place daily. The resident only needs to be isolated until the initial treatment has been given.

In the case of Crusted Norwegian Scabies there is often a lot of dry flaky skin in the environment; therefore isolation is necessary as well as cleaning and hoovering the immediate environment of the resident daily. The resident only needs to be isolated until treatment has been given.

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






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

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

Nottinghamshire Antimicrobial Prescribing Guidelines (2015)


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

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


Management of Spillages of Blood and Body Fluids

Introduction The management of blood or body fluid spillage is a procedure which has potential infection risks. Blood spillages, if not managed appropriately, increase the risk to the health care worker of exposure to blood borne viruses.

The aim of this policy is to: Aid in reducing the potential risk of cross infection from the spillages of blood and

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

spillage.

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

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

It is recommended that high risk body fluids as in blood are disinfected with sodium hypochlorite at strength of 10,000 ppm before disposal. Spill Kits are recommended where there is an increased risk of spillages from blood, body fluids and vaccine spillages. Spill Kits contain granules and tablets. The granules can be used to soak up most spills and the tablets provide the correct strength of chlorine to disinfect the spillage area.

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

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

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

If the urine or vomit spill is blood stained, staff must ensure that the room is well ventilated and that the spill is cleaned up with paper towels and detergent and water before using sodium hypochlorite. A risk assessment should be carried out in relation to the comfort and safety of residents before urine and blood stained vomit spills are cleaned using the spill kit. It may be necessary if practicably possible to move the resident before carrying out the procedure.

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Equipment Spill Kit

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

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

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

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

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

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

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



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

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

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

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

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

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

soon as is practicably possible

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

Education and Training Programme



All staff who may be involved in the management of blood, body fluids and vaccines spills should receive training.

The Health and Social Care Act (DH 2015) stipulates that infection prevention and control training is included for all staff at induction. Hand hygiene training is included in the induction programme. Hand hygiene training is mandatory and is offered to staff annually. Infection prevention and control updates are mandatory and are offered every 2 years.

All members of staff have an individual responsibility to ensure that they access mandatory training. ‘Glow and Tell’ machines which are used to demonstrate the effectiveness of hand hygiene techniques are available for loan from the Infection Prevention and Control Team for the use of homes who wish to carry out hand hygiene training in house. The Infection Control Matrons can be contacted on 01623 673081.


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

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

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



Management of Healthcare Waste and Sharps/Splash Injuries

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

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

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

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

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

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

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

health and safety and environmental protection.

Definitions of Waste Streams

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

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

Management of Healthcare Waste and Sharps/Splash Injuries Page 65 of 69


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

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

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

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

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

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

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

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

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

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

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

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

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



When waste bags are placed into a large storage bin outside to await collection the bin must be kept locked and secure.

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

A sharp includes any item, which has the potential to cause penetration injury i.e. Needles Stitch cutters Clip removers and wound closure clips Razor blades and disposable razors Scalpels Glass vials/ampoules Specimen containers Lancets Wound closure clips Disposable scissors Probes

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

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

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

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

handled

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

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

Many incidents of occupational exposure have been described as preventable providing there is proper adherence to standard precautions for the safe handling and disposal of



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

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

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

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

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

4. Contact the homes occupational health service or GP




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

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

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

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


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


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

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


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