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UVS FOI1 Request Healthcare associated infections
Source: WhatDoTheyKnow
Authority: University Hospitals Coventry and Warwickshire NHS Trust
Status: We're waiting for
Jordan Millar
to read recent responses and update the status.
Imported path: /opt/loancharge/imports/wdtk/requests/uvs_foi1_request_healthcare_asso
Open original request on WhatDoTheyKnow
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SOURCE: WhatDoTheyKnow
SOURCE_URL: https://www.whatdotheyknow.com/request/uvs_foi1_request_healthcare_asso
TITLE: UVS FOI1 Request Healthcare associated infections
AUTHORITY: University Hospitals Coventry and Warwickshire NHS Trust
AUTHORITY_URL: https://www.whatdotheyknow.com/body/university_hospitals_coventry_and_warwickshire_nhs_trust
STATUS: We're waiting for
Jordan Millar
to read recent responses and update the status.
REQUEST_SLUG: uvs_foi1_request_healthcare_asso
CAPTURED_AT: 2026-05-19T07:22:27+00:00
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================================================================================
MESSAGE 1 [outgoing]
HEADER: Jordan Millar
19 July 2024
Delivered
--------------------------------------------------------------------------------
Dear University Hospitals Coventry and Warwickshire NHS Trust,
We are conducting some research on behalf of UV Smart into rates of healthcare-associated infections (HAIs) across hospitals in the UK. We are particularly interested in understanding the following from you.
In your response, please can you also confirm if we have permission to reuse the information provided for news/reporting purposes and as part of communications with industry peers and the general public. We will assume that we are able to use the information in these ways unless you explicitly advise us otherwise in your response.
1. Has University Hospitals Coventry recorded any Healthcare-Associated Infections (HAIs) over the past 12 months?
- Yes
- No
2. Has there been any case in the past 12 months where a HAI has resulted in the death of a patient at University Hospitals Coventry?
- Yes
- No
3. What is the most common type of Healthcare-Associated Infection (HAI) recorded at University Hospitals Coventry?
4. How many cases of the HAI identified in the answer to question 3 has University Hospitals Coventry recorded over the past three years?
5. What specific infection control policies and procedures are currently in place to prevent HAIs?
6. How often are these policies and procedures reviewed and updated at University Hospitals Coventry (please provide dates of the last review/update period)?
7. Are there any specific protocols in place to deal with an outbreak of HAIs at University Hospitals Coventry? And have there been any recorded ‘outbreaks’ of HAIs at University Hospitals Coventry in the last three years?
8. Have any new technologies or practices have been implemented to reduce the rates of HAIs at University Hospitals Coventry over the past three years (please give details where possible)?
9. Are there any plans to explore or introduce new technologies or practices at University Hospitals Coventry to reduce the rates of HAIs over the next three years (please give details where possible)?
10. Has University Hospitals Coventry made the decision to use single-use medical equipment in place of reusable options either fully or partially because of benefits to patient safety/infection control?
- Yes
- No
Yours sincerely,
Jordan Millar
================================================================================
MESSAGE 2 [incoming]
HEADER: uhcw@infreemation.co.uk,
University Hospitals Coventry and Warwickshire NHS Trust
19 July 2024
--------------------------------------------------------------------------------
University Hospital
Clifford Bridge Road
Walsgrave
Coventry
CV2 2DX
Direct Line: 024 76968771
www.uhcw.nhs.uk
Dear Requester
We acknowledge receipt of your email to UHCW:
Freedom of Information Request Form
If you have submitted a request under the Freedom of Information Act
(FOIA) your request will be considered and you will receive our response
within the statutory timescale of 20 working days.
The reference number for your email is FOI/3837.
Should you have any further inquiries concerning this matter, please reply
to this email leaving the subject line unchanged.
Yours sincerely,
UHCW
================================================================================
MESSAGE 3 [incoming]
HEADER: uhcw@infreemation.co.uk,
University Hospitals Coventry and Warwickshire NHS Trust
16 August 2024
--------------------------------------------------------------------------------
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University Hospital
Clifford Bridge Road
Walsgrave
Coventry
CV2 2DX
Direct Line: 024 76968771
www.uhcw.nhs.uk
Our Ref: FOI 3837
Date: 16th August 2024
By email only
Dear Requester
We write further to your request for information under the Freedom of
Information Act received 19th July 2024. We have set out your request,
together with our response below.
We are conducting some research on behalf of UV Smart into rates of
healthcare-associated infections (HAIs) across hospitals in the UK. We are
particularly interested in understanding the following from you.
In your response, please can you also confirm if we have permission to
reuse the information provided for news/reporting purposes and as part of
communications with industry peers and the general public. We will assume
that we are able to use the information in these ways unless you
explicitly advise us otherwise in your response.
1. Has University Hospitals Coventry recorded any Healthcare-Associated
Infections (HAIs) over the past 12 months?
Yes
2. Has there been any case in the past 12 months where a HAI has resulted
in the death of a patient at University Hospitals Coventry?
Yes
3. What is the most common type of Healthcare-Associated Infection (HAI)
recorded at University Hospitals Coventry?
Sars-Cov-2
4. How many cases of the HAI identified in the answer to question 3 has
University Hospitals Coventry recorded over the past three years?
1785 recorded as possible or probable nosocomial infections
5. What specific infection control policies and procedures are currently
in place to prevent HAIs?
CG - Guidelines For The Management of
Tuberculosis
CG - Isolation Guideline
CG - Management of an Outbreak or Incident
CG - National Infection Prevention and Control
Manual for England
CG - Respiratory Infections Guideline
CG - Screening, Prevention and Management of
Methicillin Resistant Staphylococcus aureus
(MRSA)
COP 96 - Cleaning and Disinfection of
Non-invasive Equipment & Computers
CP - Bed space cleaning procedure, including bed
and mattress cleaning
CP - Management of Multi-Resistant Organisms,
Carbapenemase Producing Enterobacteriaceae Multi
Resistant Acinetobacter baumanni
CP - Trust wide Clinical Operating Procedure and
Principles for Aseptic Non Touch Technique (ANTT)
CP - Management of Clostridioides difficile for
adults
CP - Management of Norovirus
CP - Trust wide Procedure for the Home Laundering
of staff Uniforms
COP 209 - Body Infestations
COP 914 - Viral Haemorrhagic Fever (VHF): Acute
Identification and management guide.
CP - Procedure for the laundering of Soiled
Patients Clothing in the Home Setting
COVID-19 Screening Requirements SOP
Hand Decontamination Policy
Trust Decontamination Policy
Food Hygiene Guidelines
Infection Prevention and Control Policy
Management of Health Care Workers Living and
Working with Blood Borne Viruses Policy
CG - Screening and management of Sepsis in Adults
CG - Vancomycin Resistant Enterococci Guidelines
Please see attached policies and guidelines
6. How often are these policies and procedures reviewed and updated at
University Hospitals Coventry (please provide dates of the last
review/update period):
Expiry dates for policies and procedures do not exceed three years.
Documents are reviewed and updated if changes are required before three
years.
7. Are there any specific protocols in place to deal with an outbreak of
HAIs at University Hospitals Coventry? And have there been any recorded
‘outbreaks" of HAIs at University Hospitals Coventry in the last three
years?
There is a specific protocol in place to deal with outbreaks. There have
been outbreaks recorded in the last three years.
8. Have any new technologies or practices have been implemented to reduce
the rates of HAIs at University Hospitals Coventry over the past three
years (please give details where possible)?
Yes. Introduction of the Imop in clinical areas. Introduction of Hiprex
where clinically indicated for prophylaxis of UTI's. Rapid PCR testing.
Air scrubbers.
9. Are there any plans to explore or introduce new technologies or
practices at University Hospitals Coventry to reduce the rates of HAIs
over the next three years (please give details where possible)?
Yes. HLD electronic track and trace
10. Has University Hospitals Coventry made the decision to use single-use
medical equipment in place of reusable options either fully or partially
because of benefits to patient safety/infection control?
Yes
As we have provided the information that we do hold your request is now
closed. We trust that this is satisfactory but if you are dissatisfied
with the way that it has been handled you have the right to ask for an
internal review. Internal review requests should be submitted within two
months of the date of receipt of the response to your original letter and
should be addressed to: David Walsh, Director of Corporate Affairs,
University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge
Road, Coventry CV2 2DX.
If you are not content with the outcome of the internal review, you have
the right to apply directly to the Information Commissioner for a
decision. The Information Commissioner can be contacted at: Information
Commissioner’s Office, Wycliffe House, Water Lane, Wilmslow, Cheshire, SK9
5AF.
Yours sincerely
Andrea Phillips
FOI & Access to Health Records Manager
================================================================================
ATTACHMENT TEXT EXTRACTION / OCR
================================================================================
--------------------------------------------------------------------------------
ATTACHMENT: 1.pdf
TEXT_FILE: 1.pdf.txt
METHOD: pdf_native
OCR_USED: False
PAGES: 29
--------------------------------------------------------------------------------
--- PDF page 1 ---
Editorial Check: XXXX
1
Guidelines For the Management of Tuberculosis
Related
National
Guidance
NICE Guidance (NG 33) 2016
https://www.nice.org.uk/guidanc
e/NG33/NG33
E-library
number
CG1362
Version
number
10
Purpose
The purpose of this guideline is to ensure that all employees of UHCW have access to
TB information consistent with national guidance regarding screening, management
and infection prevention and control, which will help prevent cross infection, protect
patients, visitors, and staff.
Primary
Specialty
Infectious Diseases
Related
Specialtie
s
Infection Prevention and Control
Tb Nurse Specialist Team
Specialty
Clinical
Guideline
Lead
Dr Vjeran Cajic Consultant in Infectious Diseases
Authors
Lead Author:
Melanie Gallo
Infection Prevention and Control Nurse
Melanie.gallo@uhcw.nhs.uk
Reviewer(s):
Dr Vjeran Cajic Consultant in Infectious Diseases
vjeran.cajic2@uhcw.nhs.uk
Linda Nicholson Clinical Nurse Specialist TB Nurse
Linda.nicholson@uhcw.nhs.uk
Kamlesh Hallett TB Specialist Nurse Lead
Kamlesh.hallett@uhcw.nhs.uk
Approvin
g Forums
Infection Prevention & Control Committee
Respiratory QIPS
Approval
QIPS
11.10.2023
--- PDF page 2 ---
Editorial Check: XXXX
2
Dates
MMC
N/A
Other (specify)
Review
Date
September 2025
Keywords TB, Pulmonary MTB
Clinical guideline content: Clinical Guidelines assist in decision-making; they do not replace clinical
judgement. Regardless of the strength of evidence, it remains the responsibility of the clinician to
interpret the application of the clinical guidance to local circumstances and the needs and wishes
of the individual patient. Where variations of any kind do occur, it is important to document the
variations and the reason for them in the patient’s health record. If in doubt, seek senior advice.
Equality and Diversity Statement: Throughout its activities, the Trust will seek to treat all people
equally and fairly. This includes those seeking and using the services, employees and potential
employees. No-one will receive less favourable treatment on the grounds of sex/gender (including
Trans People), disability, marital status, race/colour/ethnicity/nationally, sexual orientation, age,
social status, their trade union activities, religion/beliefs or caring responsibilities nor will they be
disadvantaged by conditions or requirements which cannot be shown to be justifiable. All staff,
whether part time, full-time, temporary, job share or volunteer; service users and partners will be
treated fairly and with dignity and respect.
Rationale
Tuberculosis (TB) is a chronic, progressive infection which most commonly affects the
respiratory tract but can involve any organ of the body. These guidelines relate to
Mycobacterium Tuberculosis (MTB). Bacteria of the MTB complex include
(M.Tuberculosis, M.Bovis and M.Africanum) these are acquired through inhalation of
infective droplets.
Due to the infectious nature of this disease, certain infection prevention and control
procedures should be employed.
Methods of detecting this infection using laboratory tests are also outlined, as these will
help to determine the degree of infectivity.
Dissemination and related guidance
Available on e – library
Training
Fit Testing for an FFP3 respirator is carried out by a nominated cascade trainer.
The infection prevention and control team provide fit testing training to a cascade trainer in all
departments and can be booked via contacting the IPCT on ext 24791.
--- PDF page 3 ---
Editorial Check: XXXX
3
All staff are responsible for ensuring they have had fit testing training prior to wearing an FFP3
respirator and training record given to their line manager.
All staff are responsible for ensuring they have been fit tested on at least 2 different FFP3 respirators
that are available in the trust.
All staff must ensure they are fit tested every 2 years or be re – fit tested if any facial changes occur
within the 2 years i.e losing weight.
Mandatory Infection Prevention and Control Training is completed on a yearly basis via the e –
learning system.
Madatory Hand Hygiene Training
Donning and Doffing training can be requested from the IPCT
Patient Information
TB leaflet awaiting comments from Health Information
Audit & Monitoring
Audit
title
Audit Lead
Monitoring method and
frequency
Committee responsible
N/A
.
Changes from previous version
Date
Updated information
17.10.20
23
Pg 6 AFB section, replaced precedes the identification of the culture with the
exact mycobacterium with - In the majority cases these TB bacilli, but in
majority cases could be Non – Tuberculosis Mycobacteria
Pg 6 Negative pressure room section, added in ward 31a to list of wards
where negative pressure rooms are available.
--- PDF page 4 ---
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4
Pg 6, PHE has been changed to UKHSA
Pg 11 Added in Microbiology responsibilites
Pg 14, table 1 Notifiable disease section, notification form on the intranet page
are old – we should focus attention on early referral to TB Service with
appropriate clinical and social details so that electronic UKHSA notification can
be done by the TB service
Pg 14, table 1, screening on admission section changed AAFB to TB PCR on
one of the samples
Pg 16, table 1, Hand Hygiene section, added in link to Hand Decontamination
Policy and the link to the National IPC manual
Pg 17, table 1, Notice for door section – added in link to the trust’s isolation
door labels
Pg 17, table 1, added in list of AGP’s
•
Pg 21, table 1 Visitors section added this sentence - Visitors who have
not been identified as a close contact should not visit unless under
exceptional circumstances for example on compassionate grounds. Visiting
under these circumstances must be discussed with the ID consultant. The
trust is not able to offer any fit testing for an FFP3 respirator to visitors,
however consideration to offer a FFP3 Respirator with a fit check can be
considered with risks explained to the visitor.
Pg 23, A negative PCR does not rule out TB, as the sensitivity of this test is not good
currently, especially from specimens such as CSF or smear negative sputum.
Treatment should be commenced on clinical grounds in these circumstances. If
detected the PCR test will also report common mutation which lead to rifampicin
resistance. This sentence has been changed to the sentence below.
A negative PCR does not rule out TB, treatment should be commenced on clinical
grounds in these circumstances. If detected the PCR test will also report common
mutation which lead to rifampicin resistance
Pg 26 TB quick action guide updated notification information and the wearer of
FFP3 mask must be fit tested and undertake a fit check every time the mask is
donned, added re to request a PCR on one of the sputum samples
Put the whole guideline into the new template
Put in new links to the National IPC manual throughout the document
Removed CRRS to EPR throughout document
--- PDF page 5 ---
Editorial Check: XXXX
5
Contents
Definitions ............................................................................................................................................... 5
Introduction ............................................................................................................................................ 7
Scope ....................................................................................................................................................... 8
Roles and Responsibilities ....................................................................................................................... 9
Clinical guidance ................................................................................................................................... 11
Appendices ............................................................................................................................................ 26
References ............................................................................................................................................ 28
Definitions
MTB
Mycobacterium tuberculosis
Drug Sensitive TB
Where there is no resistance to the first line anti-
tuberculous drugs tested.
MDR-TB
Multi Drug Resistant Tuberculosis (MDRTB) is
defined as Mycobacterium tuberculosis that is
resistant to rifampicin and isoniazid (two key
antibiotics). Although MDR-TB is no more
infectious than fully drug susceptible TB, the
consequences of acquiring MDR-TB are much
more serious. This is due to the greater difficulty
and cost of treating it with prolonged therapy and
the risk of much poorer outcomes.
XDR –TB
Extensively Drug Resistant TB
XDR-TB is defined as MDR-TB that is also
extensively resistant to second line drugs.
(fluoroquinolones and capreomycin, kanamycin or
amikacin this list is not exhaustive
Respiratory Precautions
This covers airborne or droplet transmission.
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Smear
Direct film from sputum, stained with Ziehl –
Neelsen or auramine to look for acid fast bacilli
(AFB) under microscopy.
Smear negative
AFB not seen on microscopy. This does not
exclude TB but is important with regards to
assessing infectivity.
Smear positive
AFB seen on microscopy from the primary sample.
Close Contacts
Are people who have prolonged, frequent or
intense contact with a person with infectious TB.
For example household contacts or frequent
visitors to the household. Depending on the
circumstance co – workers occasionally are
classed as close contacts.
AFB
Acid Fast Bacilli - In majority cases these are TB bacilli,
but in minority cases could be non-tuberculous
mycobacteria.
Negative Pressure Room
Defined as an isolation room that maintains
negative pressure compared to the outside
environment, thus not allowing the respiratory
droplets from infectious TB patients to exit the
room. There are negative pressure rooms on
ward 30, 31 and GCC & 31A.
OH
Occupational Health
UKHSA
United Kingdom Health Security Agency
PPE
Personal Protective Equipment
FFP3 Respirator
Filtering Face Piece Particulate Respirator
DPD
Deceased Patient Details
PCR
Polymerase Chain Reaction
CCDC
Consultant in Communicable Disease Control
TBNS
TB Nurse Specialists
DIPC
Director For Infection Prevention and Control
IGRA
Interferon Gamma Release Assay
ETS
Enhanced Tuberculosis Surveillance
WHO
World Health Organisation
EPR
Electronic Patient records
ICB
Integrated Care board
OPD
Outpatient Department
IPCT
Infection Prevention and Control Team
ATT
Antituberculosis Treatment
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ART
Antiretroviral Treatment
HIV
Human Immunodeficiency Virus
QAG
Quick Action Guide
SICP
Standard Infection Prevention and Control
Precautions
Standard Infection prevention and Control
Precautions are the minimum infection
prevention practices that apply to all patient care,
regardless of suspected or confirmed infection
status of the patient, in any setting where health
care is delivered.
https://www.england.nhs.uk/national-infection-
prevention-and-control-manual-nipcm-for-
england/
TBP
Transmission-Based Precautions are for patients
who are known or suspected to be infected or
colonized with infectious agents, including certain
epidemiologically important pathogens, which
require additional control measures to effectively
prevent transmission.
There are three categories of Transmission-Based
Precautions: Contact Precautions, Droplet
Precautions, and Airborne Precautions.
Transmission-Based Precautions are used when
the route(s) of transmission is (are) not
completely interrupted using Standard
Precautions alone.
https://www.england.nhs.uk/national-infection-
prevention-and-control-manual-nipcm-for-
england/
Introduction
Mycobacterium tuberculosis (MTB) is a bacterial infection. It is caught by ‘breathing in’ the bacteria
that causes it. Bacteria are present in tiny droplets produced from sneezing or coughing by someone
who has MTB. Some people become ill with TB within a few weeks or months of breathing in the
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bacteria. This is called ‘active TB.’ In most people, the body’s immune system kills the bacteria and
the person does not get ill. In other people the bacteria are not killed but stay in the body at a low
level, contained by the hosts’ immune system so the person does not get ill and is not infectious.
This is called ‘latent MTB’. If the bacteria start to multiply again months or years later (for example if
the person’s immune system is weakened by another disease such as HIV), the person could develop
active MTB, but in most cases this does not happen.
MTB is a chronic, progressive infection that mainly affects the lungs (pulmonary MTB) but it can
affect other parts of the body (extra pulmonary MTB).
Due to the infectious nature of pulmonary MTB, certain Infection Prevention and Control procedures
should be employed and these are highlighted in this guideline.
Scope
This guideline applies to trust personnel working within the University Hospitals Coventry and
Warwickshire NHS Trust (UHCW). Each member of staff has a personal responsibility to ensure they
comply with this guideline to prevent and manage Mycobacterium Tuberculosis.
The purpose of this guideline is to ensure that all employees of UHCW have access to TB information
consistent with national guidance regarding screening, management and infection prevention and
control standard and transmission-based precautions.
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Roles and Responsibilities
This guideline applies to all clinical staff temporary and permanent working at UHCW. It is the
responsibility of all, including students and contractors to :
Understand and apply the principles of TB prevention and control by maintaining competence, skills and
knowledge in Infection Prevention and Control
Clinical staff have a responsibility to ensure that they risk assess promptly patients with suspected
infectious pulmonary or laryngeal TB before or at presentation to the hospital. This reduces the risk of
cross infection for themselves and other patients. Staff can reduce the risk of cross infection by wearing
the appropriate personal protective equipment (PPE) and ensuring the patient with suspected or
confirmed TB is isolated until they are no longer deemed to be infectious.
Directors/ Lead Clinicians/ Senior Managers
•
All Directors, Lead Clinicians and Senior Managers are responsible for ensuring that this guideline
is known to their staff and that its requirements are followed at all times, by all staff within their
Directorate.
•
Following standard and transmission based precautions
Infection Prevention and Control Team (IPCT)
Critical functions of the Infection Prevention Team include:-
•
The development of policies / guidelines, education, training, specialist advice, patient
information, audit, surveillance, management and coordinating of incidents.
•
Recognition of a TB incident and undertaking contact tracing.
•
Arranging a TB incident meeting where an infectious patient has been nursed in an open bay with
other patients.
•
Liaison with clinical teams to ensure prompt recognition of and response to cases.
•
Training on the correct use of personal protective equipment ( PPE) where required. Contact the
IPCT if training required.
•
Training on donning and doffing of PPE. Contact the IPCT if training is required.
Consultants and their junior doctors
The Consultants and their junior doctors are responsible for:-
•
Prompt recognition of TB symptoms on admission or during admission and ensuring the patient is
isolated if deemed infectious
•
Reviewing patients with suspected/ confirmed TB
•
Attend incident meetings
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•
TB notification to the TB nursing team
•
Commencing appropriate antibiotic treatment for TB in a timely manner
•
Informing the Infection Prevention and Control Team when an infectious patient has been nursed
in a bay so contact tracing can be initiated
•
Inform IPCT if TB suspected
•
Ensure that correct specimens are sent to the laboratory in a timely manner
•
Referral to Infectious diseases if suspected or confirmed TB
•
Antibiotic Stewardship
•
Following standard and transmission based precautions
Matrons/ Ward Managers
•
Matrons and Ward Managers are responsible for ensuring all staff are aware of this guideline and
comply with all aspects with particular reference to:
•
•
Recognising patients at risk
•
Acting promptly in response to patients with symptoms of TB
•
The timely/ appropriate collection of specimens
•
Prompt isolation of patients
•
Following standard and transmission based precautions
•
Antibiotic Stewardship
•
Availability of correct PPE
•
Informing Infection Prevention and Control if an infectious patient has been nursed in a bay
and if any AGP’S have been carried out
•
Providing Infection Prevention and Control and Occupational Health with a contact list for the
purpose of contact tracing if requested
•
Attending incident meeting
•
Ensuring staff are aware of this guideline
All Health Care workers
All Health care workers have a clinical and ethical responsibility to carry out effective infection prevention
and control procedures applicable to the control of TB including the correct use of (standard and
transmission based precautions and to act in a way which minimises risk to the patient, other patients and
themselves.
The Occupational Health Department
•
Is responsible for ensuring that all new healthcare workers have standard health clearance before
they have clinical contact with patients i.e. be free from TB disease, a pre-employment BCG is
given if required and information leaflet given to staff regarding the symptoms of TB.
•
Occupational Health is responsible for the screening and follow up of any member of staff who
have been identified as a contact of TB
•
Is responsible for informing Infection Prevention and Control if a member of staff has been
diagnosed with Infectious TB
Role of the Hospital Infection Prevention & Control Committee
•
The Hospital Infection Prevention and Control Committee are responsible for approving this
document.
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Role of Respiratory Physicians / Infectious diseases
•
To offer support and expert advice to the Infection Prevention and Control Team to establish
infectiousness of patients for the purpose of contact tracing
•
To attend Incident meetings
•
The lead TB clinician for the Trust will assess or organise for assessment of which patients that
have been exposed to infectious TB may require screening, considering individual patient risk
They will also consider any relevant investigations undertaken (e.g. at least 8 weeks post
exposure) that could exclude further screening for TB.
•
To inform the Infection Prevention and Control Team if an infectious patient has been nursed in a
bay
•
To offer expert advice on management and treatment of TB
•
The Lead TB physician will provide annual TB awareness sessions in the Grand Round and provide
other teaching session as and when required
•
To follow standard and Transmission based precautions
TB Nurse Specialists (TBNS)
•
Arrange screening of discharged patients that have been a known contact of infectious TB whilst
an inpatient (who will have been written to by the Trust following risk assessment)
•
Attend incident meeting when required
•
Offer expert advice when required
•
To liaise with UKHSA to follow up community contacts
•
To liaise with the ICB if care home facility involved
Histopathologist
•
If TB is identified on post mortem the Pathologist must inform the Director for Infection
Prevention and Control (DIPC) and the IPCT and Consultant in Communicable Disease Control
(CCDC) at the (UKHSA). The DIPC will then be responsible for alerting relevant members of staff
as contact tracing may be required.
Microbiology
•
Communicating positive results to the wards / departments
•
Informing IPC if infectious patient in bay
•
Alerting IPC, TB team and Infectious diseases of any MDR / XDRTB
•
Electronic cascade form to be emailed out to IPC, Infectious diseases and TB Team
Clinical guidance
MTB is curable, but it is important that it is identified and treated quickly to avoid serious
consequences and prevent it spreading through the body or to other people.
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Symptoms of Pulmonary MTB include: -
•
persistent cough
•
Haemoptysis
•
losing weight unintentionally
•
Breathlessness
•
Anorexia
•
night sweats (usually drenching)
•
Fever
Risk Assessment for Pulmonary MTB
Cough for more than 3 weeks – Consider TB!
(Especially if from high incidence country (See link below) or ethnic group, immunocompromised,
chronic alcohol dependence, social deprivation or homeless).
https://www.gov.uk/government/publications/tuberculosis-tb-by-country-rates-per-100000-people
HIV & unexplained chest infiltrates – Consider TB!
Patients with suspected TB should be risk assessed, and admitted to a side-room preferably a
negative pressure side room with en - suite whilst this assessment is made. The risk assessment
should include:
How Infectious?
•
Infectious TB is active tuberculosis disease that presents a risk of transmission of infection to
others. For most practical purposes, this means sputum-smear positive pulmonary
tuberculosis in which acid-fast bacilli (AFB) are present on direct microscopy of sputum.
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•
Active TB affecting other parts of respiratory tract e.g. laryngeal TB or oral cavity is also
considered infectious.
•
If the patient has a cavity on chest X-ray the patient is likely to be infectious
•
Patients who are coughing may be considered infectious
Patients whose bronchial washings are positive on direct microscopy should be managed as
infectious TB if:
•
sputum is also smear positive
•
on a ward with immunocompromised patients
•
known or suspected as having MDR-TB
Risk factors for MDRTB / XDRTB
•
Prior TB treatment
•
Treatment failure
•
Contact with a known case of drug resistant TB
•
Birth in a foreign country with high incidence of MDR TB. see link in Appendix 1
If any of the above apply then MDRTB / XDRTB should be suspected
If you suspect TB in a patient or have confirmed TB (microbiologically) then commence the TB Quick
Action Guide (QAG) in appendix 2 and follow the appropriate interventions as stated in the QAG.
Table 1: General TB Information, Transmission Based Precautions (TBP) and Standard Infection
Control Precautions (SICP)
Table 1
Clinical
Condition
Pulmonary and laryngeal TB both require respiratory precautions (Airborne)
For those with extra – pulmonary TB disease the TBP in this guideline must be followed
until pulmonary involvement can be ruled out.
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Mode of
Spread
Airborne: The infectious particles are very small droplets (1-5 um) containing tubercle bacilli
expelled during talking, singing but especially coughing, and inhaled by susceptible
individuals.
Incubation
period
2-8 weeks to cause an immune reaction. May be many years before disease develops.
Notifiable
disease
Yes - If a patient is commenced on anti-TB treatment for presumed, suspected or
confirmed TB then the doctor caring for the patient must ensure early referral to the TB
Service with appropriate clinical and social details so that electronic UKHSA Notification can
be completed by the TB service. A referral to the TBNS can be made through the TB nurse
nhs email below.
uhc-tr.covwarkstb@nhs.net
At UHCW, the TB Nurse Specialist Service (TBNS) must be informed by the diagnosing
clinician as soon as a patient is commenced on ATT medications or discharged with
suspected TB (pending results) so they can support the patient to complete their treatment
once discharged home, ensure that the appropriate risk assessment is undertaken prior to
discharge home and contact tracing of community contacts is carried out (Nice 2016) and
ensure appropriate follow – up by a consultant is arranged.
If TB is identified on post mortem the Pathologist must inform the Director for Infection
Prevention and Control (DIPC), the IPCT and Consultant in Communicable Disease
Control (CCDC) at the UKHSA. The DIPC will then be responsible for alerting relevant
members of staff, including Infection Prevention and Control Team as contact tracing
may be required.
Admission to
hospital
Patients with suspected infectious or confirmed pulmonary /laryngeal TB should not
routinely be admitted to hospital for diagnostic tests or for care unless there is a clear
clinical or public health need e.g. homelessness and then a multi-disciplinary team will agree
a plan for that patient (NICE 2016).
Screening on
admission
Pulmonary tuberculosis should be considered in any patient with an unexplained cough
lasting more than three weeks, with or without weight loss, anorexia, fever, night sweats or
haemoptysis. They should usually have three separate sputum samples sent to the
laboratory and a chest X- Ray. These specimens should be marked ‘URGENT’ and request a
TB PCR on one of the samples, in addition to culture. Patients whose history is indicative of
pulmonary tuberculosis on admission should be isolated as shown in figure 1
Risk
assessment
for MDRTB
•
Prior TB treatment
•
Treatment failure
•
Contact with a known case of drug resistant TB
•
Birth in a foreign country with high incidence of MDR TB. see link in Appendix 1
If any of the above apply then MDRTB should be suspected
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If MDR-TB
Suspected
A risk assessment should be carried out by the medical team and if MDR -TB is
suspected:
•
The patient should be isolated in a monitored negative pressure ventilated side
room (refer to Isolation Guideline 2023). If none are available, the patient must be
transferred to a hospital that has these facilities.
•
Inform the Infection Prevention & Control Team immediately.
•
Refer the patient to the named physician with a responsibility for TB or Infectious
Disease consultant for their expert advice as soon as possible. Several second or
third line agents may be used to treat these patients.
•
Inform the Duty Microbiologist so that rapid testing for rifampicin resistance can
be arranged where appropriate.
Any patient commenced on treatment for TB must be referred to Infectious Diseases and
inform the TBNS by the diagnosing clinician and notified to the UKHSA. MDR –TB will be
monitored by the national MDR-TB group
Contact
Tracing
The Infection Prevention and Control Team will communicate with the infectious disease
consultant as to whether patient contact tracing is required. If contact tracing is required,
the infectious disease consultant will risk assess each patient contact to ascertain if
screening or information and advice letters are required.
If patient contacts require screening the TBNS will arrange this if they have been discharged
home. The IPCT will inform the TBNS if patients have been discharged home. If the patient
contacts are still in hospital, then the IPCT will inform the consultant to arrange screening.
Occupational Health (OH) will be responsible for contact tracing any staff contacts in liaison
with the individual wards / department manager.
OH will inform the IPCT if any staff test positive for TB whereby contact tracing may be
required of their patient contacts.
The TBNS will undertake any community contacts contact tracing.
TB Incident
An assessment will be made by the IPCT and infectious disease lead to ascertain if an
incident meeting is required depending on the nature of the incident e.g large number of
contacts. The IPCT will be responsible for co –ordinating the meeting and ensuring all
actions are completed. OH will be responsible for completing any actions involving staff.
Outbreak
The investigation of a suspected outbreak will require input of a multidisciplinary team and
the UHCW outbreak and incident policy will be instigated.
The (IPCT) will complete a Datix (Low Harm) on all TB incidents / outbreaks.
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The IPCT will document every TB notification on the IPC TB database & document any
actions undertaken on the IPCT TB data base.
Persons
most at Risk
of acquiring
TB once
exposed
• Individuals whose cumulative exposure time is more than 8 hours to sputum smear
positive patient.
• Those who have immunodeficiency for any reason
Waste
Waste should be designated as clinical/ healthcare waste and placed.
In an orange bag. Please refer to UHCW Waste Management Policy (2019)
Equipment
No special requirements provided equipment is decontaminated as per the University
Hospitals Coventry and Warwickshire NHS Trust (2019) Clinical Operating procedure for
Cleaning and Disinfection of Non Invasive Equipment and computers
https://uhwebapps.uhcw.nhs.uk/eLibrary/filecon/download.aspx?Doc=119740&DocRetur
n=/elibrary/&VERI=yw82bpjm
Hand
Hygiene
Hand Hygiene should be carried out as per the World Health Organisations (WHO) 5
moments for Hand Hygiene and the UHCW Hand Decontamination Policy (2020).
Hand Hygiene Decontamination V10 (1).pdf
https://www.england.nhs.uk/national-infection-prevention-and-control-manual-nipcm-
for-england/chapter-1-standard-infection-control-precautions-sicps/#1-2
Last Offices /
Mortuary
Special precautions are required for Last Offices.
If a patient with suspected or confirmed TB dies, the body must be placed in a cadaver
bag.
Information regarding the patient’s infection must be stated on the deceased patient’s
details (DPD) form so that appropriate infection prevention and control precautions can
be taken by mortuary staff.
https://www.england.nhs.uk/wp-content/uploads/2022/09/national-infection-
prevention-and-control-manual-appendix-12.pdf
Moving
between
Avoid unnecessary movement of patient until therapy has been established. If movement
is necessary, for smear positive adult patients within the first 14 days of therapy, ask the
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wards,
hospitals
and
departments
(including
theatres)
patient to wear a fluid repellent surgical mask or if still deemed to be infectious after 14
days of treatment, seek advice from Infectious diseases if unsure if patient remains
infectious (Nice 2016).
Patients that require ventilation and transfer to GCC must be isolated in a negative
pressure room. A closed ventilator system must be used. Use of an oscillator should be
avoided as this is not a closed system.
If the patient has infectious TB and requires an operation, then the patient must be
intubated and recovered in the operating theatre. Please liaise with IPC beforehand to
ensure the correct procedures are followed.
Notify the receiving department on any transfer.
Outpatient Department
Outpatient lists are risk assessed and individuals who are infectious / likely to be
infectious must not wait in waiting areas with other patients and the room should be
well ventilated. Infectious patients must also wear a FRSM.
Isolation
door label
Yes, if patient is isolated place isolation door label (Red hand) on to the door
NB Keep door closed until restrictions are lifted. Please find door label in link below.
Guidelines and Posters | University Hospitals Coventry and Warwickshire NHS Trust
Patient
clothing
No special requirements. Advise relatives that there is no risk from washing the patient’s
clothes at home.
Respiratory
Hygiene /
Cough
Etiquette
Advise patient to cover nose and mouth with a tissue when coughing or sneezing, dispose
of tissue immediately into clinical waste and decontaminate hands, this will reduce aerosol
generation into the air.
Advise patient to wear fluid resistant surgical mask if there is a requirement to leave the
isolation room.
(NICE 2016)
Personal
Protective
Equipment
(PPE)
Wear FFP3 Respirator in the following situations: -
•
All staff who enter the room of/have contact with an infectious patient, must wear
and FFP3 respirator, whether in an inpatient, outpatient or community setting.
•
While undertaking a procedure on lesion (s)
•
While doing an AGP , list of AGP’S are listed in the link below.
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NHS England » Chapter 2: Transmission based precautions (TBPs)
•
If MDR-TB / XDR- TB is confirmed or being considered
Remove respirator carefully avoiding contamination of the hands (avoid touching the front
of the mask) and wash the hands using soap and water.
Do not re-use respirator they are single use.
Dispose of respirators as clinical waste, outside the isolation area.
Gloves:
Wear gloves only when touching blood or bodily fluids.
Remove gloves on completion of task, dispose of as clinical waste and decontaminate hands
inside the room.
Apron:
Only wear an apron if at risk of uniform getting contaminated i.e during toileting or log
rolling the patient.
Remove apron on completion of the task, dispose of as clinical waste inside the isolation
room.
Fluid Repellent Gown:
Only wear a gown for procedures where there is a risk of contamination of clothing from
splashing or during AGP.
Remove the gown on completion of task and dispose in clinical waste inside the isolation
room.
Full Face Visor :
When undertaking and AGP or risk of splash to the eyes and face
Remove the visor on completion of the task and dispose of in clinical waste inside the
isolation room.
Ensure hands are decontaminated once PPE has been removed.
Refer to links below for correct order of donning and doffing .
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_
data/file/911332/PHE_COVID-
19_Donning_Airborne_Precautions_quick_guide_gown_version.pdf
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https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_
data/file/911304/PHE_COVID-
19_Doffing_Airborne_Precautions_quick_guide_gown_version.pdf
Personal protective equipment (PPE) when applying transmission based precautions (TBPs)
Appendix 5b (england.nhs.uk)
Appendix 6: Putting on and removing PPE (donning and doffing)
Putting on and Removing PPE v3 (england.nhs.uk)
Fit Testing &
Fit Checking
of a FFP3
Respirator
Fit Testing
It is a requirement that any HCW required to wear an FFP3 respirator should have
undertaken respirator fit testing prior to using it and should be fit tested on at least 2
different respirators that are available in the trust.
Fit testing should be repeated regularly (every 2 years) and whenever a need is identified,
for example if a new product is used or where the users face shape may have changed due
to weight loss or gain, major dental work, injuries/moles etc.
In the event of a breach in infection prevention and control procedures, such as incorrectly
worn FFP3 respirators during an aerosol generating procedure, staff should be reviewed by
occupational health.
Each ward and department in the Trust has a cascade trainer who will do the fit testing as
and when required
If for any reason a staff member cannot be fit tested with an FFP3 Respirator then hoods
and training are available, please contact the sterile services department.
FFP3 Fit Check
Whenever a FFP3 respirator needs to be worn a fit check must be undertaken each time.
Refer to donning FFP3 respirator video and poster link below which demonstrates how to
don an FFP3 respirator and how to undertake a fit check.
For further information refer to the UHCW Fit Testing SOP on elibrary.
https://books.hse.gov.uk/Posters/?DISPLAY=PF&DI=652757
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https://www.hse.gov.uk/pubns/disposable-respirator.pdf
Precautions
Required
Until
Sputum Smear positive not including MDR TB / XDR TB:
Consider de-escalating isolation after 2 weeks of treatment, considering the risks and
benefits if: -
•
The person is showing tolerance to the prescribed treatment
•
There is agreement to adhere to treatment
•
There is resolution of cough
•
There is definite clinical improvement on treatment; for example, remaining
afebrile for a week
•
There are no immunocompromised patients, such as transplant recipients, people
with HIV and those on antitumor necrosis factor alpha or other biologics, in the
same ward
•
The person’s initial smear grade was not high; for example, 2 or less
•
There is not extensive pulmonary involvement, including cavitation
•
There is no laryngeal TB
•
(NICE 2016)
Seek the advice from infectious disease team and IPC before removing a patient from
isolation. Once removed from isolation keep the patient under review. Return to
isolation if they deteriorate clinically.
MDR TB:
•
For duration of stay
XDR TB:
•
For duration of stay
Discuss all cases of MDR or XDR TB with infectious disease consultant
Procedure
Restrictions
•
AGP’s should be undertaken in a single / negatively-pressurised room with the
door closed. Only carry out AGP in a ventilated area ideally in a negative
pressure room (Nice 2016)
•
Only carry out AGP when necessary
•
Bronchoscopies in those suspected of Pulmonary TB should be done last with
adequate ventilation as above.
Bronchoscopy suites managers should be aware of the number of air exchanges and the
duration of time required before staff and other patients can re- enter the area.
(NICE 2016)
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Referral to
Infectious
Diseases
The Microbiologist will inform the clinician by telephone of positive smear results.
The clinician must then refer the patient to a respiratory physician or infectious diseases
consultant to seek expert advice on ATT and other management requirements.
Cleaning of
Isolation
Room
Chlorine dioxide (Tristel) must be used for daily cleaning of the rooms and for the terminal
clean following discharge.
https://uhwebapps.uhcw.nhs.uk/eLibrary/filecon/download.aspx?Doc=117645&DocReturn
=/elibrary/&VERI=gfppjcxp
Visitors
•
Children should not be allowed to visit unless exceptional circumstances.
•
Visitors who have not been identified as a close contact should not visit unless
under exceptional circumstances for example on compassionate grounds. Visiting
under these circumstances must be discussed with the ID consultant. The trust is
not able to offer any fit testing for an FFP3 respirator to visitors, however
consideration to offer a FFP3 Respirator with a fit check can be considered with
risks explained to the visitor.
•
The TBNS team can give further information on who has been identified as a close
contact and give further advice on visiting.
•
Inform the patient and family of the TBNS on 02476961351 and advise them to
direct any enquiries about contact screening to community TB team, not to their
GP.
•
It is important to make sure that parents/carers are not themselves infectious
with TB before allowing them to visit/stay in hospital with the child.
•
In the case of suspected or proven pulmonary MDR or XDR TB a plan for visiting
should be discussed with the TBNS and in the first instance and Infectious disease
consultant
•
Those who are immunocompromised should not visit.
ATT
Contact respiratory doctor / infectious diseases for advice regarding commencing
treatment.
Child with
suspected
active TB
•
Clinical enquiries regarding patients with suspected TB should be directed to Dr
Rajesh Srikantaiah for further guidance.
•
The child is most likely to have been infected by a close adult, so staff would be
advised to consider the health of a visitor to a child with TB in hospital and to inform
the community TBNS who can initiate screening in the community.
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•
Relatives with symptoms of infectious TB should be screened and advised to keep
separate from other people on the ward until they have been excluded as a source
of infection
Discharge
Planning
•
As soon as discharge is planned, inform the TBNS (see contact details above in
notification section) so that arrangements for the supervision of all anti-tuberculosis
therapy can be appropriately made by the team with the patient.
•
If the patient is of no fixed abode, they must not be discharged until a discharge-
planning meeting has been held with the TBNS to ensure the patient is suitably
accommodated for them to complete their treatment and reduce the risk of spread
of infection.
•
A completed discharge letter detailing the patient’s medication and date of follow
up appointment in the Out-Patient Department (OPD) with either the respiratory
physician or Infectious diseases can be printed from the Electronic Patient Records
by the TBNS.
•
A decision to discharge a patient with MDRTB must be discussed with the TBNS prior
to discharge so secure arrangements for supervising and administrating all ATT
(NICE 2016).
•
N.B If MDRTB TTO IS REQUIRED ORDER 2 DAYS PRIOR TO THE ESTIMATED
DISCHARGE DATE
--- PDF page 23 ---
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*NOTE: Tissue/Biopsy specimens should not be placed in formalin if culture is required. However, for
histological diagnosis of tuberculosis tissue/biopsy specimens should be placed in formalin pots and
sent to histopathology. Culture is not possible once the specimen is placed in formalin.
--- PDF page 24 ---
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Polymerase Chain Reaction (PCR)
Molecular tests for Mycobacterium tuberculosis complex must be discussed with the duty
Microbiologist. They will be considered in the following circumstances:
•
From smear positive sputum if rapid confirmation of a TB diagnosis would alter the patient’s
care or before conducting a large contact-tracing initiative
•
The patient has HIV. Before conducting a large contact tracing initiative
•
From other samples only after discussion with the duty Microbiologist
A negative PCR does not rule out TB, treatment should be commenced on clinical grounds in these
circumstances. If detected the PCR test will also report common mutation which lead to rifampicin
resistance.
Specimens must be sent to the laboratory in a sealed bag and labelled biohazard
--- PDF page 25 ---
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25
•
Refer to infectious diseases if TB suspected & commence TB quick
action guide – Appendix 2
•
Do a TB risk assessment for infectious TB & MDRTB see table 1
•
Avoid admission to wards with immunocompromised patients
•
Wear FFP3 respirator while patient suspected or deemed to be
infectious
•
Isolate patient if considered infectious
--- PDF page 26 ---
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Appendices
Appendix 1
Countries with a high incidence of MDR-TB (defined by WHO monitoring data):
The three High Burden Countries lists of 30 countries each that will be used by WHO 2016–2020
Please click link for full report: http://www.who.int/tb/publications/global_report/en/
--- PDF page 27 ---
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Appendix 2 - TB Quick Action Guide
Management of patients with confirmed or suspected Tuberculosis (TB)
(Please see trust TB Guidelines for full details)
Suspected Case □
Confirmed Case □
Suspected or confirmed Pulmonary TB – Please tick the symptoms the patient has
□ Cough > 3weeks
□ Weight loss
□ Night sweats
Other please comment:
□ From high incidence country or ethnic group see link https://www.gov.uk/government/publications/tuberculosis-tb-by-
country-rates-per-100000-people
Multi-Drug Resistant (MDR) TB Risk Assessment – If Any of the below apply MDRTB should be suspected.
□ Prior TB treatment
□ Treatment failure
□ Contact with a known case of drug resistant TB
□ Birth in a foreign country with high incidence of MDR TB. see link in appendix 1
ACTION TO TAKE IF INFECTIOUS TB SUSPECTED OR CONFIRMED
Date
Completed
Signed
Isolate patient in a monitored negative pressure isolation room (preferably on ward 30 & 31,
W31A) N.B. Check alarm is working and pressure is correct before transferring patient into the
room. The acceptable range of pressure is (-.007 )or less i.e (-.030). The minus sign must be
present on the monitor. Daily checks of pressure rooms must be recorded. Contact help desk on
25555 (state priority job) if alarm is not working or pressure range is not correct and inform
Infection Prevention and Control urgently
Attach red isolation door label to the door and keep door closed
Inform infection prevention and control team
Refer to TB physician / Infectious diseases
Collect 3 sputum samples for AFB (1 must be early morning) for microscopy and culture for TB.
Request a TB PCR on one of the samples
Chest X – ray
HIV test if TB confirmed or strongly suspected
Wear FFP3 Respirator at all times when in contact with a patient who has suspected or confirmed
infectious TB or when undertaking a procedure on lesion (s)
The wearer must be fit tested and do a fit check when donning the mask
Educate patient to cover mouth with tissue when coughing & wash hands
Visitors must not visit an infectious patient unless identified as a close contact (contact TBNS team
on 02476961351 to seek further advice on who has been identified as a close contact to the
suspected infectious or confirmed infectious patient). Non close contacts who wish to visit discuss
with the ID consultant prior to visiting.
Patient must wear FRSM if being transferred (Not an FFP3 respirator)
Place Patient ID Label here
Date:
Ward:
New Case:
Previously positive:
--- PDF page 28 ---
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Tuberculosis (TB) Quick Action Guide, Infection Prevention and Control Team, Version 5, updated
November 2023
References
National infection prevention and control manual for England – appendices - Appendix 5a: Personal
protective equipment (PPE) when applying standard infection control precautions (SICPs)
Appendix 5a (england.nhs.uk)
National infection prevention and control manual for England – appendices - Appendix 5b: Personal
protective equipment (PPE) when applying transmission based precautions (TBPs)
Appendix 5b (england.nhs.uk)
National infection prevention and control manual for England – appendices – Appendix 6: Putting on
and removing PPE (donning and doffing
National infection prevention and control manual for England – appendices - Appendix 11a: Aide
memoire for optimal patient placement and respiratory protective equipment (RPE) for infectious
agents in hospital inpatients (based on evidence from WHO, CD and UKHSA
Microsoft Word - Document5 (england.nhs.uk)
National infection prevention and control manual for england – appendices – Appendix 12:
Transmission Based Precautions for deceased patients with infection
https://www.england.nhs.uk/wp-content/uploads/2022/09/national-infection-prevention-and-
control-manual-appendix-12.pdf
If transferring patient to another department / ward the department must be informed prior to
transfer
Contact TB nurse specialist on 02476961351 to inform them the patient is an inpatient on the ward
& prior to discharge and send an email to TBNS - uhc-tr.covwarkstb@nhs.net
Chlorine dioxide (Tristel) must be used for daily cleaning of the rooms and for the terminal clean
following discharge.
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NHS Estates. Isolation facilities in acute settings: In patient accommodation
Clinical diagnosis and management of tuberculosis, and measures of its prevention and control. NICE
guidance. 2011
www.nice.org.uk
WHO (2018) Tuberculosis Key Facts http://www.who.int/news-room/fact-sheets/detail/tuberculosis
Immunisation against infectious disease ‘Green Book’ Department of Health.
https://www.gov.uk/government/collections/immunisation-against-infectious- disease- the-
green-book
HPS (2017) Transmission Based Precautions Literature Review: Respiratory Protective
Equipment (RPE)
http://www.nipcm.hps.scot.nhs.uk/documents/tbp-respiratory-protective-equipment-rpe/
Health and Safety Executive (2013) Respiratory Protective Equipment Regulations. HSE: London
https://www.hse.gov.uk/pubns/books/hsg53.htm
https://www.hse.gov.uk/pubns/indg479.pdf
NICE Guidance (NG 33)
Recommendations | Tuberculosis | Guidance |
NICE
https://www.gov.uk/topic/health-protection/infectious-diseases
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ATTACHMENT: 10.pdf
TEXT_FILE: 10.pdf.txt
METHOD: pdf_native
OCR_USED: False
PAGES: 21
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--- PDF page 1 ---
Clinical Operating Procedure
Procedure Title:
Trust wide Clinical Operating Procedure and Principles for
Aseptic Non Touch Technique (ANTT)
Procedure Ref No: COP 193
Review date:
December 2023
Expiry date:
June 2024
Version Number:
V13
Summary statement /scope of the procedure:
This document sets out the guidelines, clinical procedure and principles of aseptic
non touch technique (ANTT)
This COP is applicable to all staff trust wide who undertake ANTT. It is a staff member’s
responsibility to make themselves aware of the contents of this guideline and to put
the guidance into practice. Clinical staff who undertakes ANTT must complete the e-
learning ANTT course available on ESR.
Recommendations for procedure content:
Clinical operating procedures should detail clear and explicit recommendations for practice
and behaviour specific instructions; what, who, when, where and how. This will increase the
likelihood of adoption of the procedure.
Please note: The following systems have been replaced by the trust Electronic Patient Record system
(EPR). If any of these systems are identified within the document, please substitute them for the appropriate
EPR alternative system and refer to relevant corresponding EPR procedures.
1. Opera (theatres)
2. Centricity (Critical Care)
3. Wardview
4. Extramed
5. CRRS
6. VitalPack
7. Adastra (CUTC)
8. K2 (maternity portal replaced by PPUK)
9. i.PM
10. Athena (Maternity)
11. SCIT App (replaced by camera capture)
Please contact EPREnquiries@uhcw.nhs.uk if you have any questions about the systems listed
or the EPR system introduced in their place.
On review of this document please ensure the systems listed are removed from the text and
replaced with the relevant EPR system and process.
--- PDF page 2 ---
1. Definitions
Aseptic technique: the method by which precautions are taken during invasive clinical
procedures to prevent the transfer of microorganisms from the healthcare worker, procedure
equipment or the immediate environment to the patient. Regardless of the setting the aim is
always to prevent the transfer of pathogenic micro-organisms from the healthcare worker,
procedure equipment or the immediate working environment into or onto the patient
Aseptic Non Touch Technique (ANTT): A specific type of aseptic technique with a unique
Theoretical and Practice Framework.
Aseptic field: a designated aseptic working space that contains and protects the procedure
equipment, in ANTT there are differing aseptic fields:
Critical aseptic field: an aseptic field using a dressing pack or sterile drape where only
aseptic Key-Parts can come into contact with it. A critical aseptic field is used to ensure
asepsis and requires critical management
General aseptic field - is used to promote asepsis rather than ensure it, this may be through
the use of a clean tray or trolley. Micro critical aseptic field (MCAF is used to ensure Key-
Part asepsis and requires general management.
Micro critical aseptic field (MCAF): a small critical aseptic field used to protect a specific
key-part, e.g. a syringe cap or needle cover, other examples may include ‘backing’ to
dressings
Critical management: The whole main aseptic field (usually a sterile drape) is maintained
aseptically. i.e. Only sterile or aseptic equipment can come into contact with the critical
aseptic field, sterile gloves are used to maintain aseptic continuity
General management: Whilst the main aseptic field (Usually a plastic or paper tray) is still
managed aseptically and helps to promote a safe working space, it is not as aseptic as a
sterile drape and therefore is not relied upon as the primary method of equipment protection.
Equipment asepsis is maintained by protecting Key-Parts individually with micro critical
aseptic fields (caps and covers).
Healthcare associated infection (HCAI): any infection acquired by a person as a
consequence of healthcare interventions regardless of where care is delivered
Key-Part: the critical part of procedural equipment that comes into contact with the patient
(a Key-Site) or other procedural equipment i.e. liquid infusion during the procedure.
Key-Site: can be a wound, insertion and access sites for a medical device
Non-touch technique: an integral component in achieving aseptic technique and should
always be applied where practically possible and relates to Key-Parts and Key-Sites which
should not be handled unless unavoidable to do so.
2. Aim/indications
--- PDF page 3 ---
The aim of using an ANTT is to reduce infections by preventing the introduction of
potential pathogens into susceptible sites such as wounds, the bladder or other
organs/vessels. It is also to prevent the transfer of potential pathogens from the Health
Care Worker to patient and vice versa.
An ANTT should be used during any invasive procedure that bypasses the body’s natural
defences of the skin and mucous membranes (Dougherty and Lister 2015) E.g:
• Wound management – Appendix 1
• Intravenous cannulae insertion and management - Appendix 5
• IV drug administration – Appendix 4
• Venepuncture – Appendix 3
• Central line insertion and management
• Urinary catheter insertion and management – Appendix 2
3. Assessment
An assessment of the individual patient must be undertaken prior to deciding whether
the procedure requires an aseptic non touch technique. The practitioner must then
decide whether a standard or surgical ANTT is required.
Choice of Surgical ANTT or Standard ANTT is based on assessment of risk - according
to the technical difficulty of protecting key parts and key sites see figure 1.
Key-Parts & Key-Sites
Key sites are the areas on the patient such as a wound, or IV insertion site that must be
protected from microorganisms.
Key- Parts: the aseptic parts of the procedure equipment that need to have direct
contact with aseptic key parts of the patient, key sites or any liquid infusion. If
contaminated, key-parts provide a direct route for transmission of pathogens between
the procedure and the patient.
--- PDF page 4 ---
There are many causes of infection in healthcare, but during aseptic technique there is
ultimately one cause or decisive failure; the contamination of key-parts and key- sites.
Contamination will occur via the healthcare professional as a vector of infection, or by
risks present in the immediate physical and air environment including the patient’s flora.
ANTT combats this fundamental principle with the essential practice of identifying,
cleaning effectively (if required), and optimally protecting the key-parts and key-sites at
all times during a procedure.
Examples on how to protect key-parts in IV therapy is to ensure syringe tips are always
protected by dedicated caps, capped needles or the inside of syringe packets.
The effective cleaning of key-parts is critical. For example, when cleaning an
intravenous port, introduce the port tip into the centre of a large 70% alcohol 2%
chlorhexidine impregnated wipe. Scrub the tip hard generating friction for at least 15
seconds. Use different parts of the wipe in order to clean away as well as kill any harmful
organisms.
Glove choice
In ANTT, if it is necessary to touch key-parts directly then sterile gloves should be used
to minimise the risk of contamination. Otherwise, non-sterile gloves are usually the
logical glove of choice. Non sterile gloves need to be stored appropriately and not moved
from dirty to clean rooms.
Aseptic Fields
Aseptic fields are considered important because they help promote or ensure the
integrity of asepsis during clinical procedures by providing a controlled aseptic working
space. It is also important that aseptic fields are fit for purpose. For example, in IV
therapy, mobile aseptic fields, such as trays, should provide an adequate aseptic
working space with high sides to contain equipment, sharps and spillages.
Aseptic field equipment can include a plastic tray or a procedure trolley. Typically,
aseptic fields are increased in size and sterilised drapes or towels added on the basis of
procedure complexity. When sterile towels or drapes are introduced it is generally
--- PDF page 5 ---
considered acceptable for sterile equipment and key- parts to be unprotected and
exposed when necessary, however they should be protected where possible i.e a urinary
catheter must remain within the inner packet (critical micro aseptic field) until insertion
takes place.
ANTT involves two grades of aseptic field that require different management
Critical Aseptic Fields
Critical aseptic fields are used when key-parts, usually due to their size or number,
cannot easily be protected at all times with covers and caps, or handled at all times by a
non touch technique (such as in a peripherally inserted central catheter (PICC), or when
particularly open, invasive or technical procedures demand large aseptic working areas.
In such cases, the main critical aseptic field demands to be managed as a key-part (i.e.
only equipment that has been sterilised and is aseptic can be introduced into the critical
aseptic field, which consequently demands the use of sterile gloves).
Critical Micro Aseptic Fields
A sub-type of critical aseptic field is the critical micro aseptic field. Traditional non touch
techniques have protected key-parts by way of syringe caps, sheathed needles, covers
or packaging. This traditional method is often understated as the inside of such caps
and covers have been sterilised and thus provide optimum micro aseptic fields for key-
parts.
General Aseptic Fields
General aseptic fields are used when key-parts can easily and optimally be protected by
critical micro aseptic fields and a non touch technique. As a result, the main general
aseptic field does not have to be managed as a key-part and is essentially promoting
rather than ensuring asepsis. Subsequently, aseptic technique is considerably simplified
and typically involves non-sterile gloves.
Surgical and Standard-ANTT
Surgical ANTT
--- PDF page 6 ---
This is demanded when procedures are technically complex, involve extended periods
of time, large open key-sites or numerous key-parts (i.e. wound management or central
venous catheter (CVC) insertion on a ward). Subsequently, a main critical aseptic field
and sterile gloves are demanded. Surgical ANTT should still utilise critical micro fields
and non – touch technique where practical to do so.
Standard ANTT
Procedures managed with standard ANTT will typically be technically simple, short in
duration (in general, less than 20 minutes), and involve smaller key-sites and key-parts
(e.g. IV therapy, or peripheral cannulation). Standard aseptic technique typically
requires a main general aseptic field i.e. a plastic tray or procedure trolley and non-
sterile gloves. It relies heavily on a non-touch technique and the use of critical micro
aseptic fields to protect key-parts.
Figure 1
--- PDF page 8 ---
The two types of ANTT can be simplified into ‘The ANTT-Approach’. The ANTT-Approach
highlights and promotes the essential elements of safe aseptic technique figure 2 above:
--- PDF page 9 ---
Hand Washing
Hand decontamination remains an essential component of ANTT. In Standard ANTT,
hand decontamination is considered to be a promoter of asepsis.
Clinical Operating Procedure for SURGICAL Aseptic Non Touch Technique (ANTT)
i.e. Wound Dressing see Appendix 1 or Urinary catheter insertion see Appendix 2
for step by step guide
4. Basic Equipment Required
The patients care plan must be checked prior to commencing any procedure and the
equipment should be appropriate for the procedure to be undertaken.
• A clean procedure trolley
N.B any sticky tape residue should be removed from the trolley.
Procedure trolleys must not be used for any other purpose, i.e. linen or collection of
crockery. Separate trolleys may be labelled up and kept separate for this purpose.
• Alcohol hand-rub.
• Plastic disposable apron.
• Sterile equipment dependant on the procedure being undertaken
E.g. for wound care sterile dressings and a wound care pack will be required
For urinary catheter insertion a catheter insertion pack and correctly sized catheter will
be required
ACTION
RATIONALE
Avoid carrying out procedure immediately
after bed-making or similar activities, e.g.
cleaning, protective meal times etc.
Close windows, turn off fans
To ensure that airborne bacteria will be
minimal
Explain and discuss the procedure with
the patient gain consent, provide
analgesia if required and encourage
questions.
To ensure the patient understands the
procedure and gives informed consent
(UHCW 2019). To maintain patients’
privacy and dignity
--- PDF page 10 ---
Draw screens around the patients bed
and ensure adequate light is available
Make patient comfortable in an
appropriate area. Ensuring the site of the
procedure is accessible
Ensure accessibility of site to enable the
procedure to be undertaken
Wash hands as per UHCW Hand
Decontamination Policy (2020)
To minimise contamination whilst
assembling equipment.
Don clean plastic apron and non sterile
gloves
To protect uniform from contamination
and to minimise the potential for micro-
organisms on the uniform reaching the
patient and vice versa.
Decontaminate trolley with Tristel fuse or
Jet foam.
To ensure a clean working surface
Wash hands as per UHCW Hand
Decontamination Policy (2020)
To minimise contamination whilst
assembling equipment
Assemble the equipment, checking the
integrity and expiry date of the
packaging. Ensure that single use items
are used for single patient use only
To ensure that equipment is sterile, safe
and readily available
Wash hands again as per UHCW Hand
Decontamination Policy (UHCW 2020)
To prevent cross infection if handling
contaminated material
i)
Create a critical aseptic field on
the procedure trolley with a sterile
waterproof sheet or procedure
pack handling the corners of the
sterile outer sheet only.
ii)
Place hand inside waste bag or
use sterile gloves to position items
on the critical aseptic field and
secure the adhesive edge of the
bag below the upper tier of the
trolley
Open all other sterile equipment by
peeling packages apart and sliding
contents carefully onto the field, ensuring
that outer packages do not come into
contact with the critical aseptic field
Ensure all equipment remains within the
field throughout the procedure; items that
become contaminated must be discarded
To prevent contamination of the critical
aseptic field during ANTT
To provide area for disposal within easy
reach and protect the area from
contamination to conform with the
UHCW Waste management Policy
(UHCW 2019)
To prevent contamination of the critical
aseptic field during ANTT
To prevent contamination of the critical
aseptic field during ANTT
--- PDF page 11 ---
Wash and dry hands again if soiled. If
hands are visibly clean, apply alcohol
hand-rub to all surfaces of hands and
wrists and allow to dry as per UHCW
Hand decontamination Policy (2020)
To minimise the risk of cross infection
and to prevent contamination of gloves
Apply non sterile gloves to commence
procedure e.g.
• to remove old dressing (wound
care)
• clean urethral meatus ( prior to
catheterisation)
dispose of all waste and non sterile
gloves in waste bag
To minimise the risk of cross infection
Apply alcohol hand-rub to all surfaces of
hands and wrists and allow to dry as per
Trust Hand decontamination Policy
(2020)
To minimise the risk of cross infection
Apply sterile gloves, touching only cuffs
To avoid contamination of gloves.
Complete the task according to care plan
or procedure guidelines ensuring key
parts and key sites are not contaminated
To ensure compliance with best practice
standards
To minimise the risk of cross infection
On completion, dispose of clinical waste
into clinical waste bag, seal it shut prior
to leaving the bedside and dispose of
sharps into sharps containers in
accordance with UHCW Waste
management Policy (UHCW 2019).
To minimise the risk of cross infection
and ensure safe disposal of sharps.
Make patient comfortable
To maintain patients dignity and comfort.
Wash hands as per UHCW Hand
Decontamination Policy (UHCW 2020)
To minimise the risk of cross infection
Take clinical waste to sluice and discard
as per Waste management Policy(UHCW
2019)
To ensure safe disposal of clinical waste.
Dismantle equipment.
Decontaminate procedure trolley with
Tristel fuse or jet foam , commencing at
the top surface and including all rails ,
lower surface and stopping at the wheel
buffers. UHCW Clinical operating
procedure for the cleaning and
disinfection of non invasive equipment
In order to maintain a tidy environment
--- PDF page 12 ---
and computers (UHCW 2019) and
decontaminate hands.
Complete the appropriate documentation
stating that the procedure was completed
using an aseptic non touch technique,
referring any concerns to the nurse or
clinician in charge.
To ensure continuity of care, early
recognition of problems and appropriate
treatment and compliance with
guidelines for record keeping (NMC
2015).
Clinical Operating Procedure for STANDARD Aseptic Non Touch Technique
(ANTT) i.e. cannula insertion see Appendix 5
ACTION
RATIONALE
Avoid carrying out procedure
immediately after bed-making or similar
activities, e.g. cleaning, protective meal
times etc.
Close windows, turn off fans
To ensure that airborne bacteria will be
minimal.
Explain and discuss the procedure with
the patient gain consent, provide
analgesia if required and encourage
questions.
Draw screens around the patients bed
and ensure adequate light is available
To ensure the patient understands the
procedure and gives informed consent.
To maintain patients’ privacy and dignity
Make patient comfortable in an
appropriate area. Ensuring the site of the
procedure is accessible
Ensure accessibility of site to enable the
procedure to be undertaken
Wash hands as per UHCW Hand
Decontamination Policy (2020)
To
minimise
contamination
whilst
assembling equipment
Don clean plastic apron and non sterile
gloves.
To protect uniform from contamination
and to minimise the potential for micro-
organisms on the uniform reaching the
patient and vice versa.
Decontaminate procedure trolley with
Tristel fuse or jet foam , commencing at
the top surface and including all rails ,
lower surface and stopping at the wheel
buffers.
To ensure a clean working surface.
Wash hands as per UHCW Hand
Decontamination Policy (2020)
To
minimise
contamination
whilst
assembling equipment.
Assemble the equipment, checking the
integrity and expiry date of the packaging.
To ensure that equipment is sterile, safe
and readily available.
--- PDF page 13 ---
Ensure that single use items are used for
single patient use only
Wash hands again as per UHCW Hand
Decontamination Policy (UHCW 2020)
To prevent cross infection if handling
contaminated material.
iii)
Create a general aseptic field on
the tray
iv)
Open all other sterile equipment
by peeling packages apart,
ensuring that key parts remain
within their own micro critical
aseptic field.
To prevent contamination of the general
aseptic field during ANTT
To prevent contamination of the key
parts
Wash and dry hands again if soiled. If
hands are visibly clean, apply alcohol
hand-rub to all surfaces of hands and
wrists and allow to dry as per UHCW
Hand decontamination Policy (2020)
To minimise the risk of cross infection and
to prevent contamination of gloves.
Apply non sterile gloves to commence
procedure
To minimise the risk of cross infection
Complete the task according to care plan
or procedure guidelines ensuring key
parts and key sites are not contaminated
To ensure compliance with best practice
standards
To minimise the risk of cross infection
On completion, dispose of clinical waste
into clinical waste bag, seal it shut prior
to leaving the bedside and dispose of
sharps into sharps containers in
accordance with UHCW Waste
management Policy (UHCW 2019).
To minimise the risk of cross infection and
ensure safe disposal of sharps.
Make patient comfortable
To maintain patients dignity and comfort.
Wash hands as per UHCW Hand
Decontamination Policy (UHCW 2020)
To minimise the risk of cross infection.
Take clinical waste to sluice and discard
as per Waste management
Policy.(UHCW 2019)
To ensure safe disposal of clinical waste.
In order to maintain a tidy environment
Dismantle equipment.
Decontaminate procedure trolley with
Tristel fuse or jet foam , commencing at
the top surface and including all rails ,
lower surface and stopping at the wheel
--- PDF page 14 ---
buffers. UHCW Clinical operating
procedure for the cleaning and
disinfection of non invasive equipment
and computers (UHCW 2019) and
decontaminate hands
Complete the appropriate documentation,
referring any concerns to the named
nurse or clinician in charge.
To ensure continuity of care, early
recognition of problems and appropriate
treatment and compliance with
guidelines for record keeping (NMC
2015).
If the Reviewer and Author is the same person please tick box ✓
If the Reviewer and Author is not the same person please provide the Reviewer
details below
Reviewer Name:
Fiona Wells
Reviewer Job Title:
Infection Prevention and Control Nurse
Reviewer email address:
Fiona.Wells @uhcw.nhs.uk
Approved by:
Infection Prevention and Control Committee
Date Approved:
May IPC
Primary Specialty:
Infection Control
Secondary Specialty:
N/A
Other Specialty:
N/A
Are there any UHCW documents related to this topic area Yes✓
No
If yes please provide Title
Does this Clinical
Operating Procedure relate
to a Clinical Guideline?
Peripheral Cannulation
Venepuncture
Author Name:
Melanie Gallo
Amy Verdon
Author Job Title:
Melanie Gallo – Infection Prevention and Control Nurse
Amy Verdon – Tissue Viability Nurse
Author email address:
Melanie.gallo@uhcw.nhs.uk
Amy.verdon@uhcw.nhs.uk
TRAINEE NURSING ASSOCIATES or NURSING ASSOCIATES - A NEW NURSING ROLE
If Registered Nurses or Student Nurses will be undertaking a role, or carry out
procedures in your area, you will now need to consider the role/input/restrictions for
Trainee Nursing Associates/Nursing Associates and refer to them within your
document. If you require any further information please contact Karen Mogan Practice
Facilitator karen.mogan@uhcw.nhs.uk<mailto:karen.mogan@uhcw.nhs.uk>
--- PDF page 15 ---
University Hospitals Coventry and Warwickshire NHS Trust (2019) Consent for
examination or treatment policy. UHCW.
University Hospitals Coventry and Warwickshire NHS Trust. (2020) Trust wide hand
Decontamination Policy.UHCW
University Hospitals Coventry and Warwickshire NHS Trust. (2019) Cleaning and
disinfection of Non-Invasive Equipment and computers.UHCW
University Hospitals Coventry and Warwickshire NHS Trust. (2019) Waste
management Policy, UHCW
Guideline and Competency Package for the Insertion and Management of Peripheral
Venous Cannula (2019)
Scope of professional practice training package and guideline for obtaining a venous
blood sample (2017)
References
Aseptic Non Touch Technique The ANTT Clinical Practice Framework 2015; 4.
www.antt.org
Dougherty L. Lister S (2015) Aseptic Technique In: L Dougherty & S Lister (eds) The
Royal Marsden Hospital Manual of Clinical Nursing Procedures 9th Ed. UK. Wiley-
Blackwell 110-112 Chapter 3. March 2015.
Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database of Systematic
Reviews 2002, Issue 4. Art. No.: CD003861. DOI: 10.1002/14651858.CD003861.pub2
Griffiths R. Fernadez R. Ussia C (2001). Is tap water a safe alternative to normal saline
for wound irrigation in the community setting? Journal of Wound Care. 10:10. 407-410.
http://antt.org/ANTT_Site/patient_involvement.html
Infection Control Nurses Association (2003) “Asepsis: Preventing Healthcare
Associated Infection”
National Audit Office. (2004) The Management and Control of Hospital Acquired
Infection in Acute NHS Trusts in England. London: NAO
NICE (2012) Infection: prevention and control of healthcare-associated infections in
primary and community care. National Clinical Guideline Centre Available: Last
updated 2017
--- PDF page 16 ---
http://guidance.nice.org.uk/CG139/Guidance/pdf/English
Nursing and Midwifery Council (2015). The code professional standards of practice
and behaviour for nurses and midwives
Loveday HP, Wilson JA, Pratt RJ, Golsorkhia A, Tingle A, Bak J, Browne J, Prieto J and Wilcox
M (2014) epic3: National evidence based guidelines for preventing health care associated
infections in NHS hospitals in England, J Hosp Infect (86), Supplement 1, S1-S70. 13
Rowley S. (2001) Aseptic non-touch technique. Nursing Times. Feb 15th Vol 97, No 7.
Rowley S, Clare S, Macqueen S, Molyneux R (2010) ANTT V2: An updated practice
framework for aseptic technique British Journal of Nursing (Intravenous Supplement) Vol
19 No 5
Rowley, S. Clare, S. Baks, G. Fernandes, P. (2012) ANTT Aseptic Non Touch
Technique http://www.antt.org.uk/ANTT_Site/core_guidelines.html
Surgical Site Infection Surveillance Scheme. (2003) Health Protection Agency Colindale
London
Appendix: 1
1.1
--- PDF page 17 ---
Appendix 2:
Appendix 3:
--- PDF page 18 ---
:
Appendix 4:
Appendix 5:
--- PDF page 19 ---
Appendix : 6
6.1
--- PDF page 20 ---
6.2
--- PDF page 21 ---
Appendix 7:
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--- PDF page 1 ---
1
Clinical Operating Procedure
Procedure Title:
Management of Clostridioides difficile
(Previously known as Clostridium difficile) for adults
Procedure Ref No:
COP 978
Review date:
March 2024
Expiry date:
September 2024
Version Number:
V3
Summary statement /scope of the procedure:
•
Clostridioides difficile is a Gram positive, anaerobic spore-forming organism implicated in
Clostridioides difficile infection (CDI) and pseudomembranous colitis (PMC).
•
The overgrowth of the organism within the large intestine and toxin production causes cellular
damage and increased fluid accumulation in the gut.
•
Infection and/or colonisation is usually acquired by ingestion after contact with a contaminated
environment, equipment, other patients or the hands of staff.
•
Clostridioides difficile is part of the normal flora of up to 3% of the adult population and up to
90% of children less than 2 years. Asymptomatic carriage in healthcare patients is relatively
common.
This Clinical Operating Procedure provides details on how to reduce the risk of transmission of CDI
within the healthcare setting and information on the appropriate treatment of patients with CDI.
--- PDF page 2 ---
2
Please note: The following systems have been replaced by the trust Electronic Patient Record system
(EPR). If any of these systems are identified within the document, please substitute them for the appropriate
EPR alternative system and refer to relevant corresponding EPR procedures.
1. Opera (theatres)
2. Centricity (Critical Care)
3. Wardview
4. Extramed
5. CRRS
6. VitalPack
7. Adastra (CUTC)
8. K2 (maternity portal replaced by PPUK)
9. i.PM
10. Athena (Maternity)
11. SCIT App (replaced by camera capture)
Please contact EPREnquiries@uhcw.nhs.uk if you have any questions about the systems listed or the EPR system
introduced in their place.
On review of this document please ensure the systems listed are removed from the text and replaced with the relevant
EPR system and process.
Guiding Principles of management
Appendix A-Diarrhoea Assessment tool
Appendix B- Management of the Clostrioides difficile Positive Patient
Appendix C- Algorithm for CDI Management
Appendix D- Oral vancomycin administration details
Appendix E- Bristol Stool chart
--- PDF page 3 ---
3
1. Transmission and Prevention
CDI can be spread by person-to-person contact, contact with contaminated surfaces, or exposure in
the environment (by colonised medical equipment).
Careful attention to infection prevention control procedures, such as hand hygiene and
environmental cleaning, can reduce the risk of transmission.
Once this organism becomes established in a unit, it can be extremely difficult to eradicate, so
preventing it from becoming established is very important.
It is important that patients are isolated as soon as CDI is suspected. Do not wait for a
positive result to come back.
Call microbiology to discuss re-sampling within 28 days for C. difficile/ to discuss the need
for further treatment.
2. Patient Risk Group
Risk factors which increase chances of colonisation and/or infection with CDI include (please be
aware this list is not exhaustive and clinical judgement must be exercised):
•
Recent and ongoing antibiotic treatment – particularly cephalosporins, clindamycin,
quinolones, penicillins, macrolides etc.
•
Aged ≥65 years
•
Prolonged stay in hospital
•
Severity of underlying disease
•
Gastrointestinal procedures/ bowel surgery
•
Immunocompromised including HIV and transplant
•
Proton Pump Inhibitors (PPI) and H2 antagonists
•
Enteral feeding/ NG tube
•
Aperients (lactulose/enema)
•
Patients who have had previous CDI diarrhoea, or who have had previous
‘equivocal’ c. diff stool report
•
Prolonged stay in other institutions e.g. nursing homes
3.Sending Samples
The first episode of diarrhoea with either: a positive Toxin test, a pending Toxin test, or clinical suspicion of
CDI, a sample should be taken.
For recurrent episodes (at least 3 consecutive type 5, 6 or 7 stools) after 28 days of previous CDI episode.
*** Call microbiology to discuss re-sampling within 28 days for C. difficile/ to discuss the need for further
treatment. ***
3.Staff working with C diff patients
Staff caring for patients with confirmed or suspected CDI should do so with strict adherence to contact
precautions and use of PPE must be maintained. Hands must be washed with soap and water when
entering and leaving rooms. Alcogel is insufficient.
Where practically possible see all other patients prior to those with confirmed or suspected C diff.
Transporting a patient with CDI in the hospital on a bed, trolley or in a wheelchair is a low risk activity.
There is no requirement for porters to wear gloves, aprons or other PPE on transferring patients.
Equipment should be decontaminated after transportation using chlorine dioxide solution (e.g. Tristel).
All therapy services will continue as clinical need dictates. Ideally the CDI case will be visited
last after other areas have been attended to. Staff will adhere strictly to the use of PPE and good
hand hygiene.
--- PDF page 4 ---
4
3. Mattresses
After a patient is discharged the mattress must be thoroughly checked and decontaminated using
chlorine dioxide solution (e.g. Tristel). Dynamic mattresses should be sent to the mattress library after
a Tristel clean and apply a clean certificate onto it.
4. Transferring of Patients
Infection Prevention and Control measures should not compromise the patients care and should not affect
the patient’s freedom to be mobilised or attend other departments for health care related visits.
It is the responsibility of the nursing staff on the transferring ward to make direct contact with staff on
the receiving ward or department (e.g. radiology) to make sure that they are aware of the patient’s
CDI status in advance of the transfer to another ward or institution.
5. Laundry
All laundry must be considered contaminated and placed in a red alginate bag inside a white outer
bag.
6. Cutlery and Crockery
Ordinary cutlery and crockery can be used.
Disposable crockery and cutlery are not required.
Under no circumstances should any crockery or cutlery be washed by hand.
7. Visitors
Visitors are not required to wear protective clothing unless involved in the patient’s personnel care,
when an apron should be worn. Visitors should wash their hands immediately with soap and water
prior to leaving the isolation room and should not wander around the ward and visit other patients.
8. Last offices
No special precautions are needed for CDI positive patients.
9. Terminal Cleaning
Once the patient has been discharged, transferred or no longer deemed infectious. A terminal clean is
required of the bay or side room the patient was symptomatic in.
10. Hydrogen Peroxide Vapour (HPV) Fogging
If symptomatic, the side room used for isolation should be fogged on discharge/ de-escalation of
isolation on symptom improvement. Contact Infection Prevention and Control team if assistance
required with this. If unable to fog the side room then a signed off terminal clean should be completed.
11.
Toxigenic C. difficile NOT detected.
Please note sensitivity of test is less than 100% and infection may therefore be present in a small
number of cases despite a negative test. If symptoms still suggest possibility of C. difficile please send
repeat sample and contact medical microbiologist. This sample is not tested, as positive within the
last 28 days. Please discuss with the Clinical Microbiologist if any clinical concerns.
TOXIGENIC Clostridioides difficile detected.
The toxin is present and is likely causing clinical disease. Please review the patient's condition and
liaise with microbiology.
Please refer to the local intranet guidelines for management of C. difficile induced diarrhoea and colitis
or NICE guidance on the management and treatment of C. difficile infection" for community patients.
--- PDF page 5 ---
5
If the patient has diarrhoea with no other identified cause, consider treating as per the national
guideline. First, review the severity of the disease. For mild or moderate infection please prescribe
oral vancomycin, 125mg 6 hourly.
If patient meets the criteria for severe infection (as per Trust/ National guidance) or if there are any
clinical concerns such as relapsing disease please contact microbiology urgently. Stop all concurrent
antibiotics unless absolutely necessary and review the use of PPI's.
Neither loperamide nor laxatives should be given at this time. If the patient is in a hospital, they should
be isolated in line with Trust Infection Prevention and Control Policy.
Clostridioides difficile TOXIN GENE detected.
The toxin producing gene is present but it may NOT be expressed i.e. Causing clinical disease. Please
review the patient's clinical condition and liaise with microbiology if required.
Please refer to the local intranet guidelines for management of C. difficile induced diarrhoea and colitis
or NICE guidance on the management and treatment of C. difficile infection" for community patients.
If the patient has diarrhoea with no other identified cause, consider treating as per the national
guideline. First, review the severity of the disease. For mild or moderate infection please prescribe
oral vancomycin, 125mg 6 hourly.
If patient meets the criteria for severe infection (as per Trust/ National guidance) or if there are any
clinical concerns such as relapsing disease please contact microbiology urgently. Stop all concurrent
antibiotics unless absolutely necessary and review the use of PPI's.
Neither loperamide nor laxatives should be given at this time. If the patient is in a hospital, they should
be isolated in line with Trust Infection Prevention and Control Policy.
--- PDF page 6 ---
6
Inpatient Management of Clostrioide Difficile Infection (CDI) – see appendix C for reporting of results and
interpretation
Patient suspicion of CDI
OR Symptomatic patient who is previously known CDI
toxin/equivocal positive
No action is required for asymptomatic previously known
individuals
Newly diagnosed CDI
Investigation of suspicion of CDI
Appendix A
Algorithm of
severity
Appendix C
•
Cleaning of theatre surfaces, should be
carried out using Tristel after every case
•
Air exchanges in theatre are of a
sufficient standard no “rest” period is
required between cases
•
If clinically possible place patient last on
list
Theatres
Quick Action Guide
Management of the Clostrioides difficile Positive Patient
Appendix B
--- PDF page 7 ---
7
Investigation of suspicion of CDI
Appendix A
•
Strict adherence to the WHO five
moments of hand hygiene is required
•
There is no need to remove furniture or
equipment from consulting rooms
•
Surfaces that the patient has been in
direct physical contact with, e.g. the
couch, should be wiped down with
chlorine dioxide solution (e.g. Tristel)
Newly diagnosed CDI
Patient suspicion of
OR Symptomatic patient who is previously known CDI
toxin/equivocal positive
No action is required for asymptomatic previously known
individuals
Outpatient Department Management of Clostrioide Difficile Infection (CDI)
Algorithm of severity
Appendix C
•
Where clinically appropriate
place patient at the end of
the list
•
Terminal clean to be carried
out at the end of procedure
Endoscopy
--- PDF page 8 ---
8
APPENDIX A Diarrhoea Assessment Tool
YES
-Monitor bowel chart
NO
-Ensure antibiotic stewardship
(Refer to Trust Antibiotic
Guideline CG 1168)
-No further action required
(including previously known
toxin/equivocal positives)
YES
Review. Clinical suspicion of CDI?
-Stool chart – at least 1 episode of type 5,
6 or 7 stools within a 24-hr period?
-General condition
-Rise in WCC, CRP, Creatinine
- Previous history/ alerts on CRRS?
YES
NO
NO
NO
YES
-Monitor Bristol stool chart
-Ensure antibiotic stewardship
-No further action required
(including previously known
toxin/equivocal positives)
Version 4.0 June 2022
Assess history. Are there underlying factors?
E.g.
-Inflammatory bowel disease
-Overflow- constipation
-Aperients e.g. enema/ laxatives
-Enteral feeding
-New medication
-Antibiotics
-Patients normal bowel habits
-PPI
-Checked CRRS alerts?
Patient has had 1 x episode of type 5, 6 or 7 on Bristol
Stool Chart/ Increased frequency/ offensive smell?
Infection suspected
Ensure all actions, conversations and clinical plans for patient are well documented within the patient’s notes.
Consider treatment of CDI infection BEFORE test results if
signs of severe clinical infection (see Quick Action Guide
Appendix C)
-Raised WCC
-Raised CRP
-Temperature
-Abdominal or radiological signs of severe colitis (number of motions
less reliable)
-Isolate in a side room with ensuite/ own commode
-Terminal clean of bay if not in isolation
-Door closed with isolation sign
-Obtain specimen send for CDI and MC+S and document in
notes date and time taken
-Dedicated equipment/single use equipment e.g. BP Cuff
-Stool monitoring chart
-commence QAG (quick action guide) See page 6/Appendix B
Non-infective diarrhoea.
-Review/modify treatment
-Underlying cause
-Medication
-Maintain Bristol stool chart and fluid
balance
Review clinical response 24-48
hours. Is there an improvement?
--- PDF page 9 ---
7
--- PDF page 10 ---
8
--- PDF page 11 ---
9
--- PDF page 12 ---
10
--- PDF page 13 ---
10
Appendix C: Algorithm for Clostrioide Difficile Infection (CDI) Management
Result
Actions
=
•
Complete Quick Action Guide (page 7/8)
•
Isolation until 48 hours asymptomatic
•
Review all medications and symptoms regularly
•
See Page 9 for C. diff treatment options
•
Consider prompt Surgical review if colitis suspected
•
Contact Microbiology for additional antibiotic advice.
•
Assess symptoms and only start treatment if symptomatic
•
Complete Quick Action Guide (page 7/8)
•
Consider other causes of diarrhoea
•
Discuss treatment options with Microbiology
•
If symptomatic please continue single room isolation and other infection
prevention and control measures
•
Consider other causes of diarrhoea.
•
If non-infective cause consider ending single room isolation.
GDH Positive, Toxin EIA Positive
CDI is likely to be present- TOXIGENIC
Clostridioides difficile detected.
Red alert on CRRS
For mandatory reporting to UK HSA by
the Infection Prevention and Control
team
GDH Positive, Toxin EIA Negative, PCR
Positive
CDT could be present i.e. potential
Clostridioides difficile excretor.
Reported as Clostridioides difficile
TOXIN GENE
detected.
No requirement to be reported to UK
HSA (may still need to be reported
locally and carries a potential
transmission risk).
GDH Positive, Toxin EIA Negative, PCR
Negative
CDT in unlikely to be present. Reported
as Toxigenic C. difficile NOT
detected.
No requirement to be reported to UK
HSA, however may carry a potential
transmission risk (other pathogens).
If POSITIVE CDT result: retesting is not recommended for ongoing symptoms or proof of infection clearance
Consider treatment of CDI BEFORE results come back if evidence of severe disease:
•
Raised WCC
•
Raised Creatinine
•
Temperature
•
Clinical or Radiological evidence of colitis
--- PDF page 14 ---
11
Appendix D- Oral vancomycin administration details
Vancomycin is given via the oral route for the treatment of CDI, and the preferred method of administration to
inpatients is to give the IV injection orally (capsules may be supplied on discharge).
•
Reconstitute the vancomycin vial with the required volume of water for injection as specified by the
manufacturer
•
Labels vial for specific patient with date and time reconstituted, each vial will last for 24hours when
stored between 2 and 8 degrees.
•
This solution can also be used to administer vancomycin via enteral feeding tubes.
Vancomycin 500mg Powder for infusion. Wockhardt UK Ltd. Available from medicines.org.uk Date accessed
26/01/21
Vancomycin Monograph. The NEWT guidelines. Wrexham Maelor Hospital Pharmacy department. Available at
https://access.newtguidelines.com/V/Vancomycin.html Date accessed 26/01/21
--- PDF page 15 ---
12
Appendix E- Bristol stool chart
--- PDF page 16 ---
13
Appendix F Stool monitoring Chart
--- PDF page 17 ---
14
Does this Clinical
Operating Procedure relate
to a Clinical Guideline?
No
Yes
(if Yes, please detail )
Author Name:
Fiona Wells
Author Job Title:
Infection Prevention and Control
Author email address:
Fiona.Wells@uhcw.nhs.uk
TRAINEE NURSING ASSOCIATES or NURSING ASSOCIATES - A NEW NURSING ROLE
If Registered Nurses or Student Nurses will be undertaking a role, or carry out
procedures in your area, you will now need to consider the role/input/restrictions for
Trainee Nursing Associates/Nursing Associates and refer to them within your
document. If you require any further information please contact Karen Mogan Practice
Facilitator karen.mogan@uhcw.nhs.uk<mailto:karen.mogan@uhcw.nhs.uk>
If the Reviewer and Author is the same person please tick box
If the Reviewer and Author is not the same person please provide the Reviewer details below
Reviewer Name:
Madaleine Winterton
Reviewer Job Title:
Lead Antimicrobial Pharmacist
Reviewer email address:
Madaleine.Winterton@uhcw.nhs.uk
Approved by:
Medicines Management Committee
Date Approved:
July 2021
Primary Specialty:
Infection Control
Secondary Specialty:
Other Specialty:
Are there any UHCW documents related to this topic area
Yes
No
If yes please provide Title
Adult Antibiotic Guidelines CG 1168 v16
UHCW Hand Hygiene Policy (2020)
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ATTACHMENT: 12.pdf
TEXT_FILE: 12.pdf.txt
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--- PDF page 1 ---
1
Clinical Operating Procedure
Procedure Title:
Management of Norovirus
Procedure Ref No:
COP- 954
Review date:
March 2024
Expiry date:
September 2024
Version Number:
V1
Summary statement /scope of the procedure:
•
Norovirus is characterised by the acute onset of nausea, vomiting in more than 50% of
cases (often projectile) and abdominal cramps (72%).
•
Vomiting is more common in the young, with watery diarrhoea a more common feature in
adults. Other symptoms may include fever, rigors, muscle and joint pain and headache.
•
The incubation period is usually 24 to 48 hours, with the mean duration of 12 to 60 hours.
Viral excretion precedes the onset of symptoms by several hours and persists well beyond
the symptomatic phase staff.
•
Infection and/or colonisation is usually acquired by ingestion after contact with a contaminated
environment, equipment, other patients or the hands of
This Clinical Operating Procedure provides details on identifying and managing norovirus within the
healthcare setting.
Please note: The following systems have been replaced by the trust Electronic Patient Record system (EPR). If
any of these systems are identified within the document, please substitute them for the appropriate EPR
alternative system and refer to relevant corresponding EPR procedures.
1. Opera (theatres)
2. Centricity (Critical Care)
3. Wardview
4. Extramed
5. CRRS
6. VitalPack
7. Adastra (CUTC)
8. K2 (maternity portal replaced by PPUK)
9. i.PM
10. Athena (Maternity)
11. SCIT App (replaced by camera capture)
Please contact EPREnquiries@uhcw.nhs.uk if you have any questions about the systems listed or the
EPR system introduced in their place.
On review of this document please ensure the systems listed are removed from the text and replaced
with the relevant EPR system and process.
--- PDF page 2 ---
2
General Information
A suspected case of norovirus:
a) Vomiting: Two or more episodes of vomiting of suspected infectious cause occurring in a 24-hour
period in the absence of other clinical diagnosis
b) Diarrhoea: Three or more type 6/7 stools on Bristol Stool Chart in a 24-hour period in the absence of
other clinical diagnosis (appendix 1)
c) Diarrhoea and vomiting: One or more of both symptoms occurring within a 24-hour period in the
absence of other clinical diagnosis
Confirmed case:
a, b or c above with laboratory confirmation
An outbreak is 2 or more cases as defined above, occurring in a functional unit within the hospital (appendix
2)
Symptoms
Acute onset of:
•
Non-bloody watery diarrhoea and/or
•
Vomiting (often projectile)
•
Abdominal cramps
•
Myalgia (muscle pain)
•
Headache
•
Malaise
•
Low grade fever (up to 50% of cases)
•
Other possible symptoms
Please note: Some individuals experience only diarrhoea OR vomiting
Usually symptoms will resolve within 2-3 days
40% of those affected can still be symptomatic at day 4
Transmission
Faecal-oral
Incubation Period
Usually 12 - 48 hours
Period of
communicably
Patients and staff affected should be considered infectious
Until 48 hours symptom free or
Until stools have returned to normal for the individual
All precautions and exclusions should continue until the criteria above are met.
Individuals at risk
Can affect any individual regardless of age
Care Management
Isolation
If a patient is suspected/ confirmed norovirus and is in a bay they must remain
so, and the bay closed to attempt to contain the spread of infection.
--- PDF page 3 ---
3
If the affected individual is transferred to a side room, the remaining patients
in the bay require (cohort) isolation and monitoring for 48 hours as they could
be incubating the virus. Do not admit into empty bed.
Personal protective
equipment (PPE)
•
Plastic aprons and disposable gloves should be worn when in direct
contact with the patient or the patient’s immediate environment. Hand
hygiene must be carried out following removal of PPE.
•
Risk assess requirement for facial protection when at risk of splashing
and spraying of body fluids i.e. full-face visor or Surgical facemask and
eye protection
Hand Hygiene
Hands must be decontaminated as per the 5 moments for Hand Hygiene:
1. Before touching a patient
2. Before clean/aseptic procedure
3. After body fluid exposure risk
4. After touching a patient
5. After touching patient surroundings
Alcohol Based Hand Rub (ABHR) cannot be used to decontaminate hands.
Patients should be encouraged/assisted to wash their hands with soap and
water or skin cleansing wipes after using the toilet and prior to eating.
Testing
If suspecting an outbreak, before sending a specimen the SIPC Nurse must be
informed. They will then assess the case and advise virology
•
Can be of a stool sample (swab tip in universal container)
•
Vomit sample in a pot
•
For same day testing, sample must be in the lab
Monday to Friday by 12:00
Weekends by 09:00
Once norovirus is identified on a ward or in a single bay, further testing will
only be performed in atypical cases or if the patient becomes symptomatic in
another bay.
Movement of patients
•
Stop unnecessary transfers to unaffected wards/ departments unless
clinical need outweighs infection risk – Patient must go into a sideroom
•
If essential, notify the receiving department prior to transfer
•
Aim to place patients at the end of the list when clinically suitable
•
If transferring to another hospital – inform the hospital and ambulance
service prior to move
Discharge
•
Do NOT transfer affected patients until 48 hours after symptoms have
stopped
•
If patient has not had any symptoms but is from a closed ward/bay
they can only be transferred to own home providing carers are not
required
--- PDF page 4 ---
4
•
Do NOT transfer patients who are potentially incubating the virus to
other care facilities, including to own home with package of care
•
Terminal Clean, Bay/Sideroom
Food
•
No open packets of food on the closed area (discard any that are
found)
•
Separate kitchen facilities to areas not closed (IPC in conjunction with
ISS)
•
Food trays must not go into affected bays
Patient Use Equipment
•
Where available, use single use/single patient use equipment.
•
All single use/single patient use equipment must be discarded as
clinical waste
•
Equipment should be kept to a minimum
•
All shared or reusable equipment must be decontaminated between
patients using a chlorine releasing agent such as Tristel.
Clinical Waste
All waste must be discarded as clinical waste.
Staff
Movement of staff between clinical areas should be restricted during an
outbreak of Norovirus
•
IPCT will advise on separation of staff during bay closures within a ward
area
•
Staffs who have worked for their entire shift in an area closed due to a
Norovirus outbreak should wait 48 hours from the end of their last
shift before working in another area. This is particularly relevant to
Bank Staff
•
Symptomatic staff members should be excluded until 48 hours
symptom free. Contact the Occupational Health Team for further
advice and support
Visitors
•
Visiting stopped unless exceptional circumstances i.e. the patient’s
medical condition suddenly deteriorates or end of life
•
Next of kin to be telephoned before visiting (when possible) and
informed to minimise disruption
•
Provide relatives with a contact telephone number and advise of a time
to call
•
If a visitor does attend, explain the risk and provide with a an
information leaflet (These can be found on E-Library)
Dekomed
•
Ensure working
--- PDF page 5 ---
5
APPENDIX 1 Diarrhoea Assessment Tool
Version 3. September 20
Patient has type 6 or 7 on Bristol Stool Chart/ Increased
frequency/ offensive smell?
-Monitor bowel chart
-Ensure antibiotic stewardship
-No further action required
(including previously known
toxin/equivocal positives)
NO
Assess history. Are there underlying factors?
E.g.
-Inflammatory bowel disease
-Overflow- constipation
-Aperients e.g. enema/ laxatives
-Enteral feeding
-New medication
-Antibiotics
-Patients normal bowel habits
YES
YES
Review. Clinical suspicion of C diff?
-Stool chart - >3 type 6 or 7 stools within a
24-hr period?
-General condition
-WCC, CRP, Creatinine
Non-infective diarrhoea.
-Review/modify treatment
-Underlying cause
-Medication
-Maintain stool chart and fluid
balance
Review clinical response 24-48
hours. Is there an improvement?
Infection suspected
NO
-Isolate in a side room with ensuite/ own commode
-Door closed with isolation sign
-Obtain specimen
-Dedicated equipment
-Stool monitoring chart
Medical review – including antibiotic therapy
-Monitor bowel chart
-Ensure antibiotic stewardship
-No further action required
(including previously known
toxin/equivocal positives)
YES
NO
Consider treatment of C diff infection BEFORE test results if
signs of severe clinical infection (QAG Page 3)
-Raised WCC
-Raised CRP
-Temperature
-Clinical or radiological evidence of colitis
NO
YES
--- PDF page 6 ---
6
Appendix 2: Could this be an outbreak of norovirus?
A patient develops diarrhoea and/ or vomiting – could this be an infectious outbreak?
Are 2 or more patients affected who are in the same area and whose symptoms appear to
be connected?
Are two or more of the below
outbreak markers present –
•
Symptom onset was sudden
•
Vomiting is projectile
•
Diarrhoea is watery (Type 6/7 on
Bristol Stool chart)
•
Symptomatic patients have not had
laxatives or enemas in the last 48
hours
Unlikely to be an outbreak
•
Isolate patient
•
Refer to appendix 1 diarrhoea
assessment tool to ascertain if
there are any potential
contributory factors
NO
YES
NO
During an outbreak
•
Display outbreak posters to indicate that there
is an infection present.
•
Admissions or transfers must not be accepted
into the closed bay unless approved by SIPC
team
•
Discharges to own homes can continue
•
Visiting to the closed side room/ bay/ ward is
for compassionate reasons only
•
Patients to be discouraged from keeping food
•
Hand hygiene for staff and patients
paramount
•
Inform Control Room
•
Frequent cleaning of touchpoints
YES
Suspected Outbreak
•
Inform IPC on ext. 24791 or out of
hours on call microbiologist
•
Ensure stool chart and fluid balance
charts in place
•
Samples to be obtained and sent to
laboratory, delivered by hand to
pathology
•
Inform Virology Team
--- PDF page 7 ---
7
Appendix 3. Ward/ Department Checklist and Reference Guide
DATE ACTIONED BY WHOM
ACTIONS FOR STAFF IF POTENTIAL/SUSPECTED NOROVIRUS ON WARD/DEPARTMENT
FOR NURSE IN CHARGE
DATE
SIGNATURE
If a patient is in a bay and is symptomatic of norovirus then do not
move,
If in your clinical opinion it is more likely to be clostridium difficile or any other infectious
organism then move patient/s into isolation immediately, have the bay terminally
cleaned.
Separate toilet facilities (use en-suite in bay) for potential/suspected infected patients .
At Rugby St Cross, bays to use en-suites, side rooms must have a dedicated commode (if
no ensuite)
Laminated signs at all entrances to the ward/area/bay that is closed. These can be
obtained from IPCT or out of hours, UHCW control room/ St Cross Rugby Urgent Care
Centre reception.
Increase the frequency of routine ward, bathroom and toilet cleaning including staff
toilets. Liaise with ISS to arrange this and log this request on the ISS help desk on Ext
25555.
Increase the frequency of cleaning to touch surfaces. Liaise with ISS to arrange this and
log this request on the ISS help desk on Ext 25555
Staff to have own designated toilets on ward/department – This includes if an area of a
ward is closed
Ward staff to inform IPCT of any ward staff that become symptomatic
Ward staff to be dedicated to work in the infected area only
ISS to inform IPCT of any ISS staff that become symptomatic.
ISS staff to be dedicated to work in the infected area only.
All staff to remain off work for 48 hours after their last episode of symptoms, if having
reported in unwell
Prioritise cleaning to public areas where vomiting or uncontrolled diarrhoea has
occurred. Report on Ext 25555
Stop visiting to infected area UNLESS for extenuating circumstances i.e. the patient’s
medical condition suddenly deteriorates or for compassionate reasons. Fully inform the
visitors of the risk of visiting and encourage hand washing with soap and water.
If visitors become symptomatic to inform ward staff.
Provide a time to visitors that contact can be made for updates.
Nurses and Support staff to use Tristel to decontaminate patient equipment in between
use, and for damp dusting and touch points.
Nursing staff to use a mask with visor to clean up diarrhoea and vomiting, and to utilise
gloves, apron and strict hand washing with soap and water.
Every patient should be commenced on a Bristol stool chart from admission to ward,
ensure it is filled in correctly.
Document nausea and or vomit on fluid balance chart.
Ensure hydration status monitored.
Bank/agency staff if needed, should be block booked to work on affected wards and
should be discouraged from working in other unaffected areas or kept off duty until they
are out of the incubation period (48-72 hours)
Discard any food that may have been contaminated in the vicinity (usually fruit, opened
biscuits etc.) Throw away flowers, plants beside a patient bed.
Dekomed to be checked daily, ensuring optimum temperature is achieved, and that
bedpans etc are not scratched. Ensure daily checklist is completed
--- PDF page 8 ---
8
If the Reviewer and Author is the same person please tick box
If the Reviewer and Author is not the same person please provide the Reviewer detail
Reviewer Name:
Lisa Berry
Reviewer Job Title:
Consultant Virologist
Reviewer email address:
Lisa.Berry@uhcw.nhs.uk
Approved by:
IPC committee
Date Approved:
17/03/21
Primary Specialty:
Infection Prevention and Control
Secondary Specialty:
N/A
Other Specialty:
N/A
Are there any UHCW documents related to this topic area Yes
No
If yes please provide Title
Does this Clinical
Operating Procedure relate
to a Clinical Guideline?
No Yes
(if Yes, please detail )
Author Name:
Fiona Wells
Author Job Title:
Infection Prevention and Control
Author email address:
Fiona.Wells@uhcw.nhs.uk
TRAINEE NURSING ASSOCIATES or NURSING ASSOCIATES - A NEW NURSING ROLE
If Registered Nurses or Student Nurses will be undertaking a role, or carry out
procedures in your area, you will now need to consider the role/input/restrictions for
Trainee Nursing Associates/Nursing Associates and refer to them within your
document. If you require any further information please contact Karen Mogan Practice
Facilitator karen.mogan@uhcw.nhs.uk<mailto:karen.mogan@uhcw.nhs.uk>
--- PDF page 9 ---
9
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ATTACHMENT: 13.pdf
TEXT_FILE: 13.pdf.txt
METHOD: pdf_native
OCR_USED: False
PAGES: 4
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--- PDF page 1 ---
Clinical Operating Procedure
Procedure Title:
Trust wide Procedure for the Home Laundering of staff Uniforms
Procedure Ref No:
COP 211
Review date:
February 2024
Expiry date:
August 2024
Version Number:
Version 10
Summary statement /scope of the procedure:
To ensure uniforms that are laundered at home are decontaminated adequately preventing
the possibility of cross – contamination to patients from staff uniforms.
Recommendations for procedure content:
Staff to familiarise themselves with the following procedure and implement in to every day
practice.
Please note: The following systems have been replaced by the trust Electronic Patient Record system
(EPR). If any of these systems are identified within the document, please substitute them for the
appropriate EPR alternative system and refer to relevant corresponding EPR procedures.
1. Opera (theatres)
2. Centricity (Critical Care)
3. Wardview
4. Extramed
5. CRRS
6. VitalPack
7. Adastra (CUTC)
8. K2 (maternity portal replaced by PPUK)
9. i.PM
10. Athena (Maternity)
11. SCIT App (replaced by camera capture)
Please contact EPREnquiries@uhcw.nhs.uk if you have any questions about the systems
listed or the EPR system introduced in their place.
On review of this document please ensure the systems listed are removed from the text and
replaced with the relevant EPR system and process.
--- PDF page 2 ---
Introduction
Studies show that uniforms may become contaminated by micro-organisms; although
no evidence is currently available linking the transmission of bacteria to patients (Wilson
et al 2007, DoH, 2010). It is important to note that all clothing worn by staff has the
potential to become contaminated via environmental micro-organisms or those
originating from patients or the wearer (RCN 2020).
Uniforms and workwear should not impede effective hand hygiene, and should not
unintentionally come into contact with patients during direct patient care activity.
Similarly, nothing should be worn that could compromise patient or staff safety during
care (NHSI 2020).
Maximum contamination occurs in areas of greatest hand contact, for example, pockets,
cuffs and apron areas (Loh 2000), and potentially causes the re-contamination of
washed hands.
National recommendations are that home laundering will easily and safely remove any
infectious micro-organisms if the laundry guidance is followed (RCN 2020) this includes
SARS 2 COV (Coronavirus).
Aim
To ensure uniforms that are laundered at home are decontaminated adequately
preventing the possibility of cross – contamination to patients from staff uniforms.
Therefore, staff are required to domestically launder their uniforms at 60°C to
ensure safe removal of micro-organisms (Riley et al, 2017).
Recommendations for effective home laundering of uniforms:
ACTION
RATIONALE
1.
Change into a clean uniform at the
start of each shift.
Maintains a professional appearance.
The way staff dress is an important influence
on peoples overall perceptions of the
standards of care they experiences and
promotes public confidence
2.
Wash uniforms at the hottest
temperature suitable for the fabric.
A wash for ten minutes, at 60°C, removes
most micro-organisms (Riley et al, 2017 and
DoH, 2010).
3.
Clean washing machines and
tumble driers regularly and
maintain according to
manufacturer’s instructions.
Dirty or underperforming machines can
result in contamination with environmental
microorganisms.
Regular cleaning of the machine will protect
the machines washing efficiency.
4.
Where necessary, in order to avoid
overloading, wash uniforms
separately from other clothes.
Overloading machine will reduce wash
efficiency.
--- PDF page 3 ---
5.
Once the uniform is dry, iron with a
hot iron
To allow heat to remove any existing micro-
organisms and to be aesthetically pleasing.
6.
Uniforms should then be stored
folded and flat in a fresh, unused
plastic bag.
To minimise the risk of contamination
following laundering.
7.
Hands should be washed prior to
donning uniform.
To minimise the risk of contamination
following laundering.
8.
Uniforms should preferably be
taken home in a plastic bag. (Refer
to uniform policy for information
about travel in uniform)
To minimise contamination of other items.
9. If uniform becomes contaminated when
on duty it must be changed immediately.
To minimise cross contamination
Ensure you have an adequate number of uniforms allocated to you (one per shift, up to
a maximum of five).
PLEASE NOTE:
• These guidelines do not apply to theatre clothing, which must NOT be taken home
for laundering.
If
the Reviewer and Author is the same person please tick box ✓
If the Reviewer and Author is not the same person please provide the Reviewer
details below
Reviewer Name:
Melanie Gallo
Reviewer Job Title:
Infection Prevention and Control Practitioner
Reviewer email address:
Melanie.gallo@uhcw.nhs.uk
Approved by:
Infection Prevention and Control Committee
Date Approved:
August 2021
Primary Specialty:
Infection Prevention and Control
Secondary Specialty:
Does this Clinical
Operating Procedure relate
to a Clinical Guideline?
No Yes
(if Yes, please detail )
Author Name:
Merja Thomas
Author Job Title:
Infection Prevention and Control Practitioner
Author email address:
Merja.thomas@uhcw.nhs.uk
TRAINEE NURSING ASSOCIATES or NURSING ASSOCIATES - A NEW NURSING ROLE
If Registered Nurses or Student Nurses will be undertaking a role, or carry out
procedures in your area, you will now need to consider the role/input/restrictions for
Trainee Nursing Associates/Nursing Associates and refer to them within your
document. If you require any further information please contact Karen Mogan Practice
Facilitator karen.mogan@uhcw.nhs.uk<mailto:karen.mogan@uhcw.nhs.uk>
--- PDF page 4 ---
Other Specialty:
Are there any UHCW documents related to this topic area Yes✓
No
UHCW Corporate Appearance and Uniform policy (2017)
References
Department of Health (2010) Uniforms and workwear: Guidance on uniform and workwear
policies for NHS employers. London: Crown Copyright.
Loh W, NG W, Holton J (2000) Bacterial flora on the white coats of medical students, Journal
of Hospital Infection, 45, pp.65-68.
NHS England and NHS Improvement Uniform and Workwear: guidance for NHS employers
(2020). NHS Improvement.
RCN (2020) Uniform and workwear guidance
Riley, K., Williams, J., Owen, L., Shen, J., Davies, A., Laird, K. (2017) The effect of low-
temperature laundering and detergents on the survival of Escherichia coli and Staphylococcus
aureus on textiles used in healthcare uniforms. Journal of Applied Microbiology. July 2017, vol.
123, Issue 1, pp 280-286.
Wilson J, Loveday P and Pratt R (2007) Uniform: an evidence review of the microbiological
significance of uniforms and uniform policy in the prevention and control of healthcare
associated infections. Report to the Department of Health (England), Journal of Hospital
Infection, 66, pp.1602-1604.
--------------------------------------------------------------------------------
ATTACHMENT: 14.pdf
TEXT_FILE: 14.pdf.txt
METHOD: pdf_native
OCR_USED: False
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--- PDF page 1 ---
Page 1 of 9
Body Infestations
Related Clinical
Document
Standard Infection Prevention and Control Precautions Guideline -
CG 885
eLibrary number
COP 209
Version number
V10
Does this Clinical
Procedure relate
to a Clinical
Guideline?
Standard Infection Prevention and Control Precautions Guideline -
CG 885
Purpose/Rationale
The purpose of this guideline is to describe the practices and
procedures to be followed to prevent and control the potential of cross
infection.
And to understand how the infection is transmitted and how it can be
managed effectively
Primary Specialty
Trust wide
Related
Specialties
Specialty Clinical
Procedure Lead
Fiona Wells
Infection Prevention and Control and Sepsis Nurse
Fiona.Wells@uhcw.nhs.uk
Please note: The following systems have been replaced by the trust Electronic Patient Record
system (EPR). If any of these systems are identified within the document, please substitute them
for the appropriate EPR alternative system and refer to relevant corresponding EPR procedures.
1. Opera (theatres)
2. Centricity (Critical Care)
3. Wardview
4. Extramed
5. CRRS
6. VitalPack
7. Adastra (CUTC)
8. K2 (maternity portal replaced by PPUK)
9. i.PM
10. Athena (Maternity)
11. SCIT App (replaced by camera capture)
Please contact EPREnquiries@uhcw.nhs.uk if you have any questions about the systems
listed or the EPR system introduced in their place.
On review of this document please ensure the systems listed are removed from the text
and replaced with the relevant EPR system and process
--- PDF page 2 ---
Page 2 of 9
Clinical Procedure
1. Introduction
The aim of this policy is to ensure the relevant action and management of patients with
parasitic infestation are undertaken and to prevent further spread of
infestation. Infestations caused by parasites (scabies, body, and head lice) and
threadworm are often only minor irritations. Parasites can thrive because individuals are
reluctant to admit to having them or to take steps to eliminate them. Infestations caused
by
parasites, if not detected, can create problems within healthcare facilities.
Infestations occur within all community settings periodically and can result in debilitating
and distressing symptoms for those affected by them. This policy outlines the Trust
response to the management of individuals and co-ordination of outbreaks which is
required to prevent further transmission. Standard infection prevention precautions
together with a coordinated approach to treatment must be employed so
that morbidity for patients and contacts is avoided.
2. Equipment Required for the Clinical Procedure
N/A
--- PDF page 3 ---
Page 3 of 9
3. Description of Procedure
Organism
Transmission
Symptoms
Diagnosis
Treatment
Isolation
Cleaning
Head louse
(Pediculus
humanus
var.capitis)
Direct,
prolonged
head-to-head
contact with an
infested
person i.e.
parent to child
or contact
between
children in
play.
Lice rely on
the warmth of
the scalp for
food and
survival and
therefore
cannot survive
on chair
backs, pillows,
hats or clothes
for long
periods. Head
lice cannot fly,
jump or swim
but spread by
clumbering
from head to
head.
Intense
itching,
which can
take from
one week
to 2-3
months
after initial
infection.
Diagnosis is usually
clinical but may be
confirmed by
microscopic
examination.
Commonly found behind
the ears and at the back
of the neck and may be
confused with dandruff.
Dandruff is dull, flaky
and easily removed,
whereas nits are shiny
and firmly attached to
the hair shaft.
Adult lice can
sometimes be seen
moving on the scalp.
Lice are best detected
by fine tooth combing of
the hair when it is wet.
The lice can be
removed from the comb
onto a piece of damp
tissue paper for
inspection, preferably
with a magnifying glass.
Only people with the live lice need treatment (use of insecticide
should be used after consultation with the pharmacist).
Nits (empty egg cases) without the presence of live lice are not an
indication for treatment.
The nits may stay on the hair for several weeks after treatment, and
grow out with the hair itself. New eggs are only laid close to the scalp.
Please refer to BNF guidance for current treatment
Equipment:
Fine tooth comb, detection comb **
Disposable apron and gloves Clean hospital
towel
NB please make sure that the patient has not used conditioner or a
combination shampoo/conditioner prior to application as may result
in treatment failure.
1. Discuss treatment/procedure with the patient
2. Screen patient’s bed space or take patient to bathroom prior
to the commencement of treatment
3. Staff to wash hands, put on disposable plastic apron and
gloves
4. Place towel over patient’s clothing
5. Comb hair with ordinary comb followed by detection comb,
drawing the comb from the top of the scalp, down the hair shaft
towards the edge of the hair. Treatment should be applied to all
areas of the scalp Apply prescribed preparation as per drug
kardex, according to the manufacturer’s instructions.
6. A contact time of 8–12 hours or overnight treatment is
recommended for lotions and liquids; a 2-hour treatment is not
sufficient to kill eggs (see specific product information). In
general, a course of treatment for head lice should be 2
Patients with
head lice need
not to be
isolated,
except in
paediatric
wards where
close contact
between
children may
transmit the
lice.
Tristel
clean
--- PDF page 4 ---
Page 4 of 9
applications of product 7 days apart to kill lice emerging from
any eggs that survive the first application. All affected
household members should be treated simultaneously.
7. Remove gloves and aprons on completion of the task and
dispose of into clinical waste bag. Place used laundry into linen
bags.
8. Advise that all close head-to-head contacts should check for
head lice using an appropriate detection comb, and treat
themselves if lice are detected. Don’t treat unless infected.
9. Wash hands thoroughly.
10. Document the treatment given on patients notes.
11. Detection combing should be carried out 2-3 days after the
second treatment to ensure treatment success.
Pruritus is treated symptomatically with antihistamines and topical
corticosteroids.and to all of the hairs, from their roots to their tips
Organism
Transmission
Symptoms
Diagnosis
Treatment
Isolation
Cleaning
Pubic or
crab louse
(Phtirus
pubis)
Close physical
contact,
frequently by
sexual contact.
Pubic lice die
rapidly when
detached from
host.
Severe itch (which
is worse at night),
excoriation with
possible secondary
infection from
scratching,
detection of black
powdery substance
in underwear and
blue/grey macular
spots in affected
areas
Diagnosis is
usually clinical but
may be confirmed
by microscopic
examination.
Please refer to BNF guidance for current treatment
Change and launder clothing daily. Process linen as infected
linen. If infested washing is taken home, launder washing on a
hot wash cycle (60 centigrade or more) and iron at a hot
temperature.
If washing is not able to be taken home, obtain consent to
remove clothes from patient for incineration to prevent re-
infestation of patient and prevent cross infestation of the
environment.
Pruritus is treated symptomatically with antihistamines and
topical corticosteroids.
Not required
Tristel clean
--- PDF page 5 ---
Page 5 of 9
Organism
Transmission
Symptoms
Diagnosis
Treatment
Isolation
Cleaning
Scabies
Prolonged and
usually intimate
person-to- person
through skin- to-skin
contact especially via
the hands.
Household contacts,
children and healthcare
practitioners are at
particular risk of
infestation. During their
first infestation, people
with scabies are
infectious before the
development of a rash,
which can take 2-6
weeks to develop. In a
reinfection, the rash can
appear in 1-3 days.
Intense itching
of affected
areas,
particularly at
night. There can
also be a
pimple-like skin
rash or tiny
raised lines
caused by the
mite burrowing
into the skin to
lay eggs.
On close examination greyish, linear
burrows, around 0.5cm in length
may be found. Since the mites prefer
areas that have few hairs and low
sebaceous gland activity the flexor
surfaces of the wrists, webs of the
fingers, instep of the foot, the
foreskin of the male and areola of
the female are common burrow
sites.
Confirmation of the diagnosis is
made by microscopic identification of
skin mites, eggs or mite faeces,
usually performed by a
Dermatologist.
An expert dermatological opinion
should be obtained, and skin scrapings
are essential.
Please refer to BNF guidance for current
treatment
Please note some treatments are not licensed
in children
in 2 months old for the treatment of scabies.
Please
contact pharmacy for further advice.
Once a diagnosis has been made, ward staff
should inform the Infection Prevention and
Control Team (IPCT). A list of all patients in the
same bay and of staff with direct, hands-on care
should be made and given to the IPCT and
Occupational Health. The decision to treat
patient and staff contacts will be made on an
individual basis and after consultation with OH
and the dermatologists
Isolation in
sideroom
required
till
treatment
completed
Tristel clean
Body louse
(Pediculus
humanus
var.corporis
Close personal
contact and
overcrowded
conditions by
contact with
infested
clothing.
Body lice die
rapidly when
detached from
host.
Severe itching on
the parts of the
body affected
and sometimes a
rash caused by
an allergic
reaction to the
bites can occur.
Diagnosis is usually
clinical but may be
confirmed by
microscopic
examination.
Please refer to BNF guidance for current treatment
Patients with body lice do not require specific treatment but should be
bathed daily and wash clothes in a hot cycle. Ironing recommended.
Change and launder clothing daily. Process linen as infested linen.
If infested washing is taken home, launder washing on a hot wash cycle
(60 centigrade or more) and iron with hot iron.
If washing is not able to be taken home, obtain consent to remove clothes
from patient for incineration to prevent re- infestation of patient and prevent
cross infestation of the environment.
Pruritus is treated symptomatically with antihistamines and topical
corticosteroids.
Not
required
Tristel
clean
--- PDF page 6 ---
Page 6 of 9
Some products used for the eradication of head lice contain combustible materials. Patients and carers should be advised that they should not smoke near
treated hair and stay away from open flames. This also includes the morning after an overnight application until the hair is washed.
** Head lice can be mechanically removed by meticulously combing wet hair using a detection device (probably for around 30minutes) over the
whole scalp and repeated every 4 days for a minimum of 2 weeks and continued until no head lice are found on 3 consecutive times. Hair
conditioner may be used to facilitate the process (not to be used with the insecticide preparation).
A scabies outbreak in hospital
•
Once the diagnosis has been confirmed in two or more patients, please inform the IPC Team.
•
Both staff and patient contacts will be needed.
•
The DIPC or his/her deputy will liaise with the UKHSA
•
The management of staff will be coordinated by the Occupational Health Department and of the patients by the dermatologists, ward staff
and the IPC team.
Norwegian/
crusted
scabies
Highly contagious. It can be
easily spread by either
direct or indirect contact
and bedding, towels,
clothing, furniture etc.
It requires quick,
aggressive treatment to
prevent outbreaks.
The mites are thought to be
able to survive for longer
outside the host- up to 7
days, People who have had
minimal contact (e.g.
domestic and laundry staff)
may be at risk.
Intense itching of
affected areas,
particularly at night.
There can also be a
pimple-like skin rash or
tiny raised lines
caused by the mite
burrowing into the skin
to lay eggs.
An expert
dermatological and
infectious diseases
opinion should be
obtained
Please refer to BNF guidance for current treatment
Process linen as infected linen. Document the treatment
given on patients notes.
Once a diagnosis has been made, ward staff should
inform the Infection Prevention and Control Team
(IPCT). A list of all patients in the same bay and of
staff with direct, hands-on care should be made and
given to the IPCT and Occupational Health. The
decision to treat patient and staff contacts will be
made on an individual basis and after consultation
with OH and the dermatologists.
All close household/family contacts should treated by
their GP at the same time.
Isolation in
a sideroom
required till
treatment
completed
Tristel
clean
--- PDF page 7 ---
Page 7 of 9
Scabies in a member of staff.
•
The management of staff will be coordinated by the Occupational Health Department
•
The diagnosis is confirmed, staff should be treated, and remain away from clinical
duties until the treatment is complete, after which, normal duties should be resumed. The GP
should be asked to treat the members of the household/other close contacts.
Governance Check
Changes from previous version
Chronology of
Update of
Information
Detail of Changes
Page No.
Para No.
All
treatment/medication
removed from
previous version and
advised to refer to
BNF for current
treatment.
Trust guidance dates
updated.
Authors
Lead Author:
Ragbinder Mahal
Infection Prevention and Control and Sepsis Nurse
Ragbinder.Mahal@uhcw.nhs.uk
Reviewer(s):
Fiona Wells
Infection Prevention and Control and Sepsis Nurse
Fiona.Wells@uhcw.nhs.uk
Imran Khan
Senior pharmacist
Imran.Khan@uhcw.nhs.uk
Approving
Forums
Infection Prevention and Control Committee
Approval Dates
(All clinical
procedures require
QIPS approval prior
to review at a relevant
committee.)
QIPS
13/06/2023
MMC
Other (specify)
Review Date
30th October 2025
Keywords
Head lice (Pediculus humanus capitis), Body lice (Pediculus
humanus corporis), Crab/Pubic lice (Phthirus pubis), Scabies
(Sarcoptes scabiei), Crusted (Norwegian) Scabies and Fleas
Definitions
Head lice (Pediculus humanus capitis) - are small, greyish brown
six-legged wingless insects that are approximately 2- 3mm long.
They live, breed, and die on human scalps and eyebrow hair,
--- PDF page 8 ---
Page 8 of 9
feeding on blood from the scalp. The female louse may lay up to 10
eggs per day, which then glue themselves to the base of the hair
shaft. After seven days, the young louse hatches leaving a white,
shiny shell- like case (the nit); the louse then takes only ten days to
mature. Adult lice can be seen as black specks on the scalp; they
can move very quickly from hair to hair. Anyone can catch head lice,
but pre-school children, primary school children and their families
are most at risk. Most infestations are very light, but occasionally
there may be hundreds of lice on a head.
Body lice (Pediculus humanus corporis)- are less common than
head and pubic lice infestations, usually only occurring in vulnerable
groups such as people who are homeless, especially individuals
having and wearing only one set of clothing. Body lice live and lay
their eggs in the seams and folds of clothing and bedding, usually
only moving onto skin to feed on blood via biting. They are likely to
be found on the body (around the waist and armpits) only during
feeding.
Crab/Pubic lice (Phthirus pubis) - are tiny parasitic insects about
1-2mm long, grey or brown in colour. They are usually found in the
pubic area, but in cases of severe infestation may affect facial hair,
eyelashes, axilla and body surfaces.
Scabies (Sarcoptes scabiei) - is a contagious parasitic skin
infestation. Infestations normally affect skin folds such as between
fingers, on the wrist, elbows, knees, and around the buttock or
breast creases. The gravid female mites burrow into the keratin layer
of the epidermis where they deposit two or three eggs a day. The
mature larvae hatch after about 2 weeks and emerge to the surface
of the skin where they mate and re-invade the skin of the same or
another host.
Crusted (Norwegian) Scabies - is a contagious parasitic skin
infestation, and severe form of the disease in which the skin
develops thick crusts containing large amounts of mites/eggs. Often
persons with crusted scabies do not have the usual signs and
symptoms making the disease harder to diagnose.
Groups most at risk are those with a weakened immune system,
elderly people and people who are disabled (particularly those with
neurological disorders).
Fleas - are common bloodsucking parasites and do not live on the
body, but may be found within clothing folds and seams. Infestation
is usually associated with cats, dogs and birds bur adult fleas will
bite humans in the absence of a preferred host. They can cause a
localised bite reaction which is often inflamed and itchy. Treatment is
to bathe, dress patient in clean clothes and change all linen.
Isolation is not required, clothing and bed linen should be disposed
of in a red alginate bag.
Patient’s relatives should be advised to wash personal clothing taken
home on the hottest wash setting.
--- PDF page 9 ---
Page 9 of 9
Clinical Procedure Content: A procedure document outlines a set of actions and rationale that is
the official or accepted method of delivering clinical treatment. These are evidence based and must
be followed when indicated, therefore not guidelines e.g., Procedure for venous cannulation, or
management of Haemodialysis lines.
Regardless of the strength of evidence, it remains the responsibility of the clinician to interpret the
application of the clinical procedure in the context of local circumstances and the needs and wishes
of the individual patient. Where variations of any kind do occur, it is important to document the
variations and the reason for them in the patient’s health record. If in doubt, seek senior advice.
Equality and Diversity Statement: Throughout its activities, the Trust will seek to treat all
people equally and fairly. This includes those seeking and using the services, employees and
potential employees. No-one will receive less favourable treatment on the grounds of
sex/gender (including Trans People), disability, marital status, race/colour/ethnicity/nationally,
sexual orientation, age, social status, their trade union activities, religion/beliefs or caring
responsibilities nor will they be disadvantaged by conditions or requirements which cannot be
shown to be justifiable. All staff, whether part time, full-time, temporary, job share or volunteer;
service users and partners will be treated fairly and with dignity and respect.
Training
N/A
Monitoring of Outcomes
QIPS
Appendices
None
References
British National Formulary. September 2018 – March 2019. British Medical Association,
Royal Pharmaceutical Society. No 76.
Chosidow O. (2000) “Scabies and Pediculosis” Lancet Vol. 355 pages 819-826
Damani N (2012) Manual of Infection Prevention and Control. Third edition. Oxford
University Press.
NICE clinical knowledge summaries http://cks.nice.org.uk/scabies;
https://cks.nice.org.uk/pubic-lice https://cks.nice.org.uk/head-lice ; (Accessed: 19/11/2022)
University Hospitals Coventry & Warwickshire NHS Trust (2015) Waste Management policy.
University Hospitals Coventry & Warwickshire NHS Trust (2018) Hand Decontamination
policy. University Hospitals Coventry & Warwickshire NHS Trust (2017) Isolation Guideline.
Torok, E., Moran, E. and Cooke, F. (2015) Oxford Handbook of Infectious Diseases and
Microbiology. Oxford: Oxford University Press.
--------------------------------------------------------------------------------
ATTACHMENT: 15.pdf
TEXT_FILE: 15.pdf.txt
METHOD: pdf_native
OCR_USED: False
PAGES: 29
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--- PDF page 1 ---
1
Viral Haemorrhagic Fever (VHF) Including Ebola:
Acute Identification and management guide
Related Clinical
Document
Fever in the returning traveler CG 2385
eLibrary number
COP 914
Version number
V2
Does this Clinical
Procedure relate
to a Clinical
Guideline?
N/A
Purpose/Rationale
Viral haemorrhagic fevers (VHF) are severe and life-
threatening diseases that have been reported in parts of
Africa, South America, the Middle East and Eastern
Europe. Examples include Ebola, Lassa fever and
Crimean Congo haemorrhagic fever.
Primary Specialty
Infectious diseases and infection control
Related
Specialties
Specialty Clinical
Procedure Lead
Gorana Kovacevic. Consultant in infectious diseases
gorana.kovacevic@uhcw.nhs.uk
Please note: The following systems have been replaced by the trust Electronic Patient Record
system (EPR). If any of these systems are identified within the document, please substitute them
for the appropriate EPR alternative system and refer to relevant corresponding EPR procedures.
1. Opera (theatres)
2. Centricity (Critical Care)
3. Wardview
4. Extramed
5. CRRS
6. VitalPack
7. Adastra (CUTC)
8. K2 (maternity portal replaced by PPUK)
9. i.PM
10. Athena (Maternity)
11. SCIT App (replaced by camera capture)
Please contact EPREnquiries@uhcw.nhs.uk if you have any questions about the systems
listed or the EPR system introduced in their place.
On review of this document please ensure the systems listed are removed from the text
and replaced with the relevant EPR system and process.
--- PDF page 2 ---
2
Clinical Procedure
1. Introduction
This Clinical Operating Procedure aims to ensure that patients with possible viral
haemorrhagic fever (VHF) are identified and managed appropriately. This policy primarily
applies to clinical staff in admitting areas and the infectious diseases ward. It also applies
to site managers, emergency planning, on-call managers, infection prevention and control
staff, microbiology, virology, estates, portering, domestic, security and ISS colleagues.
2. Equipment Required for the Clinical Procedure
N/A
3. Description of Procedure
Patient screening and triage
Patients who require a VHF risk assessment are those that have:
A fever/history of fever in the past 24 hours (≥37.5)
AND
have either travelled to a VHF endemic area, been in contact with a
person/animal or bodily fluids infected with a VHF or worked in a laboratory
with the infectious agents of VHF within 21 days.
Areas where VHF is endemic is available here:
https://www.gov.uk/viral-haemorrhagic-fevers-origins-reservoirs-transmission-and-
guidelines
Areas where there is a current outbreak are regularly updated here: Home - ProMED
- ProMED-mail (promedmail.org)
National guidance for the management of patients with or suspected of having VHF
is available from UKHSA:
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachm
ent_data/file/534002/Management_of_VHF_A.pdf).
If a patient meets the above criteria, it is essential that they are first placed in a safe
space in order to conduct the risk assessment. Please see section below regarding
patient placement.
Patient entry routes and placement
Patient’s accessing care within UHCW usually present to urgent treatment centres
based at the City of Coventry Health Centre, Rugby St Cross or to the emergency
department at UHCW. Table 1 shows the most common entry points. Following
triage, if the patient is identified as being at risk of having VHF, table 1 shows where
the patient should be placed while awaiting risk assessment by the medical team.
When escorting a patient to an isolation areas, a safe distance should be kept (2m).
Table 1: Common entry points and preferred isolation rooms to be utilised for
risk assessment.
--- PDF page 3 ---
3
In Hours
Out of Hours and Weekends
GP referral via
phone call
GP liaison (10am-6pm) to speak to
infectious diseases consultant before
agreeing to accept patient. Take GP’s
phone number so that they can have direct
conversation if required.
Phone calls go to MDU. Medical registrar to
discuss with microbiology or virology on-call
before agreeing to accept patient. Take
GP’s phone number so that they can have
direct conversation if required.
To ED via
ambulance
service
If VHF is suspected, West Midlands
ambulance would take the patient to
Birmingham Heartlands Hospital. They
should not be escorted to UHCW.
If VHF is suspected, West Midlands
ambulance would take the patient to
Birmingham Heartlands Hospital. They
should not be escorted to UHCW.
Self
presents to
ED
reception
During triage the nurse will ask the
patient if they have travelled in the past
28 days. If the patient has travelled, the
streaming nurse will alert the nurse in
charge and the patient will be placed in
an isolation room. If a room is not
available, the patient should be asked to
wait outside, if safe to do so, until the
room becomes available. The nurse in
charge will alert the medical team.
During triage the nurse will ask the patient if
they have travelled in the past 28 days. If the
patient has travelled, the streaming nurse will
alert the nurse in charge and the patient will be
placed in an isolation room. If a room is not
available, the patient should be asked to wait
outside, if safe to do so, until the room
becomes available. The nurse in charge will
alert the medical team.
Self-present
to MIU
The triage nurse will ask the patient if
they have travelled within 28 days. If the
answer is yes they will isolate the
patient and notify the nurse in charge so
that an assessment can be done. The
medical team should undertake the risk
assessment and if there is a possibility
of VHF the patient should be moved to
ED (phone ED to let them know the
patient will be arriving)
The triage nurse will ask the patient if they
have travelled within 28 days. If the answer is
yes they will isolate the patient and notify the
nurse in charge so that an assessment can be
done. The medical team should undertake the
risk assessment and if there is a possibility of
VHF the patient should be moved to ED
(phone ED to let them know the patient will be
arriving)
Self- Present
to UTC in
Coventry
City of
Health
Centre
The triage nurse will ask the patient if
they have travelled within 28 days. If the
answer is yes, they will immediately be
placed in the ‘red zone’. Ask the patient
not to leave the room and reassure.
Inform doctor to perform risk
assessment.
Once risk assessment performed,
medical team at UTC to call UHCW ED
team to help with combined decision
making.
Centre open 8am – 10pm. Outside these
hours patients may present to UTC in Rugby
or ED at UHCW.
Self- Present
to UTC in
Rugby
The triage nurse will ask the patient if
they have travelled within 28 days. If the
answer is yes, the patient is to be asked
to wait outside the UCC entrance so that
isolation cubical can be made available.
Once the room has been made
available, nursing staff wearing a FRSM,
gloves and apron to meet and using the
ambulance entrance and corridor, escort
to the isolation cubicle for risk
assessment. The most senior nurse
The triage nurse will ask the patient if they
have travelled within 28 days. If the
answer is yes, the patient is to be asked to
wait outside the UCC entrance so that
isolation cubical can be made available.
Once the room has been made available,
nursing staff wearing a FRSM, gloves and
apron to meet and using the ambulance
entrance and corridor, escort at a safe
distance to the isolation cubicle for risk
assessment. The most senior nurse
--- PDF page 4 ---
4
Once the patient has been placed in isolation, reassure and ask them (and anyone
else that they have arrived with) to stay in the side room and use the en-suite in that
room. If there is not an en-suite available, a dedicated commode must be provided.
If VHF is suspected in any other admissions area they must be isolated promptly in a
side room. The doctor must call ED to discuss and make arrangements for the
patient to be escorted to the designated area in ED. Escorting staff must wear PPE
for low possibility of VHF at a safe distance (3m). If the patient has extensive bruising
or bleeding and therefore falls into the high risk category, do not move and discuss
with clinical team in ED.
should undertake the risk assessment
(Rugby UTC is a nurse led service). Ask
patient to stay in the isolation room and
reassure.
Once risk assessment performed,
medical team at UTC to call UHCW ED
team to help with combined decision
making.
should undertake the risk assessment
(Rugby UTC is a nurse led service). Ask
patient to stay in the isolation room and
reassure.
Once risk assessment performed, medical
team at UTC to call UHCW ED team to help
with combined decision making.
Self
presents to
maternity
Patient to go to triage isolation room,
preferably room 6. Nurse in charge and
most senior doctor to be notified.
Patient to go to triage isolation room,
preferably room 6. Nurse in charge and most
senior doctor to be notified.
Self
presents to
W23 EPAU
Patient to be transported through EGU
to W23 Gynae isolation room (preferably
room 1, negative pressure room). Nurse
in charge and most senior doctor to be
notified.
Patient to be transported through EGU to
W23 Gynae isolation room (preferably room
1, negative pressure room). Nurse in charge
and most senior doctor to be notified.
Child
presenting
to CED via
WMAS
If VHF is suspected, West Midlands
ambulance would take the patient to
Birmingham Heartlands Hospital. They
should not be escorted to UHCW.
If VHF is suspected, West Midlands
ambulance would take the patient to
Birmingham Heartlands Hospital. They
should not be escorted to UHCW.
Child self
presenting
to CED
Immediately place in room 2 ‘rash room’
for triage, or other available side room.
Inform nurse in charge and doctor.
Immediately place in room 2 ‘rash room’ for
triage, or other available side room. Inform
nurse in charge and doctor.
Patient on a
ward and
VHF is
suspected
If the patient is in a bay or communal
area immediately isolate in a side room.
Do not admit into that bedspace until
VHF has been ruled out and sufficient
decontamination has taken place.
Follow the initial actions on page 6.
If the patient is in a bay or communal area
immediately isolate in a side room. Do not
admit into that bedspace until VHF has been
rules out and sufficient decontamination has
taken place. Follow the initial actions on
page 6.
--- PDF page 5 ---
5
Initial actions on suspicion of VHF
Once it has been identified that the patient meets the criteria for suspicion of VHF
and the patient has been placed in isolation, a risk assessment must be carried out.
This must be done by the assessing doctor. Standard precautions and good infection
control measures are paramount while the initial assessment is being carried out. If
there is any active bruising or bleeding then categorise as a high possibility and
move to the high possibility action card, following recommended PPE. Follow the
initial actions below:
The risk assessment category will determine next steps.
VHF Unlikely: Go to page 7
VHF Low Possibility: Go to page 8
VHF High Possibility: Go to page 10
VHF Confirmed: Go to page 13
INITIAL ACTIONS FOR SUSPECTED VHF
JOB ROLE
ACTION
DATE
TIME
SIGN
All staff groups
Limit movement in and out of the room.
Pregnant and immunocompromised staff members should not have
further contact with the patient.
All staff groups
If you need to enter the room again, risk assess PPE requirements
based on symptoms.
If there is a risk of blood or body fluid exposure, wear gloves, an
apron and eye protection.
If the patient has any respiratory symptoms wear a FFP3 mask.
If there is any active bruising or bleeding then categorise as a high
possibility and move to the high possibility action card, following
recommended PPE.
Nurse in
charge
Add ‘red hand’ sign to the door (infectious patient warning).
Inform the most senior doctor in charge as a matter of urgency. Tell
the doctor if there is any active bruising or bleeding.
Obtain the risk assessment from the appendix in this document or
using the QR code below:
It can also be accessed from this link:
https://assets.publishing.service.gov.uk/government/uploads/syste
m/uploads/attachment_data/file/478115/VHF_Algo.pdf
Most senior
doctor
If there is a suspicion of sepsis, initial sepsis management should
be commenced.
If there are signs of organ failure, arrange ITU review. If required,
equipment should be brought to the patient where possible.
Undertake the risk assessment wearing appropriate PPE
(described above)
RISK CATEGORY ACCORDING TO RISK
ASSESSMENT:_______________________________
Follow instructors on next action card based upon risk
assessment outcome
--- PDF page 6 ---
6
ACTION CARD: VHF Unlikely
VHF UNLIKELY
ACTION CARD
DATE
TIME
SIGN
Most senior
doctor
Manage locally. No need to remain isolated
from a VHF perspective. Red hand sign can be
removed from the door and the patient does
not need to remain in isolation unless an
alternative infectious disease is suspected.
Document risk assessment in the patient’s
medical notes and inform team caring for
patient.
If further discussion or support is required call
ID consultant, virology consultant or
microbiology out of hours.
Most senior
doctor
Reassess patient and repeat the VHF risk
assessment if there is clinical concern, if the
patient fails to improve, develops a nose
bleed, bloody diarrhoea, sudden rise in
aspartate transaminase (AST), sudden fall in
platelets, clinical shock or rapidly increasing
O2 requirements in the absence of an
alternative diagnosis.
ACTION CARD: Low Possibility of VHF
LOW POSSIBILITY OF VHF ACTION CARD
ROLE
RESPONSIBILITY
DATE SIGN
Most
senior
doctor
Take the role of lead clinician. Reiterate the need for the patient
to stay in the side room with the door closed. Reassure the
patient and any visitors that are with them.
Immediately inform the local Infection specialist Consultant
virologist and infectious diseases in hours, on call microbiology
out of hours). Determine which investigations are clinically
appropriate, including an urgent malaria screen.
If any samples are to go to the lab or any referrals made to
specialist teams, the medical team must make it clear that the
patient has a low possibility of VHF by putting it on the
request and referral forms.
Notify operational lead, and site team. If the patient is pregnant,
notify obstetrics on call.
Nurse in
charge
Ensure that the number of entries into the room are minimised
and also the number of venepunctures required. Ensure only
clinical staff should enter the room (i.e. no domestics or Health
Care Assistants).
Pregnant and immunocompromised staff members should not
have contact with the patient.
Ensure there is a donning and doffing area available for staff to
don and doff PPE, for example the adjacent side room. If there
is no area available, contact Infection Prevention and Control
who will escalate. Estates may be required to erect an anti-
room. Ensure PPE is available in the donning area and waste
bins available in the doffing area.
--- PDF page 7 ---
7
Ensure that both Tristel and HazTab solution is made up and
available in the patient’s room.
Ensure that any samples that need to go to the laboratory are
taken by hand. Do not use the POD/air tube system in case the
samples get stuck.
Add a contact list to the door of the side room (appendix 5).
Ensure that anyone entering the room is aware of the risk
assessment and risk of infection.
Consultant
virologist
or
nominated
virologist
If malaria screen is negative and / or there is clinical concern or
continuing fever after 72 hours, they will discuss case with the
imported fever service in Porton Down.
Report to public health authorities (UKHSA).
Medical
and
nursing
staff
Point of care (POC) blood gas analysers present a risk of splashing
and should only be used in
exceptional circumstances and in a controlled environment i.e. limited
for use in the patient room by appropriately trained staff.
Most
senior
doctor and
site
team/bed
managers
See section in VHF COP on movement of patients.
If there is diarrhoea or vomiting the patient should not be
moved.
ADULTS: If the patient remains low risk, transfer to W31A side
room . Discuss with infectious diseases prior to transfer if not
already aware. Ensure room is available before transfer begins.
Follow route specified in the table. If critical care is deemed
necessary, ideally the patient will move to side room 30 on GCC,
using the bathroom as a doffing area and estates should be instructed
to erect a donning area outside the room.
CHILDREN: If the patient remains low risk, transfer to W15 bay
2. Contact paediatric bed capacity manager on bleep 2188 to
arrange. Bay 2 will be made available (i.e will be vacated by
other patients) ABR10038.
INFECTION CONTROL MEASURES REQUIRED
IT IS IMPERITIVE THAT PPE IS DONNED AND DOFFED CORRECTLY
(APPENDIX 5)
Standard precautions
Hand hygiene
Gloves
Plastic apron and gloves if there is a risk of contact with
blood or body fluids.
Additional precautions for splash
inducing procedures
Fluid repellent disposable gown
Fluid resistant surgical mask (FFP3 if there are respiratory
symptoms)
Disposable eye protection
Additional protection for potential
aerosol generating procedures
FFP3 respirator for which the wearer is fit tested.
Disposable eye protection
Equipment
Single use (disposable) equipment must be used. If needle
free IV devices are available, please use.
Sharps, laundry, waste, crockery
and cutlery
Normal procedures
Cleaning and decontamination
Nursing staff should undertake cleaning of the room. Staff
undertaking cleaning should wear the same PPE as those
looking after the patient.
Visiting
Restrict visiting to next of kin for a child. Adults should have
visiting on compassionate grounds only and risks discussed
with them .
Visitors must wear PPE as described above (but given a
FRSM rather than an FFP3 mast as they are not fit tested).
--- PDF page 8 ---
8
ACTION CARD: High Possibility of VHF
HIGH POSSIBILITY OF VHF ACTION CARD
ROLE
DATE SIGN
Most senior doctor
Take the role of lead clinician.
Reiterate the need for the patient to stay in the side room
with the door closed. Reassure the patient and any
visitors that are with them.
Immediately inform the local infection specialist
(Consultant virologist and infectious diseases in hours,
on call microbiology out of hours) and discuss which
specimens are appropriate, including urgent malaria
screen.
Does the patient have active bleeding, bruising, vomiting
or diarrhoea?
YES / NO
If Yes: Contact estates to erect infection screens
urgently. Incident team will update further and urgent
discussions should be held with the High Level Isolation
Unit at the Royal Free Hospital 02077940500.
Notify operational lead, and site team. If the patient is
pregnant, notify obstetrics on call.
Nurse in charge
Restrict the number of entries into the room and the
number of venepunctures required.
Ensure that only clinical staff enter the room (i.e. no
domestics or Health care assistants).
Add contact list to the door of the side room and ensure it
is completed (appendix 5). Ensure that all staff who need
to enter the room are aware of the infection risk.
Pregnant and immunocompromised staff members
should not have contact with the patient.
Ensure that both Tristel and HazTab solution is made up
and available in the patient’s room.
Ensure there is a donning and doffing area available for
staff to don and doff PPE, for example the adjacent side
room. If there is no area available, contact Infection
Prevention and Control who will escalate. Estates may be
required to erect an anti-room. Ensure PPE is available in
the donning area and waste bins available in the doffing
area as states in the Infection Prevention and Control
section at the bottom of this action card.
Consultant
virologist or
nominated
virologist
Discuss the case with the imported fever service at
Porton Down.
Report to public health authorities.
Convene, with IPC, an incident management meeting to
share initial impression and management.
--- PDF page 9 ---
9
Nursing and
medical staff
Two people must go into the room when samples are
going to be taken.
Once a sample has been taken, the second person must
hold out a specimen bag in order for the sample to be
placed inside. This bag must be sealed and put into a
second bag and sealed. Take samples out of the
isolation room and put into the red box for transportation.
Red boxes can be retrieved from specimen reception,
pathology, 4th floor, west wing at UHCW. The laboratory
must be made aware that samples are being sent by
calling specimen reception via switchboard.
Specimen forms and any referrals must state ‘high
possibility of VHF’ in the clinical details. The red box
must be transported to pathology by a nurse or doctor.
The red box must be given to a biomedical scientist in the
blood sciences laboratory and the biomedical scientist
made aware that it contains samples from a patient
suspected of having viral haemorrhagic fever.
If testing for VHF is recommended by Porton
Down/infection specialist, samples required are 4.5ml of
serum, 4.5ml EDTA blood and ideally a urine sample
(white capped sterile universal container).
Point of care (POC) blood gas analysers present a risk of
splashing and should only be used in exceptional
circumstances and in a controlled environment i.e. limited
for use in the patient room by appropriately trained staff.
INFECTION CONTROL MEASURES REQUIRED
IT IS IMPERITIVE THAT PPE IS DONNED AND DOFFED CORRECTLY
(APPENDIX 5)
Standard
precautions and
droplet
precautions
Have a drink and go to the toilet before donning PPE.
PPE for VHF is stored in the emergency PPE store in ED at UHCW.
Diligent hand hygiene practices are required following the correct
hand decontamination technique.
Donning and doffing of PPE must be supervised by a buddy (see
appendix 5)
Place your clothes and shoes in a plastic bag (can be a clean bin
bag, to protect them)
Don the following PPE prior to entry into the room:
Remove uniform/clothes and change into scrubs.
A fluid repellent disposable gown
Full length apron over gown
Fluid repellent wellingtons available from the
emergency PPE store in ED.
Full face disposable visor or goggles
FFP3 fluid repellent respirator for which the wearer
is FIT tested.
Powered hoods can be used if the wearer is not
able to be fit tested on an FFP3 mask. These can be
obtained from the sterile services department. They
are accessible 24 hours a day between 6am
Monday and 9pm Saturday, and also between 6am
– 9pm on Sunday. In an emergency, contact Centre Sterile Services
Department (CSSD) on call via switchboard.
Wear double gloves
Head cover
If additional PPE is required, refer to appendix 8 for emergency
supplies.
Sharps
Avoid the use of sharps where possible.
--- PDF page 10 ---
10
If required to use, place into a sharps bin inside the patients room.
If VHF is ruled out, dispose of as normal.
If VHF is confirmed, double bag the sharps bin in clinical waste bags,
swan necked and zip tied before placing into a Wiva bin (plastic
ridged bin with secure lid). Wiva bins must be cleaned with 1,000ppm
HazTab solution or Tristel before being removed from the patients
room. WIVA bins must be over-labelled with a UN3549 covering the
CAT B UN 3291 label. ISS will collect and bring a 770 Eurobin to take
waste away when required.
Equipment
Single use (disposable) equipment and supplies must be used.
Cleaning and
decontamination
Upon leaving the patients room in PPE, someone should be allocated
to mop the floor behind you until you get to the doffing area.
Routine daily cleaning should be done by the nursing staff.
Use HazTabs: 1,000 ppm for environmental decontamination or
Tristel.
Use HazTabs 10,000 ppm for dry blood (or granules for a wet blood
spillage), toilets and commodes (at least daily, preferably after each
use).
Disposable equipment should be used (i.e. mop heads and cloths).
Keep mop handle and bucket in the patient’s room. If disposable
equipment is not available, keep in the patient’s room and dispose of
upon discharge.
When the patient is discharged, gross contamination requires
cleaning and disinfection prior to fogging. ISS should be requested to
come and fog, and be given the same PPE as required for looking
after the patient. After fogging, a terminal clean must take place. This
must be logged on the helpdesk ext 25555. *
Waste
Waste can be kept inside the patient’s room while awaiting results to
confirm or exclude VHF if it is safe to do so.
Waste should be put into double clinical waste bags, only half filled,
swan necked and zip tied. They should then go into rigid containers
(wiva bins).
Wiva bins must be cleaned with 1,000ppm before taking out of the
patient’s room and placed into an open 770 litre clinical waste
Eurobin (contact ISS to bring Eurobin).
If using a commode, any body fluid (e.g. urine/diarrhoeal stool should
be solidified with high absorbency gel and disposed of directly into
clinical waste (double bagged then placed into a wiva bin followed by
a Eurobin). Single use disposable bed pans and sick bowls must be
used, and contents solidified using absorbency gel before going into
clinical waste bags, Wiva bins and Euro bins (gel is available from
emergency PPE supply in ED).
Crockery and
cutlery
Disposable crockery and cutlery must be used.
This must then be disposed of as category A waste (double bagged
and placed into a Wiva bin).
Bins must remain in patient’s room until they can be taken away by
ISS.
Linen and
laundry
Both disposable and re-usable linen from patients with a ‘high
possibility’ or ‘confirmed’ VHF infection must not be returned to a
laundry and must be treated and disposed of as category A
infectious waste (double bag, swan neck, zip tied and put into a Wiva
bin before being collected from the patients room into a Eurobin).
Visiting
No visiting is permitted until VHF has been ruled out.
Discuss any issues with infection specialist.
Other
Investigation plans, such as X rays or other investigations must be
discussed on an individual basis with the ID/Virology/
Microbiology/IPC team.
--- PDF page 11 ---
11
ACTION CARD: Confirmed VHF
CONFIRMED VHF
ACTION CARD
DATE
TIME
SIGN
Consultant
Virologist or
On-call
microbiologist
Results communicated from Porton down to
on-call service. Virologist or microbiologist to
inform most senior doctor looking after patient.
Update UKHSA.
Inform Infection Prevention and control of the
positive result
Convene, with IPC, an incident management
meeting including DIPC, public health
colleagues, emergency planning, security and
communications.
Nurse in
charge
Contact occupational health and share list of
all staff who have had contact with the patient.
Inform those in contact with the patient of the
positive result
Most senior
doctor
In liaison with the infection specialist
(Infectious diseases, microbiology or virology)
and infection control team, the transfer of the
patient to a high level isolation unit (HILU)
must be discussed. Call the Royal Free on
02077940500 or 08448480700. Transfer
arrangements will be made by HILU staff.
Occupational
Health Lead
In liaison with the incident management team,
occupational health will follow up staff contacts
Infection
prevention
and control
lead
In liaison with the incident management team,
infection control will identify and ensure follow
up of any patient contacts.
*In some scenarios, for example in an outbreak situation, it may not be possible to
transfer the patient to a HILU. They may therefore need to remain at UHCW. If this is
the case then a multidisciplinary approach will be needed to discuss placement and
containment. Include Infectious disease doctors, infectious disease nurses, infection
control including the DIPC and deputy DIPC, Virology. microbiology, site team,
estates, ISS, occupational health, health and safety and security.
--- PDF page 12 ---
12
Guidance on providing support to ventilated patients with VHF
VHF is primarily a disease causing gastrointestinal disturbance and
haemorrhagic fever, with associated problems of fluid balance. It is not a
primary respiratory condition, and the clinical need for respiratory
support is thought to be very rare.
The risk-benefit ratio of artificial ventilation and the associated creation of
aerosols, which could pose a significant risk to other patients, relations,
staff and thereby of dissemination of the condition to the wider public,
should be carefully balanced against the assumed benefit to the individual,
on a case-by-case basis.
Source: Intensive Care Society
Patient movements
Once VHF is suspected, patients should remain in isolation until the risk assessment
has been carried out. If the risk assessment states that VHF is unlikely then the
movement of the patient should not be restricted because of VHF.
If there is a low possibility and patients require admitting, then they can be moved.
Movement of a patient with suspected VHF is likely to cause distress to members of
the public, staff and patients whilst increasing the risk of exposing others to the
patient. The transfer must be planned (using the shortest route, the nearest lift, and
the route with less footfall) and receiving departments to be pre-notified. Therefore all
patient movement must be considered, planned and must adopt the following
principle:
Patient transfer should be done so in a swift continuous
manner whilst being as discreet as possible to reduce
fear and potential exposure to others.
Patients with suspected VHF who need to be moved should wear a fluid resistant
surgical mask if this can be tolerated. They should be provided with a vomax in case
of vomiting during the journey. Staff must wear appropriate PPE depending on the
risk assessment category. The receiving area must have a space for staff to doff
PPE, and if high risk then the staff must be provided with clean scrubs to change
into.
The patient should be transferred by the nursing team (not porters) with roles as the
porter and the other as the spillage nurse. Those staff who are transporting the
patient (touching the bed or chair) should avoid touching surfaces such as lift call
buttons, door handles, and handrails (a runner should do these things ahead of the
patient). However if not possible the spillage nurse will be responsible for wiping any
touch points during the journey once the team have passed through an area.
The spillage nurse will be responsible for taking appropriate cleaning products and
materials to deal with any spillage of blood or body fluids that may occur (yellow
clinical waste bags, yellow tie tags, Tristel jet, disposable paper towels and solidifying
gel. Spillages should be delt with by the spillage nurse as they happen. If it happens
--- PDF page 13 ---
13
in a lift then contact estates to take it out of action until it has been terminally
cleaned. If no spillages occur, there is no need for the corridors to be cleaned. The
spillage nurse will have cleaned the touch points.
If there is a high possibility of VHF or VHF confirmed then the patient must remain
in in admission area unless clinical need outweighs risk of moving the patient. If the
patient needs to be moved, the process of a rolling lock down must be implemented
by security and managed by the Duty Manager in order to move the patient. Where
possible this should be done in a way that both prevents access to the patient and
from others seeing the transfer. The patient must be accompanied two members of
nursing staff. One nurse will be designated the clinical nurse and the other the
spillage nurse (see above). If anyone asks why the corridors are being closed, the
response should be ‘this is a temporary closure while we transfer a patient’. Under
no circumstances should anyone say the patient may have VHF.
Discharge of a patient
Appropriate cleaning of the area, depending upon risk and action card, should take
place before the patient room and doffing area is re-used. For patients with a low
possibility of VHF, a signed off terminal clean is sufficient. For patients with a high
possibility or confirmed VHF, the room must be decontaminated. The nursing staff
will clean all spillages or gross contamination with 10,000 ppm sodium hypochlorite.
The performance team will then fog the area. Following fogging, a signed off terminal
clean should be performed.
After discharge of a patient from the area, it is important that all staff receive a debrief
to understand any results that may have come through, further actions and what may
follow in terms of follow up.
--- PDF page 14 ---
14
Appendix 1: VHF Risk Assessment
--- PDF page 15 ---
15
Appendix 2: Outline of roles and responsibilities
Chief Nurse – Director of infection Prevention and Control (DIPC)
Role: To act as the executive lead to ensure safe and effective arrangements are in place
for the treatment of a suspected or confirmed case of VHF, ensuring engagement with
external stakeholders.
Infectious diseases consultant (or on call microbiologist if out of hours)
Role: Responsible in conjunction with the admitting consultant for managing the clinical
response to a patient with suspected or confirmed VHF. To make arrangements for the
patient to be transferred to the admitting area to the designated ward area if appropriate to
do so. To arrange referral to the high consequence infectious diseases unit if required. To
provide advice to the trust on any additional arrangements and considerations that need to
be made.
Consultant virologist
Role: To liaise with UKHSA with regards to management and condition of the patient. To
ensure appropriate safeguards are in place for the handling and management if samples
sent to the laboratories.
Infection Prevention Lead Nurse
Role: To liaise with infectious diseases, virology and microbiology.
To liaise with other support services to provide advice and guidance including on the use of
PPE.
Assessing doctor
Role: To make the initial assessment and notification of suspected cases of VHF. The
assessing doctor must undertake the triage to obtain if the patient has risk factors for VHF.
The assessing doctor must escalate to an ED or IDU Senior Doctor (ST4 or above)
ED or other admitting area ST4 or above
Role: To take over the clinical management and risk assessment until transferred to ward or
different hospital. They must confirm the suspicion of VHF and ensure that steps have been
taken to protect staff, patients and visitors. They must provide a handover to infectious
diseases, virololgy (or microbiology if out of hours) and infection prevention and control.
Duty site manager
Role: To provide management support and retain overall command and coordination of the
patient’s management. To liaise with the clinical and non clinical teams involved and ensure
effective communication between teams. To make arrangements for the safe transportation
of patients with suspected or confirmed VHF should they need to move. To liaise with ISS to
arrange suitable cleaning once the patient has been moved. To ensure that patients who are
suspected of having a VHF are only admistted to designated areas when safe to do so.
Estates
Role: To provide support in the management of a suspected or confirmed case. To
undertake duties urgently where requested to maintain containment of the pathogen.
Waste manager
Role: To provide advice, guidance and supplies of equipment required for the handling of
waste from patients suspected or confirmed as having a VHF.
Occupational health
--- PDF page 16 ---
16
Role: To undertake assessment of fitness for work and of the health effects of work.
Occupational Health, in conjunction with the Health Protection Team of UKHSA will
screen and/or monitor all staff who have been involved in the patient’s treatment, if
confirmed positive, to ensure that there is no on-going risk. They will risk assess staff to
ensure that they are safe to return to work. This will include Psychological support if
required. Unless otherwise advised by UKHSA or Occupational Health there will be no
restrictions on staff returning to work
Laboratory staff
Role: To ensure the safe handling and retention of samples from patients suspected og
having a VHF. To ensure that samples are sent to reference laboratories following
regulations and that they are notified of their dispatch.
If VHF is highly possible or confirmed, an outbreak control group will need to meet. Members
will be as follows:
Chief nurse (Chair)
Chief operating officer
Consultant virologist
Emergency medicine lead
Head of infectious diseases (or deputy)
Lead nurse for infection prevention
Emergency planning officer
Communications lead
Estates manager
ISS manager
Occupational health lead
Health and safety manager
UKHSA consultant in health protection
ICB
NHSE
--- PDF page 17 ---
17
Appendix 3: After Death Care
Please contact Mortuary on ext. 27519 and liaise with them directly
Relatives must be discouraged from touching or kissing the body.
Post mortem examination
•
Post mortem examination on a person known to have died of VHF MUST NOT BE PERFORMED.
•
Where a person suspected of having VHF dies prior to receiving a definitive diagnosis, it may be necessary
on public health grounds to undertake some diagnostic tests.
•
Consultation with the infection specialist may help to determine which samples are essential for the
diagnosis or exclusion of infection.
•
Personnel undertaking diagnostic tests must wear PPE according to the risk assessment (see previous
sections in this document).
•
If tests find the deceased to be negative for VHF then a post mortem may be required.
Disposal of the deceased
•
Whether the case is suspected or confirmed, staff wearing appropriate PPE (see above) must place the
body in a double body bag.
•
Absorbent material must be placed between each bag, and the bag sealed and disinfected with 10.000 ppm
available chlorine (HazTabs).
•
The bag must be labelled as high risk of infection.
•
The bag must be placed in a coffin with sealed joints.
•
Once sealed the body bag and coffin must not be opened. It must then be kept, by prior arrangement with
mortuary staff, in a separate and identified cold store unit to await prompt cremation or burial.
•
An infection control notification sheet must be completed in readiness for the funeral directors.
•
Embalming or hygienic preparation of bodies presents an unacceptably high risk and must not be
undertaken.
•
The transportation of body/bodies out of the country is not recommended. However, ashes can safely be
transported.
•
In terms of the deceased clothing and personal effects, the family of the deceased must be consulted and
their needs and wishes respected as far as us reasonably practicable. In principal, clothing, personal effects
and valuables may be returned to relatives in accordance with normal health service procedure following
decontamination.
•
Items of clothing that are visibly contaminated must be safely disposed of. Other items must be autoclaved
prior to laundering. Jewellery and physical artefacts must be autoclaved or decontaminated using HazTabs.
--- PDF page 18 ---
18
Appendix 4: Door list
Staff list for the door of patients in low or high risk VHF categories
Name
Job title
Date
Time in
Time out
--- PDF page 19 ---
19
Appendix 5: Instructions for entering a high risk or confirmed VHF
patient’s room - donning and doffing.
If a patient falls into the high risk or confirmed VHF categories, it is imperative that PPE is donned
and doffed safely and correctly. This must be done with a buddy. The buddy’s role is to first instruct
the clinical member of staff to don PPE correctly. Secondly they will don their own PPE to be able to
assist. Fill out this form each time a member of staff donns PPE for high risk and confirmed cases of
VHF.
Donning for healthcare worker and buddy:
Health Care Worker Name…………………………….………Buddy Name……….……………………………………
--- PDF page 20 ---
20
Doffing for healthcare worker and buddy:
HCW Name…………………………….………Buddy Name……….……………………………………
Health
Care
Worker
(HCW)
Notes for buddy assisting Health Care
Worker (HCW)
Health care
worker
donned (sign
and date)
Buddy
donned (sign
and date)
Disposab
le scrubs
Have you had a drink and
been to the toilet? Have you
removed your jewellery
Have you tied your hair back
Clean hands
Boots
Tuck trousers into boots then slightly drape
excess over the top of the boots to avoid
contamination of inner
Inner gloves
Gown
Cut thumb holes in Cuffs
Check correct size and
back is covered Check
HCW has freedom of
movement
FFP3
Ensure staff member has been fit tested on
the mask used. If the wearer has not been fit
tested, powered hoods are available from
sterile services. Once donned, perform fit
check.
Head cover
Ensure all hair is enclosed in head cover or
hood, which ever is available.
Re-check fit as hood may displace mask
Apron
Write Name, Grade and discipline of HCW on
apron
Full face
visor
Outer
gloves
(long cuff)
Pull over gown sleeves
Check that all PPE is intact
Remind HCW to avoid contact where
possible with self or the environment
Check HCW is familiar with procedure
for leaving care delivery area
--- PDF page 21 ---
21
Health Care
Worker (HCW)
Notes for buddy assisting
Health Care Worker (HCW)
Health care
worker
completed (sign
and date)
Buddy
completed
(sign and
date)
Before
leaving
the
patients
room
Disinfect any visibly
contaminated PPE with
1000ppm sodium
hypochlorite (HazTab
solution)
Instruct HCW to disinfect any
visibly contaminated PPE with
sodium hypochlorite 1% Next:
instruct HCW to leave the patient
zone and to stay in the ‘dirty’ area
of the doffing room - progress
from dirty to clean
In the
doffing
area
Listen first before
removing anything
Instruct HCW slowly and
methodically.
Remove apron by pulling on
the sides and rolling so that
outer layer is inside. Place in
clinical waste bag.
Sanitise outer glove using
hand gel.
Allow gloves to air dry before
continuing
Remove outer gloves and
place into clinical waste bag
HCW should inch outside of dirty
glove to gently remove. Check
integrity of inner glove. If damaged
replace.
Sanitise inner glove with
hand gel.
Allow gloves to air dry before
continuing
Pull down gown down and
away at the hips. Roll inner
to outer and place in clinical
waste bag
Buddy to undo ties and observe
gown removal. Buddy sanitises
outer gloves and remove into
clinical waste by pinching the
outside.
Sanitise inner glove.
Sanitise inner glove with
hand gel
Allow gloves to air dry before
continuing
Sit down
Loosen HCW boots and remove
one at a time, placing feet into a
‘clean’ area. Dispose of as clinical
waste.
Sanitise inner glove with
hand gel if there was contact
with boots.
Sanitise gloves with hand gel.
Remove inner glove
Instruct HCW to pinch outside of
dirty glove to hook the clean inside
to remove.
Clean hands
Allow HCW hands to air dry before
continuing.
Put on a clean pair of gloves
Remove visor and place
in clinical waste bag.
Advise HCW not to touch
face and to turn to the side,
bend head forwards, close
eyes and pull elastic over
--- PDF page 22 ---
22
head away from the body.
Observe.
Clean gloves using hand
gel
Allow HCW gloves to air dry
before continuing.
Close eyes and remove
head covering.
Advise not to touch the
face. Pull away from the
head.
Clean gloves using hand
gel
Allow HCW gloves to air dry
before continuing.
Remove gloves
Clean hands
Allow HCW hands to air dry
before continuing.
Remove mask
Advise HCW not to touch
face. Bend forwards,
keeping eyes and mouth
closed. Pull bottom band
overhead and anchor
securely, remove top band
over the head and place
into clinical waste bag.
If a powered hood as been
used, this should be
removed without touching
the face. The hood must be
disinfected with Tristel
before being placed in the
blue box (that it came in) to
go back to sterile services.
Attach a sign to the blue
box to state high risk and
call CCSD to alert them to
this item being returned and
it has been in contact with
possible/confirmed VHF.
CCSD can be contacted on
ext 28893 or 28903.
Clean hands
Allow HCW hands to air dry
before continuing.
If scrubs are visibly soiled
put on a clean pair of
gloves before removing
Check scrubs to see if
contaminated. If top is
soiled, buddy to cut scrubs
so they can be removed
without going overhead.
If scrubs are not
contaminated, go to shower
--- PDF page 23 ---
23
Was all PPE removed without contamination to skin, mucous membranes or inner clothing? Yes /
No (HCW) (please circle as required)
Yes / No (Buddy)
If No to above question – staff member to report to occupational health.
If contamination occurred, what action was taken?
with a clinical waste bag. At
shower room, place scrubs
into waste bag.
Buddy to clean
Once HCW has doffed,
buddy to clean doffing area
with 1000ppm sodium
hypochlorite (HazTab
solution).
Buddy to doff the same as
steps above (from the
image of the apron, step 3)
--- PDF page 24 ---
24
Appendix 6: Communication of possible or confirmed VHF
Once a risk assessment has been performed and the patient meets either the low or high
risk of VHF category, an infection specialist (ID, virologist or microbiologist) must be
informed as well as the Director of Infection Prevention and Control (DIPC) for the trust.
Cases in the LOW RISK category must be communicated to silver command plus the
communications team by a member of the infection team. They must be kept up to date with
any developments.
Cases in the HIGH RISK or CONFIRMED VHF categories require formation of an incident
management team (IMT). The lead for this will be dependent upon the particular situation. At
UHCW, this will take place in the Divisional Offices on the second floor; representatives from
external agencies must be invited to dial in.
The IMT should comprise of:
a. Director of Infection Prevention and Control (DIPC)
b. Consultant Virologist / Microbiologist
c. Managing Consultant Clinician
d. Infectious Diseases Physician (if available)
e. Infection Control Lead Nurse, IPC Nurse
f. Consultant in Communicable Disease Control (from local Public Health Unit)
g. Director of Nursing
h. Director of Communications/Corporate Communications Officer
i. Duty Chief Operating Officer
j. Emergency Planning Officer
k. Senior Nurse from relevant ward area
l. Project Co. representative, via switchboard, including out of hours
m. Estates and Facilities representative (regular working hours)
n. ISS
o. Trust decontamination lead.
p. Lead Nurse Occupational Health
The IMT will also need to:
a. Inform UKHSA, as the UK competent body, if/when VHF screen result is positive
b.
Determine who is responsible for the assessment, categorisation and management of
contacts, including those outside the UK, the actions to be taken and the advice to be
given
c. Determine who is responsible for media handling
d.
Agree all key media messages between all parties
--- PDF page 25 ---
25
Appendix 7: Label to cover WIVA bin to show it contains category A
waste.
--- PDF page 26 ---
26
Appendix 8: How to obtain additional PPE stock for patients with suspected VHF
ED Nurse in Charge Requests Access to Stock
Inventory through Clinical Site Manager
Clinical Site Managers tasks Portering Supervisor to
arrange for collection of the appropriate cages from old
Social Club secure holding following the instructions
on Action Card: Appendix B
Porter supervisor identifies 2 people that can collect the stock from the
Social Club. 1 of these people must be able to drive the ISS Transport Van
(with Tail lift) and requests for them to join them in the major incident control
room.
Clinical Site Managers hands over Social Club access key
found on the Black Major Incident Cabinet in 2nd floor
Divisional Offices (Picture 1 below)
Porters collect and deliver the cages to the
Emergency Department
Porters return the key to the Clinical Site
Manager in the Control Room
--- PDF page 27 ---
27
Governance Check
Changes from previous version
Chronology of
Update of
Information
Detail of Changes
Page No.
Para No.
Authors
Lead
Author:
Katie Jones
Clinical Scientist - Infection Prevention and Control
Katie.jones2@uhcw.nhs.uk
Reviewer(s): Fiona Wells
Lead Nurse Infection Prevention and Control
Fiona.wells@uhcw.nhs.uk
Dr. Lisa Berry
Consultant Clinical Scientist in Virology
Lisa.berry@uhcw.nhs.uk
Dr. Steve Laird
Consultant microbiologist
Steven.Laird@uhcw.nhs.uk
Dr. Gorana Kovacevic
Consultant in Infectious diseases and Acute Medicine
Gorana.Kovacevic@uhcw.nhs.uk
Approving
Forums
Infectious Disease QUIPS
Infection Prevention and Control Committee
Approval Dates
(All clinical
procedures require
QIPS approval prior
to review at a relevant
committee.)
QIPS
26/04/2023
MMC
N/A
Other (specify)
IPC
Review Date
28/03/2025
Keywords
Vhf
Viral hemorrhagic fever
Ebola
Fever in the returning traveller
Lassa
Marburg
CCHF
Crimean Congo Haemorrhagic fever
Definitions
NONE (already explained)
Clinical Procedure Content: A procedure document outlines a set of actions and rationale that is
the official or accepted method of delivering clinical treatment. These are evidence based and must
be followed when indicated, therefore not guidelines e.g., Procedure for venous cannulation, or
management of Haemodialysis lines.
Regardless of the strength of evidence, it remains the responsibility of the clinician to interpret the
--- PDF page 28 ---
28
application of the clinical procedure in the context of local circumstances and the needs and wishes
of the individual patient. Where variations of any kind do occur, it is important to document the
variations and the reason for them in the patient’s health record. If in doubt, seek senior advice.
Equality and Diversity Statement: Throughout its activities, the Trust will seek to treat all people
equally and fairly. This includes those seeking and using the services, employees and potential
employees. No-one will receive less favorable treatment on the grounds of sex/gender
(including Trans People), disability, marital status, race/colour/ethnicity/nationally, sexual
orientation, age, social status, their trade union activities, religion/beliefs or caring responsibilities
nor will they be disadvantaged by conditions or requirements which cannot be shown to be
justifiable. All staff, whether part time, full-time, temporary, job share or volunteer; service users
and partners will be treated fairly and with dignity and respect.
Training
N/A
Monitoring of Outcomes
The presentation of patients with VHF is rare. Therefore individual reviews will be done
following the use of this policy.
Appendices
Appendix1: VHF risk assessment
Appendix 2: Outline of roles and responsibilities
Appendix 3: After death care
Appendix 4: Door list
Appendix 5: Instructions for entering a high risk or confirmed VHF patient’s room - donning
and doffing.
Appendix 6: Communication of possible or confirmed VHF
Appendix 7: Label to cover WIVA bin to show it contains category A waste.
Appendix 8: How to obtain additional PPE stock for patients with suspected VHF
References
DoH (2015) Management of Hazard Group 4 viral haemorrhagic fevers and similar human
infectious diseases of high consequence – Advisory Committee on Dangerous Pathogens.
Crown copyright. Available from: https://www.gov.uk/government/publications/viral-
haemorrhagic-fever-algorithm-and-guidance-on-management-of-patients
Health Protection Scotland (2016) Advice for Purchase of Required PPE for Viral
Haemorrhagic Fever (VHF) Preparedness. Available on https://www.hps.scot.nhs.uk/web-
resources-container/advice-for-purchase-of-required-ppe-for-vhf-preparedness/
Poller et al (2018) A unified personal protective equipment ensemble for clinical response to
possible high consequence infectious diseases: A consensus document on behalf of the
HCID programme. Journal of Hospital Infection 77 (2018): 496 – 502.
Public Health Wales (2014) Personal Protective Equipment (PPE) for all known or suspected
cases of Ebola Virus Disease in Acute Healthcare Settings in Wales. Available on
http://www.publichealthwales.org/ebola
--- PDF page 29 ---
29
WMAS (2018) Procedure for Viral Haemorhagic Fevers (VHF) and the management of
category 4 diseases. Procedure – 126 (Version 1).
University Hospitals Leicester Viral Haemorrhagic Fever Policy: Management Suspected or
Confirmed Cases of Ebola or other VHF Diseases (2017).
--------------------------------------------------------------------------------
ATTACHMENT: 16_1.pdf
TEXT_FILE: 16_1.pdf.txt
METHOD: pdf_native
OCR_USED: False
PAGES: 5
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Page 1 of 5
Please note: The following systems have been replaced by the trust Electronic Patient Record
system (EPR). If any of these systems are identified within the document, please substitute them
for the appropriate EPR alternative system and refer to relevant corresponding EPR procedures.
1. Opera (theatres)
2. Centricity (Critical Care)
3. Wardview
4. Extramed
5. CRRS
6. VitalPack
7. Adastra (CUTC)
8. K2 (maternity portal replaced by PPUK)
9. i.PM
10. Athena (Maternity)
11. SCIT App (replaced by camera capture)
Please contact EPREnquiries@uhcw.nhs.uk if you have any questions about the systems
listed or the EPR system introduced in their place.
On review of this document please ensure the systems listed are removed from the text
and replaced with the relevant EPR system and process.
Guidance for the laundering of Patient’s Soiled Clothing in the Home Setting
Related Clinical
Document
Laundering of Patient’s Soiled Clothing in the Home Setting
eLibrary number
COP 63
Version number
9
Does this Clinical
Procedure relate
to a Clinical
Guideline?
No
Purpose/Rationale
All staff should familiarise themselves with the following guidance to
ensure patients soiled clothing is laundered appropriately.
Primary Specialty
Trust wide
Related
Specialties
N/A
Specialty Clinical
Procedure Lead
Fiona Wells Infection Prevention and Control and Sepsis Nurse
--- PDF page 2 ---
Page 2 of 5
Clinical Procedure
1. Introduction
The purpose of this policy is to set out the procedures which must be taken to minimise the
risk of infection by making staff aware of the correct procedures for categorisation,
segregation, transportation, and handling of linen so that the risk of potential cross-infection is
minimised
On occasion, as a result of patient treatments or investigations or through the nature of illness,
a patient’s own clothing may become soiled with either blood, and or bodily fluids. Items cannot
be laundered within the hospital as no facilities are available for the laundering of personal
items; however, these can and may need to be washed at a suitable temperature within the
home setting.
Patient’s personal clothing, which has been soiled by blood/bodily fluids can pose a
potential risk of infection to a friend or relative who takes the clothing home for laundering.
The information in this guideline gives specific guidance on how best to ensure
relatives/friends are given the correct information to allow them to handle and launder
clothing safely.
The aim of this guidance is: -
•
To ensure the safe laundering of soiled items within the home setting,
•
To protect both the relatives and or carers from any blood and or bodily fluids
present on patient items
•
To ensure adequate decontamination of any soiled items
2. Equipment Required for the Clinical Procedure
•
Patient clothing bag (PCB)
•
Personal protective equipment
•
Home environment- washing machine.
3. Description of Procedure
Roles and Responsibilities
•
Follow the procedures set out in this policy.
•
Staff should physically remove any soil from items using full protective
clothing e.g., gloves, aprons, and visors. Do not attempt to sluice items
under running water as this is likely to create aerosol of bodily fluids and
will then contaminate the immediate environment and the member of staff.
•
Place items into a patient clothing bag (PCB). This bag is fully sealed and
has a soluble seam that will dissolve in the wash process.
•
Seal the PCB with the tie, do not knot the bag.
•
Remove personal protective equipment and decontaminate hands with soap
and water.
--- PDF page 3 ---
Page 3 of 5
•
Place PCB into a patient’s property bag and seal.
Process
If soiled items are no longer required by the patient, gain consent from the patient and or the
patient’s relative / carer to discard soiled items as clinical waste (please see Trust waste
management policy 2019). Document action taken in the nursing notes.
If the patient frequently soils items of their own clothing, ask the patient whether they would
prefer to wear hospital clothing, which can be laundered through the hospital’s laundry service.
If the patient is not able to make the decision due to mental or physical conditions, then ask
the relative / carer if they would prefer the patient to wear hospital clothing.
If the patient wishes to have items washed at home, inform the patient’s relative / carer of this
requirement, document this in the nursing notes and follow steps below.
If soiled items are to be laundered at home:
• Staff should physically remove any soil from items using full protective clothing e.g.,
gloves, aprons, and visors. Do not attempt to sluice items under running water as this is likely
to create an aerosol of bodily fluids and will then contaminate the immediate environment and
the member of staff.
• Place items into a patient clothing bag (PCB). This bag is fully sealed and has a soluble
seam that will dissolve in the wash process.
• Seal the PCB with the tie, do not knot the bag.
• Remove personal protective equipment and decontaminate hands with soap and water
• Place PCB into a patient’s property bag and seal.
How to wash soiled clothing at home
• In a home environment, washing machines and driers are often in the kitchen. In this
situation, be conscious of the tasks being undertaken i.e., sorting laundry, and preparing food
should not be carried out at the same time. Ensure that hands are always washed after
handling laundry and before preparing food. Clean the area around the washing machine such
as the door of the machine and work tops.
• Remove the soiled items from the property bag and place the patient clothing bag (PCB)
straight into the washing machine avoiding the need to touch any soiled items. Handle any
laundry soiled with blood or body fluids wearing gloves (disposable gloves or your bathroom
rubber gloves) and avoid touching it on your clothes or skin. Wash your hands well with warm
water and soap.
• Wash the bag of soiled clothing on its own – do not add any other linen / clothing to the
machine. Rinse using a cold pre-rinse cycle and then wash items on the hottest wash that the
material will withstand as per the care instructions on the label, preferably at or above 60
degrees. Use your normal washing powder, liquid, or tablets.
• Do not overload the washing machine as this will not wash the clothes as well.
--- PDF page 4 ---
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• The PCB has a soluble membrane on the external seam and a pink tie that dissolves once
the washing machine begins to fill with water
• The seam and tie begin to dissolve, and this will release the clothes from the PCB allowing
the contents to be washed in the normal way
• Once the wash cycle is complete remove the PCB and place into domestic waste bin
• Dry laundry as soon as possible after washing. Do not leave laundry soaking in water or in
the washing machine overnight. Tumble dry / air dry and iron the clothing on the hottest setting
as per care instructions on the label. The PCB must not be placed in the tumble dryer.
• Take the clothes back to the patient in a clean bag.
Governance Check
Changes from previous version
Chronology of
Update of
Information
Detail of Changes
Page No.
Para No.
Policy dates updated
Authors
Lead Author:
Ragbinder Mahal Infection Prevention and Control
and Sepsis Nurse
Ragbinder.Mahal@uhcw.nhs.uk
Reviewer(s):
Fiona Wells Infection Prevention and Control and
Sepsis Nurse.
Fiona.Wells@uhcw.nhs.uk
Approving
Forums
Infection Prevention and Control Committee
Approval Dates
(All clinical
procedures require
QIPS approval prior
to review at a relevant
committee.)
QIPS
23/11/2022
MMC
N/A
Other (specify)
Review Date
October 2025
Keywords
Patient clothing bag, laundering
Definitions
PCB- Patient clothing bag
IPC- Infection Prevention Control
Clinical Procedure Content: A procedure document outlines a set of actions and rationale that is
the official or accepted method of delivering clinical treatment. These are evidence based and must
be followed when indicated, therefore not guidelines e.g., Procedure for venous cannulation, or
management of Haemodialysis lines.
Regardless of the strength of evidence, it remains the responsibility of the clinician to interpret the
application of the clinical procedure in the context of local circumstances and the needs and wishes
--- PDF page 5 ---
Page 5 of 5
of the individual patient. Where variations of any kind do occur, it is important to document the
variations and the reason for them in the patient’s health record. If in doubt, seek senior advice.
Equality and Diversity Statement: Throughout its activities, the Trust will seek to treat all
people equally and fairly. This includes those seeking and using the services, employees and
potential employees. No-one will receive less favourable treatment on the grounds of
sex/gender (including Trans People), disability, marital status, race/colour/ethnicity/nationally,
sexual orientation, age, social status, their trade union activities, religion/beliefs or caring
responsibilities nor will they be disadvantaged by conditions or requirements which cannot be
shown to be justifiable. All staff, whether part time, full-time, temporary, job share or volunteer;
service users and partners will be treated fairly and with dignity and respect.
Training
None
Monitoring of Outcomes
Clinical area monitoring process
Appendices
None
References
Patient information leaflet- Patient clothing bag (PCB) leaflet available on E-Library.
Department of Health (2016) Health Technical Memorandum 01-04: Decontamination of
linen for health and social care. Engineering, equipment, and validation
https://www.england.nhs.uk/wp-content/uploads/2021/05/Engineering.pdf (Accessed
14/11/2022)
Dougherty & Lister (2015) (Ed) The Royal Marsden Hospital Manual of “Clinical Nursing
procedures 9th Edition Chapter: 3.
https://www.wiley.com/egb/The+Royal+Marsden+Manual+of+Clinical+Nursing+Procedures,+9th+Ed
ition,+Professional+Edition-p-9781118745915 (Accessed 14/11/2022)
--------------------------------------------------------------------------------
ATTACHMENT: 17_1.pdf
TEXT_FILE: 17_1.pdf.txt
METHOD: pdf_native
OCR_USED: False
PAGES: 10
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Page 1 of 10
Standard Operating Procedure (SOP)
COVID-19 screening requirements
August 2022
--- PDF page 2 ---
Page 2 of 10
Summary:
This Standard Operating Procedure describes
COVID-19 and respiratory virus screening
requirements.
Review date:
30th November 2022
Version number:
(To be rounded number)
1.1
Supersedes previous document:
(ID reference no and document title, as
appropriate)
Cross Reference with:
(Associated relevant documents)
Transfer to Rugby SOP V6
Author(s):
(Name and Title)
Fiona Wells, Lead Nurse
Lisa Berry, Consultant Virologist
Reviewer(s):
(Name and Title)
Vicky Williams, Deputy Chief Nursing Officer
Location of document:
--- PDF page 3 ---
Page 3 of 10
INDEX
Sections
Section Titles
Page(s)
1
Introduction
4
2
Definitions
4
3
Details of the Procedure
5
4
Appendices
-
--- PDF page 4 ---
Page 4 of 10
1.0 INTRODUCTION
The following pathways for management are described within this Standard Operating Procedure (SOP) for
all patients attending UHCW
•
Outpatient appointments
•
Diagnostic attendance
•
Elective/ planned admission
•
Emergency admission
This document has been written in line with recent National guidance documents C1662 (COVID-19
Testing in periods of low prevalence, NHS England August 2022). It replaces the previous national
guidance produced by The National Institute of Health and Care Excellence (NICE) July 2020 publication
(NG 179) and publications C1263 and C1264.
2.0 DEFINITIONS
LFD – Lateral Flow device
PCR - Polymerase Chain Reaction
--- PDF page 5 ---
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3.0 DETAILS OF THE PROCEDURE
General principles
•
Elective/ planned care patients to have undergone full pre-operative/ procedure assessment and
be considered fit to proceed prior to listing as per pre-pandemic arrangements.
•
A contact number will be communicated to all patients in order to report symptoms of COVID-19 in
the preoperative period.
•
Previous principles of self-isolation prior to procedure, PCR testing and “green” pathways are no
longer a standard requirement of elective/ planned care
•
A contact number will be communicated to all patients in order to report symptoms of COVID-19 in
the preoperative period.
•
Access to free LFD kits for patients can be accessed at Order coronavirus (COVID-19) rapid lateral
flow tests - GOV.UK (www.gov.uk)
•
Emergency patients include any direct access pathway route
1. Outpatient appointments
•
Social distancing measures will be removed from all areas
•
Mask wearing for patients and staff recommended (subject to exemptions as before)
•
Additional accompanying persons are able to attend with patients
•
Flow should be managed to reduce congestion in the department
•
No testing requirements
2. Diagnostics appointments
•
Social distancing measures will be removed from all areas
•
Mask wearing for patients and staff recommended (subject to exemptions as before)
•
Additional accompanying persons are able to attend with patients
•
Flow should be managed to reduce congestion in the department
•
No testing requirements
3. Elective/ planned Admissions
There is no longer any need for an isolation period prior to admission for all patients
•
No routine COVID-19 test will be required
•
If symptomatic
•
Clinical review if positive and risk assess on decision to proceed / cancel (see point 5)
•
Manage placement accordingly (i.e. if positive and requires procedure, side room or COVID
positive cohort bay)
Where expected day cases convert to an inpatient – PCR test is only necessary if symptomatic.
--- PDF page 6 ---
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4. Emergency Admissions
Patients admitted through any direct access pathway as an emergency admission should be
assessed for signs and symptoms of COVID-19 and respiratory virus.
Clinical staff should consider COVID/ respiratory virus if the patient exhibits symptoms (see below)
and there is no other clinical explanation
•
If symptomatic a Rapid PCR should be taken
•
If asymptomatic
5. Inpatients
Clinical staff should consider COVID/ respiratory virus if the patient exhibits the following symptoms
and there is no other clinical explanation.
•
A high temperature
•
A new, continuous cough
•
A loss or change to your sense of smell or taste
•
Shortness of breath
•
An aching body
•
Headache
•
Sore throat
•
Blocked or runny nose
•
Loss of appetite
•
Diarrhoea
A PCR test can be ordered using the CRRS request system as per previous procedure.
Known patient contacts of COVID-19 will not require swabbing on a daily basis, but will require
daily observation for 4 days for symptoms developing.
6. Immunocompromised patients
•
Wards 34/ 35 and 50 will perform a PCR on admission to the area due to volume of
immunocompromised patients on these wards. This will be reviewed in the future.
•
Where a clinician deems that a patient’s risk profile warrants a PCR test in advance of a
procedure, arrangements for a PCR test can be made. This will be managed within groups.
•
Patient management of these patients must be a consideration, with use of isolation rooms
and/ or cohorted bays
7. COVID-19 test positive result
--- PDF page 7 ---
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1. Swab positivity or symptom reporting may require deferral of surgery and this decision must be
made following clinical review to balance the risks of proceeding vs cancellation. There is guidance
available from specialty associations to support this decision, but it must be made on an individual
patient basis balancing risk of cancellation with risk of proceeding by the clinician.
2. Patients cancelled for positivity should not be re-swabbed (PCR) within 90 days, unless meeting
UKHSA guidance on being immunocompromised or having new onset of symptoms. Patients who
are found to be positive on PCR testing preoperatively, but have a recent history of COVID-19
positivity (within 90 days) should not be automatically cancelled. Clinical review of the case will
determine risk/likely current COVID-19 status and will inform decision to proceed or cancel.
8. Patients transferring to nursing home/ residential homes
There are no changes to the requirement for testing patients who are transferring to nursing/
residential homes.
If a patient is not known to have been positive in the last 90 days – a PCR is required
If a patient is known to have been positive in the last 90 days – a LFD is required
--- PDF page 8 ---
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Elective procedure - General Anaesthetic (GA)
Symptomatic
Clinical staff should consider COVID/
respiratory virus if the patient exhibits
the following symptoms and there is
no other clinical explanation.
•
A high temperature
•
A new, continuous cough
•
A loss or change to your sense of
smell or taste
•
Shortness of breath
•
An aching body
•
Headache
•
Sore throat
•
Blocked or runny nose
•
Loss of appetite
•
Diarrhoea
Asymptomatic
Clinical review to
determine whether to
proceed or delay
If decision to proceed, as
procedure is deemed too
urgent to delay:
•
Admit to side-room
•
Arrange full diagnostic
testing for respiratory
pathogens*
-
1 swab COVID
-
1 swab Full respiratory panel
*This is for diagnostic and clinical
management purposes
No testing
required
Elective procedure -
General Anaesthetic
Consideration must be taken within group SOP’s as to how to protect immunocompromised
patients
Use Isolation facilities/cohorting for Clinically Extremely Vulnerable (CEV) individuals
Is the patient immunocompromised?
No
Immunocompetent
Clinical decision to test.
Patient to carry out LFD at
home and report to
national system.
Clinical team to document
result
This is not for IPC purposes but
to manage any risk due to
procedure and patient being
asymptomatically positive
Yes
--- PDF page 9 ---
Page 9 of 10
Elective procedure – Non GA
Elective procedure –
Non GA
Symptomatic
Clinical staff should consider COVID/
respiratory virus if the patient exhibits
the following symptoms and there is
no other clinical explanation.
•
A high temperature
•
A new, continuous cough
•
A loss or change to your sense of
smell or taste
•
Shortness of breath
•
An aching body
•
Headache
•
Sore throat
•
Blocked or runny nose
•
Loss of appetite
•
Diarrhoea
Asymptomatic
Is the patient immunocompromised?
Yes
No
Immunocompetent
No testing
required
Clinical review to
determine whether to
proceed or delay
If decision to proceed, as
procedure is deemed too
urgent to delay:
Patient to carry out LFD at home
and report to national system.
Clinical team to document result
Clinical decision to test.
Patient to carry out LFD at
home and report to
national system.
Clinical team to document
result
This is not for IPC purposes but
to manage any risk due to
procedure and patient being
asymptomatically positive
--- PDF page 10 ---
Page 10 of 10
Emergency Admission Testing Pathway
Patient requires admission
Symptomatic rapid COVID test to
be ordered
Consideration must be taken within group SOP’s as to how to protect immunocompromised patients
Use Isolation facilities/cohorting for CEV individuals
Admit to side-room if negative
or
Appropriate isolation/ cohort area if
positive
Lab will process all
negative tests for a full viral
respiratory screen.
No testing required* – admit to
appropriate clinical pathway
*W34/35 and W50 test on admission
If repatriation from another hospital to ward
43/ CTCC/ GCC test on admission
Symptomatic
Clinical staff should consider COVID or
respiratory virus if the patient exhibits the
following symptoms and there is no other
clinical explanation.
•
A high temperature
•
A new, continuous cough
•
A loss or change to your sense of
smell or taste
•
Shortness of breath
•
An aching body
•
Headache
•
Sore throat
•
Blocked or runny nose
•
Loss of appetite
•
Diarrhoea
Asymptomatic
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ATTACHMENT: 18_1.pdf
TEXT_FILE: 18_1.pdf.txt
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--- PDF page 1 ---
Version number: 9.0
Trust-wide CBR title: Hand Decontamination Policy
Hand Decontamination Policy
eLibrary ID Reference No:
OPER-POL-002-10
Newly developed Trust-wide CBRs will be allocated an eLibrary reference number following Trust approval.
Reviewed Trust-wide CBRs must retain the original eLibrary reference number.
The Quality department will progress all new, re-written and reviewed CBRs for final Trust approval.
Version:
(must be a rounded number, i.e. 6.0,7.0 etc.)
10.0
Title of Approving Committee:
Patient safety Committee
Date Approved:
November 2020
Risk Rating:
(this must be applied by the Author prior to being submitted to the
Quality Dept. ( refer to CBR guidance pack on eLibrary)
Moderate
Next Review Date:
(this must be applied by the Author dependant on risk rating or
record alternative date if required to meet national guidance)
November 2023
If printed, copied or otherwise transferred from eLibrary, Trust-wide Corporate
Business Records will be considered ‘uncontrolled copies’. Staff must always
consult the most up to date PDF version registered on eLibrary.
As a controlled Trust-wide CBR, this record should not be saved onto local or
network drives but should always be accessed from eLibrary.
--- PDF page 2 ---
Page 2 of 21
Version number: 10.0
Trust-wide CBR title: Hand Decontamination Policy
Summary of Trust-wide CBR:
(Brief summary of the Trust-wide Corporate Business
Record)
To provide guidance for staff on effective hand
decontamination when this is to be implemented
and by whom.
Purpose of Trust-wide CBR:
(Purpose of the Corporate Business Record)
To illustrate that UHCW NHS Trust has a process
for ensuring the delivery of effective hand
decontamination training to all permanent staff
groups and how this is implemented and monitored
Audience
(Who the CBR is intended for)
Trust-wide CBR to be read in conjunction with:
(List overarching/underpinning strategies, policies and
procedures – refer to CBR Evidence Summary)
Trust Mandatory Training Policy.
Training needs analysis.
Trust wide glove Policy on e library
Relevance:
(State one of the following: Governance, Human
Resource, Finance, Clinical, ICT, Health & Safety,
Operational)
Clinical
Superseded Trust-wide CBRs (if applicable):
(Should this CBR completely override a previously
approved Trust-wide CBR, please complete the ‘Request
for Removal of CBR’ form and submit to Quality Dept –
please refer to eLibrary and state full title and eLibrary
reference number and the CBR will be removed from
eLibrary)
N/A
Author’s Name, Title and email address:
(must not be the same as reviewer)
Carolyn Dawson – Infection Prevention and
Control Research Practitioner
Carolyn.Dawson@uhcw.nhs.uk
Reviewer’s Name, Title & email address:
(must not be the same as author)
Kate Prevc – Lead Nurse, Infection Prevention and
Control, and Decontamination
kate.prevc@uhcw.nhs.uk
Chief Officer’s Name, Title:
Nina Fraser – Chief Nursing Officer
Title of Group/Department/Specialty:
Infection Prevention and Control
Version
Consulting & Endorsing Stakeholders,
Committees/Meetings/Forums etc for this version only
List all Consulting & Endorsing Stakeholders for this version, this can
include direct consultation with individuals,
Committees/Forums/Bodies/Groups, refer to guidance pack.
Date
--- PDF page 3 ---
Page 3 of 21
Version number: 10.0
Trust-wide CBR title: Hand Decontamination Policy
Corporate Business Record Policy/Procedure Summary
Hand Decontamination Policy
Purpose of CBR
To illustrate that UHCW NHS Trust has a process for ensuring the delivery of effective hand
decontamination training to all permanent staff groups and how this is implemented and
monitored
Description of vision of CBR
Key Points of CBR
Effective hand hygiene can prevent spread of infection, and forms part of mandatory
training for all staff.
The IPCT is responsible for training and measurement of hand hygiene.
Training is provided on technique and practice, to ensure hand hygiene is effective,
timely, and appropriate.
Measurement is performed on training (individual compliance) and performance of staff in
accordance to the WHO 5 Moments of hand hygiene.
Who does CBR affect?
All UHCW NHS Trust employees
--- PDF page 4 ---
Page 4 of 21
Version number: 10.0
Trust-wide CBR title: Hand Decontamination Policy
Table of Contents
Paragraph
Number
Description
Page
No.
1.0
Scope
5
2.0
Introduction
5
3.0
Statement of Intent
7
4.0
Details of Policy
11
5.0
Duties / Responsibilities
14
6.0
Dissemination and Implementation
14
7.0
Training
14
8.0
Monitoring Compliance with Policy
15
9.0
Staff Compliance Statement
16
10.0
Equality & Diversity Statement
16
11.0
Ethical Considerations
16
12.0
Definitions
16
13.0
References & Bibliography
16
14.0
UHCW Associated CBRs
18
15.0
Appendices
19
--- PDF page 5 ---
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Version number: 10.0
Trust-wide CBR title: Hand Decontamination Policy
1.0
SCOPE
1.1 This policy applies to Trust personnel working within the University Hospitals
Coventry and Warwickshire NHS Trust. Each member of staff has a personal
responsibility to ensure they comply with the policy. This policy will cover routine hand
decontamination by the use of soap & water and alcohol based hand rub. Surgical hand
washing will be covered separately by the scrubbing technique found on eLibrary.
2.0
INTRODUCTION
2.1 The spread of infection via hands is well established. (Larson 1981; Ayliffe et al.,
1999; Pittet et al., 1999; Creamer et al., 2010). It is also well established that hand
decontamination is one of the most important procedures for the prevention of cross
infection, and that effective measurement and feedback processes are essential to
ensure adherence to best practice (Girou et al., 2002; WHO 2009).
Healthcare associated infection (HCAI) remains a significant problem, with both human
and financial cost implications. Application of existing knowledge and implementation of
realistic infection prevention interventions can significantly reduce HCAI (Schreiber,et al.,
2018).
The simplest, most important of these interventions, supported by clear and indisputable
evidence, is that all healthcare workers need to decontaminate their hands at 5 specific
moments of patient care (WHO, 2009) (Figure 1).
--- PDF page 6 ---
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Version number: 10.0
Trust-wide CBR title: Hand Decontamination Policy
Figure 1: WHO 5 Moments for Hand Hygiene
The emergence of antibiotic resistant organisms can also be partly attributed to the
failure of healthcare workers to wash their hands, either as often or as efficiently as the
situation requires, despite appropriate written infection control policies (Heenan 1996).
--- PDF page 7 ---
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Version number: 10.0
Trust-wide CBR title: Hand Decontamination Policy
3.0
STATEMENT OF INTENT
3.1 Hand hygiene has been identified as the single most important strategy to prevent
healthcare associated infections (Sax et al., 2009).
The aim of hand hygiene is to prevent:
Cross-colonisation - the transfer of (multi-resistant) micro-organisms can been seen
to contribute to increasing antimicrobial resistance (AMR) and a reservoir of potential
pathogens.
Cross-infection – if micro-organisms invade the body serious illness may occur. This
is more likely for those with compromised immune systems, like many hospital
patients.
Hand hygiene prevents cross-colonisation between patients, staff and the environment.
Effective hand hygiene can be achieved by following the WHO 5 Moments (WHO 2009),
using soap and water, or alcohol based hand rub (ABHR) as advised by Trust policy.
4.0
DETAILS OF POLICY
4.1 Examples of When to Decontaminate Hands
The WHO 5 Moments provides guidelines on when hand hygiene should be performed
to prevent cross-colonisation. Each Moment covers the full range of patient care
activities, with specific focus on incorporating hand hygiene into routine workflow.
4.2 The Correct Technique
Hand decontamination whether hand washing or by the use of gel, with a good
technique which covers all surfaces of the hands is more important than the agent used
or length of time of hand decontamination, (Ayliffe et al.1992, Royal College of Nursing
(RCN) 2004). However, ideal duration of hand hygiene for ABHR is 20-30 seconds,
increasing to 40-60 seconds when soap and water is used (WHO, 2009b).
To facilitate good hand decontamination technique healthcare workers should ensure
they comply with current uniform guidelines which outline BBE working (DOH 2010):
--- PDF page 8 ---
Page 8 of 21
Version number: 10.0
Trust-wide CBR title: Hand Decontamination Policy
a) Nails are kept short, clean and natural.
b) Stoned rings are not worn (a plain band is permissible)
Wearing rings increases the likelihood that hands will become contaminated
with microorganisms (Trick et al. 2003)
c) Hands are free from nail polish and false nails.
Polished nail surfaces may make decontamination harder, especially if polish
becomes chipped, cracked or flaky (White, 2013).
Artificial nails provide a surface more likely to harbour bacteria than natural
nails. Even effective hand hygiene is not sufficient to remove all of these
pathogens from artificial nails (White, 2013) Fungal growth occurs frequently
under artificial nails, (Jeans & Green 2001).
d) Wrist watches and bracelets are removed, wrists should be included when
washing hands.
Wrist watches can collect microorganisms which may then spread to hands
when the watch is touched or removed (Jeans et al. 2010).
e) Short sleeves are worn.
f) No cotton bracelets, friendship bangles or charity bands to be worn.
4.2.1 Risk assessment
NB:- Soap and water is the only effective way of decontaminating hands following
contact with patients with diarrhoea and/or vomiting. (This is because ABHR is
not effective against C diff and Norovirus). This is also the only effective way to
decontaminate hands which are physically/visibly dirty.
The type of hand decontamination to be done should be based on the following
principles:
•
What have you just done?
•
What are you about to do?
4.2.2 Hand Decontamination (Soap & Water)
Action
Rationale
1. Wet hands thoroughly with running
water.
To prevent irritation from the undiluted
cleansing agent.
2. Apply one dose of soap to a cupped
hand and work soap into hands.
To ensure an even distribution of the
cleansing agent.
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Version number: 10.0
Trust-wide CBR title: Hand Decontamination Policy
3. Follow the hand washing technique
(Appendix 1) using five strokes for each
step using a backward and forward
motion for 10-20 seconds in total.
(Ayliffe 1999)
To remove dead skin cells and reduce
the bacteria present on hands.
4. Rinse hands under running water.
To remove the bacteria and soap.
6.
Dry
hands
thoroughly
using
disposable paper towels.
To reduce the carriage of transient
bacteria and prevent the deterioration of
the skin surface.
7. Dispose of paper towels into a foot
operated bin.
To prevent the recontamination of
hands.
8. Apply moisturising protector cream/
lotion at regular intervals.
To protect the integrity of the skin from
chapping, potentially leading to the
colonisation of hands by bacteria.
4.2.3 Hand Decontamination Technique (Alcohol Based Hand Rub - ABHR)
Please note: alcohol is not effective with patients with C diff and Norovirus, or if hands
are physically dirty.
Action
Rationale
1. Apply one dose of ABHR (approx 3
mls) to a cupped hand and work gel into
hands.
To ensure an even distribution of the
cleansing agent.
2. Follow the hand decontamination
technique (Appendix 1) using five
strokes for each step using a backward
and forward motion for 10-20 seconds in
total. (Ayliffe 1999)
To ensure effective coverage of gel to all
surfaces of hands and wrists.
3. Ensure gel thoroughly worked into
hands until hands feel dry.
Allowing gel to evaporate will ensure
removal of transient bacteria from hands.
ABHR should be available in all clinical areas either as wall mounted, or via pump
dispensers located at the point of care.
--- PDF page 10 ---
Page 10 of 21
Version number: 10.0
Trust-wide CBR title: Hand Decontamination Policy
ABHR is an effective alternative to soap and water when hands are visibly clean,
allowing rapid hand disinfection (WHO, 2009) e.g.
Before patient contact
During bed making
After touching objects within the patient environment e.g. notes, curtains
4.2.4 Drying
Hand drying is important in the control of infection as wet surfaces transfer micro-
organisms more effectively than dry ones (Hoffman & Wilson 1994).
Hands should be dried using disposable paper towels (RCN 2004). These operate
effectively by rubbing away organisms and old dead skin cells loosely attached to the
hand surfaces.
Paper towels should be disposed of as household waste. Towels should be placed into a
foot operated bin to avoid recontamination of the hands.
4.2.5 Skin care
Micro-organisms will increase when the skin is damaged. Hands should therefore be well
protected by:
Wetting skin prior to applying soap.
Thorough rinsing and drying.
The application of hand cream (this should be available in all clinical areas).
Reporting of any chronic skin conditions or irritation to the Occupational Health
Department.
Keep cuts and lesions covered with a clean waterproof dressing.
It is the responsibility of the Ward Manager to ensure moisturiser is available to all
staff and that sufficient stock is maintained to replenish dispensers.
4.3 Hand Hygiene Measurement
Trust wide measurement of adherence to the WHO 5 Moments is conducted monthly by
IPC link staff, overseen by the IPCT, who provide feedback to enable improvement. The
IPCT perform WHO 5 Moments measurement in areas with increased incidence of alert
organisms to ensure staff are supported in achieving hand hygiene standards.
--- PDF page 11 ---
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Version number: 10.0
Trust-wide CBR title: Hand Decontamination Policy
5.0
DUTIES / RESPONSIBILITIES
5.1 Trust Board
The Trust Board will ensure that the Policy is implemented.
5.2 The Chief Executive
Ensures there are effective and adequately resourced arrangements for infection
prevention and control within the organisation.
5.3 Director of Infection Prevention and Control
The Director of Infection Prevention and Control will oversee local control of infection
policies and their implementation and that the effectiveness is monitored and reviewed
as necessary.
5.4 Senior Managers
They are responsible for ensuring staff receive appropriate training to support
implementation of this policy. Senior managers are responsible across the Trust for the
co-ordination of Health and Safety activities and ensuring decisions are implemented in
accordance with this policy and associated guidelines.
5.5 Infection Prevention and Control Committee
The Infection Control Committee has a responsibility to ensure that this Policy allows the
Trust to comply with advice and guidance from the Department of Health and other
bodies. These guidelines will be binding on employees under Health & Safety Legislation
and the Health and Social Care Act 2008.
5.6The Infection Prevention and Control Team
5.6.1 Training
Full training for practical hand decontamination will be given by the Infection Prevention
and Control Team (IPCT) via mandatory and Trust induction sessions.
An educational pack has been devised to provide evidence regarding hand
decontamination, based on the WHO 5 Moments, covering Why (practice), When
(practice), How (technique), the role of Bare Below the Elbows (BBE), and Trust
Measurement practice. Educational sessions are provided by IPCT members at the
request of ward managers/modern matrons, or in response to clinical need.
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The educational pack is also used by the IPCT to train IPC hand hygiene cascade
trainers in all aspects of hand decontamination, enabling them to be a point of reference
to clinical staff at ward level/departmental. The IPC hand hygiene cascade trainers will
deliver mandatory, yearly training in their specific areas. This will be practically assessed
by use of the glow box, underpinned by the material in the educational pack.
5.6.2 Measurement
Hand decontamination is measured in two ways; (i) mandatory (technique), using the
glow box, and (ii) hand hygiene practice according to the WHO 5 Moments.
Hand decontamination is part of Mandatory training. The IPC hand hygiene cascade
trainers will perform mandatory (technique) hand hygiene assessments for all new staff
inductions, with data recorded by the IPCT.
Measurement of hand hygiene practice against the WHO 5 Moments is conducted
monthly by IPC link staff, overseen by the IPCT. Data is recorded by the IPCT, and
reviewed by modern matrons/ward managers at the monthly Trust IPC Performance
meeting. Data is available for review on the IPC scorecard. Ad-hoc WHO 5 Moment
measurements are conducted by the IPCT in response to clinical need.
The IPCT will review any urgent communications from the Department of Health or other
bodies and decide on what action is necessary to deliver and support practice through
training programmes.
5.7 Occupational Health Department
The responsibilities of the Occupational Health Department are to:
Undertake pre-employment screening to identify staff who will be working in
clinical areas who may have pre-existing allergies, and provide subsequent
advice to management;
Receive referrals from managers or from staff who have concerns about
allergy/skin problems;
Monitor areas of high incidence of skin problems allergy and make
recommendations to the appropriate manager and Health and Safety staff on
remedial action;
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Assist in risk assessment when required.
5.8 Team Leaders/Managers
Ward and departmental managers are ultimately accountable to the Chief Executive of
the Trust for the implementation of these guidelines within their sphere of responsibility.
Ward and departmental managers must ensure that:
The Occupational Health Department is notified of staff exposed to latex to
enable regular health surveillance to be undertaken;
Any reaction by staff thought to be due to the working environment (particularly
products containing latex) is immediately referred to The Occupational Health
Department.
Advice received from the Occupational Health Department regarding glove
selection and use and/or skin health is implemented.
Team Leaders/Managers have a responsibility to ensure staff are aware of their
responsibilities under this Policy and associated guidelines. Managers must
inform new employees of their responsibilities under this Policy. In addition they
must ensure all employees within their area of responsibility comply with this
Policy and associated guidelines.
5.9 Employees
Employees should ensure that:
They safeguard their own health, and that of colleagues and patients by following
the advice set out in the guidelines, in particular use of standard precautions and
appropriate glove selection.
They pay attention to their own skin care to protect against damage and
cooperate with the skin surveillance check.
They refer themselves to the Occupational Health Department with any skin
condition that results in broken skin including eczema/dermatitis, especially if it is
thought to be work-related.
All employees have a responsibility to abide by this Policy and associated guidelines and
any decisions arising from the implementation of them. This Policy is enforceable through
Health and Safety Legislation and disciplinary procedures. If employees are aware that
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the Policy is not being complied with they must first take the issue to their line manager
and follow the process as defined in section 7.
6.0
DISSEMINATION AND IMPLEMENTATION
Dissemination of hand decontamination is undertaken via training in accordance with the
Trust Mandatory Training Policy.
Roadshows are done on national and international hand hygiene days and other days of
IPC relevance, engaging both staff and public. The IPC healthcare support worker
makes weekly rounds of all ward areas ensuring local competence, providing an
opportunity for staff to complete mandatory training for practical hand decontamination
(technique). Findings from these rounds are fed back to the IPCT meeting and IPC
performance meeting, where Matrons provide feedback and an action plan against their
hand hygiene measures.
Non-compliance with the guidance by staff
Following reasonable attempts at local level to address individual members of staff that
are found to be in breach of the policy the staff member will be issued with a stage 1
letter (Appendix 2). This outlines the standards expected and responsibility of all staff.
The letter confirms that should there be a further breach of this policy that consideration
of a formal investigation in line with the Trusts Disciplinary Procedure will follow. This
could result in a disciplinary sanction being issued. If there is a further breach following a
formal letter then it will be subject to performance management with Human resources.
7.0
TRAINING
Training required to fulfil this policy will be provided in accordance with the Trust’s
Training Needs Analysis (TNA). The process for checking all permanent staff groups
complete relevant hand hygiene training is set out in the TNA. Management and
monitoring of training is in accordance with the Trust’s Mandatory Training Policy.
Staff who fail to attend practical hand decontamination training will be identified and
followed up in accordance with the Trust’s Mandatory Training Policy.
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An educational pack is available from the IPCT to underpin training. Each clinical area
has a nominated hand hygiene link person who can provide additional training in practice
with the support of the IPC healthcare support worker.
8.0
MONITORING COMPLIANCE
8.1 Monitoring Table
Aspect of
compliance or
effectiveness
being
monitored
Monitoring
method
Individual
department
responsible
for the
monitoring
Frequency
of the
monitoring
activity
Group /
committee
which will
receive the
findings /
monitoring
report
Group /
committee /
individual
responsible for
ensuring that
the actions are
completed
How the Trust
records that all
permanent staff
complete
hand
hygiene training,
in line with the
Training
needs
analysis
Hand hygiene training is monitored in line with the Mandatory Training
Policy. Data is recorded on the IPC performance scorecard, discussed
monthly by matrons.
How the Trust
follows up those
who
do
not
complete
hand
hygiene training
The process for
ensuring
the
delivery
of
effective
hand
hygiene training
to all permanent
staff groups and
follow-up of non-
attendance
is
followed.
Review of
the
local
audits and
data
on
OLM
Infection
Prevention
and Control
Team,
Modern
Matrons.
Quarterly
Nursing
and
Midwifery
Performance
Management
group.
Trust Board
Mandatory
training leads
Infection
Prevention
and
Control
Committee.
Nursing
and
Midwifery
Performance
Management
Group.
Duties
The duties will be monitored through review of the other aspects above.
9.0
STAFF COMPLIANCE STATEMENT
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All staff must comply with this Trust-wide Corporate Business Record and failure to do so
may be considered a disciplinary matter leading to action being taken under the Trust‘s
Disciplinary Procedure. Actions which constitute breach of confidence, fraud, misuse of
NHS resources or illegal activity will be treated as serious misconduct and may result in
dismissal from employment and may in addition lead to other legal action against the
individual/s concerned.
A copy of the Trust’s Disciplinary Procedure is available from eLibrary.
10.0
EQUALITY & DIVERSITY STATEMENT
Throughout its activities, the Trust will seek to treat all people equally and fairly. This
includes those seeking and using the services, employees and potential employees. No-
one will receive less favourable treatment on the grounds of sex/gender (including Trans
People), disability, marital status, race/colour/ethnicity/nationality, sexual orientation, age,
social status, their trade union activities, religion/beliefs or caring responsibilities nor will
they be disadvantaged by conditions or requirements which cannot be shown to be
justifiable. All staff, whether part time, full-time, temporary, job share or volunteer;
service users and partners will be treated fairly and with dignity and respect.
11.0
ETHICAL CONSIDERATIONS
The Trust recognises its obligations to maintain high ethical standards across the
organisation and seeks to achieve this by raising awareness of potential or actual ethical
issues through the CBR consultation and approval process. Authors of CBRs are
therefore encouraged to liaise with the Trust’s Clinical Ethics Forum to seek input where
necessary.
12.0
DEFINITIONS
N/A
13.0
REFERENCES AND BIBLIOGRAPHY
Ayliffe GAJ, Babb JR & Taylor LJ (1999). Hospital Acquired Infections: Principles and
Prevention. 3rd Edition. Oxford. Butterworth Heinemann.
Ayliffe GAJ, Lowburry EJL, Geddes AM & Williams JD (1992). Control of Hospital
Infection A Practical Handbook. 3rd Edition. Chapman and Hall.
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Creamer E, Dorrian S, Dolan A, et al. (2010). When are the hands of healthcare
workers positive for methicillin-resistant Staphylococcus aureus? Journal of Hospital
Infection.75(2): 107-11.
Department of Health (2008). The Health and Social Care Act 2008: Code of Practice
on the prevention and control of infections and related guidance. London. Department
of Health.
Department of Health (2010). Uniforms and workwear: Guidance on uniform and
workwear policies for NHS employers. London. Department of Health.
Girou E, Loyeau S, Legrand P, Oppein F & Brun-Buisson C. (2002). Efficacy of
Handrubbing and Alcohol Based Solution Versus Standard Handwashing with
Antiseptic Soap. Randomised Clinical Trial. British Medical Journal, 325(7360):362.
Hoffman P & Wilson J (1995). Hands, hygiene and hospital. PHLS Microbiology
Digest, 11(4): 211-6.
Jeans AR, Moore J, Nicol C, Bates C, Read RC (2010). Wristwatch use and hospital-
acquired infection. Journal of Hospital Infection, 74(1):16-21.
Jeans A & Green J (2001). Nail Art: a review of current infection control issues.
Journal of Hospital Infection, 49(2): 139 –142.
Larson E (1981). Persistent carriage of gram-negative bacteria on hands. American
Journal of Infection Control, 9(4): 112-119.
National Institute for Clinical Excellence (NICE) (2003). Infection Control: Prevention
of Healthcare-associated Infection in Primary & Community Care. Clinical Guideline
2. Thames Valley University. London
Pittet D, Mourouga P, Perneger TV (1999). Compliance with handwashing in a
teaching hospital. Infection Control Program. Annals of Internal Medicine, 130(2):
126–30.
Royal College of Nursing (RCN) (2004). Good Practice in Infection Control: Guidance
for Nursing Staff. London, RCN Publication.
Sax H, Allegranzi B, Uçkay I, Larson E, Boyce J, Pittet D (2009). 'My five moments
for hand hygiene': a user-centred design approach to understand, train, monitor and
report hand hygiene. Journal of Hospital Infection, 67(1):9-21.
Schreiber PW, Sax H, Wolfensberger A, Clack L, Kuster SP, SwissNoso (2018).
The preventable proportion of healthcare-associated infections 2005-2016:
Systematic review and metaanalysis. Infection Control and Hospital Epidemiology,
39(11):1277-1295. DOI: https://doi.org/10.1017/ice.2018.183
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Trick WE, Vernon MO, Hayes RA. et al. (2003). Impact of Ring Wearing on Hand
Contamination and Comparison of Hand Hygiene Agents in a Hospital. Clinical
Infectious Diseases, 36(11):1383–90.
White J (2013). Jewellery and Artificial Fingernails in the Health Care Environment:
Infection Risk or Urban Legend? Clinical Microbiology Newsletter, 35(8): 61-67.
WHO (2009). WHO Guidelines on Hand Hygiene in Health Care: First Global Patient
Safety Challenge Clean Care is Safer Care. Geneva: WHO Press.
ISBN: ISBN 978 92 4 159790 6. WHO reference number: WHO/IER/PSP/2009/01
WHO. (2009b). Tools as reminders in the workplace: How to Handrub; How to
Handwash
[Online](http://www.who.int/gpsc/5may/tools/workplace_reminders/en/index.html)
Geneva: WHO Press.
14.0
UHCW ASSOCIATED RECORDS
Mandatory Training Policy
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15.0
APPENDICES
Appendix 1: Hand decontamination Technique
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Appendix 2: Stage 1 letter
Dear Colleagues/ Colleague
Re The Trust Corporate workwear and Hand decontamination policies
I have been made aware that colleagues working in the ward areas are not
complying with the Trust requirements in relation to the Trust Appearance and
Uniform policy. Specifically this relates to the requirements for bare below the
elbow and hair not being tied back.
In order to remind you of your responsibilities I specially refer to these requirements
from within the policy; can you please all ensure that you are compliant moving
forward.
All staff that enters clinical areas must ensure that their sleeves either stop above the
elbow or are rolled up above the elbow.
There will be no variation to this clause without discussion with senior staff,
disposable sleeves are available to any employee that may require them, however
disposable sleeves must be treated in the same way as disposable gloves. They
should be changed between patients and activity, when hand decontamination is
required. They should not be worn for prolonged periods of time.
Rational:
To minimise risk of transmission of organisms
To enable effective hand decontamination.
To promote a professional appearance
Hair
For all staff, hair should be clean, neat and tidy.
for staff with regular direct patient contact and staff who work in a clinical area, hair
that is collar length or longer must be tied back and worn up so that it does not reach
below the collar or fall into the face when leaning forward.
Rational
To maintain a professional image.
To reduce risk of transferring micro-organisms either directly from one patient to
another or indirectly via a shared piece of equipment such as computer keyboard, or
telephone.
To prevent hair being pulled or caught during patient contact.
To reduce risk of transferring micro-organisms from staff to the theatre environment
and susceptible patient sites.
The Policy aims to protect the safety of patients and staff by ensuring that the
uniform and dress code of staff complies with infection control requirements and
health and safety legislation and to ensure that staff present a clean, smart,
professional image and promote a positive image to the general public.
Please note, should there be a further breach of this policy consideration of a formal
investigation in line with the Trusts Disciplinary Procedure will follow.
Yours Faithfully
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ATTACHMENT: 19_1.pdf
TEXT_FILE: 19_1.pdf.txt
METHOD: pdf_native
OCR_USED: False
PAGES: 91
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Trust-wide CBR title: Decontamination Policy
This Trust-wide CBR has been developed /reviewed in accordance with the Trust approved ‘Development & Management of
Trust-wide Corporate Business Records Procedure (Clinical and Non-clinical strategies, policies and procedures)
Trust Decontamination Policy
eLibrary ID Reference No:
OPER-POL-001-07
Newly developed Trust-wide CBRs will be allocated an eLibrary reference number following Trust approval. Reviewed Trust-
wide CBRs must retain the original eLibrary reference number.
The Quality department will progress all new, re-written and reviewed CBRs for Trust approval.
Version:
11
Date Approved by Trust Board:
N/A
Title of Board Sub-committee:
N/A
Date Approved by Board Sub-committee:
N/A
Title of Trust Approving Committee:
Patient Safety Committee
Date Approved by Approving Committee:
13th April 2021
Risk Rate:
Moderate
Review Date:
30th September 2023
Title of Author:
Trust Decontamination Lead
Title of Chief Officer:
Chief Nursing Officer
Target Audience:
All Trust Staff
If printed, copied or otherwise transferred from eLibrary, Trust-wide Corporate Business
Records will be considered ‘uncontrolled copies’. Staff must always consult the most up to
date PDF version which is registered on eLibrary.
As a controlled Trust-wide CBR, this record should not be saved onto local or network drives
but should always be accessed from eLibrary.
--- PDF page 2 ---
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Trust-wide CBR title: Decontamination Policy
This Trust-wide CBR has been developed /reviewed in accordance with the Trust approved ‘Development & Management of
Trust-wide Corporate Business Records Procedure (Clinical and Non-clinical strategies, policies and procedures)
Author’s Name, Title and email address:
Simon Lambert Trust Decontamination Lead
simon.lambert@uhcw.nhs.uk
Reviewer’s Name, Title & email address:
Neil Harper Sterile Services Manager
Neil.harper@uhcw.nhs.uk
Chief Officer’s Name, Title:
Nina Morgan- Chief Nursing Officer
Title of Group/Department/Specialty:
Sterile Services
Version
Consulting & Endorsing Stakeholders,
Committees/Meetings/Forums etc
Date
10
Decontamination Committee
10th Sep 2020
10
Infection Prevention & Control Committee
15th Dec 2020
10
Patient Safety Committee
Summary of Trust-wide CBR:
This policy has been updated to address and include
the recently issued revised guidance of the
management and decontamination of invasive
medical devices. HTM 01-01(2016) provides the best
practice guidance on the whole decontamination
cycle including the management and
decontamination of surgical instruments used in
acute care.
Purpose of Trust-wide CBR:
1. To set out the organisational requirements and
approach for the safe management and
decontamination of invasive, reusable medical
devices
2. To formulate a Trust policy utilising national
guidance providing a framework. This supports
self-management by clinical and associated
services of the various aspects of the NHS
Estates Medical device life cycle.
3. Ensure that this updated policy is aligned to
NHSLA/CQC requirements.
Trust-wide CBR to be read in conjunction with:
Infection Control policies including CJD Policy,
Decontamination Prior to Service or Repair Policy,
IPC Cleaning and Disinfection Policy
Relevance
Governance, Infection Prevention & Health & Safety
Superseded Trust-wide CBRs (if applicable):
9
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This Trust-wide CBR has been developed /reviewed in accordance with the Trust approved ‘Development & Management of
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Policy on a page
Trust Decontamination Policy
The Trust Decontamination Policy outlines the guidelines and standards
that relate to decontamination of medical devices including surgical
instruments, flexible endoscopes and decontamination equipment.
Responsibilities are clearly defined for staff, who are responsible for
ensuring decontamination equipment is maintained and tested in
accordance with Hospital Technical Memorandums HTMs.
The policy highlights the importance of not re-using medical devices
designed for single use only, and ensuring re-usable devices are
compliant with UK decontamination cleaning and sterilising parameters;
and are CE marked prior to putting into service.
All chemicals including high level disinfectants are approved via the
Decontamination Committee to ensure cleaning and disinfection efficacy
is maintained as well as Medical Device compatibility. The
Decontamination Committee provides assurance through the Infection
Control Committee regarding safe systems and practice are established.
All aspects of controlling re-usable medical devices including safe
handling, storage, shelf life and Loan equipment are also included in this
policy.
This policy applies to all Trust staff that have a responsibility for
decontaminating re-usable medical devices.
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Trust-wide CBR title: Decontamination Policy
This Trust-wide CBR has been developed /reviewed in accordance with the Trust approved ‘Development & Management of
Trust-wide Corporate Business Records Procedure (Clinical and Non-clinical strategies, policies and procedures)
Paragraph
Number
Description
Page
Number
1.0
Scope
4
2.0
Introduction
4
3.0
Statement of Intent
5
4.0
Definitions & Risks
9
5.0
Duties & Responsibilities
20
6.0
Details of the Policy
6.1 Acquisition of Invasive Medical Devices
6.2 Use of Detergents & High Level Disinfectants
6.3 Traceability of Invasive Medical Devices
6.4 Transportation, Handling, Storage & Disposal of Invasive
Devices
6.5 Reusable, Limited Use & Single-Use Medical Devices
6.6 Flexible Endoscopes
6.7 Management of Bedpan Washer Disinfectors
6.8 Management of On Loan Medical Devices.
28
32
38
41
48
50
61
65
7.0
Dissemination and Implementation
70
8.0
Training
70
9.0
Monitoring Compliance
9.1 Monitoring Table
74
10.0
Staff Compliance Statement
74
11.0
Equality and Diversity Statement
77
12.0
References and Bibliography
77
13.0
UHCW Associated Records
78
14.0
Appendices
78
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This Trust-wide CBR has been developed /reviewed in accordance with the Trust approved ‘Development & Management of
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1.0
SCOPE
This policy extends to all Trust staff, Private Finance Initiative (PFI) partners and where
applicable third party contractors, designated and appointed by the Trust who operate,
maintain, test and validate decontamination equipment, and also those individuals
responsible for this equipment to ensure that all medical devices reprocessed within them
are also fully compatible with the system process, to ensure that all Trust devices used in
patient care are clean, decontaminated, where applicable sterile, and at all times fit for
purpose.
2.0 INTRODUCTION
2.1 Standards
This policy seeks to meet the various requirements as detailed within Health Technical
Memorandum (HTM) guidance. These are detailed within this policy the Medical Devices
Annex V of Council Directive 93/42/EEC Limited to Sterility as amended by Directive
2007/47/EC, ISO14971:2019 Medical Device Risk Management, European Standards and
the requirements outlined in the Health and Social Care Act 2008 (Code of Practice for
Health and Adult Social Care on the Prevention and Control of Infection and Related
Guidance – compliance with relevant criteria).
2.2 Specific Exclusions
This policy does not generally cover specific details or replace procedural documents
relating to Sterile Services. The Sterile Services Department (SSD) has its own
accredited Quality Management System (ISO 13485:2016) which is externally
inspected, audited and approved in line with the Medical Devices Directive 93/42
EEC by a UKAS Notified Body at least annually.
The Policy does not include management of ‘known, suspected or at risk’ patients in
relation to transmissible spongiform encephalopathies, notably Crutzfeldt-Jacob
Disease (CJD).
Other Infection Control Policies relating to non-invasive equipment decontamination
principles and including Decontamination Prior to Servicing or Repair Protocol.
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This Trust-wide CBR has been developed /reviewed in accordance with the Trust approved ‘Development & Management of
Trust-wide Corporate Business Records Procedure (Clinical and Non-clinical strategies, policies and procedures)
Medical Equipment and Bioengineering Services (MEBS) policies are ISO9001:2008
accredited and are located within the Quality System of the Medical Physics
Department.
3.0
STATEMENT OF INTENT
The Trust Decontamination Policy has been reviewed and updated to ensure that it meets
and complies (where appropriate) the guidance of HTM 01-01(2016). This new HTM
replaces the previous document CfPP 01-01 document series. The published HTM is
designed to reflect the need to improve efficiency and outcomes in terms of safety, clinical
effectiveness, and patient experience in line with the overall health policy direction.
This Policy is intended to be accessible to, and read by, all staff who work in departments
that:
Decontaminate flexible endoscopes
Use bed pan washer-disinfectors
Purchase surgical instruments or other medical equipment which requires
decontamination between uses
Undertake surgical instrument decontamination processes (Sterile Services)
Undertake transportation of used, clean or sterilised medical devices.
The policy is divided into a series of sections to aid navigation as not all sections will be
relevant to all staff. It is a requirement that designated staff read the policy and familiarise
themselves with the sections relevant to them; this series of documents has been produced
to ensure that:
Staff are aware of current national requirements which relate to their work
responsibilities and all associated activities are carried out safely to protect both staff
and patients from harm.
Interfaces between stakeholders (e.g. clinical service users, Sterile Services, and
maintenance staff are clear and responsibilities are defined in line with this guidance.
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Trust-wide CBR title: Decontamination Policy
This Trust-wide CBR has been developed /reviewed in accordance with the Trust approved ‘Development & Management of
Trust-wide Corporate Business Records Procedure (Clinical and Non-clinical strategies, policies and procedures)
This policy identifies roles and responsibilities which are critical to achieving all
Essential Quality Requirements (EQR) and to develop as an organisation to further
achieve Best Practice in all aspects of Decontamination.
It reinforces, considers and drives forward all requirements contained within this
policy through effective risk management processes already established and by
which the organisation seeks to achieve and demonstrate best practice in all aspects
of decontamination.
Many of the requirements within the policy are not new, but continue to accurately reflect our
existing standards and methods of working, while evolving and enhancing these practices
built on national guidance from the MHRA and existing Trust procedures. This document
brings together the various elements into one single resource for Trust staff.
The master copy is available on the e-Library and an ‘all users’ email will be sent to advise
staff if specific sections are updated. When this occurs, please ensure that any hard copies
in your departments have the updated section replaced.
With specific reference to HTM 01-01(2016) this policy demonstrates that:
It complies with the current Health Technical Memorandum’s providing guidance
maintaining, identifying and establishing Essential Quality Requirements with the
objective of ensuring that plans are in place for progression to recognised Best
Practice;
Decontamination of reusable medical devices takes place in appropriate facilities
designed and maintained to minimise the risks that are inherent and ever present;
That appropriate procedures are followed for the acquisition, maintenance, testing,
validation operation and where required, disposal of decontamination equipment;
Staff are trained in cleaning and decontamination processes and hold appropriate
competences for their role; and a record-keeping regime is in place to ensure that
decontamination processes are fit for purpose and use the required quality systems.
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This Trust-wide CBR has been developed /reviewed in accordance with the Trust approved ‘Development & Management of
Trust-wide Corporate Business Records Procedure (Clinical and Non-clinical strategies, policies and procedures)
3.1
Risk Management Approach
To assess and achieve Best Practice, this function will be led by the Decontamination
Committee. The Group will assess decontamination requirements and consider what aspects
of Best Practice will be prioritised and should be implemented, based on improving patient
outcomes, decontamination benefits, efficiencies and risks, including those prion risks as
defined by the ACDP-TSE Risk Assessment subgroup.
The Director of Infection Prevention and Control (DIPC) will have a key responsibility within
the overall leadership across the organisation for Decontamination risk. Other members
within the Group will include, but not restricted to the following:
The DIPC’s designated appointee;
The Trust Decontamination Lead;
Representative(s) from the Infection Control Team;
Representative(s) from heads of departments who are deemed as device “Users”
Representatives(s) from engineering functions who maintain decontamination
equipment
An Authorising Engineer (Decontamination).
Attainment of Essential Quality Requirements should also include ISO 14971:2019 Medical
Devices Application ‘Risk Management to Medical Devices’ a local risk assessment for
surgical instrument management, encompassing the provision of instruments that are safe to
use and the reliable provision of all required instruments.
3.2
Management approach
The following provides a brief explanation as to the approach that will be taken to ensure that
the decontamination process will be managed by functional experts and coordinated by the
Decontamination Committee ensuring a high profile, coordinated approach to the
development and maintenance of standards
3.3
Essential Quality Requirements is a term that encompasses all existing statutory
and regulatory requirements. Essential Quality Requirements incorporate the requirements of
the Medical Devices Directive and approved Codes of Practice as well as relevant applicable
Standards. They will help to demonstrate that UHCW as a service provider operates safely
with respect to the management and decontamination of instruments.
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This Trust-wide CBR has been developed /reviewed in accordance with the Trust approved ‘Development & Management of
Trust-wide Corporate Business Records Procedure (Clinical and Non-clinical strategies, policies and procedures)
Both Trust and local departmental policies define how the organisation and individual
departments attain and maintain essential quality requirements (EQR) and through audit and
testing, define how these are changed and improved, ensuring a move towards continued
best practice and compliance with CQC outcomes and other Department of Health
requirements.
Continued local policy adherence, review and enhancement by departmental managers and
leads will be the only method which demonstrates improvement and strengthening of
practices, and the required controls assurance that all aspects of the Essential Quality
Requirements are being met and attained. All areas are required to, as part of normal
management processes, to ensure that:
They identify and appoint a local decontamination lead person for each area to act as
primary point of contact to liaise with Infection Prevention Teams to ensure all
systems are in place to ensure that all devices are sufficiently decontaminated and
remain safe to use.
Review at least annually all aspects of their business to demonstrate their proactive
approach to enhancing the processes of decontamination of medical devices.
Ensure that all new and existing staff receive documented training and assessment
on all local decontamination equipment and devices, decontamination methods and
the completion of essential documentation.
These requirements will be reviewed during periodic inspections carried out by internal
Infection Prevention and Decontamination Staff. Only by regular review of compliance to
procedures, education and documentation of staff training will confirm that attainment of
Essential Quality Requirements and progression towards Best Practice has been achieved.
3.4 Best Practice is additional to the Essential Quality Requirements. Best Practice as
defined in this guidance covers non-mandatory policies and procedures that aim to
further minimise risks to patients, deliver better patient outcomes, promote and
encourage innovation and choice and achieve cost efficiencies. Best Practice should be
considered when developing local policies and procedures based on the risk of surgical
procedures and available evidence. Best Practice encompasses guidance on the whole
of the decontamination cycle, including, for example, improved instrument management;
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where there is evidence that these procedures will contribute to improved clinical
outcomes.
4.0 DEFINITIONS & RISKS
This policy covers the management, practices, training and other requirements relating to the
safe and effective decontamination of invasive, re-usable medical devices. The policy is
divided into a series of individual sections for ease of use.
The policy is based on the NHS Estates’ “Decontamination Life Cycle of the Re-usable
Medical Devices” (figure: 1), which identifies the various stages of medical device
management including procurement and disposal, validation of re-processing equipment,
cleaning, disinfection, sterilization and transport along with the requirement to ensure
appropriate location, facilities, equipment, management and policies/procedures at each
stage.
Figure 1.
This policy, in conjunction with HTM 01-01(2016), seeks to establish:
At all stages:
Location
Facilities
Equipment
Management
Policies/Procedures
CLEANING
DISINFECTION
INSPECTION
PACKAGING
STERILIZATION
TRANSPORT
STORAGE
USE
TRANSPORT
DISPOSAL
1. Scrap
2. Return to lender
ACQUISITION
1. Purchase
2. Loan
Figure 1
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Processes for the prevention and control of the risk of transmission of infection through
surgical instruments – with specific reference to the theoretical risk of human prion diseases
transmission (transmissible spongiform encephalopathies, or TSEs);
A comprehensive approach to risk control and reduction across instrument management and
decontamination;
Assurance over the management of surgical instruments, in terms of availability, quality and
suitability;
The preservation and advance of high-quality engineering through the support of both
European Norms (ENs) and International Standards Organization (ISO) Quality Management
Systems
Requirements for control and optimisation of the environment, equipment and facilities used
in surgical decontamination.
A list of resource documents for reference and further reading is provided at Appendix 1.
Service Managers are strongly encouraged to ensure that both the contents of this policy and
any relevant additional resource documents are made easily available to their staff and that
staff are familiar with these requirements.
Following medical or surgical procedures, it is essential that any re-usable medical devices
utilised are appropriately and effectively decontaminated in order to prevent transmission of
infection to subsequent patients. Decontamination is defined as:
“The process or combination of processes which are undertaken to remove sufficient
micro-organisms to render an object (e.g. surgical instrument) safe for its intended
purpose”.
Decontamination is an inclusive term for which processes will include some or all of the
following sequential stages:
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Process
Definition
Examples
Cleaning
The physical removal of contamination by organic
material and micro-organisms
Manual cleaning
Automated cleaning using a
washer-disinfector
Disinfection
A process which reduces the number of micro-
organisms on an item to a level which makes it safe
to handle, usually excluding spores
Thermal disinfection (eg hot
water)
Chemical disinfection (eg
alcohol)
High-level
Disinfection
A process which destroys most micro-organisms to
a ‘near sterile’ level, dependant on the product and
method employed
Chemicals such as Tristel,
Peracetic Acid particularly
where used in an automated
endoscope processor
Sterilization
The destruction of all micro-organisms, including
spores
Steam sterilization
Gas plasma sterilization
Figure 2.
The level of decontamination required for a particular piece of equipment is dependant on the
degree of invasiveness during clinical use and the type of body tissue which the device
comes into contact with, for example:
Figure 3.
When assessing decontamination requirements for a specific item of medical or surgical
equipment, the following should be consulted:
The device manufacturer’s instructions (must be complied with)
The Microbiology Advisory Committee Manual of Decontamination
The Infection Control Department or Director of Infection Control (DIPC)
The Decontamination Lead
All decontamination except for flexible endoscope re-processing shall be undertaken in a
specifically designed and controlled facility such as the Sterile Service Department and/or
Risk Level
Application
Recommendations
Examples
HIGH
Entry into sterile
cavities/vascular systems
Cleaning and
Sterilisation
Surgical
Instruments
Endoscopes
Implants
INTER-
MEDIATE
In contact with:
Mucous membranes
Diseased or damaged
skin
Body fluids
Cleaning and
Disinfection or
Sterilisation
Respiratory/
Anaesthetic
equipment
Bedpans
LOW
In contact with intact, healthy
skin or remote from patient.
Non-invasive items
Cleaning
Disinfection if known risk
Trolley tops, op
tables, baths,
cables and non-
invasive
monitoring
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designated trust facilities using validated procedures and systems of work and include
automated and validated washer-disinfectors and vacuum steam sterilises or gas plasma
sterilisation technology.
As flexible endoscope re-processing will be undertaken outside SSD, it is essential that this
is effectively managed and controlled in order to minimise the risks to staff and patients from
hazardous or inadequate decontamination processes in line with effective decontamination
management practices outlined in the Health and Social Care Act 2008 (Code of Practice for
Health and Adult Social Care on the Prevention and Control of Infection and Related
Guidance). The guidance, which specifically relates to endoscope decontamination and the
requirements is HTM 01-06 and should be read and be familiar to all those undertaking
endoscopy decontamination, along with the requirements of this document.
In summary, this policy applies to:
All services which undertake one or more elements of decontamination (these
services are listed in Appendix 2)
Users of invasive, reusable medical devices (theatres, clinics etc.)
Departments which have bedpan washer-disinfectors installed for non-invasive
medical equipment decontamination should specifically refer to policy section 6.7.
4.1
Centralisation Programme
From April 2007, this Trust declared that all invasive medical device re-processing had to
take place within a facility which must be fully accredited to Medical Device Regulations. It
was therefore decided that within UHCW NHS Trust, no local re-processing of invasive
medical devices – would be undertaken outside of an approved, designed and purpose built
facility.
4.2 Training
Training of staff involved in any element of re-usable, invasive medical device
decontamination is essential and training plans must recognise the technical skills required to
minimise the risks to both staff and patients. Specific training is to be developed and its
contents formally agreed by the Trust Decontamination Lead / Decontamination Committee
and reviewed on no less than an annual basis. All details must be documented by all
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providers / users in relation to relevant staff within their departments who undertake any
decontamination, housekeeping of decontamination equipment and/or operation of the same.
Details of the minimum training requirements are listed in Section 11 of this Policy.
A decontamination training database is maintained by the Trust Decontamination Lead which
is reviewed by the Decontamination Committee and it is the responsibility of all managers of
staff that engage in decontamination processes to ensure that the details of all such staff
they are responsible for are recorded, accessible within the department and maintained ‘up
to date’ on the Trust’s central database, as well as evidence of refresher training as required.
4.3
Purchase of new Decontamination Equipment
Flexible endoscope re-processing areas, along with the Sterile Services Department, will
need to replace decontamination equipment over time and where this need arises the
relevant departmental manager must in the first instance seek the advice of the Trust’s
Decontamination Lead. A special meeting of the Decontamination Committee will then be
arranged to review requirements and identify factors for consideration in the procurement
process.
The Group will assess the need and, where this is supported, will work with the department
manager through the procurement process to ensure that all requirements and implications
are considered prior to purchase. This will normally involve taking specialist advice from the
designated AE (D), Authorised Engineer (Decontamination), who is an externally appointed
subject matter expert.
4.4
Standards Compliance
All equipment for the purpose of decontamination will be purchased in compliance with
relevant British or European standards. Model engineering specifications (previously
produced by NHS Estates) will be used to interpret relevant standards as part of the
procurement process, and Pre Purchase Questionnaires (PPQ’s) will be used to make the
most appropriate selection in conjunction with consultation with procurement and the “User”
All endoscope re-processors within the Trust are HTM EQR compliant machines and it is
mandatory that these are subject to full validation and maintenance programmes in line with
HTM 01-06 and BS EN ISO15883 requirements. Any new machines purchased must also
be fully compliant to these mandatory requirements.
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The Sterile Service Department opened in 2004 and was therefore designed in accordance
with Heath Building Note 13, Sterile Services Departments and all relevant HTM’s for
ventilation, Washer Disinfectors, Steam Sterilisers, and storage of both raw materials and
process goods requirements.
The SSD maintains compliance with the requirements of the Medical Devices Directive 93/42
EEC and BS EN ISO13485:2016 including EC Declaration of Conformity and other
requirements which may emerge in the future which are essential to the accreditation and
safe re-processing of medical devices within the facility.
4.5
Manufacturer’s Instructions, Single Use and Limited-life Medical Devices
Manufacturer’s instructions for the re-processing and general management of medical
devices of all types will be adhered to in clinical areas, local re-processing areas and the
Sterile Service Department. This means that:
Instructions relating to single use will be adhered to by both clinical users (ensuring
that items are discarded after use) and sterile services (ensuring that no single use
items are knowingly re-processed). Further details on single and limited use are
included in Section 6.5.
Instructions relating to limited use items – for example laryngeal masks, diathermy
cables etc – will require implementation of usage counting mechanisms which must
be established between clinical users and sterile services. Clinical users are
accountable for establishing requirements in this respect – usually by advising SSD of
requirements - and the Theatres are accountable for ensuring that formalised
counting arrangements are actioned.
Re-processing instructions detailing methods, detergent, temperature & machine
compatibility and specialist maintenance requirements will be assessed as part of the
medical device procurement process and requirements implemented by Users.
4.6
Surgical Instrument Repairs
Clinical services are responsible for ensuring that required routine maintenance and repairs
to surgical devices are undertaken as required by the manufacturer or at the request of
surgical staff. When new equipment is purchased it is essential that any requirements for
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usage or time-related maintenance are implemented in conjunction with the Sterile Services
Department.
In addition:
All maintenance/repairs must only be undertaken by an ISO accredited specialist
surgical instrument repair company and, ideally, by the device manufacturer. The
Sterile Service Department has arrangements in place with a number of repair
companies and can advise further as required.
Routine repairs of surgical instruments (e.g. sharpening, general maintenance) along
with rigid endoscope repairs will be arranged by Sterile Services in line with the SSD
Repair Procedure during the re-processing cycle.
All instruments sent for repair must first be appropriately decontaminated and
accompanied by a Decontamination Certificate as outlined in the Infection Control
Policy Decontamination Prior to Servicing or Repair
4.7
Processing Equipment Validation
Designated ‘Users’ (i.e. managers of areas where decontamination equipment is in use) are
required to ensure that all re-processing equipment (i.e. washer-disinfectors, sterilisers and
endoscope processors) and, where applicable the environment, are validated in accordance
with the relevant sections of the HTM’s and other guidance and in line with the Equipment
Manufactures requirements. These documents also specify the periodicy of the testing and
validations to be undertaken. Further details are included within the relevant sections of this
Policy.
Annual Validation reports for sterilisers, washer-disinfectors and endoscope processors shall
be audited by the designated Authorised Engineer (Decontamination) AE(D) to ensure that
all test procedures and results are acceptable. Documentation supplied to the AE(D), along
with a response report for each item audited, must be returned to the Authorised Person
(Decontamination) AP(D) within one month of the audit date. Other periodic testing i.e.
Quarterly, Endoscopy Weekly Water tests will be audited by the AP(D). The Trust
Decontamination Lead will ensure that any non-conformities or recommendations and
required actions identified in the AE(D)’s report are swiftly implemented by the relevant
department.
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4.8
Documentation
The following documentation shall be available at all times and be kept adjacent to the
steriliser, washer-disinfector or endoscope processor:
Operating Instructions, housekeeping and daily test instructions
Daily test results and housekeeping records
Sterilizer process log books (where sterilisers are installed)
Washer-disinfector log books for instrument and endoscope washer-disinfectors
(where installed)
Manual traceability records where IT-based traceability are not available
The following documentation may be kept elsewhere, but must be made available on
request:
Weekly, quarterly and annual validation tests – where these are not included in the
daily Steriliser/Washer process log book. These are to be sent to the Trusts
Appointed AP(D). Annual Validations to be sent to AE(D) for independent audit
and sign off.
Maintenance manual and operational manuals for installed equipment
Works history (e.g. plant history file)
Certificates of standards compliance where applicable
Annual audit reports for audits undertaken
Certificates of pressure vessel insurance inspections (where applicable)
List of staff authorised to operate or maintain decontamination equipment
Training records and or certificates for each person listed above
Cycle data and traceability records (further information in Section 6.3.1)
Environmental test results undertaken to meet environmental requirements.
4.9
Validation Test Time Constraints
Users will be considered to be operating within appropriate time parameters for validation
tests which are unavoidably delayed provided the following constraints are adhered to:
Daily Tests:
no extension allowed unless the machine is out of order
Weekly Tests:
up to one day from the agreed date
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Quarterly Test:
up to one week from agreed date
Annual Test:
up to two weeks from the agreed date
All Users must have a formal schedule of validation tests including planned test dates for
each item of decontamination equipment where this applies (e.g. sterilisers, washer-
disinfectors, endoscope re-processors). This will be regular checked for compliance by the
Trust Decontamination Lead. All users are to notify the AP(D) and Trust Decontamination
lead of any variance outside of these schedules and decontamination equipment not used
without special authority from the Director of Decontamination.
4.10
Operational Changes
In order to protect both patients (from inadequate decontamination of invasive devices) and
staff (from hazardous processes or chemicals) it is essential that desired changes to
decontamination equipment, methods or materials are appropriately and formally approved
prior to such changes being implemented in local re-processing areas.
Therefore, the following non-exclusive list identifies some of the possible changes which
must be approved by review and response from the Decontamination Committee:
Changes to detergents used for manual cleaning
Changes to the disinfectants used in endoscope re-processors
Changes to validation materials and devices (e.g. chemical or steam sterilization
validity indicators)
Changes to traceability processes
Implementation of new decontamination procedures
Issues for review by the Group should be referred in the first instance to either the
Decontamination Lead or the Infection Control Team.
4.11
Instrument Asset Management and IT Systems
All surgical instrumentation is listed on an IT-based surgical instrument management system
(‘T-doc’). This is used for asset management, invoicing, planned maintenance schedules and
traceability (to SSD processes). All new items of instrumentation must be added to T-Doc via
a ‘New Tray Request’ form, available from SSD; equally, any existing trays which have not
been used for some time must be registered on T-Doc if they do not have the new style bar-
code tag attached. Data from T-Doc is backed up every 24 hours.
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Traceability data to patients is captured within the Opera theatre system (where in use,
otherwise this is recorded manually within the clinical area); the data on Opera is backed up
daily.
4.12
User Support
Although the responsibilities of designated users (i.e. managers of departments with
decontamination equipment installed) in respect of both this policy and the relevant HTM
guidance are significant, users should be assured that a mechanism for advice and support
exists within the organization as outlined below
“Competent Persons” (Formally known as Maintenance & Test Persons) are available
to give advice on testing, validation and interpretation of results
The Decontamination Lead will provide advice on general decontamination issues
and principles
The Infection Prevention & Control Team can advise on related issues
The Decontamination Committee will review general queries in terms of policy or
anticipated operational changes in relation to medical device re-processing or the
interpretation of this Policy
Updates to the Decontamination Policy will be made to the master version on the e-
Library and users will be notified by email if this occurs. Where hard copies have
been made available to staff within departments these must be replaced if notified
that updates have been made
4.13
Decontamination Safety Notices
Safety notices will be circulated to all email users within the Trust where specific risk issues
have been identified. The requirements and actions identified in these documents should be
considered to be additional components of the Trust Decontamination Policy. Actions,
responsibilities, closure and or additional governance arrangements as a result of these
safety notices will be monitored by the Decontamination Committee.
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4.14
Pharmacy Requirements
At present there are no European Standards relating to sterilisers for medicinal products.
However, medicinal sterilisers such as those installed within the pharmacy still require a
validation, testing and maintenance schedule, although rather than falling within the remit of
a designated ‘User’ the pharmacy Quality Control lead will undertake this role.
Validation arrangements should be designed by the Pharmacy Quality Controller to ensure
compliance with current standards in the field and be approved by the Pharmacy’s Notified
Body. Testing, maintenance and validation must be undertaken by qualified personnel
approved by the Trust’s AE(D).
4.15 Changes and new guidance
HTM 01-01(2016) policy replaces all parts of the previous Choice Framework for Local Policy
and Procedures (CfPP) and ensures that:
a. Decontamination processes are carried out in compliance with the policy of Department
of Health (England).
b. All personnel connected with decontamination, whether NHS (England) employees or
contract personnel, are suitably qualified and trained for their responsibilities;
c. All decontamination equipment purchased conform to legal requirements, the minimum
specifications set out in British, European and International Standards, and any additional
requirements of the UK health departments;
d. Decontamination equipment is installed correctly and safely with regard to proper
functioning, safety of personnel and environmental protection;
e. Newly installed decontamination equipment is subject to a documented scheme of
validation comprising installation qualification tests (IQ), operational qualification (OQ)
tests and performance qualification (PQ) tests before they are put into service;
f. Decontamination equipment is subject to a documented scheme of periodic tests at daily,
weekly, quarterly, yearly intervals.
g. Decontamination equipment is subject to a documented scheme of planned preventative
maintenance (PPM);
h. Procedures for production, quality control and safe working are documented and adhered
to in the light of statutory requirements and accepted best practice;
i.
Procedures for dealing with malfunctions, accidents and dangerous occurrences are
documented and adhered to.
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4.16 Auditing and assessment of policy effectiveness
Ensuring that the Decontamination Policy is fully implemented and is effective across the
organisation is fundamentally important and will be achieved on a number of levels:
a. General breaches of the policy will be referred to the Decontamination Lead who will lead
required action in conjunction with the Infection Control Team, Health & Safety and
Governance leads as appropriate. Safety Notices (1.17) will be circulated where
applicable.
b. Flexible endoscope re-processing areas will be audited annually by the Decontamination
Lead using the flexible endoscope risk assessment tool.
c. Areas which use bedpan washer-disinfectors will be audited by the Infection Control
Team as part of their audit schedule.
d. Traceability of instrument trays will be audited on an annual basis by selecting a series of
(1) patients and (2) instrument trays and following these through the IT systems to ensure
that traceability records are robust.
e. Clinical adverse event records will be used to identify policy gaps or non-adherence and
the Decontamination Lead will co-ordinate action with the Clinical Governance Teams.
f. The Sterile Service Department is independently audited as part of a planned schedule
by an external Notified Body in relation to its (EQR) compliance and ISO 13485:2016
accreditation.
g. The external AE(D) will ensure that decontamination equipment is being maintained
satisfactorily and subject to EQR validation requirements by undertaking annual audits of
AP(D) competence and test documentation and records.
5.0 DUTIES & RESPONSIBILITIES
5.1
Decontamination management and control within UHCW NHS Trust is by a number
of key roles as specified in HTM 01-01 (2016) Part A. “Management and Decontamination of
surgical instruments (medical Devices) used in Acute Care” Each role in relation to
decontamination management within the Trust is summarised within this section.
5.2
Chief Executive
The Chief Executive Officer is ultimately responsible for all elements of decontamination
within the Trust.
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5.3
Executive Lead (Chief Nursing Officer)
The Executive Lead is nominated by the Chief Executive as the person designated and
identified as the individual with ultimate management responsibility, including allocation of
resources and the appointment of personnel, for the organisation in which the
decontamination equipment is installed.
5.4
Decontamination Lead
The Trust Decontamination Lead reports directly to the Chief Nursing Officer (Executive lead)
and is organisationally responsible for the effective, and technically compliant, provision of
decontamination services. He/She is responsible for the implementation of an operational
policy for decontamination. He/she should ensure that the operational policy clearly defines
the roles and responsibilities of all personnel who may be involved in the use, installation and
maintenance of decontamination equipment.
5.5
Microbiologist
Is the person responsible for the infection control aspects of decontamination. The
designated person is accountable directly to the Chief Executive and to the Board. The
Consultant Microbiologist with responsibility for decontamination advises on infection control
elements and risks associated with life-cycle processes to minimise risks to patients and staff
which may arise due to inadequate controls or decontamination incidents.
The principal responsibilities of the microbiologist are to:
Provide general and impartial advice on all microbiology and infection risk
management matters concerned with sterilisation, cleaning and disinfection of
medical devices
Advise designated Users on the microbiological aspects of all decontamination
procedures
Oversee and advise on rinse water testing from endoscope re-processors
5.5
Authorising Engineer (Decontamination) AE(D)
The role of the AE(D) is fully independent of UHCW’s management structure for any aspect
of maintenance, testing and/or management of the decontamination equipment.
The AE(D) is defined as the person designated by Management to provide independent
auditing and technical advice on decontamination procedures, washer/disinfectors, sterilisers
and sterilisation and to review and witness documentation on validation.
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The AE(D) is required to liaise closely with other professionals in various disciplines and
services across the organisation. The AE(D) reports to the Decontamination Lead and
provides professional and technical advice to the AP(D)s, CP(D)s, Users and other key
personnel involved in the control of decontamination processes in all healthcare facilities.
The AE(D) must be registered with ‘IHEEM’ and is responsible for the annual auditing of
testing and validation of sterilisers, washer-disinfectors and Automated Endoscope Re-
processors (AER) and advising the Trust in the event of non-compliances with current
standards and guidance. The AE(D) will also undertake auditing of facilities and process
elements to support the Trust in minimising and resolving decontamination risks on request.
5.6
Director of Estates & Facilities
The Director of Estates & Facilities, as a Trust employee, is responsible for negotiating and
monitoring contractual details with Coventry & Rugby Hospital Company - the provider of
some elements of on-site technical support for decontamination equipment, notably bedpan
washers. The majority of decontamination technical support is provided by a third party,
which is reviewed annually and reports to the Decontamination Lead.
5.7
Authorised Person (Decontamination) AP(D)
The AP(D) will be an individual possessing adequate technical knowledge and having
received appropriate training, appointed by and responsible to the Director of estates (in
conjunction with the advice provided by the AE(D)), who is responsible for the practical
implementation and operation of Management’s safety policy and procedures relating to the
engineering aspects of decontamination equipment, including the operation of the permit-to-
work system (see ‘Permit-to-work’ under ‘Validation and verification’ – ‘General’). The AP(D)
should be able to undertake the safe and effective management aspects of the service.
5.8
Competent Person (Decontamination) CP(D)
The CP(D) is defined as a person designated by Management to carry out maintenance,
validation and periodic testing of washer-disinfectors and sterilizers. The CP(D) should
report directly to an appropriate member of the estates department (for example AP(D)) or
should be subcontracted by them. The principal responsibilities of a CP(D) are to:
Carry out maintenance tasks; Health Technical Memorandum (HTM) 01-01(2016):
“Management and decontamination of surgical instruments (medical devices) used in
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acute care” – Part A: Management & Provision, Part B: – Common elements. Part C:
- Steam Sterilization, Part D: - Washer-disinfectors.
Carry out repair work;
Conduct validation tests as given in HTM 01-01 (2016) Parts B, C and D;
Conduct periodic tests as given in HTM01-01 (2016) Parts B, C and D.
5.9
Sterile Service Manager
The SSD Manager reports directly to the Decontamination Lead and has primary
responsibility for the management of Sterile Services and for implementing Quality Control
systems and standards within the SSD, ensuring that compliance with MDD 93/42/EEC is
maintained.
5.10
Lead Test Person
The Lead Test Person employed has responsibility for the validation of maintenance
performed on decontamination equipment, supervising and training maintenance staff,
performing re-validation tests and advising the Trust on technical decontamination and risk
issues in relation to PFI-owned decontamination equipment. The Test Person must have
received relevant training as deemed appropriate by the AE(D), and the Decontamination
Lead and must supply evidence of initial and ongoing qualifications which are applicable to
the scope of the role.
The principle responsibilities of the Test Person for equipment owned by PFI, or which is
adopted by PFI partners by means of a PFI Contract variation, are to:
Advise on programmes of specific testing and periodic maintenance of sterilisers and
washer-disinfectors.
Advise on operational procedures for routine production from sterilisers and washer-
disinfectors.
Maintain communication links with the designated Authorised Person.
Conduct the validation tests specified in HTM 01-01(2016) parts B/C/D and to
prepare the validation report meeting all requirements of HTM01-01 (2016) parts
B/C/D.
Conduct periodic tests specified in and to prepare reports as required by the
designated User.
Conduct any additional tests at the request of the User
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Test personnel employed by the third party decontamination equipment maintenance
provider are required to fulfil the same criteria as identified above for Trust-owned
equipment.
5.11 Maintenance Persons
Are responsible for routine servicing, validation and maintenance of sterilizers, washer-
disinfectors, AER's and ultrasonic cleaning devices which have been included in the PFI
contract or have been added to the maintenance list by means of a contract variation.
Maintenance staff must be appropriately trained, to a level approved by the AED, for the
maintenance role undertaken (i.e. sterilisers / AER’s / washer-disinfectors, endoscopy drying
cabinets) and evidence of supporting qualifications must be provided to the Decontamination
Lead.
The principal responsibilities of the Maintenance Person are to carry out:
Maintenance tasks outlined in HTM01-01(2016) 01-01 parts B/C/D
Additional maintenance and repair work at the request of the User
Maintenance Persons provided by any external provider shall equally be required to comply
with the above criteria and provide certificates of competency and qualification
commensurate with the maintenance or testing required.
5.12 Infection Prevention & Control Team (IPCT)
The IPCT provide advice, support and general auditing as required to both sterile services
and local re-processing areas to reduce decontamination process risks. The Team will
highlight deviations from Trust decontamination policies (noted during planned audits of
departments) and refer them to the Decontamination Lead for action in conjunction with
Service Managers
5.13 Local Re-processing: Department Managers (Users)
Department / Service Managers are responsible for implementing and monitoring adherence
to the Trust’s Decontamination Policy as well as national standards & guidance as contained
within the HTM’s, Health service circulars and other Department of Health and MHRA
guidance, and ensuring staff training is undertaken and documented prior to staff members
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undertaking decontamination activities. The Department Manager will normally be the EQR
designated ‘User’ of decontamination process equipment and as such is responsible for
ensuring that operators are trained, that required maintenance and validation is undertaken
at prescribed intervals and ensuring that documentation relating to sterilisers and washers is
completed and stored safely.
The principal responsibilities of the Users are to:
Certify and demonstrate that safe systems of work are in place to provide assurance
that all equipment used for decontamination has been tested and fit for use.
Hold all documentation relating to the above including the names of key personnel
Ensure that the steriliser/ washer-disinfector/ AER are subject to periodic testing and
maintenance and that all records are reviewed and signed off accordingly.
Appoint operators where required and ensure that they are appropriately trained
Maintain production records (including traceability records)
Establish procedures to enable safe for product release or quarantine and
reprocessing of any failed items
5.14
Operators
Operators are defined as any persons with the authority to operate Decontamination
equipment. Their duties will include undertaking daily tests, housekeeping or using the
equipment above on either an infrequent or regular basis. The ‘User’ (2.9) is responsible for
ensuring that all operators receive training, which must be documented, in order to perform
their duties. Staff must not operate decontamination equipment unless they have received
appropriate training
Copies of job descriptions for all grades of staff working within the Sterile Services will be
held in the department outlining the duties of staff employed. All job descriptions will be
reviewed annual to ensure they remain accurate and fit for purpose. Details of any changes
will be discussed and recorded in the SSD Quality Review meetings.
Copies of job descriptions for Endoscopy staff engaged in flexible endoscopy
decontamination will be held in the Endoscopy Department and reviewed annually by Users
to ensure that they remain up to date and fit for purpose.
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5.15
Decontamination Link Staff
Managers /’Users’ of departments where local decontamination is undertaken are required to
nominate an appropriate member of staff with operational responsibility for ensuring that
Trust and Departmental control measures, policies and training programmes are adhered to.
Link staff will normally be the departmental representative at the Trust’s Decontamination
Committee and will liaise regularly with the department manager and Decontamination Lead
over decontamination issues. If a link person is nominated, the ‘User’ still remains
accountable for decontamination within their service area.
5.16
The Competent Person (Pressure Vessels)
The Competent Person is defined as the person or organisation designated by the Trust to
exercise certain legal responsibilities with regard to the written scheme of examination of any
pressure vessel associated with a sterilizer or washer-disinfector described in the Pressure
Systems and Transportable Gas Containers Regulations 1989. The role of competent person
within UHCW NHS Trust is fulfilled by the current insurance inspector appointed by Project
Co under the PFI Contract.
5.17
Authorised External Sub-contractors.
Subcontractors who undertake repair, servicing, maintenance and validation on
decontamination equipment are responsible for working within the policies and method
statements agreed with the Trust and Project Co, and all companies provide copies of
appropriate ISO accreditations and be placed on approved suppliers list For each work
undertaken or validation report provided each engineer must provide evidence of
qualification - approved by the AED - to undertake contracted work.
5.18 A list of nominated officers for each decontamination role and their respective contact
details can be found in Appendix 2 of this policy.
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5.19
Decontamination Reporting Structure
A detailed Decontamination reporting structure can be found in Appendix 9. Following each
meeting of the Decontamination Committee, a summary report of the meetings main agenda
and action points (by exception) should be prepared for the Infection, Prevention & Control
Committee by the Decontamination Lead
In addition to the above minutes, the Decontamination lead will produce and additional report
on all aspects of Trust decontamination including activities, achievements, incidents and
audit findings for the Annual Infection Control Committee Report.
5.20
Decontamination Assurance
Trust decontamination services, both within the Sterile Service Department and in local re-
processing areas, will be accountable to the Trust Board via the Infection Prevention and
Control Committee and the Patient Safety Committee as appropriate.
The Decontamination Committee is a central function which serves as the interface between
users and the forums above. Principal responsibilities of the Decontamination Committee
are:
Developing decontamination risk management strategy for the Trust;
Co-ordinating decontamination risk management programmes based on:
Decontamination risk management issues identified from within the organisation;
Decontamination risk management issues that arise from local partners in the NHS
and Social Services organisations;
Issues arising from the wider clinical governance processes in the Trust;
National Policy and guidance issues.
The current reporting structure and decontamination management structure are shown in
figure 5.19 (Above)
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6.0 DETAILS OF THE POLICY
6.1 Acquisition of Invasive Medical Devices
6.1.1 Introduction
This section covers the essential requirements associated with the procurement of invasive,
re-usable medical and surgical devices which require sterilisation or high-level disinfection
between uses, such as:
Surgical instruments
Re-usable cannula, biopsy needles or suction devices
Re-usable items which are attachments to electromechanical equipment and used during
open or minimally invasive surgery
Flexible and rigid endoscopes
Re-usable anaesthetic accessories e.g. laryngeal masks, oesophageal monitoring;
introducers for intubation are also included within scope
6.1.2 Specific Exclusions
The policy does not apply to loan or consignment instrumentation; instead, the Management
of Instruments on Loan Procedure (section 6.8) must be followed.
Electromechanical medical equipment used during clinical procedures is not covered by this
policy and Heads of Departments must seek advice from MEBS prior to purchase; however,
where such equipment requires the use of re-usable attachments, the Decontamination Lead
or nominees must be involved in the pre-purchase evaluation in conjunction with MEBS and
clinical managers
Purchasers must consider any single use, disposable or limited use issues with either the
item being purchased or with required attachments. Single use items will not be re-processed
to enable them to be reused.
6.1.3 Overview
Clear acquisition procedures are necessary to minimise risks to the health and safety of both
staff and patients which may arise due to:
Specialist re-processing requirements which may not be available within the Trust
Special maintenance requirements which may be overlooked
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Lengthy decontamination turnaround times due to non-standard processing requirements
which may affect clinical needs (e.g. ethylene oxide sterilisation)
Manufacturer’s process/equipment compatibility statements not being considered, causing
damage to the equipment or affecting function and placing patients at risk of harm
Heads of Departments must ensure that they purchase sufficient quantities of new items
required to meet clinical workload. There are significant clinical risks associated with buying
the minimal number of sets or equipment for surgical procedures and this is very strongly
discouraged.
Purchasers must not assume that:
Buying one set of an item will be offset by re-processing within the clinical area
SSD will be able to automatically meet very pressing turnaround requirements on an
ongoing basis
In any case where clinical services deem that a single set of instrumentation/ medical
equipment attachments is appropriate to service needs, a documented risk assessment must
be undertaken and submitted to the Decontamination Lead for approval prior to any
purchase being made.
In the event that a limited number of instrument sets for a specific procedure are purchased,
the purchasing department (must ensure that speciality waiting list teams are advised of the
maximum number of similar procedures that can be scheduled within each 24 hour period.
6.1.4 Responsibilities
Head of Department
Heads of Departments which purchase re-usable, invasive medical devices are responsible
for ensuring that the acquisition procedures contained within this policy are adhered to as
part of the procurement process, including pre-purchase decontamination assessments.
Where medical device purchasing is delegated to clinical staff, HOD’s must ensure that the
delegated person is a responsible staff member who has access to, understands, and follows
this policy.
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Clinical Staff / Users
Staff that use invasive medical devices in the treatment of patients during surgical or medical
procedures are responsible for ensuring that the specific equipment manufacturer’s
instructions for use, management, decontamination, maintenance and testing/calibration are
followed and all devices used for the device’s “intended purpose only”
Sterile Service Manager/Decontamination Lead
Are responsible for the design, staff training and implementation of procedures which
address the requirements of equipment manufacturers’ instructions.
Decontamination Staff
Sterile service staff, nursing staff, support workers and other staff who are required to
decontaminate
invasive,
re-usable
medical
devices
must
adhere
to
prescribed
decontamination procedures relevant to the specific equipment and not undertake
decontamination unless they have been trained to do so.
6.1.5 Acquisition Prerequisites
Prior to purchase, a decontamination assessment must be undertaken to ensure that
invasive devices being purchased are:
CE Marked
Be accompanied with manufacturer’s instructions which include EEC approved reprocessing
instructions and complying to ISO 17664(2004)
Compatible with existing processes.
Comply with all Trusts procurement policies and procedures
Secure Value for Money (VfM)
Compatible with existing process chemicals where applicable.
Able to be re-processed using methods which involve minimal specialist work.
Of a design which does not impede cleaning and/or sterilization.
Able to be re-processed and available for re-use in the timescales required by clinical users.
Where a set of instrumentation will be presented by the supplier in a moulded plastic or
metal container, the container must be assessed by the Sterile Service Manager to ensure
that it is fit for purpose.
The assessment process is variable according to the nature of the acquisition and is
illustrated in Appendix 4.
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In cases of replacement or addition of simple instruments (e.g. forceps, scalpel handles etc.)
a formal assessment is not normally required, however the Sterile Service Manager must be
satisfied that manufacturer’s re-processing instructions have not changed since previously
assessed purchases; this may involve a simple check with the supplier.
For purchase of instrument sets which may be complex, multi-material or have multiple
component types, a more detailed assessment is required – even if similar items have been
previously purchased – as instructions can change. A Decontamination Assessment Form
(DAF), found at Appendix 5, must be completed by the designated department manager of
the clinical area.
Completion of the form will require a copy of the manufacturer’s re-processing instructions
and will be reviewed together with the SSD Manager prior to the order being placed.
Information from the DAF will be risk assessed and scored appropriately. If the SSD
Manager are satisfied that safe processes can be implemented to manage the equipment life
cycle, purchasing will be approved.
In the event of High or Very High Risk items being identified, or where the group have
concerns in relation to the safe life cycle management of these devices, it may be necessary
to consider alternative suppliers or purchase options, and details of the risk issues may
require review by the Decontamination Committee and relevant Risk Committee prior to
approval for purchasing.
6.1.7 Preparation Invasive Medical Devices for Use
On delivery, simple, single items (e.g. replacement items on sets such as standard forceps,
clamps etc) can go straight onto the relevant tray and the whole tray is then fully re-
processed prior to use
Single, non-complex items which will be utilised as ‘supplementaries’ must be registered as
new items on the T-Doc system and therefore the SSD procedure ‘Request to change to
instrument set or introduction of new set’, should be followed. Clinical departments
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purchasing such items are simply required to complete a ‘new tray’ form and forward to the
SSD Co-ordinators along with the new item and any specific instructions.
New instrumentation entering SSD must not be returned to SSD in the same way as used
instrument, but taken to SSD Separately and marked for the attention of the SSD Co-
ordinators who will set up the new tray on the T-Doc system.
Instrument sets or complex / high cost single items must also be registered with the SSD
prior to entering circulation. This is necessary to:
a. Allocate a unique identification code for traceability and asset purposes
b. Enter details of the set or items on the UHCW surgical instrument register on T-Doc
c. Undertake a final review of decontamination requirements and ensure that Sterile Service
Staff are informed of re-processing methods and, where applicable, produce specialist re-
processing/management instructions. This is required to ensure that patient safety and
equipment integrity are not put at risk of harm due to inappropriate processing methods
or essential maintenance being neglected
At the time of ordering of new instrumentation, purchasers must reach agreement with the
SSD Manager over which party will take responsibility for any required maintenance, life-
cycle replacement, replaceable parts or funding for repair costs etc. and this agreement must
be in writing (e.g. using the ‘DAF’ form) for future reference.
Staff’ who order instrumentation must also ensure that arrangements are considered for the
packing medium of each new tray at an early stage. For example, it may be necessary to
purchase a ‘DIN tray’, container or other means of conveying the set at the time of ordering
instruments.
6.2
USE OF DETERGENTS & HIGH LEVEL DISINFECTANTS
6.2.1 Introduction
In selecting detergents and chemical disinfectants it is essential that appropriate products are
employed which are compatible both with re-processing equipment and medical devices to
be re-processed; compatible agents specifically prevent:
Damage to the medical equipment
Ineffective decontamination
Damage to automated washer-disinfectors and sterilisers
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Unnecessary risks to staff
In relation to compatibility of products, processes and devices, MDA Safety Notice 2001(28)
states that Users must:
Ensure that the decontamination agents used are compatible with both medical devices and
reprocessing equipment.
Consult the medical device and reprocessing equipment manufacturer / supplier before
changing any decontamination process.
Decontaminate reusable medical devices in accordance with the instructions provided by
the device manufacturer.
Ensure that appropriate decontamination facilities and compatible agents are available
before purchasing new devices.
Follow the instructions for use supplied by the manufacturer of the decontamination agent.
6.2.2 Selection of detergents
A wide range of specialist instrument cleaning detergents are commercially available and
when selecting a new product the Infection Control team must be consulted to ensure the
product selected is appropriate for the required use. Users (i.e. department managers of
applicable services) are responsible for ensuring that the requirements of the safety notice in
6.2.1 above are complied with.
In general, where detergent is to be used for manual cleaning of medical devices a neutral
pH cleaner is preferred, and the manufacturer’s instructions must be incorporated into the
documented manual cleaning procedure. The procedure must indicate a means to identify
the correct concentration of detergent where this is not automated.
Hospec or other ‘domestic’ detergents are not suitable for invasive medical device cleaning
and should not be used for this purpose unless specifically indicated by the manufacturer
and supported by the Infection Control team.
Domestic detergent must never be used in automated washer-disinfectors.
Key requirements in the use of industrial medical device detergents:
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Ensure that a COSHH risk assessment is undertaken and that staff are aware of the
location of required information in the event of spillage splashes to eye etc.
For manual cleaning detergents a PH Neutral product is preferred however the product
type must be deemed compatible by the manufacturer of the medical devices to be
cleaned; the dilution, number of uses, water temperature and other manufacturer
information must be incorporated into the clinical user’s own cleaning procedure.
6.2.3 High-level Disinfectants
The preferred method for sterilisation of re-useable medical devices is by steam in a porous
load steriliser; however certain items of medical equipment cannot withstand the high
temperatures of a steam sterilizer process (134 – 137 degrees centigrade). Such equipment
is termed ‘heat labile’ and items within this category are commonly endoscopes which have
fragile glass fibre-optics.
Where heat-labile items are required for use in surgical or medical procedures which enter
body cavities or tissues, the equipment must be effectively decontaminated to minimize risks
of infection to patients. The decontamination process for heat labile items will include a
cleaning stage and a high-level disinfection stage and the nature of both elements will be
prescribed within the product manufacturer’s instructions; however, instructions sometimes
provide a range of decontamination options which the manufacturer deems compatible with
the product, although the instructions will not normally recommend which method option is
the most microbiologically effective.
In relation to heat-labile products, specific alternatives such as Gas Plasma or chemical
processes such as Ethylene Oxide are normally the next approved method of sterilisation;
however these specialist processes may not be readily available or recommended by the
device manufacturer.
Chemical high-level disinfection agents available and manufacturer’s instructions may
approve either a single product or numerous products. In general and subject to
compatibility, either Chlorine Dioxide (e.g. ‘Tristel’) or Peracetic Acid products are most
highly recommended.
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6.2.4 Selection of Chemical Product
Both changes to existing chemical disinfectants and planned use of disinfectants where not
previously used, shall be subject to approval by the Decontamination Committee. The
following indicators will be used to assess the appropriateness of the required product:
Compatibility: the product must be compatible with both the item/s being re-processed and the
endoscope processor (where applicable) being used (MDA Safety Notice 2001 (28))
Automated Washer Disinfectors/Automated Endoscope reprocessors: require technical
adjustments and re-validation where the chemical disinfectant is changed and the costs of this
need to be considered as part of any change process.
Efficacy/time: differing products have varying ranges of efficacy in terms of the range of micro-
organisms which are destroyed and the contact time required to achieve this. The Infection
Control team representatives of the Decontamination Committee will need to be satisfied that
the efficacy is appropriate to the medical device application and that any specified contact and
concentration requirements can be consistently achieved via reproducible methods.
Health & Safety: many chemical products carry risks to the health and safety of staff and or
patients. The Decontamination Committee will ensure that COSHH elements are assessed and
identified health risks are considered as part of the approvals process. In some cases, the
Occupational Health Department will need to be involved in case health surveillance is required
for staff using the product.
Inactivation: some disinfectants are easily inactivated by organic matter, reducing efficacy where
manual cleaning processes (rather than automated) are employed.
Figure 5 (page 37) provides a summary of efficacy and application information for use as
part of the approvals process. The latest information from endoscope and endoscope
processor manufacturers on compatibility must also be referred to.
6.2.5 Implementation, Management and Use of chemical products
The designated ‘User’, AP(D) or department manager is responsible for ensuring the safe
implementation, management and use of all chemical detergents and disinfectants.
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All chemical disinfectants and detergents used in local re-processing areas must be subject
to a documented COSHH risk assessment which is retained within the area where the
product/s are used. The risk assessment, along with analysis of the manufacturer’s product
information, must be used to produce a local policy which identifies procedures for:
Storage.
PPE or health & safety protection requirements.
Mixing/ concentration and record keeping of the person, product lot numbers and date/time
where applicable.
Soak times for manual processes.
Number of uses (where applicable).
Disposal (manual processes).
6.2.6 Gluteraldehyde Use
Glutaraldehyde (in the form of ‘Cidex’, ‘Asep’ and ‘Septo DN’) is no longer accepted or
authorised for use in the Trust. Any requirements for the reintroduction of this chemical will
be refused.
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Approved High-level Chemical Disinfectants
Product
Microbicidal Activity
Stable?
Inactivation by
Organic Matter?
Corrosive/
Damaging
Irritant (I) /
Sensitising (S)
Compatibility
Spores
Mycobacteria
Bacteria
Viruses
Peracetic Acid
Good
Good
Good
Good
No
No
Slight
I
Endoscopes:
Olympus/
Keymed
Chlorine
Dioxide
(Tristel)
Good
Good
Good
Good
No
Yes
Slight
I
Endoscopes:
Olympus/
Keymed
Note: always check detergent to scope and machine compatibility with manufacturers; AER’s need to be configured to use the
required chemical products at the time of ordering.
Figure 5.
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6.3
TRACEABILITY OF INVASIVE RESUABLE MEDICAL DEVICES
Health Service Circular 2000/032 and the Health and Social Care Act 2008 require surgical
instrument trays to be tracked to, and between, patients on whom they were used; in addition,
traceability to decontamination processes is also required.
A set of instruments chosen at random should be able to be traced back to any of the above
elements of the re-processing cycle and the parameters, staff and methods employed
determined to validate each stage of the process.
A set of instruments used on a patient must be able to be tracked back to the patient, and
both previous and subsequent patients, on whom it was used.
Robust tracking of instrument sets is essential to ensure that items which were used on a
patient who was subsequently determined to be in either a 'known, suspected or at risk’ TSE
category can be immediately and easily identified and removed from circulation.
Managers of the departments where invasive, re-usable medical devices are used on patients
are responsible for ensuring that traceability systems and processes are in place and comply
with the requirements of this Policy.
6.3.1 Traceability Processes
The Sterile Service Department will achieve ongoing instrument traceability of surgical
instrument trays to decontamination processes through the use of the T-Doc Instrument
Management System. This utilises bar codes, which are attached to instrument trays, for
scanning sets at each key stage:
Instrument reception & checking
Automated cleaning & disinfection
Assembly and checking
Packing and wrapping
Sterilization and product release
Dispatch
Details of the full operational processes relating to traceability within sterile services is
included within the SSD Quality System (ISO 13485:2016)
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6.3.2 Traceability in Theatres (to patients)
All sterile instrument trays opened in theatre should have:
a. A unique identification tag attached to the tray container/ item such as an instrument
holding pin and usually:
b. A sterilisation validity indicator sticker on the outer tray wrap/sterilisation container
which contains unique identification details of the tray
Immediately prior to opening an instrument tray, the circulating person must remove the
sticker from the outer tray wrap/ container tag and place this on the reverse of the Theatre
Patient Record or Care Pathway and where available also scan the barcode electronically into
the local system being used.
6.3.3 Sterile Instrumentation provided to 3rd party theatres:
Where instrumentation (referring to both sets and, where tracked, single items) is provided,
either as part of a formal contract by SSD or on an ad-hoc basis, such as by Trust theatres,
the 3rd party is responsible for ensuring that traceability systems are in place locally which:
a. will allow the 3rd party to advise UHCW staff, where requested, to provide details of
dates and patients on whom a specific instrument set which is owned and supplied by
UHCW, was used.
b. will allow the 3rd party to determine and advise UHCW immediately, which specific
instrumentation sets were used on a patient subsequently determined by the 3rd party
to be at high risk in relation to vCJD or other TSE’s.
6.3.4 Instrument loans from 3rd parties
All instrumentation loaned by UHCW NHS Trust from third parties must be traced as per
Trust-owned equipment.
6.3.5 Traceability in Other Clinical Areas (to patients)
Instrument sets are also used for invasive procedures in areas other than theatres (e.g.
dermatology, ENT clinics etc) and these should also be traced to the patients on whom they
were used. The relevant Department Manager must implement a manual system of recording
the unique tray ID number on a dedicated register (and in the patients’ notes if deemed
appropriate by the individual department). Commercially available manual systems may be
purchased to support this activity.
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6.3.6 Traceability of Endoscopes
All rigid endoscopes are required to be reprocessed through the SSD department. Flexible
endoscopes (along with any re-usable invasive accessories) re-processed in clinical areas
shall be tracked to patients in the clinical areas where they are used and to endoscope re-
processor cycles. This should be achieved by attachment of a unique ID code to each
endoscope; wherever possible, an IT-based traceability system should be used as outlined in
Section 6.6 ‘Flexible Endoscopes’.
6.3.7 Transfer of theatre traceability data into Opera
Patient record forms with tray labels/ details are collected from theatres on a daily basis by
data input staff, who will enter the details of the trays used on the Theatre Management
System (Opera) along with other surgical episode data.
‘Loan’ trays will be treated separately as these do not have UHCW unique ID’s and therefore
traceability of short-term loan items is included in Section 6.8.
In the event of a need to determine which instrument sets were used on a particular patient,
either the Decontamination Lead or the Opera system manager should be contacted. This
information can be provided, along with details of subsequent patients on whom the items
were used if this is also required.
6.3.8 Traceability of single items
A growing number of single items are being transferred into single item containers (e.g.
ophthalmology instruments and individual endoscopes). These items will be tracked in the
same way as instrument trays, by applying a unique ID number to the container.
It is imperative that where tags are used for tracking purposes for supplementary items, these
are returned to SSD in the outer packet with the corresponding instrument. The most
significant benefit of this for users is the ability to determine which department a specific single
item belongs to and its swift return to that area.
6.3.9 Traceability Systems Efficacy
To ensure that systems in place are being adhered to and are able to produce the required
information, ad-hoc system testing will be undertaken by the Decontamination Lead and
Opera system manager, in conjunction with the SSD manager. This will involve selection of an
instrument tray at random and collation of electronic data to ensure that traceability back to
both patients and decontamination processes is wholly achievable.
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6.3.10 Instrument Inventory
An inventory of instrument trays used within the Trust will be maintained electronically on the
Trust’s T-Doc system
6.4 TRANSPORTATION HANDLING STORAGE AND DISPOSAL OF INVASIVE
REUSABLE MEDICAL DEVICES
6.4.1 Introduction
This policy section identifies the requirements for the passage of sterile products - which have
been manufactured in-house - through the system from sterile services to the end user and
back. The full details of Sterile Services’ Quality System processes are not located here,
rather in the SSD’s Quality System documentation and in this respect the Decontamination
Policy is a broad identification of SSD requirements only.
Instrument trays, procedure packs, and supplementary items which have been processed and
sterilised within the Trust’s Sterile Service Department (SSD) are all covered by this policy
and hereafter termed ‘products’.
6.4.2 Dispatch from Sterile Services
Following terminal sterilisation of medical devices in SSD and prior to dispatch, SSD staff will
routinely inspect the wrapping / packaging integrity of manufactured products for any signs of
damage or wetness, in which case products affected will be rejected and re-worked.
6.4.3 Transportation of Sterile Products
Transportation will be in containers or trolleys which are designed for purpose to take into
account:
The volume and weight of items being dispatched to each location.
The content and consequent degree of protection required for the products.
The transportation method from SSD to the end user.
In general, only approved containers and trolleys will be used, which meet all the essential
requirements for both the transportation of sterilised goods and also the safe transportation of
“used Medical Devices” in Transit
Under no circumstances may sterile products be transported between SSD and users, or
between two users, without some form of protection from the environment.
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All instrument sets shall, at all stages of handling from assembly prior to sterilisation up to
instrument set use, be maintained upright in their correct plane. Under no circumstances shall
sets be tipped on their side or upside down to inspect packing or for easy loading into
containers or trolleys. This is to avoid damage to instrument set contents, which may contain
extremely fragile components, leading to these becoming damaged and unusable during
surgery with potentially serious consequences.
At every stage of the transportation process from SSD to the point of clinical use, physical
handling by staff must be kept to an absolute minimum. Any manual handling which involves
direct contact with tray packaging should, wherever possible, be undertaken following routine
hand-washing or alcohol gel hand disinfection.
In addition, staff handling wrapped trays must ensure that:
Trays are always lifted directly from, not dragged across, shelving or racking or any
other surfaces.
Trays are never lifted or pulled by their wrapping.
6.4.4 Receipt
On receipt of sterile in-house manufactured products, the end user shall inspect the delivered
item/s and prior to acceptance and placing on the shelves ensures that:
There is no packaging damage.
The item(s) is / are not wet.
Sterility indicators demonstrate that the item has been through a sterilisation process.
The delivered item belongs to them (i.e. it has not been delivered to an incorrect location).
Any problems which mean that a delivered item is not fit for purpose should be reported to the
SSD co-ordinators within one hour of delivery and all damaged items (if any) arrangements
made to return these to SSD for immediate reprocessing.
6.4.5 Storage
Trays and other manufactured products which are not required for immediate use are likely to
be stored either temporarily or indefinitely within the clinical area, and in some cases within
the SSD clean store; it is essential that appropriately configured storage is utilised to avoid
sterility being compromised.
Appropriate storage is the responsibility of:
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The SSD Manager for products held within the SSD.
Clinical area Managers for products transferred to clinical areas.
Appropriate storage is defined as:
A dry area of standard humidity (approx 55%).
At room temperature (approx. 16-22 degrees C).
Out of direct sunlight.
Safe from tampering by unauthorized persons.
Not in contact with outside walls.
Having no windows or doors which open to the outside environment.
On suitable shelving which allows gentle air circulation.
Away from sharp objects
Protected from damage by passing trolleys, staff etc.
Not in a main thoroughfare (i.e. in dedicated room or area).
Fully segregated from soiled items or sluices, wash areas etc.
Segregated from any chemical products.
Stored in such a way as to minimise unnecessary handling of products when
searching for one particular item.
Storage areas must be configured to facilitate easy location and accessibility of sterile
products. All items must be stock rotated and a good practice such as a first in first out
principle used to ensure stock dies not go out of date.
Specific identified locations and clear signage for set types or specialities is encouraged to
enable staff to locate quickly essential items, particularly in an emergency situation, and
consequently minimise any risks to patients should items be required urgently
6.4.6 Shelf Life
Provided products are stored in the conditions stated in section 6.4.5 (above), they remain
sterile indefinitely; however, due to general Trust issues with limited storage space which
frequently results in more handling of products than is desirable, a shelf-life of 12 months has
been determined as appropriate. Items unused 12 months after manufacture must be returned
to SSD for re-processing or for removal from the system if no longer required.
All departmental managers are to ensure that staff undertake good housekeeping duties such
as expiry date checks at least monthly to ensure that out of date items are not present in their
areas of responsibility. However, in emergency situation, and where there no other
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instruments are available, where any delay would be detrimental to that patient and life or limb
endangered, then the Consultant or Lead Clinician may opt to use these devices, provided the
integrity of the packaging has not been compromised in any way. In this event the incident
must be recorded on Datix as a CAE and managed accordingly.
In all circumstances the responsibility for monitoring the shelf life of all sterile products lies
with the equipment/instrument owner.
6.4.7 Returning soiled items to SSD
Soiled items (i.e. used during medical or surgical procedures) present a risk of injury and
infection to transport and SSD staff. Therefore, dedicated transport containers which are
suitable for this purpose shall be used at all times and shall have the following characteristics:
Leak proof
Easy to clean
Rigid to contain instruments and prevent sharp items penetrating the container
Capable of being securely closed
Lockable, where appropriate, to prevent tampering
Clearly labelled to identify the user and the nature of the contents
Sufficiently robust to prevent instruments being damaged in transit
The SSD manager will advise all clinical areas on the correct type of containers which can be
used. To minimise the risks to staff who are involved in the dispatch, transport or receipt
stages of soiled items the following requirements apply:
All re-usable or disposable drapes must be removed from instrument sets prior to
dispatch by the clinical user with the exception of the single outer wrap which sets
must be wrapped in to retain set contents together during transportation.
All single use or disposable items must be removed from sets and discarded
appropriately.
All fluids and body tissue must be removed/drained from receivers etc prior to dispatch
Soiled items must never be transported in the same container as clean/sterile goods
To preserve traceability, items removed from sets during use must be replaced on their
original set and all ID tags supplied with single items must be placed in the outer viewpack
along with the item.
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Any endoscopes or single items supplied in containers must be replaced in the correct
container, with the lid securely closed; the same applies to whole sets installed in product-
specific cases or sterilisation containers.
6.4.8 Cross-site Transportation
Soiled goods being transported from an off-site location to the SSD shall be, without
exception, transported in containers which are constructed to UN18282/ADR. In addition:
Users are responsible for ensuring that all loaded trolleys are securely locked prior and
stored in locations not accessible by unauthorised persons such as members of the
public, patients or other members of staff other than those doing so in the course of
their duties.
Not overloaded as to present damage to the instruments within or to cause any
manual handling risks to transport staff.
Trays which do not have lids and which contain fragile contents must never be
stacked.
In relation instruments used on known, suspected or at risk TSE patients, these must
never be transported within other items and segregated, containerised and handled in
accordance with Trust CJD Policies and Clinical Operating Procedures.
6.4.9 Internal distribution arrangements for invasive medical devices
ISS Mediclean are responsible for the on-site collection of used equipment from clinical areas
for return to SSD and the distribution of sterile products from SSD back to end users. Detailed
arrangements for the interfaces between clinical services, ISS and SSD are identified in the
section 6.4.13.
6.4.10 Disposal of surgical instrumentation
Due to the liability issues (outlined in MDA DB 9801) involved in selling on used surgical
instrumentation to another legal entity within Europe, owners of obsolete surgical
instrumentation are advised to deal with disposal issues carefully and seek advice where
relevant as follows:
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Instrumentation which is broken and unusable should be identified as such and returned to
SSD for decontamination prior to disposal. SSD will then order the replacement item to ensure
that instrument set contents remain as per their intended checklist.
Under all circumstances where instrumentation is being disposed of in the form of sold or
transferred into new ownership the entire batch is required to be decontamination to render it
safe to handle. All items must be accompanied by a certificate of decontamination specifying
the status of these items.
Under no circumstances may any instruments, endoscopes or other medical devices which
have been identified as being used on a patient with a definitive, likely or possible diagnosis of
variant CJD or any other TSE be auctioned, transferred or disposed of via the methods
outlined above. In all cases where potentially CJD infected items require disposal they must
be discarded as ‘special waste’ and micro-managed in conjunction with the Trust’s waste
contractor, the Health & Safety Team and Waste Policy.
6.4.11 Management of Instrument Logistics
This document outlines the interface arrangements for the collation, dispatch and return of
soiled/sterile surgical instruments and medical equipment from clinical departments within the
Trust and sent for re-processing at the Sterile Services Department.
Clinical staff preparing soiled instruments for dispatch should be aware that these items are
classed as “Used Medical Devices” All external containers (i.e. trolleys and blue transport
boxes) must therefore be of the approved type.
In all circumstances it is prohibited to send used medical devices by taxi or private
vehicle.
6.4.12 Equipment from Wards and Clinics at St Cross
All wards and clinics have been supplied with two containers/cases in which to transport
Instruments. The containers will be marked to identify ‘soiled equipment’ and ‘sterile
equipment ’; containers must not be mixed up.
Clinical department staff are responsible for ensuring that disposable needles, syringes,
blades, dressings and gallipots of fluids etc. are removed from any instrument sets or medical
equipment prior to packaging.
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Sets and individual instruments must be packed in such a way that will protect items from
damage during transportation. This may include loosely re-wrapping in original drapes.
Equipment will be processed and returned in the clinical departments’ ‘clean’ container.
6.4.12 Surgical Instruments from Theatres St Cross
Theatre staff are responsible for ensuring that disposable needles, syringes, blades, dressings
and all fluids are removed from any instrument sets prior placing in the trolley for return to
SSD.
Sets and individual instruments must be packed in such a way that will protect items from
damage during transportation. This may include loosely re-wrapping in original drapes.
Supplementary items and very small sets may be placed within a smaller transport box, which
should then be placed in the trolley.
Once the trolley is ready for collection it will be collected at several times during the day as
agreed by SSD and Theatres and specified on the agreed delivery schedule.
6.4.13 University Hospital Site Arrangements
Sterile Services
The Sterile Services Department is responsible making loaded trolleys and containers
available for collection and distribution by ISS Mediclean at the Instrument Dispatch Point at
the scheduled times. The Dispatch Point is the ‘goods out’ door of the Sterile Services
Department.
ISS Mediclean
ISS are responsible under the PFI Contract for all on-site internal distribution at University
Hospital; this responsibility includes distribution of ‘clean’ goods from the Dispatch Point to
clinical departments, collection of soiled goods from departments for return to the SSD
Delivery Point (i.e. the Wash area lobby) and the general movement of trolleys and containers
as required. Ad-hoc urgent requests will be notified to ISS by the relevant clinical area.
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Clinical Departments
All wards and clinics (which do not use transport trolleys) will use instrument transport boxes
which are approved by the Sterile Services Manager in which to transport soiled/ clean
equipment. The containers must be marked to identify its contents as “Used Medical Devices.”
Clinical staff are responsible for ensuring that disposable needles, syringes, blades, dressings
and fluids are removed from any instrument sets or medical equipment prior to return to SSD.
All items must be packed in such a way that will protect items from damage during
transportation.
When the soiled container is ready for collection and the contents list has been completed, the
clinical area need to ensure that the container is left at the agreed collection point in time for
ISS Mediclean to collect.
On arrival at SSD, staff will empty the container and undertake the departmental cleaning
procedure for transport trolleys, making the cleaned container available for the next delivery.
6.4.14 University Hospital Theatres
Sets and individual instruments must be packed in such a way that will protect items from
damage during transportation; this may include loosely re-wrapping in original drapes. Single
“supplementary” items must be returned to SSD in their labelled outer wrap. Trays should not
be stacked if the contents are fragile or likely to be damaged by doing so.
Once the trolley is ready for collection, it must be locked and left at the dispatch points which
ISS Mediclean have been notified of for each area in good time for the scheduled collection.
6.5
REUSABLE LIMITED USE & SINGLE USE MEDICAL DEVICES
6.5.1 Reusable and Limited Use Medical Devices
Strict regulations & standards exist which govern the use of medical devices and the
information which must be supplied by manufacturers for their devices. ISO 17664
“Information to be provided by the manufacturer for the processing of sterilisable Medical
Devices” is this standard. Contained within this document it clearly identifies the “intended
purpose” of the device, instructions for set up and preparation along with any required pre-use
checks or calibrations required prior to use.
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With specific regards to decontamination, this document specifies includes information which
must always be fully adhered to. These include:
Whether a product is reusable, Limited Use or SingIe Use.
If a product can be re-processed, the max number of times this can be carried out prior
to disposal or removal and any technical inspection or periodic servicing requirements
to be carried out by the manufacturer.
Methods of disassembly and disinfection
Specific requirements such as times, temperatures and methods for both washing and
sterilisation and additional requirements such as the pH of detergents and methods of
reassembly and function testing.
In all cases where instruments being considered for use within the Trust, whether purchased
or on loan, the reprocessing instructions but be reviewed and accepted by SSD prior to the
item being purchased or hired to ensure compatibility with the SSD Departments systems and
processes.
Breach of a manufacturer’s instructions may lead to either a product not being effectively
decontaminated prior to re-use, the product being damaged during the re-processing cycle
rendering it non-functional at the point of use or to fail during use compromising patient safety.
Any breach of instructions by users which subsequently causes injury to a patient may result
in legal action and major consequences to the Trust.
6.5.2 Single Use Medical Devices
The legislation, requirements and responsibilities for the control, management implementation
and use of Single Use Medical Devices is published by the MHRA and is entitled:
MHRA DB2006 (04) Single Use Medical Devices – “Implications and Consequences of
Reuse” (October 2006).
Single use medical devices are items which are intended for one clinical treatment
episode/use only and within UHCW NHS Trust shall never be used in the treatment of more
than one patient or more than once on the same patient. Single use items are usually supplied
as pre-sterile sterile products however there are some rare examples where manufacturers
provide these items non sterile. Where this is the case the Manufacturer’s instructions indicate
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that these devices are able to be reprocessed for their initial use and then discarded following
this single use episode.
These are designated by the symbol below.
6.5.3 Single Patient Use Items
Products designated by the manufacturer as being ‘for single patient use’ are generally
intended to be used for either a specified period of time or a specified number of uses on the
same patient only; in the case of the latter, some element of decontamination or disinfection
between uses may be indicated dependant on the device type and application.
6.5.4 Limited Use Items
Items commonly associated with this classification include devices such as some anaesthetic
devices and electro medical items such as Diathermy cables which have a limited use. This is
indicated by the manufacturer and cannot be exceeded. Purchasers of limited use items are
responsible for the replacement of these items once the life expectancy of the item has been
reached.
6.6
FLEXIBLE ENDOSCOPES
6.6.1 Requirements & Specialist Provision
Requirements for the, procurement, management, cleaning, decontamination, and storage of
heat liable fibre optic flexible endoscopes is contained within Health Technical Memorandum
01-06 “Decontamination of Flexible Endoscopes” 2016
This section should be read in conjunction with the Endoscopy Decontamination Policy
and other local Endoscopy Standard Operating Procedures, which apply to all areas of
the Trust including Rugby St Cross.
Flexible endoscopes are a group of medical devices which present some of the most
significant challenges in relation to effective decontamination. This is because:
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A wide range of Flexible endoscopes are used which have different lumens and
connections therefore there are subtle differing requirements regarding their
decontamination.
They are unable to be reprocessed by any other means other chemical processes in a
sophisticated AER.
Due to the high value of the endoscopes, there being few in number and the high
turnover of quick procedures, these specialist decontamination areas must be located
close to the point of use.
The decontamination process is a wet process and processed scopes require
specialist drying & storage or use within three hours of being reprocessed through the
AER.
This policy section has therefore been developed to support users of flexible endoscopes in
the management and decontamination of these devices. However this policy itself cannot be
exhaustive due to the range of endoscopes in use and is therefore to identify the principles of
this area of responsibility and must be supplemented by practical information and procedures
gained from endoscope and automated endoscope re-processor (AER) manufacturers.
6.6.2 Information sources
A wide range of information is available to support staff that use and/or decontaminate flexible
endoscopes. However, primary sources of information which staff should read and utilise are
as follows:
Health
Technical
Memorandum (HTM)
01-06
“Decontamination
of
Flexible
Endoscopes” 2016
BS EN ISO 15883-4:2009 Requirements and Tests for Washer Disinfectors Employing
Chemical Disinfection for Thermoliable Endoscopes
BS EN ISO 16442:2015 Controlled Environment Storage Cabinet for Processed
Thermoliable Endoscopes
National Endoscopy Programme Decontamination Standards for Flexible Endoscopes
March 2008
BSG Guidelines for Decontamination of Equipment for Gastrointestinal Endoscopy
February 2016
The MHRA Microbiology Advisory Committee Decontamination manual (MAC Manual)
part 3
MHRA Top Ten Tips Endoscope Decontamination 2013
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6.6.3 General Requirements where flexible endoscopes are re-processed
Departmental managers are responsible for ensuring that staff are aware of the contents and
location of the Trust Decontamination Policy, which must be maintained up to date, accessible
to staff, and used to determine departmental policies and procedures as required.
Implementation of specific requirements for the management of flexible endoscopes, along
with ongoing staff training, are the responsibility of the HTM (EQR) designated ‘User’, which
by default will be the department manager. The definitions of the User’s role and the role of
staff operators of all washer- disinfectors (including AER’S) are included within section 5,
which should be referred to.
Users are accountable to the Chief Executive via the Infection Prevention and Control
Committee for implementation of the this policy and national decontamination requirements.
The Decontamination Lead will maintain a list of designated ‘Users’; Department Managers
are responsible for ensuring that personnel changes are communicated to the
Decontamination Lead.
Either the ‘User’ or a responsible person designated by the User (such as a support worker
who uses the washer-disinfector regularly) must take primary responsibility for cascade
training and general overseeing of the management of the washer-disinfector and should have
received initial training by the manufacturer. Even where responsibilities are delegated, the
User remains accountable for washer-disinfector management.
Department ‘Users’ must ensure that for each AER a ring binder file (with wipe-clean cover)
has been set up to collate all essential documentation. A template of contents required (the
‘Process Log Book’) is available on the Intranet and this can be tailored to each individual
department.
Accessories used during endoscopic procedures should be single use wherever possible.
Some items are not available as single use products; these must be fully decontaminated in
the SSD between uses and traced to patients.
There are three areas within the Trust which have AER’s installed (endoscopy and theatre
suites at University Hospital and The Hospital of St Cross). Other departments which use
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flexible endoscopes must make arrangements with these departments for their own
endoscope decontamination. Although this service may be chargeable, it will be a cheaper
alternative to the running costs of additional local facilities.
Where flexible endoscopes require transfer from the clinical area to and from a
decontamination location, specialist separate polythene bags must be used for transporting
clean and dirty scopes which are available from numerous suppliers.
6.6.4 Purchasing of flexible endoscopes
It is imperative that prior to purchasing new flexible endoscopes the appropriate pre-
purchasing assessments are undertaken in line with the principles outlined in sections 6.1 and
6.2. This will ensure that:
As flexible endoscopes are re-processed locally rather than in the SSD, some elements of the
acquisition documentation (i.e. the DAF) are not applicable, however the form should still be
used and a copy sent to the Decontamination Lead for recording purposes.
When purchasing either new/replacement flexible endoscopes or new/replacement AER’s it is
essential that the correct adaptors are purchased to connect the AER connection tubing to the
specific endoscopes being cleaned. Suppliers will provide advice on this.
6.6.5 Accommodation
The requirements for decontamination accommodation within flexible endoscope re-
processing areas include that they should:
Be physically separated from all other work areas, including patient treatment areas.
Be accessible from a service corridor.
Be mechanically ventilated.
Have walls and other surfaces finished with flush junctions; be smooth, water resistant and
able to withstand frequent cleaning.
Have floors sealed with a washable non-slip finish.
Have adequate lighting available to permit good working practices.
Have hand washing and personal protective equipment facilities located in or near to the
decontamination area.
The area must have sufficient worktop and floor area space to facilitate safe activities and
movement within the area.
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A ‘one-way flow’ of scopes into, through and out of the decontamination area is extremely
important to avoid re-contamination of processed endoscopes. Achieving this is more
straightforward now that AER manufacturers are marketing ‘pass-through’ machines.
Specialist double manual cleaning sinks with aerosol extraction canopies above are
required, along with appropriate receptacles for cleaning brushes and cloths.
6.6.6 Health & Safety
Both chemicals and machinery employed by decontamination processes involve risk to
operators and these risks must be managed safely by designated Users.
Users must undertake standard and COSHH risk assessments (which must be fully
documented for audit purposes) relating to AER’s and detergents employed, and any
identified risk issues must be addressed by means of documented departmental operational
procedures which staff are made fully aware of and adherence monitored to ensure ongoing
compliance.
Staff must be aware of the location of COSHH risk assessments in the event of a detergent
spillage or detergent splashes to eyes etc.
Staff must not operate or undertake housekeeping on AER’s until they have received training,
which must be documented in a list such as that provided in the Process Log Book.
Standard Personal Protective Equipment is required during flexible endoscope
decontamination including the loading of AER’s including:
Chemical resistant rubber gloves (i.e. not surgical gloves) for handling of soiled devices.
Disposable polythene aprons.
Visor-masks or alternative as indicated by the Infection Control Policy.
6.6.7 Policies and Procedures
A detailed manual wash procedure must be devised by each department which
decontaminates flexible endoscopes. This must be in accordance with MDA DB 2002 (05) and
the endoscope manufacturer’s specific instructions; it will also take account of the manual
cleaning detergent supplier’s instructions for dilution and use. The importance of rigorous
manual cleaning cannot be understated as this is the most critical element of defence against
transmission of infection between patients. The key requirements for inclusion within the
cleaning procedure are as follows:
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a. Step by step cleaning technique which supports a consistently reproducible method
b. Identification of compatible (preferably enzymatic unless contra-indicated by the scope
manufacturer) detergent, method of achieving the correct concentration and water
temperature, length/ number of uses
c. Use of correct cleaning brushes identified by the scope manufacturer and post-use
decontamination or disposal of these
d. Disassembly of scope attachments and leak testing
e. Flushing of channels and final rinsing prior to AER processing
Basic operator instructions for each type of AER should be provided by the AER manufacturer
and must be included in the relevant section of each Process Log Book; the User must hold
the full Operational Manual supplied with the AER
A local spillage procedure is required to ensure that staff are equipped to deal with major
detergent or disinfectant leaks from AER’s, or the spillage of high level disinfectants from their
containers
A local traceability procedure is required which meets the criteria outlined in the following
section.
6.6.8 Traceability
Health Services Circular 2000/032 states that all NHS healthcare providers are to “have
robust systems in place to ensure that all instruments are traceable to the patients to whom
they have been used”
It is therefore mandatory that flexible endoscopes are fully traceable to both patients and
decontamination processes in the same way that surgical instruments are traceable. To
achieve this, a unique ID must be assigned to each flexible endoscope either by the
manufacturer or locally using a waterproof ID tag.
During each usage cycle the following must be recorded:
The pre-use decontamination cycle number in the AER either by entering/scanning the
scope ID into the AER tracking software or recording the AER cycle number in a record of
usage of the individual endoscope. Records must show which member of staff operated
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the AER and confirmed that the cycle had passed, along with the cycle parameters of the
AER process – these will normally be via a print out from the AER
The patient on whom the endoscope was used. This may be electronically recorded (the
optimal solution) such as on Opera or by entering the PID into AER tracking software, or
manually recorded if there is no IT-based alternative available. This element of traceability
must facilitate in the most optimal way:
o Identifying which scope was used on a specific patient.
o Which subsequent patients the scope was used on.
6.6.9 Staff Training
Users are responsible for complying with the principles of section 8. Specifically for
departments which use endoscopes this will include the following elements as applicable:
All ‘Users’ must have attended an accredited training course on flexible endoscope
decontamination.
Either the User or designated staff lead(s) must have been trained to undertake
housekeeping, daily tests and operate AER’s by the manufacturer. This training must be
documented in the form of a certificate provided by an approved training provider.
Staff trained above may cascade train their colleagues in the use of the AER, provided the
appropriate elements of their training are cascaded in full. Responsible AER suppliers will
provide a staff information booklet for this purpose.
All staff who are required to use or conduct daily tests/housekeeping on AER’s must have
received training either from the manufacturer or be ‘cascade trained’; this must be
documented on the Trust Decontamination competency database, which is to be regularly
reviewed and updated by Unit Managers or nominated Decontamination Leads.
The phrase ‘decontamination of flexible endoscopes and operation and housekeeping of
AER’s’ must be included in the job descriptions of staff.
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6.6.10 Validation, Testing and Maintenance
AER’s are included within the scope of HTM 01-06 and BS EN ISO 15883 and therefore
require a mandatory programme of maintenance and validation tests to ensure that they are
functioning satisfactorily. The key requirements are as follows:
6.6.11 Daily “Pre-Use” Testing
A series of basic operational tests, including a physical check of the machine and associated
loading equipment and accessories, door seals and detergent levels. These tests are to be
undertaken prior to the AERs being used and usually undertaken at the beginning of the
working day. These are undertaken by departmental staff and recorded on a daily check
sheet. Completed daily check sheets should be filed within the Process Log Book.
6.6.12 Weekly Tests
Weekly tests may be performed by either the ‘User’ or designated and appropriately trained
“operators” or by qualified test or maintenance personnel from equipment manufacturers or
external authorised and competent contractors known as “Competent Persons.”
Again, weekly test sheets/ test method statement should be obtained from the AER supplier or
designed by the AED on behalf of the User. Completed sheets should be filed within the
Process Log Books and retained for 20 years.
6.6.13 Rinse water tests
These are an essential requirement of EQR and the Standard Operating Procedure (SOP) for
Flexible Endoscopes within the organisation and must be undertaken by the User, Operator or
Competent Person CP(D) on a weekly basis. This sampling method can be found in section
13 of the Decontamination SOP for Flexible Endoscopes which provides a step-by-step
procedure for taking of final stage RO water, the labelling and sending of water samples and
the interpretation and actions to be taken and recorded on receipt of water testing results. In
all cases the method or taking these samples is to be carried out using an “aseptic technique.”
A Summary of the water Microbiology pass/fail limits are summarised below.
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Aerobic colony count
in 100 mL at 35oC for 72 hr
Green
Acceptable
– indicates that bacterial numbers are under a
Yellow
reasonable level of control
Unsatisfactory
- investigate potential problems and self-disinfect
Orange
or super-chlorinate
Unacceptable
- take AER out of service until water quality
Red
improved
Source: Willis C, Epidemiol. Infect. 134 (2):279-84, 2005
Colour grade
Over 100
Note:
Mycobacterium sp. not detected in 100 mL water satisfactory
1-9 on a regular basis
10-100
Microbiology
Interpretation/action
Less than 1
Satisfactory
Figure 6.
A pragmatic approach is required with any failures. A risk assessment should be undertaken
to establish whether the risk is greater to the patient by not having the procedure. Advice
should be sought by the user from the Director of Infection Control and the Decontamination
Lead.
6.6.14 Quarterly and Annual Tests
These are performed by the AER supplier during the first 12 months of a new installation and
thereafter can be undertaken by the supplier, the third party decontamination maintenance
provider or VINCI. These tests are expensive and purchasers of AER’s are advised to
consider year 2 costs of this at the time of purchasing the machine.
Whoever undertakes the validation tests, the designated ‘User’ is accountable for ensuring
that such tests have been undertaken and therefore the User is strongly advised to use a
checklist to monitor adherence to the validation programme.
It is imperative that Users view and sign off completed test documentation. The test person
will advise if there are any problems with the test procedure or results obtained and what
action – if any – is required. Completed documentation should be managed as outlined above
in ‘weekly tests’.
6.6.15 Storage
After all decontamination processes, the aseptic properties of endoscopes has to be
maintained and assured, up to the point of use or subsequent reprocessing. All reprocessed
scopes must be used within three hours or stored in specialist “Drying/Storage” cabinets or
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stored in a conventional state and declared as a non-usable state until such time as they are
reprocessed again prior to use. Where this is the case there are two storage options available.
Controlled Clean Air Cabinet Storage
(Scopes can be stored for up to 28 days and used immediately from that cabinet)
Maintained, tested and validated to the requirements of BS EN ISO 16442.
Conventional storage systems
(All Scopes must be fully decontaminated again prior to use)
All flexible endoscopes should be stored vertically in these, dedicated cupboards which are
themselves validated, maintained and Monitored to BS EN 16442:2015 “Controlled
Environment Storage Cabinet for Processed Thermoliable Endoscopes” The internal design
provided a bacterial free highly filtered positive air circulated environment.
In addition to controlled circulated HEPA filtered air the cabinets also allow the user to identify
the time each scope has been in each cabinet to ensure all are used and removed in a timely
manner. Users are required to ensure that all cabinets are made available to ensure that there
is no slippage in the schedule of maintenance and testing of these machines.
6.6.16 Use of flexible endoscopes on patients identified with a known or ‘at risk’ TSE
Status
Standards and requirements for all medical devices, including surgical instruments and
flexible endoscopes can be found in Health Services Circulars 1999/178 and 1999/179.
HTM 01-06 provides specialist and specific requirements in the receipt, handling, storage and
decontamination or disposal of these items.
Advice on this area continues to develop and it is not appropriate to provide a ‘cover all’
statement of policy, rather each case should be reviewed individually in conjunction
with the infection control team and neurologists. Key points in this area are as follows:
Traditionally, scopes have been quarantined after use on a patient with a known,
suspected or at risk diagnosis of variant CJD or other transmissible spongiform
encephalopathies. This effectively means that the scope will usually be discarded at a
later stage.
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A summary of this guidance recommends the following:
In cases of confirmed diagnoses the scope should be cleaned manually and
quarantined for possible future use on the same patient only, otherwise discarded.
Where the scope has been retained for a further use on that patient only, the scope
should be stored in a locked and controlled area to prevent that scope being
mistakenly used upon any other subsequent patient. The SSD Department has a
specialist “Vault” for the quarantining and secure storage of such items.
In suspected or ‘at risk’ cases it may be permissible to re-use the scope on other
patients provided the endoscopy procedure has not breeched or vaporised gut
mucosa and an unsheathed accessory has not been withdrawn through the working
channel of the endoscope.
A further proviso would be that the manual cleaning has been undertaken by a trained
staff member in accordance with the departmental documented procedure and the
scope is disinfected in a fully validated AER.
In every case the advice from the Infection Prevention & Control Team, The Endoscopy
Unit Manager, The Trust Decontamination Lead, and neurologists must always be
sought in each case.
6.6.17 Flexible Nasendoscopes
Pre-purchase assessment and prior to using of flexible nasendoscopes is particularly
important as the manufacturers cleaning and decontamination reprocessing instructions may
advocate the use of Glutaraldehyde disinfection which is not used at UHCW.
In all cases guidance from the Trust Decontamination Lead and Infection Control is to be
sought in the use and decontamination of these devices.
The desirable decontamination method is for nasendoscopes to be re-processed after each
use in a validated AER. No other method can provide a proven, reproducible and validated
means of effectively decontaminating these devices. In areas where nasendoscope usage is
high, consideration should be given to the acquisition of a commercially available specialist
nasendoscope washer-disinfector however; the initial procurement, installation,
commissioning, cycle and validation costs of these will need to be considered, along with the
suitability of the local environment.
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Most departments which use nasendoscopes report that they have insufficient scopes to allow
remote re-processing in central AER’s. Where this is the case business planning should be
undertaken to allow for this best practice solution to be adopted and implemented.
Nasendoscopes are manually cleaned and high level disinfected using Tristel 3 Wipe System
at UHCW and St. Cross.
6.7
MANAGEMENT & USE OF BEDPAN WASHER-DISINFECTORS
6.7.1 Introduction
Bedpan washer-disinfectors have been installed in numerous wards and departments within
the Trust for the purpose of decontaminating non-invasive medical equipment.
Bedpan washers do not fall within the primary scope of the Decontamination Policy (as they
are not used for invasive medical devices); however, national standards for the management,
use and maintenance of washer-disinfectors HTM 01-01 (EQR) are applicable. Additional
guidance is found in BS EN ISO 15883 (Part 3) Requirements & Tests for Washer Disinfectors
Employing Thermal Disinfection for Human Waste Containers. This policy section has
therefore been developed to support users of bedpan washers in ensuring that these are
managed appropriately and safely in line with current guidance.
6.7.2 Applications of bedpan washer-disinfectors
Bedpan washers are intended to be used primarily for the cleaning and thermal disinfection of
re-usable bedpans only. Within the Trust the only items which are to be cleaned and
disinfected in these washers are:
Re-usable bedpans
Urine collection equipment
Mop buckets
Under no circumstances may bedpan washers be used for invasive, re-usable medical
devices (surgical instruments) or any other invasive or non-invasive items. If in any doubt the
Infection control team or Decontamination Lead must be consulted.
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6.7.3 General Requirements where bedpan washers are used
Departments must ensure that staff are aware of the contents and location of the Trust
Decontamination Policy, which must be maintained up to date, accessible to staff, and
used to determine departmental policies and procedures as required.
Implementation of specific requirements for the management of bedpan washers,
along with ongoing staff training, are the responsibility of the designated ‘User’, which
by default will be the department manager. The definitions of the User’s role and the
role of staff operators of all washer-disinfectors are included within Section 5, which
should be referred to.
Users are ultimately accountable to the Chief Executive via the Infection Prevention
and Control Committee for implementation of the Decontamination Policy and national
decontamination requirements.
Either the ‘User’ or a responsible person designated by the User (such as a support
worker who uses the washer-disinfector regularly) must take primary responsibility for
cascade training and general overseeing of the management of the washer-disinfector
and should have received initial training by the manufacturer. Even where
responsibilities are delegated, the User remains accountable for washer-disinfector
management.
Department ‘Users’ must ensure that for each bedpan washer a ring binder file (with
wipe-clean cover) has been set up to collate all essential documentation. This file is
termed the ‘Process Log Book’ and a full template version is available from the
Decontamination Lead.
A process to facilitate the ordering of detergent has been set up and further
information is available from the supplies department. However, it should be noted that
only a high alkaline detergent pH12 from the manufacturer must be used.
6.7.4 Accommodation
The requirements for decontamination accommodation within local re-processing areas are
that they should:
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Be physically separated from all other work areas, including patient treatment
areas and also:
Be accessible from a service corridor
Be mechanically well ventilated
Have suitable wall coverings and finishes with flush joints, smoot, water resistant and
able to withstand frequent daily cleaning.
Have floors of a robust, washable non-slip finish
Have good lighting to permit good working practices, cleaning and maintenance.
Have both hand washing and disposable personal protective equipment facilities in
that area
6.7.5 Health & Safety Requirements
Both chemicals and machinery employed by decontamination processes involve risk to
operators and these risks must be managed appropriately by designated Users.
Users must have undertaken standard and COSHH risk assessments relating to
bedpan washer-disinfectors and detergents and any identified risk issues must be
addressed by means of departmental operational procedures
Staff must be aware of the location of COSHH risk assessments in the event of a
detergent spillage or detergent splashes to eyes etc.
Staff must not operate or undertake housekeeping on bedpan washers until they have
received training, which must be documented
Personal Protective Equipment is required to be worn during the loading and unloading
of bedpan washers including:
o Full length disposable aprons
o Full face visors to protect both eyes and airways.
o Heavy duty rubber disposable rubber gloves
6.7.6 Policies and Procedures
Manufacturer’s operating procedures along with daily test record sheets have been included
within the Process Log Book. Designated ‘Users’ are wholly accountable for ensuring that
manufacturer’s instructions along with local and national requirements for the management
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and safe use of bedpan washers (see 9.10) are implemented; this may require additional
procedures to be devised which are specific to departmental use and applications.
6.7.7 Staff Training
Users are responsible for complying with the principles of Decontamination Training (Section
11). This includes ensuring that all staff within their remit that have responsibility for the use of
bedpan washers:
Are listed and the list maintained up to date and available on request for auditing
purposes (a template is included within the Process Log Book).
Have documented, including dates and content, training relating to their responsibilities
(e.g. manufacturer’s training certificates for departmental leads).
Have ‘operation and housekeeping of bedpan washer-disinfectors’ included in their job
description.
6.7.8 Resources
Comprehensive lists of downloadable decontamination documents, including a template
Process Log Book, are available on the Intranet.
6.7.9 Workflows
Users must ensure that workflows are appropriately designed to ensure that soiled and
decontaminated items are segregated during re-processing. As a general principle, users
must ensure that a ‘one-way’ flow of equipment being decontaminated is in place – i.e. from
‘dirty’ to ‘clean’ – and that clean and dirty items cannot be mixed. Decontaminated items
should not be stored in the area where cleaning of used/contaminated items are cleaned.
6.7.10 Validation, Testing and Maintenance
Bedpan washer-disinfectors are included within the scope of requirements listed within HTM
01-01 and therefore require a mandatory programme of maintenance and validation tests to
ensure that they are functioning satisfactorily. Requirements are as follows:
Daily Housekeeping Tests
A series of basic operational tests are required to comply with HTM 01-01 and these
are to be undertaken by departmental staff each day and these must be recorded on
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the Daily Check sheet; a sample copy is provided in the Process Log Book (PLB) and
completed copies should also be filed in the PLB.
Weekly, Quarterly and Annual tests
These are performed by VINCI to a set of national standards and should be
undertaken automatically by the contracted PFI partners. However, the designated
‘User’ is accountable for ensuring that such tests have actually been undertaken and
therefore the User is strongly advised to use a checklist to monitor this validation
programme.
It is imperative that Users view and sign off test documentation provided prior to the device
being brought back into normal use. The Test Person will advise if there are any problems
with the test procedure or results obtained and what action – if any – is required.
6.8
MANAGEMENT OF INSTRUMENTS ON LOAN
6.8.1 Introduction
From time to time instrumentation is rented either for a short-term period (for example one or
two days for a specific patient/s) from instrument manufacturers, or other healthcare
providers. Sometimes Instruments are issued to the Trust by the supplier on a long-term free
consignment basis. Instrumentation in both these scenarios would be deemed ‘loan
equipment. The following standards and Health service documents (below) are applicable and
fully enforceable across the Trust in all cases.
6.8.2 Key Reference Documents
Managing Medical Devices, Guidelines for healthcare & Social Services Organisations
MHRA April 2015
MHRA SN 2002(17) – Management of loaned medical devices, equipment or
accessories from manufacturers or other hospitals.
MHRA SN 2000(18) – Handling of Surgical Instruments on Loan from another
Organisation.
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AfPP IDS’c Loan Set Management Principles 2010
UHCW Protocol ‘Decontamination prior to servicing or repair’
6.8.3 Risks Associated with Loan Equipment
Loan equipment elicits a number of issues which may present risks to the Trust if not
managed appropriately, such as:
Staff unfamiliarity with the loaned instrument sets. None or limited time for all staff to
become familiar with the contents of the instruments prior to decontamination or use.
Increase in the risk may be delivered with items missing and, if this is not noted, may
adversely affect surgery or result in patient cancellation.
Inappropriate/unclear reprocessing instructions
Certain sets may require specialist re-processing methods not normally employed
within the Trust, leading to the set not being available in time for surgery.
Sets delivered in plastic containers which may cause a lengthy delay in the
reprocessing of the devices due to a prolonged and temperature stable drying time
being required in excess of the time allowed to reprocess these items resulting in wet
loads
Components of sets may involve complex assembly/ disassembly procedures during
re-processing and SSD staff who have not been trained may omit these, resulting in
sub-optimal cleaning and sterilization or damage.
Traceability of loan sets presents difficulties as these are not listed on the Trust’s
instrument management system and due to the prolonged duration required to add
these individual components to the system.
6.8.4 Risks Associated with Consignment Equipment
Consignment equipment differs from loan equipment in that it is usually supplied free of
charge on the basis that associated implants are used to pre-agreed annual volumes.
Consignment equipment, as loan equipment, is usually high-cost and contains specialist and
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complex components, which in turn may have a greater potential to be damaged during use or
not effectively decontaminated. Risks which may apply to consignment equipment include:
6.8.5 Essential requirements in the Management of Loan Instrumentation
The MHRA Safety Notices referenced above provide details of basic criteria required for the
appropriate management of risks in relation to loan and consignment instrumentation as
follows (paraphrased):
Ensure that appropriate procedures are in place and followed to manage the use of
loaned instrumentation which include staff training and inventory checks of all
components.
The devices are from a UK or European Medical Company and all instruments must
be CE marked and have a Medical Devices Declaration of Conformity as to their
medical devices class status.
Ensure that adequate time is allowed to carry out effective decontamination prior to
and after use
That relevant EEC/European/UK re-processing instructions are provided and reviewed
by SSD ahead of any agreements or delivery of the items, along with a full and
accurate contents list; if inappropriate time/temperatures are quoted the instruments
should not be used loaned.
For consignment items, a list of the items and contents, along with a copy of the
consignment agreement, must be provided to the Decontamination Lead
Periodic checking/ maintenance arrangements and responsibilities of consignment
stock must be agreed and remain the responsibility of the supplier and in agreement
with Trust contracts and procurement teams.
During negotiations over consignment stock arrangements prior to delivery, clinical
services are strongly advised to request that sets are supplied by the consignor in
sterilisation containers wherever possible. This will eliminate the risk of wrapping
damage during transport.
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6.8.6 Procedure for Acquisition and Use of Loan Instrumentation
All loans of third party instrumentation must be recorded in loan registers held within
(a) the theatre suite and (b) the Sterile Services Department
All loan instrumentation must be delivered to the Trust’s theatres in ‘good time’ to allow
pre-use checks and re-processing to be undertaken. ‘Good time’ is defined as:
48 Hours prior to planned use. This is to allow for:
Theatres to check sets with the supplier’s representative.
Training of SSD and Theatre staff in decontamination and use of the loan items.
Checking of decontamination instructions prior to possessing.
Entry of the set into T-Doc to allow traceability.
The item to be recorded in SSD and theatre loan registers.
Container and weight assessment and validation requirements to be met.
Loan sets must be made available to SSD during weekday working hours to allow SSD
admin staff time to produce traceability labels and outline tray sheets as required.
Prior to delivery, the person arranging the loan must ensure that standard re-
processing parameters can be met i.e.
-
Able to be processed in an automated washer-disinfector at 90 degrees Celsius.
-
Steam sterilisable at up to 137 degrees Celsius or alternative Low Temp Gas
Plasma Sterilisation.
In all circumstances the supplier’s re-processing instructions must be provided to the SSD
management – who will advise on any perceived difficulties with the prescribed
decontamination method.
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6.8.7 Loan sets Arrival and Delivery Instructions
All loan sets are to be delivered directly to theatres and accompanied by a complete and
accurate list of contents; theatre staff is responsible for ensuring that the contents are correct
as per the contents list, prior to forwarding to the Sterile Service Department for
decontamination.
Within SSD there are strict requirements regarding the receipt of Loan instruments. These
include:
No loan trays are to be delivered to the SSD after 4.00pm.
Despite UHCW Sterile Services Department being an accredited department, all loan
items must be accompanied by a decontamination certificate when returned to the
supplier. The principles of Trust Policy ‘Decontamination Prior to Servicing or Repair’
must be adhered to and a sample form for instrumentation is included within that
policy.
Appendix 6 illustrates the required arrangements for loan instrumentation in a flowchart
format.
6.8.8 Requirements Associated with Consignment Instrumentation
To ensure that clear arrangements and responsibilities exist in relation to long-term
consignment instrumentation, the procuring (clinical) department must establish the following
elements with the supplier and these must be in the form of a written agreement:
A full schedule and the length of the consignment – which may be indefinite and
dependant on the continued use of associated implants
The number of procedures/ annual spend on implants required to retain the
instrumentation
Agreement on which party is responsible for paying for damage, missing items and
routine maintenance or replacing limited use or items which have been identified as
being unusable as a result of normal wear and tear.
The Decontamination Lead must receive a copy of the consignment agreement and
indemnity form prior to acceptance of the instruments for reprocessing.
6.8.9 Loaning UHCW Instrumentation to other Organisations
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The loaning of UHCW instrumentation to other organisations without careful consideration is
strongly discouraged, however, it is recognized that in some circumstances this is unavoidable
if a patient’s best interests are to be given priority; in other cases this may occur on a planned
basis with private sector partners for mutual benefit. Where this does occur, the following key
requirements apply:
The sending department must ensure that the tray will not be required at UHCW whilst
away on loan. The Theatre Manager or her representative is required to make this
declaration and ensure that it is communicated effectively throughout the organisation.
The tray must be returned in good time for re-processing for subsequent re-use within
the Trust
A loan agreement record sheet (Appendix 7) must be completed for each loan and a
copy retained in theatres; the agreement is intended to protect UHCW and confirm
liability arrangements in the event of problems arising i.e.
The borrower is responsible for arranging transport and transport costs (both to and
from the borrower) where and by when the item should be delivered to and returned to
and the period of the loan and charges to be applied.
Which party will accept repair or replacement costs in the event of damage or loss and
at which point (if applicable) in the delivery/use/return loop liability changes between
the parties.
Agreement over liability in the event that the loaned items are deemed not fit for use
for any reason by the borrower.
From commencement of instrument re-processing charges being applied to service users, the
theatre/speciality loaning an item to another organisation will be liable for charges unless the
SSD manager has been provided with details of any third party who are to be charged directly.
A form to pass on the details is included in this policy at Appendix 8. Such re-processing
charges must be agreed with the third party in advance.
7.0 DISSEMINATION & IMPLIMENTATION
Dissemination and implementation via Trust intranet following ratification and approval.
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8.0 DECONTAMINATION TRAINING
8.1 Introduction
Use of decontamination equipment presents a number of risks to both staff operators and
patients on whom decontaminated devices are to be used such as:
Burns or scalds sustained by operators from steam or hot water egress from sterilisers
or washer-disinfectors
Respiratory problems due to inhalation of chemical vapours
The risk of infection from failed or inadequately decontaminated products being
released for use
It is essential therefore that all Users ensure that operators within their areas of remit are
appropriately trained to operate, undertake housekeeping and complete documentation in
relation to sterilisers, washer-disinfectors and endoscope processors (AER’s) installed within
their department. In order to monitor this, the Trust’s Decontamination Lead maintains a
Decontamination Training Database which is available for inspection on request.
A series of training elements in relation to decontamination (where undertaken) must be
implemented in local departmental training policies:
8.2 Local Training Tools
A number of approved training tools have been developed for use within areas (where
relevant) which include:
8.3
Standard Operating Procedures (SOP) For Flexible Endoscopes
These have recently been produced to replace the previous Flexible Endoscope Training
Handbook and provide up to date current guidance for all department managers in areas
where an automated endoscope re-processor (‘AER’) is installed, for use by each individual
staff member who operates or undertakes daily tests or housekeeping on the AER. The SOP
contains essential information and outline procedures which are to be adopted locally.
Copies of associated signed off training records must be retained in the employee’s personal
file and any separate training files and the original returned to the staff member. In addition,
all Users must provide Trust’s Decontamination Lead with full details of all staff training in
decontamination processes for entry / update onto the Trust’s Decontamination Training
Database.
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8.4
The Sterile Service Department Training Handbook
This is a comprehensive training and assessment document which covers the foundational
aspects of decontamination within Sterile Services. All new and existing staff’ are required to
work through this tool, with assessment and sign-off by the Sterile Service Co-ordinators at
key stages.
8.5
Local Training Packs
It is recognised that general training plans for new and existing staff vary in scope and content
across the Trust. Some services have included decontamination training, where undertaken,
in their induction packs or other documents, however it is essential that the scope of the
approved documents above is, as a minimum, included in each departmental training plan
where decontamination is undertaken.
Any training documents which are used locally are deemed to be unapproved unless these
have been submitted via the Decontamination Lead to the Decontamination Committee for
approval and this has been granted. This measure is necessary to ensure that the required
levels of training, for both staff and patient safety, are fully covered and that training content is
accurate.
8.6
External Training
External training may be provided on-site or off-site to meet a number of requirements:
8.6.1 In SSD, all new and existing production staff and operational managers are required to
undertake the NHS Estates Online Decontamination Training Programme as determined by
existing SSD Training Policy outlined in the department’s Quality System. Staff working in
areas outside the SSD who have decontamination responsibilities are also required to
undertake this training (relevant modules – e.g. endoscopy) and should contact the SSD
manager for further information.
8.6.2 All new decontamination equipment installations must, during commissioning, include
comprehensive staff and managerial training provided by an appropriate representative of the
equipment supplier. Part of this training will lead to the production of local procedures for the
maintenance, validation, testing and product release of items re-processed prior to utilising the
equipment. The training must include provision of certification by the trainer and copies of this
evidence must be held within the employees’ personal files, any local training files and the
original version, along with any other training information documentation, issued to the staff
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members trained. Further in-house ‘cascade’ training is acceptable provided the schedule of
training is available for future reference; this should be obtained from the manufacturer.
8.6.3 All departments where medical device decontamination is undertaken must ensure
that either the departmental manager, or the designated ‘User’ if different, attend a relevant,
approved User’s Course. In general, this would be the washer-disinfector/ sterilizer course/
endoscope course for managers run by organizations such as Eastwood Park Training Centre
or similar City & Guilds course such as those provided by endoscope processor
manufacturers. In sterile services, all managers and co-ordinators must have attended a
Decontamination Course for Managers.
8.6.4 Other ad-hoc training events may be accessible and services are recommended to
ensure that, where these are appropriate to decontamination processes employed, such
opportunities are undertaken and that subsequent ‘cascade training’ is undertaken by the
attendee/s and documented.
8.7
Training Updates
An annual assessment will be made of decontamination training requirement through
Specialty Leads and individuals’ training records updated accordingly by their departmental
managers. Training requirement and implementation is monitored through the Trust’s
Decontamination Committee.
8.8
Training Opportunities within the Sterile Service Department
In addition to the training mechanisms outlined in this policy, the Sterile Service Department
will accommodate training requests or short-term placements for staff of all designations
where this may be of benefit to their training or development plans. Further, ODP and nursing
students are able to access placements in the SSD on written request from their training
manager to the SSD manager.
8.9
Central Training Register
All Users and departments where decontamination of invasive devices takes place are
required to document and maintain details of staff training and competency on the Trust’s
Decontamination Training Database. Users are required to review and where applicable
update this document at least quarterly.
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9.0
MONITORING COMPLIANCE
9.1 Monitoring Table
Aspect of
compliance or
effectiveness
being
monitored
Monitoring
method
Individual/
department
responsible for
the monitoring
Frequency
of the
monitoring
activity
Group /
committee which
will receive the
findings /
monitoring
report
Group /
committee /
individual
responsible for
ensuring that the
actions are
completed
Adherence to
Legislation &
Standards
Review of
Standards &
Guidance
changes which
affect policy and
practice
Trust
Decontamination
Lead
Annually
Decontamination
Committee
Decontamination
Committee
Staff Training
Review of
Training
Competencies
and maintaining
the
decontamination
central training
dashboard
Individual unit
managers
involved with
decontamination
and nominated
“Users”
Quarterly
Decontamination
Committee
Decontamination
Committee
Environmental
monitoring
and
Document
control
(including
validation and
vesting
regimes
By visits to
decontamination
areas x 2 yearly,
review of
maintenance,
testing and
validation
paperwork
Trust
Decontamination
Lead
AP(D)
And Infection
Prevention and
Control staff
2 x annual
visits to
each area
Ad Hoc as
required.
Decontamination
Committee and
infection
Prevention
Committee
Reporting
Reports
reviewed and
reported at
Decontamination
Committee
10.0
STAFF COMPLIANCE STATEMENT
All staff must comply with this Trust-wide Corporate Business Record and failure to do so may
be considered a disciplinary matter leading to action being taken under the Trusts Disciplinary
Procedure. Actions which constitute breach of confidence, fraud, misuse of NHS resources or
illegal activity will be treated as serious misconduct and may result in dismissal from
employment and may in addition lead to other legal action against the individual/s concerned.
A copy of the Trust’s Disciplinary Procedure is available from eLibrary.
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11.0
EQUALITY & DIVERSITY STATEMENT
Throughout its activities, the Trust will seek to treat all people equally and fairly. This includes
those seeking and using the services, employees and potential employees. No-one will
receive less favourable treatment on the grounds of sex/gender (including Trans People),
disability, marital status, race/colour/ethnicity/nationality, sexual orientation, age, social status,
their trade union activities, religion/beliefs or caring responsibilities nor will they be
disadvantaged by conditions or requirements which cannot be shown to be justifiable. All
staff, whether part time, full-time, temporary, job share or volunteer; service users and
partners will be treated fairly and with dignity and respect.
12.0
REFERENCES & BIBLIOGRAPHY
Legislative & Standardisation Documents
Reference & Year
Title & Publisher
MDD 93/42 EEC
The Medical Devices Regulation
European Commission
BS EN ISO 13485 (2016)
Medical Devices
Quality Management Systems for Regulatory Purposes
British Standards
Health Building Note 13 (1992)
Sterile Services Departments
NHS Estates
Health Technical Memorandum
01-01 (2016)
Management and Decontamination of Surgical
Instruments (Medical Devices) in Acute Care.
Department of Health
SI no 618 (2002)
Consumer Protection: The Medical Devices Regulations
Health Service Circular 2000/032
(2000)
Decontamination of Medical Devices
NHS Estates
National Decontamination Strategy
BS EN ISO 15883 - 2 (2009)
Washer Disinfectors. Requirements & Tests for Washer-
Disinfectors Employing Thermal Disinfection for Surgical
Instruments.
MHRA DB 2006(04)
Single Use Medical Devices: Implications and
Consequences of Reuse
MDA/MHRA
Guidance of Decontamination, The Microbiology
Advisory Committee to the Department of Health
MHRA (2015)
Managing Medical Devices, Guidance for Health and
Social Service Organisations
MDA SN2000(18)
Handling of Surgical instruments on Loan from Another
Organisation
MDA SN 2002(17)
Management of Loan Medical Devices
AfPP & IDSc (2010)
Loan Set Management Principles
MHRA 2003 (05)
Management of Medical Devices Prior to repair, service
or investigation
MDA 2006(55)
Handpieces used with Oral/Maxillio-facial surgery drills
MDA SN 2000(28)
Compatibility of medical Devices/Reprocessing
equipment And Decontamination Agents
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MDA DB 1998(01)
Guidance on The Sale, Transfer and Disposal of Used
Medical Devices
MHRA SN 2004(28)
Risk of Transmission of Infection Because of Inadequate
Decontamination
CJD Management Guidance & Requirements
Reference & Year
Title & Publisher
Health Service Circular 1999/178
(1999)
Variant Crutzfeldt-Jacob Disease (vCJD) Minimising the
risk of Transmission. Department of Health
Health Service Circular 1999/179
(1999)
Controls Assurance in Infection Control: Decontamination
of Medical Devices. Department of Health
National Institute for Clinical
Excellence (NICE) (2006)
Patient Safety, Reduction of Risks of Transmission of
Crutzfeldt-Jacobs Disease (CJD) via Interventional
Procedures
Endoscopy Guidance & Requirements
Reference & Year
Title & Publisher
Health Technical Memorandum
01-06 (2016)
Decontamination of Flexible Endoscopes
Department of Health
BS EN ISO 15883 – 4
(2009)
Washer Disinfectors. Requirements & Tests for Washer
Disinfectors Employing Chemical Disinfection for
Thermoliable Endoscopes
BS EN 16442
(2015)
Controlled Environment Storage Cabinet for Processed
Thermoliable Endoscopes. Department of Health
BSG Decontamination Guidelines
(2006)
Decontamination of Equipment for GI Endoscopy
National Health Services
(2008)
Decontamination of Flexible Endoscopes. National
Endoscopy Programme
External Sources
Organisation
Website
Medicines & Healthcare
Regulatory Agency (MHRA)
https://www.gov.uk/government/organisations/medicines-
and-healthcare-products-regulatory-agency
Institute of Decontamination
Sciences (IDSC)
http://www.idsc-uk.co.uk/
Central Sterilising Club
http://centralsterilisingclub.org/
Health Technical Memorandum
01-01 Decontamination of
Surgical Instruments
https://www.gov.uk/government/publications/management-
and-decontamination-of-surgical-instruments-used-in-
acute-care
Association for Perioperative
Practice (AfPP)
https://www.afpp.org.uk/home
British Society of
Gastroenterology (BSG)
www.bsg.org.uk
Department of Health Website
https://www.gov.uk/government/organisations/department-
of-health
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13.0 UHCW ASSOCIATED RECORDS
14.0 APPENDICES
Appendix 1 - Approved Decontamination Areas within UHCW NHS Trust
Appendix 2 - UHCW Decontamination Nominated Officers
Appendix 3 - Decontamination Equipment Inventory
Appendix 4 - Surgical Instrument Procurement Flowchart
Appendix 5 – Decontamination Assessment Form
Appendix 6 – Loan Instrumentation Management Flowchart
Appendix 7- Loan Agreement Form for 3rd party borrowers
Appendix 8 - Loans to third party organisations: Re-processing charge allocation form.
Appendix 9 – Decontamination Reporting Structure
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APPENDIX 1
Approved Trust Decontamination Areas
Site
Department
Approved Scope
Key Requirements
User
University
Hospital
Sterile Service
Department
Medical and surgical
instrument re-
processing
MDD 93/42/EEC
ISO 13485:2012
SSD Manager
University
Hospital
&
Rugby
St Cross
Endoscopy
Departments
Flexible Endoscope
processing
HTM 01-06
Decontamination of
Flexible Endoscopes
Flexible endoscope
training handbook tool
used for all staff
Process Log Books
Endoscopy
Unit Manager
University
Hospital
Main Theatres
Flexible Endoscope
processing
As Endoscopy
Theatre
Manager
Note:
Bedpan washer-disinfector ‘Users’ are maintained in a separate list held by the Trust
Decontamination Lead and Infection Control Department
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APPENDIX 2
UHCW Decontamination Nominated Officers
Decontamination Lead
Simon Lambert
Sterile Services Department
University Hospital
Clifford Bridge Road
Coventry
CV2 2DX
Tel: 07786 277766
Email. Simon.lambert@uhcw.nhs.uk
Microbiologist:
via Kate Prevc, Infection Prevention Modern Matron
Infection prevention & Control Department
University Hospital
Ext 25408
Authorised Engineer (Decontamination)
James Tinsdeall
Healthcare Estates Consultant Services
15 The Parade
Truro
Cornwal
TR1 1QE
07464123247 M 07464 123247
E jthecs@gmail.com
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policies and procedures)
APPENDIX 3
UHCW NHS Trust - Decontamination Equipment Inventory
Location
Department
Equipment
Manufacturer
Model Number
Serial Number
Local User
Reference
Responsible Officer
(User)
University Hospital
Sterile Services
Washer Disinfector
Getinge 88 Series
W50019510
Washer 1
Sterile Services Manger
University Hospital
Sterile Services
Washer Disinfector
Getinge 88 Series
W50019508
Washer 2
Sterile Services Manager
University Hospital
Sterile Services
Washer Disinfector
Getinge 88 Series
W50037157
Washer 3
Sterile Services Manger
University Hospital
Sterile Services
Washer Disinfector
Getinge 88 Series
W50041511
Washer 4
Sterile Services Manager
University Hospital
Sterile Services
Washer Disinfector
Getinge 88 Series
W50041497
Washer 5
Sterile Services Manager
University Hospital
Sterile Services
Washer Disinfector
Medisafe Niagara
03154282601
Washer 6
Sterile Services Manager
University Hospital
Sterile Services
Steam Sterilizer
Getinge
2112057-010-02
Autoclave 1
Sterile Services Manager
University Hospital
Sterile Services
Steam Sterilizer
Getinge
2112057-010-01
Autoclave 2
Sterile Services Manager
University Hospital
Sterile Services
Steam Sterilizer
Getinge
2112980-010-01
Autoclave 3
Sterile Services Manager
University Hospital
Sterile Services
Steam Sterilizer
Getinge
2112980-020-01
Autoclave 4
Sterile Services Manager
University Hospital
Sterile Services
Steam Sterilizer
Getinge
0011213444-010-01
Autoclave 5
Sterile Services Manager
University Hospital
Sterile Services
Gas Plasma
Sterrad 100NX
001070027
Sterrad
Sterile Services Manager
Location
Department
Equipment
Manufacturer
Model Number
Serial Number
Local User
Reference
Responsible Officer
(User)
University Hospital
Endoscopy
AER
Lancer FC4
5M011245
AER 1
Endoscopy Unit Manager
University Hospital
Endoscopy
AER
Lancer FC4
5M011246
AER 2
Endoscopy Unit Manager
University Hospital
Endoscopy
AER
Lancer FC2
6M051423
AER 3
Endoscopy Unit Manager
University Hospital
Endoscopy
AER
Lancer FC4
1M012236
AER 4
Endoscopy Unit Manager
University Hospital
Endoscopy
AER
Lancer FC4
1M012237
AER 5
Endoscopy Unit Manager
University Hospital
Endoscopy
Drying Cabinet
Lancer FD8E
7M021528
CAB 1
Endoscopy Unit Manager
University Hospital
Endoscopy
Drying Cabinet
Lancer FD8E
7M021562
CAB 2
Endoscopy Unit Manager
University Hospital
Endoscopy
Drying Cabinet
Lancer FD8E
1M012233
CAB 3
Endoscopy Unit Manager
University Hospital
Endoscopy
Drying Cabinet
Lancer FD8E
1M082287
CAB 4
Endoscopy Unit Manager
St Cross Hospital
Endoscopy
AER
Lancer FD4
8M041723
Lancer 1
Endoscopy Unit Manager
St Cross Hospital
Endoscopy
AER
Lancer FD4
8M041722
Lancer 2
Endoscopy Unit Manager
St Cross Hospital
Endoscopy
Drying Cabinet
Lancer FD8E
3M062435
CAB
Endoscopy Unit Manager
University Hospital
Main Theatres
AER
Lancer FC4
6M051424
AER1
Theatre Manager
University Hospital
Main Theatres
AER
Lancer FC4
1M012241
AER3
Theatre Manager
University Hospital
Main Theatres
Drying Cabinet
Lancer
1M012224
Decon Room
Theatre Manager
University Hospital
Main Theatres
Drying Cabinet
Lancer
OM11219
Decon Room
Theatre Manager
University Hospital
Main Theatres
Drying Cabinet
Cantel Medical
GSESC-721
Th16
Theatre Manager
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APPENDIX 4
Surgical Instrument Procurement Flowchart
Departmental Decision to
Purchase
Is the item additional to
current instruments.
Y/N
Complete Decontamination
Assessment form (DAF)
Forward to SSD Manager
for assessment and
confirmation of support
Are the decontamination
requirements consistent
with items already in use
Y/N
Proceed to Purchase
DRG to identify safe
management processes or
other purchasing options
Y/N
Decon Risk group approve
purchase
Does it have lumins
Does it require Disassembly/
Reassembly
Does it possess CE mark
Obtain Suppliers re processing
instructions
Confirm with supplier that is washer
disinfector/autoclave method safe
User Assess requirements
New/Replacement
Assess Risk of item being
easily managed within
current processes
Recommend user
reassess requirements
identify other instruments
Report risks to Decontamination
Group
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APPENDIX 5
Decontamination Assessment Form
Supplier:
Description of device/set:
Part 1: Ease of Cleaning
1.1 Does the device/set consist of: (tick all that apply)
a) Smooth, non-jointed surfaces with no lumens
Simple-jointed instrument with jaws/ratchet
Multi-part device which can easily be dismantled into components
b) Multi-part/jointed instrument which cannot be fully dismantled
c) Complex items which cannot be fully dismantled
1.2 Can the device/set be cleaned in an automated washer-disinfector with disinfection at 90
degrees C?
YES / NO
(If ‘No’, then please attach details of the Manufacturer’s cleaning procedure)
1.3 For items in category 1.1 (a-c), is an autoclavable, dedicated equipment tray/ case to be
supplied?
YES / NO
(If ‘yes’, a container assessment will be required)
Part 2: Reassembly & Maintenance
2.1 Please identify any specific maintenance/testing/calibration/technical inspection which is
required as part of the re-processing procedure on a regular basis:
D/A No:
0X/
SAMPLE FORM
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Part 3: Sterilization
3.1 Which of the following methods of sterilization may be applied: (tick all that apply)
a) Steam Sterilization at 134-137 degrees C
b) Chemical Disinfection: Peracetic Acid
c) Low Temperature Sterilisation: (Sterrad/Gas Plasma)
d) Other methods Specified by the manufacturer (please detail below)
Part 4: Other Considerations
4.1 Are any disposable/ limited use components required to be added to the item / set?
YES / NO
If yes, state below arrangements for purchasing and inclusion in the set:
Part 5: Summary
PURCHASE APPROVED: YES / NO
REFERRED TO DECONTAMINATION BOARD: YES / NO
ENTERED ON DAF REGISTER (date):
CONTAINER ASSESSMENT:
NOT APPLICABLE/ PASS / FAIL
LIFE CYCLE/ MAINTENANCE RESPONSIBILITY:
CONSUMABLE FUNDING RESPONSIBILITY:
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APPENDIX 6
Loan Instrumentation Management Flowchart
Delivery to theatres
Transfer to SSD
New/ irregular loan
Regular loan
YES
NO
Send to theatres
At time of placing loan order:
Theatres check decontamination instructions and container
details and ensure set will be delivered ‘in good time’
Theatres check contents are correct as per supplier’s list and
ensure that any specific instructions are conveyed to SSD
SSD complete Quality System Loan Form and re-check re-
processing instructions and container
SSD:
Create loan ‘T-Doc’ tag
Use photocopied contents
list as ‘traylist’
Attach loan ‘t-doc’ label to
contents list and outside of
set/s
SSD complete Quality System Loan Form.
Is loan tray list built into T-Doc?
Add to T-Doc using
existing list but ensure
contents have not
changed
Build full tray list on T-
Doc
Pack tray as normal, attaching T-Doc labels
to outside of tray and traylist
Theatres: after use return outside tray label to SSD with
instructions for return to supplier
SSD: wash, re-assemble and sterilise tray/s and
complete decontamination certificate ready for return
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APPENDIX 7
Loan Agreement Form for 3rd party borrowers
UNIVERSITY HOSPITALS COVENTRY & WARWICKSHIRE NHS TRUST
Surgical Instrument Loan Agreement Form
For each instance of UHCW instrumentation being loaned to another healthcare organisation
this form must be completed as follows:
1. Following a request to loan, a responsible member of theatre staff at UHCW shall
complete the form to establish the loan arrangement details. Completion will include
confirming the relevant details with a representative of the organisation requesting the
loan.
2. Once completed, a copy of the form should be sent (e-mail, fax or post) to the recipient
organisation’s representative who must sign the form and return a signed copy to
UHCW in advance of the loan taking place.
1. Person responsible for co-ordinating the loan (UHCW):
2. Organisation requesting the loan (e.g. hospital name and location):
3. Person responsible for the loan at the recipient organisation:
4. Contact telephone number for the above:
5. Recipient organisation/s email/fax number to receive a copy of this completed
agreement:
6. UHCW fax number for return copy of agreement signed by recipient:
7. Item/s to be loaned out:
Tray/ Item Description
UHCW Tray ID *
It may not be possible to complete this field until the time of dispatch
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8. Date/s (and time/s if applicable) items require to be delivered to recipient
organisation:
9. Who is responsible for making delivery transport arrangements (name and
organisation):
10. Agreed date (and time if applicable) that items will be returned to UHCW by:
11. Who is responsible for making return transport arrangements (name and
organisation):
12. Agreed location for return of item/s:
13. Loan charge applicable (in addition to decontamination costs):
Form completed by (UHCW):
Date:
Signature:
I agree to UHCW NHS Trust’s loan terms and conditions as follows:
UHCW cannot accept any liability in the event that the requested loan item/s cannot be
made available on the date/time agreed due to an emergency or unplanned demand at
UHCW, however the designated member of staff identified above shall make all
reasonable efforts to ensure that the agreement is adhered to. Where an unforeseen
event occurs which precludes UHCW from maintaining this agreement the UHCW
representative shall advise the recipient organisation’s contact above at the earliest
possible opportunity
The recipient organisation agrees to pay such re-processing charges – which are
available on request – to the Coventry Sterile Service Centre or nominee for the re-
processing of loaned items. Where required re-processing times relating to either
dispatch or re-use at UHCW following the loan are less than standard SSD turnaround
--- PDF page 88 ---
Page 88 of 91
Version number: 11.0
Trust-wide CBR title: Decontamination Policy
This Trust-wide CBR has been developed /reviewed in accordance with the Trust approved ‘Development & Management of
Trust-wide Corporate Business Records Procedure (Clinical and Non-clinical strategies, policies and procedures)
times the Sterile Service Centre shall apply ‘fast-track’ charges of £70- per item as
applicable
In the event that loaned items are lost or stolen during the time between dispatch from
UHCW and documented return to UHCW the recipient organisation agrees to
reimburse UHCW for the full replacement cost of the items if these cannot be
recovered within a reasonable time. ‘Reasonable time’ depends of the urgency of the
item’s loss to UHCW and may be negotiated between the parties however in the event
that the loss has a major impact on UHCW’s clinical activity the replacement costs will
be deemed payable if the missing item is not located within 48 hours of the agreed
return date and time. In the event that the loaned items are consignment stock, the
recipient organisation will be required to reimburse the equipment consignor for the
replacement costs of the missing items
UHCW’s Sterile Service Centre is MDR 2017/745 registered and therefore items
provided on loan may be deemed sterile and suitable for immediate use on arrival
subject to inspection demonstrating that packaging is intact and dry, and that
sterilisation indicators demonstrate that the item has been subject to a sterilisation
process. The recipient organisation will not be liable for double re-processing costs in
the event that items delivered on loan are unfit for use due to wrapping damage, tray
wrap wetness or failed sterilisation processes provided this is reported to the Sterile
Service Centre immediately on arrival. Whilst UHCW cannot accept and liability for
financial or other losses arising from such deficiencies, UHCW shall arrange return
transport at its own cost and re-process as quickly as possible for return to the
recipient organisation as required
The recipient organisation must satisfy themselves that item/s supplied are fit for
clinical purpose
The recipient organisation is responsible for ensuring that mandatory traceability to the
patient on whom loaned instrument sets are used is recorded appropriately and in the
event that the patient is at any time in the future subject to a known or possible
diagnosis of CJD (or any other Transmissible Spongiform Encephalopathy) agree to
make such information available to UHCW immediately
The recipient organisation agrees to reimburse UHCW for any damaged or missing
items noted on return to UHCW unless these were deemed damaged or missing at the
--- PDF page 89 ---
Page 89 of 91
Version number: 11.0
Trust-wide CBR title: Decontamination Policy
This Trust-wide CBR has been developed /reviewed in accordance with the Trust approved ‘Development & Management of
Trust-wide Corporate Business Records Procedure (Clinical and Non-clinical strategies, policies and procedures)
time of use; in such event, the recipient organisation must advise UHCW’s responsible
person of the missing item/ damage at soon as reasonably practicable but prior to the
items being returned
The recipient organisation will be liable for the replacement costs of any consumable
items included within, or as accessories to, the item being loaned where used or where
a consumable item included within a set is not used but where repeat sterilisation is
contra-indicated by the device manufacturer
Used items must be decontaminated in line with the device/set manufacturer’s
instructions prior to return to UHCW after use and accompanied by a decontamination
certificate and a signed tray checklist
The recipient organisation agrees to return the items by the date and time agreed and
to immediately advise the UHCW responsible person of any anticipated delay; in such
event and where clinical workload at UHCW would be disrupted by such a delay the
loaning organisation agrees to return the item unused to UHCW if requested to do so
The loan may be subject to specific loan charges, identified by the item owner at the
time of the loan request, to contribute to the life-cycle replacement of the equipment
and administrative costs of the loan. Such charges will be agreed in advance of the
loan and may be included within the re-processing invoice – if so such charges will be
specifically identified
Both re-processing costs and any loan charge applied will be subject to vat at the
prevailing rate
Named representative of third party organisation:
Signature:
Date:
--- PDF page 90 ---
Page 90 of 91
Version number: 11.0
Trust-wide CBR title: Decontamination Policy
This Trust-wide CBR has been developed /reviewed in accordance with the Trust approved ‘Development & Management of
Trust-wide Corporate Business Records Procedure (Clinical and Non-clinical strategies, policies and procedures)
APPENDIX 8
Loans to third party organisations: Re-processing charge allocation form
--- PDF page 91 ---
Page 91 of 91
Version number: 11.0
Trust-wide CBR title: Decontamination Policy
This Trust-wide CBR has been developed /reviewed in accordance with the Trust approved ‘Development & Management of
Trust-wide Corporate Business Records Procedure (Clinical and Non-clinical strategies, policies and procedures)
APPENDIX 9
UHCW Decontamination reporting structure
Decontamination Lead AP(D)
Infection Prevention Lead
Estates Manager (Co-Opted)
Consultant Microbiologist Lead IPC
Authorised Engineer AE(D)
Head
of
Medical
Equipment
Management
Members of Oversight Groups below
Decontamination Oversight Groups
1. Endoscopy
User Group
2. Ward Department
Decontamination User
Group
3. Sterile Services
User Group
4. Medical
Equipment
Committee
Governance and Assurance Remit
1. Endoscopy User Group
Endoscopy Machine Validation
Machine Water Quality Compliance, Risk
Assessing, Future Planning.
Endoscopy User & Manager
Trust Decontamination lead
Decontamination Production &
Development Manager
Decontamination Quality Manager
IPC Lead / Link
2. Ward Department Decontamination
User Group
Yearly comprehensive audit with
Decontamination Lead / IPC Lead Nurse
Confirm and Challenge meeting with each of
the following departments:
Ultrasound Department
ENT Outpatients
Ophthalmology Department
Max Fax Implant Department
MEL Manager
IPC Lead / Link
3. Sterile Services User Group
Decontamination Equipment Updates, User
& Liaison Reports, Quality and Production
Reporting, Risk Assessing, Future Planning
Decontamination Quality Manager
Decontamination Production &
Development Manager
Trust Decontamination Lead
Theatre Manager
Instrument Link Workers
IPC Lead / Link
4. Medical Equipment
Committee
Attendance by the
Decontamination Lead/
representative to ensure
equipment for UHCW meets
the required
decontamination standards
for purpose.
Trust Decontamination Committee
--------------------------------------------------------------------------------
ATTACHMENT: 2.pdf
TEXT_FILE: 2.pdf.txt
METHOD: pdf_native
OCR_USED: False
PAGES: 34
--------------------------------------------------------------------------------
--- PDF page 1 ---
1
Isolation Guideline
Related National
Guidance
Public Health England (2016) Infection control precautions to
minimize transmission of acute respiratory tract infections in
healthcare settings.
E-library number
CG334
Version number
V11
Purpose
The purpose of this guideline is to describe the practices and
procedures to be followed to prevent and control the
potential of cross infection with the use of appropriate and
safe use of isolation facilities the use of Transmission Based
Precautions and Stand Infection Prevention and Control
Precautions.
Primary Specialty
Infection Prevention Control and Sepsis
Related Specialties
n/a
Specialty Clinical
Guideline Lead
Fiona Wells Lead Nurse Infection Prevention and Control and Sepsis
Authors
Lead Author:
Fiona Wells
Lead Nurse Infection Prevention and Control
and Sepsis
Fiona.Wells@uhcw.nhs.uk
Reviewer(s):
Emma Evans
Infection Prevention Control and Sepsis Nurse
Emma.Evans@uhcw.nhs.uk
Approving Forums
Infection Prevention Control Committee
Approval Dates
QIPS
January 2023
MMC
Not required
Other (specify)
Review Date
January 2026
Keywords
Infection, isolation, guideline, side rooms
Please note: The following systems have been replaced by the trust Electronic Patient Record
system (EPR). If any of these systems are identified within the document, please substitute them
for the appropriate EPR alternative system and refer to relevant corresponding EPR procedures.
1. Opera (theatres)
2. Centricity (Critical Care)
3. Wardview
4. Extramed
5. CRRS
6. VitalPack
7. Adastra (CUTC)
8. K2 (maternity portal replaced by PPUK)
9. i.PM
--- PDF page 2 ---
2
10. Athena (Maternity)
11. SCIT App (replaced by camera capture)
Please contact EPREnquiries@uhcw.nhs.uk if you have any questions about the systems
listed or the EPR system introduced in their place.
On review of this document please ensure the systems listed are removed from the text
and replaced with the relevant EPR system and process.
Clinical guideline content: Clinical Guidelines assist in decision-making; they do not replace clinical
judgement. Regardless of the strength of evidence, it remains the responsibility of the clinician to
interpret the application of the clinical guidance to local circumstances and the needs and wishes
of the individual patient. Where variations of any kind do occur, it is important to document the
variations and the reason for them in the patient’s health record. If in doubt, seek senior advice.
Equality and Diversity Statement: Throughout its activities, the Trust will seek to treat all people
equally and fairly. This includes those seeking and using the services, employees and potential
employees. No-one will receive less favourable treatment on the grounds of sex/gender (including
Trans People), disability,
marital status, race/colour/ethnicity/nationally, sexual orientation, age,
social status, their trade union activities, religion/beliefs or caring responsibilities nor will they be
disadvantaged by conditions or requirements which cannot be shown to be justifiable. All staff,
whether part time, full-time, temporary, job share or volunteer; service users and partners will be
treated fairly and with dignity and respect.
Rationale
Sources of Evidence
NICE Evidence
TRIP Database
Google Advanced Search
Cochrane Library
PubMed
Dissemination and related guidance
This will be on e-library to for all staff to access.
Training
• Donning and Doffing Training – with IPC and Cascade Trainers
• Ready to Care Session – with IPC
• FIT testing – DoH department and IPC to train Cascade Trainers
Patient Information
Infection Control – Isolation and Barrier Nursing Patient Information Leaflet
https://uhwebapps.uhcw.nhs.uk/eLibrary/filecon/download.aspx?Doc=122217&Doc
Return=/elibrary/&VERI=m36cbfvm
--- PDF page 3 ---
3
Audit & Monitoring
Audit title
Audit Lead
Monitoring
method and
frequency
Committee
responsible
PPE audit
Infection Prevention
Control safety huddle
team
Quarterly
IPC Committee
Changes from previous version
Date
Updated information
14/11/2022
Page 5: made a table to simplify reading for source isolation,
protective isolation.
14/11/2022
Page 7 to 8: made a table to describe pressure rooms
14/11/2022
Page 8 to 11: made a table to describe modes of transmission
for easier reading.
14/11/2022
Page 13: Added a link for the use of Cadaver bags and the
criteria for infection. Criteria 1 to 4 is described.
14/11/2022
Page 13 to 14: described where to locate quick action guides
in this document and other documents for Infection Prevention
Control.
14/11/2022
Appendix 1: Updated to include Mpox
14/11/2022
Appendix 2: Updated the latest Infection Prevention and
Control Risk Assessment Tool
14/11/2022
Appendix 3: Updated the latest sign
14/11/2022
Appendix 4: Updated the latest sign
14/11/2022
Appendix 5: updated the latest sign
14/11/2022
Appendix 7 Updated the latest PPE poster
14/11/2022
Appendix 8: Introduced the Measles quick action guide
14/11/2022
Appendix 9: Introduced Measles Quick Action Guide
03/01/2023
Appendix 10: Introduced Isolation of patients with multidrug
resistant (MDR) Gram negative organisms at UHCW NHS
Trust V4
Contents
Definitions ............................................................................................................................................... 4
Introduction ............................................................................................................................................ 4
Scope ....................................................................................................................................................... 4
Roles and Responsibilities ....................................................................................................................... 4
Clinical guidance ..................................................................................................................................... 5
--- PDF page 4 ---
4
Appendices .................................................................................................... 13
References ............................................................................................................................................ 30
Definitions/ Abbreviations
PPE – Personal Protective Equipment
HEPA – High Efficiency Particulate Air
MDRTB – Multi-Drug Resistance Mycobacterium Tuberculosis
TB – Mycobacterium Tuberculosis
SARS – Severe Acute Respiratory Syndrome
VHF – Viral Hemorrhagic Fever
HCW – Healthcare Worker
Introduction
These guidelines are necessary as Standard Infection Control Precautions (SICPs)
may be insufficient to prevent cross transmission of specific infectious agents.
Therefore, additional precautions Transmission Based Precautions (TBPs) are
required to be used by staff when caring for patients with a known or suspected
infection or colonisation.
Clinical judgement and decisions should be made by staff on the necessary
precautions. This must be based on the:
• suspected or known infectious agent
• severity of the illness caused
• transmission route of the infectious agent
• care setting and procedures undertaken
TBPs are categorised by the route of transmission of infectious agents (some
infectious agents can be transmitted by more than one route, the management of
infectious patients quick reference guide in this document provides details of the type
of precautions, isolation requirements, mode of transmission and period of infectivity.
Application of TBPs may differ depending on the setting and the known or suspected
infectious agent.
(Siegel et al 2007) Last updated July 2019
Scope
The guidance applies to: All health care staff who manages patients at UHCW with a
suspected or confirmed infectious disease.
Roles and Responsibilities
--- PDF page 5 ---
5
The purpose of this guideline is to describe the practices and
procedures to be followed to prevent and control the potential of cross infection with
the use of appropriate and safe use of isolation facilities the use of Transmission
Based Precautions and Stand Infection Prevention and Control Precautions.
The guidance applies to: All health care staff who manages patients at UHCW with a
suspected or confirmed infectious disease.
Clinical guidance
1) Isolation:
Please see appendix 1: side room priority isolation guideline for criteria of isolation.
There are two categories of isolation. Source isolation and protective isolation.
Patients must be screened using the Infection Prevention and Control Risk
Assessment Tool on admission and transfer to a clinical area (appendix 2).
Source Isolation is the physical separation of one patient from another, in order to
prevent the spread of infection or resistant organism. Single room isolation will not by
itself prevent the transmission of organisms; additional precautions may be needed
dependent on the source and mode of spread.
Actions for Source isolation:
Isolate patients
Patients are placed in a single room and the door
should be kept closed. If the door cannot be kept
closed due to whatever reason, please inform
Infection Prevention and Control and ensure that
the infection control risk assessment and patient’s
notes have the reason for not having the door
closed documented.
Door sign
The Trust approved A4 laminated Isolation door
sign should be clearly displayed on the patient’s
side room door.
Red hand sign to be displayed for: Confirmed and
suspected infections such as C.Diff, MRSA, VRE,
ESBL, CPE and others.
(see appendix 3).
Purple hand sign to be displayed for: Covid-19 and
Influenza
(see appendix 4).
This advises anyone wishing to enter the side
room to seek advice from the nurse in charge prior
to entry
Equipment
All unnecessary equipment is removed from the
room.
--- PDF page 6 ---
6
Patients must be allocated single patient use
equipment where possible. For example, BP cuff,
stethoscope, and tourniquet. Where this is not
possible the equipment must be cleaned and
disinfected with Tristel.
Pressure rooms
In cases where patients are highly infectious
diseases the patient should be in a monitored
negative pressure room
Medical
notes
and
documentation
Patient’s notes and charts must be kept outside of
the room
Protective
Isolation
is
the
physical
separation
of
patients
who
are
immunocompromised / immunosuppressed in order to prevent the acquisition of
infection from other patients, staff or visitors. There is conflicting evidence to support
single room isolation for most immunocompromised patients; however, a single room
may help to reinforce the need for rigorous attention to Infection Prevention and
Control practice (Siegel et al 2007).
Neutropenic patients should be nursed in an isolation room with HEPA filtered air at
positive pressure as this may help reduce exposure to airborne infections, particularly
Aspergillus Spp.
Actions for Protective
isolation:
Isolate patients
Patients are placed in a single room and the door
should be kept closed. If the door cannot be kept
closed due to whatever reason, please inform
Infection Prevention and Control and ensure that
the infection control risk assessment and patient’s
notes have the reason for not having the door
closed documented.
Door sign
The Trust approved A4 laminated Isolation door
sign should be clearly displayed on the patient’s
side room door. This advises anyone wishing to
enter the side room to seek advice from the nurse
in charge prior to entry.
Blue
hand
sign
to
be
displayed:
Immunocompromised/Neutropenic patents.
(see appendix 5).
Equipment
All unnecessary equipment is removed from the
room.
Patients must be allocated single patient use
equipment where possible. For example, BP cuff,
stethoscope, and tourniquet. Where this is not
possible the equipment must be cleaned and
--- PDF page 7 ---
7
disinfected with Tristel.
Pressure rooms
In cases where patients immunocompromised /
immunosuppressed, use positive pressure room.
Medical
notes
and
documentation
Patient’s notes and charts must be kept outside of
the room
2) Pressure rooms
An understanding of the ventilation concepts and operation of monitoring devices /
alarms is essential to ensuring the correct management of the patient. Should a
situation arise where there is a mismatch between the room ventilation and the
patient’s requirements this may not only place the patient at increased risk, but also
other patients and staff on the ward
All pressure rooms should be checked daily and a clear audit trail kept of the outcome
on the daily check list.
The hospital has a variety of single rooms with varying pressure differentials, which
can be used for both source and protective isolation.
Patients should be risk assessed prior to placement in the room. This should be on
going, they might develop an infection requiring them to be moved out of the positive
pressure room for example. The use of risk assessment should be applied when
assessing requirements for precautions and specialist advice should be sought from
the Infection Prevention and Control Team or Microbiologist / Virologist
Amongst these are 118 side rooms with special ventilation characteristics. These are
as follows:
• 12 Monitored negative pressure rooms
• 9 positive pressure rooms
• 13 Switchable pressure rooms- (rooms that can be switched manually from
positive to negative pressure or visa/versa)
The rooms are identifiable by a silver plate on the outside of the door stating either:
• Monitored negative pressure room
• Positive pressure room
• Switchable pressure room
Pressure rooms
Positive Pressure
Rooms
Positive pressure rooms are designed to reduce the risk of
infection to patients with severely compromised immune
systems.
The ventilation in positive pressure rooms reduces the risk
from airborne infection by passing the air through a HEPA
(high efficiency particulate air) filter prior to it entering the
room. The room is at a positive pressure to prevent airborne
pathogens from entering the room to avoid transmission of
--- PDF page 8 ---
8
infection.
**FAILURE TO KEEP THE WINDOWS OR DOOR SHUT
WILL CIRCUMVENT THE PROTECTION OFFERED TO THE
PATIENT.
Preferentially designed for patients with prolonged profound
neutropenia who are NOT colonised/ infected with a significant
pathogen.
Negative
Pressure Rooms
Negative pressure rooms are designed to barrier patients that
have highly infectious diseases.
The room is negative pressure to allow uncontaminated air to
flow into the isolation room when the door is opened.
Mechanisms are used n the ventilation to suck the
contaminated air out of the isolation room to a designated
area.
Rooms should be monitored using ‘Monitor Pressure Room
Checklist’ (appendix 8)
Switchable
Pressure Rooms
Switchable rooms are designed to the airflow can alternate
between positive and negative are pressure. These rooms
must be checked prior to the patient being admitted to the side
room.
Rooms that are in negative pressure mode should be
monitored using ‘Monitor Pressure Room Checklist’ (appendix
8)
3) Modes of Transmission
Several classes of pathogens can cause infection, including bacteria, viruses, fungi,
parasites, and prions. The modes of transmission vary by type of organism and some
infectious agents may be transmitted by more than one route. Organisms can be
transmitted in three main modes: contact (direct/indirect), airborne and droplets
(Siegel et al, 2007) and transmission-based precautions must be used to prevent cross
infection.
Mode
of
Transmission
Transmission
Transmission
based
Precautions
Transmission Based Precautions, in addition to Standard Infection
Control Precautions (SIPC), are a set of measures that should be
implemented when patients are either suspected or known to be
infected with a specific infectious agent, when aiming to prevent
and control spread, particularly in relation to Healthcare Associated
Infections.
Transmission based precautions are categorised according to the
--- PDF page 9 ---
9
route of transmission of the infectious agent such as droplet,
contact and / or airborne.
Contact
Transmission
The most common mode of transmission, contact transmission is
divided into two subgroups: direct contact and indirect contact.
Direct
transmission
Occurs when microorganisms are transferred from one person to
another person, i.e. through direct body contact without
involvement of inanimate objects or other people.
Examples are by touching patient’s skin, lesions, nasal secretions
or dealing with infected body fluids, such as diarrhoea.
Indirect
Contact
Transmission
Indirect transmission involves the transfer of an infectious agent
through a contaminated intermediate object or person.
Contaminated hands of healthcare staff are important contributors
to indirect contact transmission.
Contact precautions include:
• Isolation
• Hand hygiene
• Care
of
equipment
and
environment
including
decontamination
• Safe handling of linen and waste
• Disposable gloves and plastic aprons should be put on
before and worn during care activities where there will be
contact with the blood or bodily fluid.
• Face / eye protection including masks and full face visors
may be required if there is a risk of mucosal splashing
(mouth or eyes) or when droplet transmission is considered
e.g. Influenza.
Airborne
Transmission
Airborne transmission occurs by dissemination of either airborne
droplet nuclei or small particles in the respirable size range
containing infectious agents that remain infective over time and
distance (e.g., spores of Aspergillus spp, and Mycobacterium
tuberculosis). Aerosols are smaller than droplets and can remain
in the air for longer and there is potential to transmit infection by
mucous membrane or inhalation.
Microorganisms carried in this manner may be dispersed over long
distances by air currents and may be inhaled by susceptible
individuals who have not had face – to – face contact with (or been
in the same room with) the infectious individual. Preventing the
spread of pathogens that are transmitted by the airborne route
requires the use of special air handling and ventilation systems.
Aerosol generating procedures (AGP) are
Monitored negative pressure rooms have their own extract system
these are to be used for organisms such as MDRTB multi drug
resistant mycobacterium tuberculosis; Endoscopy unit has one
--- PDF page 10 ---
10
such facility for patients who require procedures such a bronchial
lavage.
Airborne precautions include:
• Isolation
• Hand hygiene
• Care
of
equipment
and
environment
including
decontamination
• Safe management of linen and waste
• Respiratory masks FFP3
• Face visor - may be required if there is a risk of mucosal
splashing to the face as a result of, coughing, sneezing, or
aerosol – generating procedures.
Droplet
Transmission
Droplet transmission may be transmitted by the direct and indirect
routes. Droplets carrying infectious pathogens transmit infection
when they travel directly from the respiratory tract of the infectious
individual to susceptible mucosal surfaces of the recipient,
generally over short distances, necessitating facial protection.
Respiratory droplets are generated when an infected person
coughs, sneezes, or talks. The nasal mucosa, conjunctivae and
less frequently the mouth, are susceptible portals of entry for
respiratory viruses. Droplets remain in the air for short periods and
travel one to two metres, so physical closeness is required for
transmission.
Droplet precautions include:
• Isolation
• Hand hygiene
• Care
of
equipment
and
environment
including
decontamination
• Safe handling of linen and waste
• A fluid resistant surgical mask
• Face / eye protection is required if there is a risk of mucosal
splashing to the eyes, nose, and mouth.
Further information please refer to the Guidelines for Standard Infection Prevention
and Control Precautions CG 885, Version 11.
4) Personal Protective Equipment (PPE)
PPE is used in addition to normal work clothing (uniforms or own clothing) to protect
both the patient and Healthcare Worker (HCW) from the potential risks of cross
infection. PPE refers to a variety of barriers and respirators used alone or in
combination to protect mucous membranes, airways, skin and clothing from contact
with infectious agents.
--- PDF page 11 ---
11
The selection of PPE is based on the nature of the patient interaction and / or the likely
mode(s) of transmission. Items of PPE can include gloves, gowns, aprons, masks,
FFP3 respirators or full-face visors. (please see appendix 8)
Gloves and aprons should be kept in a Dani centre attached to a wall outside the side
room. Spare boxes should not be stored on hand rails outside of the room.
5) Safe Management of Laundry
Guidelines for Procedure for the laundering of Soiled Patients Clothing in the Home
Setting COP 63 can be referred to and found on the trust’s intranet site.
Leaflets can be given to the patient ‘Patient's Clothing bags (PCB) - Doissolvo Sacks’
found on the trust’s intranet site.
6) Hand washing
Hand hygiene forms part of standard infection prevention & control precautions. (Refer
to Hand Decontamination Policy eLibrary ID Reference No: OPER-POL-002-10,
Version 10)
Leaflets can be given to the patient ‘Clean Hands are Caring Hands. Have You
Washed Your Hands?’ found on the trust’s intranet site.
7) Safe Management of Waste
All waste generated from an isolation room must be disposed of as clinical waste
For further information please refer to the trusts Waste Management Policy eLibrary
ID Reference No: H&S-POL-003-07 Version 5) can be referred to and found on the
trust’s intranet site.
8) Patient Information
Staff must ensure that the reasons for isolation are explained fully to the patients and
or carer/relatives to ensure compliance with all isolation precautions. An information
leaflet should be given to reinforce verbal information given ‘Isolation and Barrier
Nursing’ found on the trust’s intranet site.
9) Termination of Isolation
A terminal clean of the isolation room is required when a patient vacates the room or
they are deemed no longer infectious to others, to ensure that all surfaces are
thoroughly cleaned and disinfected with Tristel to prevent cross infection. However,
daily cleaning of the isolation rooms, using designated equipment must be carried out
by the domestic services for the duration of the isolation.
Please see Appendix 10 for ‘Isolation of patients with multidrug resistant (MDR) Gram
negative organisms at UHCW NHS Trust’ and management of isolating patients.
All terminal cleans must be logged on the help desk and job number recorded.
Please see ‘Bed and Mattress Cleaning Procedure COP 222, version 9’ for terminal
--- PDF page 12 ---
12
clean checklists found on the trust’s intranet site.
Please note that there are some instances where hydrogen peroxide fogging will
be used following a terminal clean. For example when a patient has had
Clostridium Difficile, Multi resistant acinetobacter baumannii (MRAB) or
Carbapenemase Producing Enterobacteriaceae (CPE).
If hydrogen peroxide fogging is required following a terminal clean this must be
communicated on the help desk when booking the terminal clean.
Hydrogen Peroxide Vapour (Fogging Clean). Carried out by the Performance team &
requested as a pre-fogging terminal clean via the Help desk Ext 25555 & then by
contacting the Performance team (Bleeps 2129/4723/2635/1840).
Fogging cleans are to be used in the following situations:-
• To disinfect rooms when a patient with Clostridium difficile becomes 48 hours
asymptomatic.
• To disinfect side rooms when there is evidence of an outbreak of Clostridium
difficile or with other organisms
• When a patient with a multi resistant organism has vacated a room
• This service is available seven days a week Monday-Friday 8-2pm & Weekends
8-12pm. Outside these hours, if the fogging cannot be completed then a
terminal clean should be requested and signed off by a senior staff member. If
a room can be kept vacant then fogging can be completed the following day.
• Note that once fogging has been commenced the room will be out of action for
3 hours
** Please note: If the patient is moved to a different bed space and remains an
inpatient, in order to have a ‘Fogging Clean’ – please ensure the bed is changed
for the patient. This is to ensure the bed is decontaminated effectively from
spores for future use.**
10) Cadaver Bags
Indications for the use of Cadaver bags are:
All category 3-4 infectious diseases require a cadaver bag. Please see link for
category of disease: https://www.hse.gov.uk/pubns/misc208.pdf
Category 1: Unlikely to cause human disease.
Category 2: Can cause human disease and may be a hazard to
employees; it is unlikely to spread to the community
and there is usually effective prophylaxis or
treatment available.
Category 3: Can cause severe human disease and may be a
serious hazard to employees; it may spread to the
community, but there is usually effective prophylaxis
or treatment available.
Category 4: Causes severe human disease and is a serious
hazard to employees; it is likely to spread to the
community and there is usually no effective
prophylaxis or treatment available.
--- PDF page 13 ---
13
A deceased patient details sheet must be completed and it must be indicated on this
sheet if a cadaver bag is required. Please refer to the Care After Death (Last Offices)
- COP 92 (V2).
11) Quick Action Guide
There are quick action guides for the following and they are to be commenced when
the patient has either confirmed or suspicion of infection:
1) CDI – found in ‘Management of Clostridioides difficile for adults’ COP 978
(V1)
2) CPE - found in ‘Management of Multi-Resistant Organisms, Carbapenemase
Producing Enterobacteriaceae (CPE), Multi Resistant Acinetobacter
baumanni (MRAB) and Extended Spectrum Beta-Lactamases (ESBL)’ COP
915 (V1)
3) ESBL – found in ‘Management of Multi-Resistant Organisms, Carbapenemase
Producing Enterobacteriaceae (CPE), Multi Resistant Acinetobacter baumanni
(MRAB) and Extended Spectrum Beta-Lactamases (ESBL)’ COP 915 (V1)
4) Influenza – found in ‘Respiratory Infections Guideline - CG 2032’
5) Measles – found in this guideline ‘Appendix 9’
6) MRAB - found in ‘Management of Multi-Resistant Organisms,
Carbapenemase Producing Enterobacteriaceae (CPE), Multi Resistant
Acinetobacter baumanni (MRAB) and Extended Spectrum Beta-Lactamases
(ESBL)’ COP 915 (V1)
7) MRSA – found in ‘Screening, Prevention and Management of Meticillin
Resistant Staphylococcus aureus (MRSA)’ - CG 1583 (V8)
8) Neonatal MRSA - found in ‘Screening, Prevention and Management of
Meticillin Resistant Staphylococcus aureus (MRSA)’ - CG 1583 (V8)
9) Neonatal Respiratory Virus - ?????
10) TB – found in ‘Guidelines For The Management of Tuberculosis’ (V9)
11) VRE – found in ‘Vancomycin Resistant Enterococci Guidelines’ (V9)
12) Whooping Cough - found in this guideline ‘Appendix 11’
Appendices
Appendix 1: Side Room Priority Isolation Guidance
Appendix 2: Infection Prevention and Control Risk Assessment Tool
Appendix 3: Isolation Red Hand Door Sign
Appendix 4: Isolation Purple Hand Door Sign
Appendix 5: Isolation Blue Hand Door Sign
Appendix 6: Ward Closed poster
Appendix 7: Bay Closed poster
Appendix 8: Monitor Pressure Room Checklist
Appendix 9: Measles quick action guide
Appendix 10: Isolation of patients with multidrug resistant (MDR) Gram negative organisms
--- PDF page 14 ---
14
at UHCW NHS Trust V4
Appendix 11: Management of patients with confirmed or suspected Bordetella Pertussis
(Whooping Cough)
--- PDF page 15 ---
15
Appendix 1: Side Room Priority Isolation Guidance
Side Room Prioritisation Tool THOSE WITH SUSPECTED/CONFIRMED CASES OF BELOW REQUIRE A SIDE ROOM
COVID-19
CONFIRMED – Remain in isolation until 10 days then follow de-escalation, if immunocompromised 14 days, then follow de-
escalation
SUSPECTED – Remain in isolation until clinical suspicion is de-escalated or isolation period ends
Mpox
CONFIRMED – Remain in isolation for 21 days or discharge
SUSPECTED - Remain in isolation until clinical suspicion is de-escalated or isolation period ends
Diarrhoea
and
Vomiting
Clostridium difficile
SYMPTOMATIC – Isolate until 48 hours clear of symptoms
Previously alerted on CRRS but asymptomatic does NOT require isolation
Diarrhoea of unknown origin
Isolate until 48 hours clear of symptoms
Viral gastroenteritis e.g. Norovirus, Bacterial
gastroenteritis
salmonella, shigella, E coli 0157, campylobacter
Isolate until 48 hours clear of symptoms
Resistant
Organisms
MRSA
Patients with psoriasis/ dermatitis/ poor skin condition, exudating wounds
For other MRSA please refer to amber
ESBL
In sputum
For other ESBL please refer to amber ( GCC patients – contact IPC for further discussion)
MRAB
CONFIRMED – Remain in isolation for the duration of their hospital stay (and ALL future admissions)
SUSPECTED – Isolate until result known, if negative discontinue isolation
CPE
CONFIRMED – Remain in isolation for the duration of their hospital stay (and ALL future admissions)
SUSPECTED – Isolate where possible, if required manage in a bay with contact precautions.
Respiratory
Symptoms
TB
Confirmed/ suspected pulmonary TB to be isolated and discussion held with IPC
Influenza
(Flu A and Flu B)
Remain in isolation until asymptomatic
Immunocompromised and GCC patients – contact Virology for further discussion
Respiratory Viruses –NOT COVID-19
e.g. RSV
Remain in isolation until asymptomatic
Immunocompromised and GCC patients – contact Virology for further discussion
Group A Strep
Isolate until 48 hours of effective antibiotic administered
Skin
Infection
and Rashes
Chicken pox / Shingles
Isolate until lesions or blisters are dry
Scabies
Isolate until 2 doses of effective topical treatment applied
Measles/Mumps/ Rubella/Parvovirus
Place in isolation, discuss with Virology duration requirements (individual risk assessment required)
Group A Strep, Including Blood Cultures
Isolate until 48 hours of effective antibiotic administered
Impetigo/ Scarlet Fever
Isolate until lesions or blisters are dry
Viral Haemorrhagic Fever
Isolate – Discuss with Virology/IPC
Travel
Related
Infection/
Transfers
Typhoid/ Paratyphoid
Isolate – Discuss with Microbiology/IPC
Fever related to foreign travel
Isolate – Discuss with Virology/IPC
From other healthcare facilities (UK/abroad)
Isolate until negative screens returned
MRSA, MRAB, CPE,ESBL
Bacterial Meningitis
Isolate until 48 hours of effective antibiotic administered
THE FOLLOWING CONDITIONS, AFTER RISK ASSESSMENT COULD BE MANAGED IN A BAY
Resistant
Organisms
MRSA
In a covered non-exudating wound, Patient has received 5 days of decolonisation and/or negative screen
Positive MRSA in urine sample, patient is continent
ESBL
Unless otherwise stated by IPCT
VRE
Unless otherwise stated by IPCT
--- PDF page 16 ---
16
Appendix 2: Infection Prevention and Control Risk Assessment Tool
--- PDF page 17 ---
17
Appendix 3 : Isolation Red Hand Door Sign
--- PDF page 18 ---
18
Appendix 4 Isolation Purple Hand Door Sign
--- PDF page 19 ---
19
Appendix 5: Isolation Blue Hand Door Sign
--- PDF page 20 ---
20
Appendix 6: Ward closed poster
Ward closed to visitors
Access is currently restricted to this ward and we are asking that
visitors do not enter unless for compassionate reasons.
Anyone who does come onto the ward must observe strict hand
hygiene. If you have suffered from diarrhoea or vomiting
yourselves please do not visit. For more information please
contact the nurse in charge
--- PDF page 21 ---
21
Appendix 7: Bay closed poster
Bay closed to visitors
Access is currently restricted to this ward and we are asking that visitors
do not enter unless for compassionate reasons.
Anyone who does come onto the Bay must observe strict hand hygiene. If
you have suffered from diarrhoea or vomiting yourselves please do not
visit. For more information please contact the nurse in charge
--- PDF page 22 ---
22
Appendix 8: Monitor Pressure Room Checklist
University Hospitals Coventry & Warwickshire NHS Trust
Daily checking sheet of all monitored positive and negative
Pressure Rooms
POSITIVE PRESSURE ROOMS SHOULD ONLY BE CONSIDERED FOR CHRONIC PROFOUND
NEUTROPAENIA.
If fault detected, Log fault via Help desk on ext. 25555 and ensure job is treated
as urgent.
Date
Tim
e
Pressur
e
Gauge
reading
e.g. -
.007
or 007
Fault
Detect
ed
Yes
No
Action taken
Signed
--- PDF page 23 ---
23
Appendix 9: Measles Quick Action Guide
Measles Quick Action Guide
Infection Prevention and Control Team & Virology, Version 2, June 2022
Full guidance is available from:
https://assets.publishing.service.gov.
uk/government/uploads/system/uploads/attachment_data/file/849538/PHE_Measles_Guideli
nes.pdf
Clinical and epidemiological features of measles
List patient
symptoms and date
of onset
Prodrome: Fever, coryza, cough and conjunctivitis.
Macopapular Rash which is non vesicular and usually not itchy. It typically starts
on the face and behind the ears, expands to the face, trunk and can sometimes
be generalised.
Koplik Spots in the mouth around the time of the rash (small white / bluish lesions
on the buccal mucosa, 2-3 mm in diameter).
Generally unwell
Further information
Has the patient had natural measles?
Has the patient received measles vaccine? If so how many doses and the date of
the last vaccination?
Is the patient a known contact of a positive case? If yes state date of contact
Has the patient travelled outside of the UK during the incubation period
(in the past 7 – 21 days)? If so state which country and dates travelled?
Is the patient from a high risk community e.g travelling, charedi orthodox Jewish,
anthroposophic or migrant?
Is there a local outbreak in the community?
ACTION TO TAKE IF MEASLES SUSPECTED OR CONFIRMED
Date
Completed
Signed
Isolate patient in a monitored negative pressure isolation room (preferably on ward
30 & 31)if an adult patient N.B. Check alarm is working and pressure is correct
before transferring patient into the room. The acceptable range of pressure is
(-.007 )or less i.e (-.030). The minus sign must be present on the monitor.
Daily checks of pressure rooms must be recorded. The form can be located
on http://trustnav/infection-prevention-control/infection-controlresources/
Under Monitored pressure rooms check list. Contact help desk on 25555
(state priority job) if alarm is not working or pressure range is not correct and
inform Infection Prevention and Control urgently.
Attach isolation door label to the door and keep door closed. The sign can be found
in the link under red hand sign http://trustnav/infection-prevention-control/infection-
control-resources/
Inform Infection Prevention and Control Team immediately on 24791 to assess
whether contact tracing is required
Inform Virology immediately on 25471 or 25473 if within normal working hours. If
not able to make contact via telephone email clinical Virology,
clinicalvirology@uhcw.nhs.uk If outside of normal working hours, call the on call
microbiologist via switchboard.
--- PDF page 24 ---
24
Appendix 10: Isolation of patients with multidrug resistant (MDR) Gram negative organisms at
UHCW NHS Trust V4
--- PDF page 25 ---
25
--- PDF page 26 ---
26
--- PDF page 27 ---
27
Appendix 11: Management of patients with confirmed or suspected
Bordetella Pertussis (Whooping Cough)
--- PDF page 28 ---
28
--- PDF page 29 ---
29
--- PDF page 30 ---
30
References
Sources of Evidence
NICE Evidence
TRIP Database
Google Advanced Search
Cochrane Library
PubMed
Search Strategy
PubMed:
(((("single
room
in
hospital"[Title/Abstract])
OR
"patients
Isolation"[Title/Abstract]) OR "isolation facilities"[Title/Abstract]) OR "Isolation
procedure"[Title/Abstract]) OR "Isolation policy"[Title/Abstract]
((((("single person"[MeSH Terms] OR ("single"[All Fields] AND "person"[All Fields])
OR "single person"[All Fields] OR "single"[All Fields]) AND room[All Fields] AND in
hospital[Title/Abstract])
OR
Isolation
policy[Title/Abstract])
OR
isolation
procedure[Title/Abstract]) OR isolation facilities[Title/Abstract]) AND ("Secondary
Care"[Mesh] OR "Hospitals"[Mesh])
Google, Cochrane, Dynamed, Trip , NHS evidence, Google scholar: "source isolation"
OR "protective isolation" OR "pressure room" OR "transmission based precaution"
HSE (2021) The Approved List of biological agents Advisory Committee on
Dangerous Pathogens:
https://www.hse.gov.uk/pubns/misc208.pdf
Public Health England (2016) Infection control precautions to minimize transmission
of acute respiratory tract infections in healthcare settings
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attach
ment_data/file/585584/RTI_infection_control_guidance.pdf
Infection prevention and control (IPC) (includes isolation)
https://www.england.nhs.uk/coronavirus/secondary-care/infection-control/
COVID-19: infection prevention and control (IPC)
https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-
prevention-and-control/covid-19-guidance-for-maintaining-services-within-health-
and-care-settings-infection-prevention-and-control-recommendations
--- PDF page 31 ---
31
UHCW policies:
Bed and Mattress Cleaning Procedure COP 222, version 9
Care After Death (Last Offices) - COP 92 (V2)
Hand Decontamination Policy eLibrary ID Reference No: OPER-POL-002-10,
Version 10)
Patient's Clothing bags (PCB) - Dissolvo Sacks
Waste Management Policy eLibrary ID Reference No: H&S-POL-003-07 Version 5
--- PDF page 32 ---
32
Management of patients with confirmed or suspected Bordetella Pertussis (Whooping
Cough)
(Refer to Public Health England Guidelines for full details in the link below)
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attach
ment_data/file/762766/Guidelines_for_the_Public_Health_management_of_Pertussis_i
n_England.pdf
Suspected Case □
Confirmed Case □
Whooping Cough Quick Action Guide, Infection Prevention and Control Team & Microbiology, Version
1, November 2022
Suspected or Confirmed Whooping Cough – General information
Pertussis (whooping cough) is an acute bacterial infection caused by Bordetella pertussis, an exclusively human
pathogen that can affect people of all ages. While adolescents and adults tend to have a prolonged cough illness but
without other major symptoms, young unimmunised infants are the most vulnerable group with the highest rates of
complications and death. Transmission of the organism occurs because of close direct contact with an infected
person. It is highly contagious, with up to 90% of household contacts developing the disease.
The incubation period of pertussis is on average between 7-10 days (range 5-21 days).
The usual clinical presentation, Initial catarrhal stage with a cough that becomes paroxysmal. Paroxysms of cough
usually increase in frequency and severity as the illness progresses and persist for 2-6 weeks. These paroxysms may
end in vomiting, cyanosis and/or a characteristic inspiratory whoop. Patients with pertussis are most infectious in the
initial catarrhal stage and during the first 3 weeks after the onset of cough. Symptoms slowly improve in the
convalescent phase, which generally lasts 2-6 weeks but can persist for months. Adults generally have a non-
productive cough illness without fever.
Information to be documented in the patient’s notes
Date of onset of Symptoms
Details of patient’s symptoms
Details of any close contact with a known case in the last 21 days?
Whooping Cough vaccination history (document if unknown)
Action to take if Whooping cough suspected or confirmed.
Date
Completed
Signed
Patient placement
Isolate the patient in a side room (isolation required from onset of symptoms until 48 hours
of appropriate antibiotic treatment has been completed or for 21 days from onset of
symptoms if no antibiotic treatment received).
Document in the notes date when isolation has been stepped down
Attach isolation door label (red) to the door and keep door closed
Communication & samples required for whooping cough?
Inform Infection Prevention and Control Team (extn 24791) and Microbiology via the
switchboard immediately on suspicion of whooping cough. Microbiology will give advice on
Place Patient ID Label here
Date:
Ward:
New Case:
Previously positive:
--- PDF page 33 ---
33
antibiotic treatment if appropriate).
Whooping cough and suspected Whooping Cough must be notified to Public Health
England
PHE telephone number - 0344 225 3560
Explain result to patient / carer and symptoms/management of whooping cough
Answer any questions
Sample for whooping cough
Bordetella pertussis grows in the pernasal cavity
Normal culture swabs are not suitable for Bordetella pertussis investigation as they will not
reach the pernasal cavity.
For Bordetella pertussis/whooping cough ONLY, pernasal swabs must be used and other swabs
will not be processed.
Use aseptic technique
•
Prior to starting antibiotics where possible
•
Insert the flexible, ultra-fine swab through a nostril and advance along the floor of
the nose until it reaches the naso-pharynx.
•
Hold against the posterior naso-pharynx for a few seconds. Place the swab into
the transport media. See picture below of correct swab to use
Please see details of pernasal swabs NHS supply chain below. For queries, please
contact the department on 02476965446
Contact tracing
Nurse in charge to compile list of patient contacts using contact tracing form provided by
IPC team.
Medical team to complete a risk assessment of vulnerable contacts
If there are any staff contacts, then refer to occupational health. Nurse in charge is
responsible for collating a list of staff and sending to Occupational Health and a risk
assessment of vulnerable contacts will be made by Occupational Health
Transmission based precautions listed below to be used in conjunction with
standard precautions. (Transmission route: contact and droplet)
•
FFP3 Respirator if undertaking an AGP (wearer must be fit tested and complete a
fit check every time respirator is donned
--- PDF page 34 ---
34
Fluid resistant mask if not doing AGP
•
Full face visor at all times
•
Gloves if risk assessment to be exposed to blood and bodily fluids
•
Apron (Full length gown if AGP undertaken)
•
The 5 moments for hand hygiene must be adhered to at all times
Patient Transfer
Patient must wear fluid resistant surgical mask when being transferred if it can be
tolerated.
If transferring patient to another department / ward the department must be informed prior
to transfer and not wait in waiting rooms with other patients.
Environmental Decontamination
Terminal Clean of room with Tristel once patient vacates room using Terminal clean check
list available on e-library
Daily ? twice daily clean of isolation room by ISS using Tristel
All laundry must be placed be placed in a red alginate liner then placed in a white plastic
bag & secured prior to leaving the ward
Equipment
Single use equipment must be used where possible, or equipment dedicated to the patient
while in isolation and then decontaminated prior to being put back in general use
Waste
All waste generated in the isolation room must be placed in clinical waste bin (Orange
bag)
Visitors must be offered appropriate PPE – fluid resistant surgical mask and face visor
--------------------------------------------------------------------------------
ATTACHMENT: 20_1.pdf
TEXT_FILE: 20_1.pdf.txt
METHOD: pdf_native
OCR_USED: False
PAGES: 13
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--- PDF page 1 ---
1
Food Hygiene
Related National
Guidance
Evidence Based
E-library number
CG 1585 (was COP 196)
Version number
9
Purpose
All staff should familiarise themselves with the following guidance to
ensure that all food and drinks offered to patients are safe to
consume.
Primary Specialty
Trust wide
Related
Specialties
N/A
Specialty Clinical
Guideline Lead
Fiona Wells Infection Prevention and Control and Sepsis Nurse
Authors
Lead
Author:
Ragbinder Mahal Infection Prevention and Control
and Sepsis Nurse
Reviewer(s): Fiona Wells Infection Prevention and Control and
Sepsis Nurse
Approving
Forums
Infection Prevention and Control Committee
Approval Dates
QIPS
23/11/2022
MMC
N/A
Other (specify)
Review Date
October 2025
Keywords
Food Hygiene, Fridge, Refrigerator, Ward, Kitchen, Service, Snacks,
Ice machines, Water Cooler
Clinical guideline content: Clinical Guidelines assist in decision-making; they do not replace clinical
judgement. Regardless of the strength of evidence, it remains the responsibility of the clinician to
interpret the application of the clinical guidance to local circumstances and the needs and wishes
of the individual patient. Where variations of any kind do occur, it is important to document the
variations and the reason for them in the patient’s health record. If in doubt, seek senior advice.
Equality and Diversity Statement: Throughout its activities, the Trust will seek to treat all people
equally and fairly. This includes those seeking and using the services, employees and potential
employees. No-one will receive less favourable treatment on the grounds of sex/gender (including
Trans People), disability, marital status, race/colour/ethnicity/nationally, sexual orientation, age,
social status, their trade union activities, religion/beliefs or caring responsibilities nor will they be
disadvantaged by conditions or requirements which cannot be shown to be justifiable. All staff,
whether part time, full-time, temporary, job share or volunteer; service users and partners will be
treated fairly and with dignity and respect.
--- PDF page 2 ---
2
Rationale
Guidance has been cross referenced with CEBIS
Dissemination and related guidance
Guidance will be shared trust wide on E-Library
Training
None
Patient Information
None
Audit & Monitoring
Audit title
Audit Lead
Monitoring method
and frequency
Committee responsible
Changes from previous version
Date
Updated information
20/10/2022
Policy dates updated
--- PDF page 3 ---
3
Contents
Definitions ............................................................................................................................................... 3
Introduction ............................................................................................................................................ 4
Scope ....................................................................................................................................................... 4
Roles and Responsibilities ....................................................................................................................... 5
Clinical guidance ..................................................................................................................................... 5
Appendices ............................................................................................................................................ 11
References ............................................................................................................................................ 13
Definitions
CCP
Critical Control Point.
The point at which if control is lost an incident may
occur
Contamination
The adulteration of food by microbial pathogens,
chemicals, foreign matter, or spoilage which may
affect or compromise the safety of food
EBM
Expressed Breast Milk
Food Handler
Any person who, directly or indirectly, handles food
and fluids
Food Hygiene
All measures necessary to ensure the safety, soundness
and wholesomeness of food at all stages from
procurement, storage, production, post production
storage and distribution of manufacture
until its final consumption
Food Poisoning
An illness normally characterised by acute diarrhoea
and/or vomiting caused by the ingestion of food
contaminated with pathogenic micro-organisms. This is a
notifiable illness.
HACCP
Hazard Analysis Critical Control Point – formal system
of identifying hazards i.e., risk assessment
associated with food
IPC
Infection Prevention Control
IPCT
Infection Prevention Control Team
--- PDF page 4 ---
4
Monitoring
A planned sequence of observations or
measurements to assess whether a CCP is under
control
PFI
Private Finance Initiative
Introduction
It is the responsibility of University Hospitals Coventry and Warwickshire (UHCW) Trust to
provide nutritionally balanced meals and safe catering provision service for patients, staff and
customers.
Handling food properly and safely is essential to preventing food borne illness. At its basic
level, good food hygiene practice helps to ensure that food contamination which could lead to
illness/harm to our patients, staff and visitors is prevented and food safety assured.
Each year many thousands of UK citizens are stricken by food poisoning and food borne
illness. The effects on individuals range from minor nausea, diarrhoea and sore head to in
extreme cases, death.
Hospital caterers are confronted by a challenge in that they produce food for the most
vulnerable and immunocompromised members of the community i.e., the very young, the
elderly and the infirm. This means that there must always be a robust emphasis on food safety,
during the storage, preparation, production, and service of food.
Scope
This guideline identifies the requirements of UHCW Trust to achieve compliance with Food
Safety Legislation, whilst ensuring that catering services are patient focused and delivered to
a high standard. It applies to ward level food services provided by Trust employees.
--- PDF page 5 ---
5
Roles and Responsibilities
•
All staff must ensure that all food is stored and handled safely, including
enteral feeds and milk used for infants
•
High risk foods must be refrigerated to a temperature of between 0 – 8
celcius and temperatures recorded twice daily
•
If the refrigerator or freezer temperature are unsatisfactory the food must
be discarded, and fridge not used and reported to the help desk on 25555
•
Patients and visitors must be discouraged from bringing any food on to the
ward other than ready to eat non – perishable snacks, fruit and non –
alcoholic bottled or canned drinks
•
Staff must not store their own food in the patient fridges
•
When serving food to patients, hand hygiene should be undertaken in
accordance with the Trust Hand Decontamination policy (2020)
•
Safe use and maintenance of water coolers
Clinical guidance
Purchase and delivery
Only food which has been purchased and delivered via the main kitchen will be served to ward
patients within the Trust. The contracted caterer has systems in place to ensure only reputable
suppliers are used, and that monitoring at the point of delivery is carried out to help ensure
that all food accepted onto the Trust premises is suitable.
For organisations whose food is not purchased and delivered via the main kitchen (for example
Friends of St Cross), must have suitable procedures in place to ensure they are purchasing
from reputable suppliers regarding food safety. This organisation must also have suitable
arrangements in place to ensure food is delivered in a safe and hygienic manner.
For food brought into the hospital premises by patients and their visitors, see section ‘Storage
of food brought into hospital’ below.
Food Storage
Food must be stored in an appropriate area, covered and away from sources of contamination
and at the appropriate temperature.
A system of stock rotation must be in place (place items with the shortest shelf life at the front
and always use the oldest first). Date checks must be regularly carried out, and food disposed
of as necessary to ensure that food is not stored past its ‘use by’ or ‘best before’ date.
It is the responsibility of the ward staff to check dates and dispose of food as necessary to
avoid the storage of out of date food in beverage point on wards, and the responsibility of the
hostess from ISS in the main kitchen.
--- PDF page 6 ---
6
Refrigerated storage
High risk foods must be stored in the refrigerator, by law always maintaining a food
temperature of between 0oC and 8oC (target air temperature 5oC or below).
Temperature is to be monitored and recorded twice daily and corrective action taken and
recorded as required on the daily check sheet (see appendix 1).
It is the responsibility of ward staff to monitor and record the temperature of fridges in the
beverage bay on the wards, and the responsibility of the hostess from ISS to monitor in the
main kitchen.
•
All food in refrigerators and freezers must be covered and date labelled
•
All special formula feeds for infants and children must be labelled as per specific
guidelines
•
Refrigerators should be cleaned daily and as spillages occur.
•
On no account must raw meat, poultry or shell eggs be stored in the ward
refrigerator
•
Refrigerators identified for food storage are to be used for storage of food items
ONLY (no specimens, drugs etc.)
•
All refrigeration units should be in a good state of repair to facilitate cleaning.
•
It is the responsibility of ward staff to clean the refrigerator in the beverage bay
•
It is the responsibility of ISS to clean the refrigerator in the main kitchen
Breakdown procedure
If refrigerator or freezer temperatures are unsatisfactory the person checking the temperature
should advise the manager.
The help desk on Ext 25555 should be informed and the job number documented. Food
discarded and fridge not used.
Any replacement patient refrigerators must meet food hygiene legislation.
Dry storage
Dry Goods must be stored in cupboards or storage containers designated for food storage
only. They must not be stored on the floor, in open packages or left uncovered.
Storage of food brought into hospital
Patients and their visitors should be strongly discouraged from bringing any food on to the
ward other than ready to eat non-perishable snacks and fruit and non-alcoholic bottled or
canned drinks.
--- PDF page 7 ---
7
The following foods can constitute a serious health risk if inappropriately handled:
•
Cooked meats & meat products
•
Fish, shellfish, and other seafood, for example, prawns.
•
Milk, cream, artificial cream, custards, and dairy produce.
•
Soft cheeses
•
Fresh cream products e.g., trifles, cream cakes etc.
•
Cooked eggs and products made with eggs, for example mayonnaise, but
•
excluding pastry, bread, and similar baked goods.
•
Cooked rice and pasta
•
Sandwiches
Relatives must be informed of the need to ensure food is covered, and if it requires
refrigeration, that it is brought from home without delay so that it can be placed into the ward
fridge.
Food of this nature requiring refrigeration must be labelled with the patients name and date it
has been brought on to the ward. If items are not consumed by the use-by or best before
dates, they are to be returned or discarded.
For food that does not have a best before or use-by date on it, staff must label the item/s with
the date bought in and discard or return within 24 hours if not used. This should be clearly
explained to relatives.
Food brought in by staff
Foods brought in by staff should not be stored with food and drink designated for patient
consumption due to the risk of cross contamination. Storage in beverage bay areas or
beverage kitchens is therefore not permitted.
Staff food should be stored either in a designated staff fridge or cool bags/boxes should be
used.
Access to ward kitchens
At the University Hospital (Coventry) site
•
Only permitted ISS staff have access to the main ward kitchens.
•
The kitchens close at 19:00 each day. The hostesses should leave a supply of dry
food items and a hot beverage trolley on the ward outside of these hours.
•
Patient meals are also available through the helpdesk on 25555
At Rugby St Cross site
•
Ward kitchens are shared between Trust and service provider
•
Patient meals are also available through the helpdesk on 25555
--- PDF page 8 ---
8
Food Service to Patients
The service provider will ensure all controls are in place prior to nursing staff receiving pre-
plated patient meals.
The service of food to patients must begin immediately once the food arrives. Delays could
lead to both bacterial growth and deterioration.
Holding back hot patient meals after service is strictly prohibited. Meals must NOT be kept to
one side at ward level for re-heating by microwave and neither must
bought-in ready meals be re-heated via the microwave by non-catering staff. If a patient is
unable to eat at the planned mealtime an alternative meal should be provided. The original
meal must be discarded.
Patient trays should be checked after removing to check for any extraneous items
e.g., dentures, sputum pots, dressings, insulin needles etc. which must be removed at ward
level.
All unused food, hot or cold, must be returned to the kitchen with the food trolley. Any other
food must be disposed of via a waste disposal unit. Waste food should not be disposed into
plastic bin sacks and held at ward level as this could encourage pest infestation.
Temperature Control
The service provider will ensure appropriate temperature monitoring is in place for food.
Snacks and Supplements
Meals and snacks should not be left with patients for excessive lengths of time (longer than 1
hour) due to the risk of microbiological growth at room temperature.
Made-up sip feeds such as Build Up soups and shakes should not be left standing on the
bedside locker for longer than 4 hours, after which they should be discarded.
Fortisip Compact and Fortijuce should be consumed on the same day they are opened.
Hand hygiene
When serving food to patients, hand hygiene should be undertaken in accordance with the
Trust Hand hygiene policy.
•
All food handlers are required to wash their hands before and after contact with food.
•
Hands must be washed properly using liquid soap and running water and then dried
thoroughly using disposable paper towel.
•
Hand washbasins are for hand washing only and must not be used for any other
purpose.
--- PDF page 9 ---
9
•
Minor cuts or abrasions to the hands must be covered with a blue waterproof dressing.
•
Jewellery (except for a plain band), nail varnish or false nails should not be worn.
•
“Bare below the elbows” policy should always be adopted.
•
Gloves are not required for meal service distribution
Protective Clothing
All main catering food handlers shall wear the uniform / protective clothing as provided by the
employer. Uniform will be kept clean and in good repair by the food handler and will be
changed into at work and not worn outside of the workplace to and from work. Protective
clothing should be laundered at a temperature of at least 60oC (Trust wide Procedure for the
Home Laundering of Staff Uniforms 2021)
All other occasional food handlers (i.e., nursing staff) shall wear a yellow plastic disposable
apron during any food or drink preparations. This should not be worn for any other purpose
and disposed of after each use.
Staff Health
For all staff:
•
All staff must report if they are suffering from, or have suffered from diarrhoea or
vomiting, throat infections, skin rashes, boils, or any other skin lesion.
•
Staff suffering from diarrhoea or vomiting are not allowed back to work until they have
been symptom free for 48 hours.
•
Occupational Health should be consulted if there are concerns regarding symptoms,
and The Food Standards Agency ‘Food Handlers Fitness to work guidelines’ observed.
•
It is important that if a ward/department manager has more than one member of staff
off duty at one time with gastro-intestinal illness that the Infection Prevention Team is informed.
Enteral Feeding
Enteral tube feeding can be associated with complications relating to the possibility of
microbial contamination. The use of nutritionally complete, sterile feed is always
recommended, unless directed otherwise by a doctor or dietician. An Aseptic Non-Touch
Technique that maintains the asepsis of the system, and minimises handling, must be used to
attach feeds to administration equipment.
Dilution of feeds is bacteriologically undesirable. If dilution is unavoidable, feed and container
should not hang for more than 4 hours and should thereafter be discarded.
Milk kitchens and Infant Feeds
Please refer to UHCW Infant feeding Policy 2020 on E-Library
Use of water coolers
Water coolers provide ready access to fluids in many staff and patient areas. However, if these
machines are not cleaned and maintained correctly, they may pose a risk to infection.
--- PDF page 10 ---
10
Regular cleaning is required, nursing staff empty the drip tray and clean on a regular basis,
ISS do the outside. The company sanitise the machine on a quarterly basis. Any breakdowns
report to helpdesk.
Ice machines
Only ice provided by the regeneration kitchen is to be used by patients for oral intake. The
service provider maintains these machines as per the PFI agreement, and the provision of ice
is by ISS hostess staff.
There is one ice machine in the hospital at ward level which is used post-surgery on ward 32.
Outbreak Management
It is vital that patients receive their meals promptly and safely.
In a room, bay or area closure, the food trolley should continue from the beverage bay as
normal.
If a whole ward is closed, the hostess member of staff is allocated to the area and must not
work elsewhere until 48 hours after their last shift on the infected area.
The kitchen will be allocated to the infected ward if possible, and other arrangements made
for any other ward areas using the same facility.
In the case of a norovirus outbreak, the Infection Prevention and Control Team will liaise with
ISS Hostess management; this information will be fed back to local staff.
--- PDF page 11 ---
11
Appendices
Fridge Checklist – Appendix 1
--- PDF page 12 ---
12
Fridge Checklist – Appendix
WEEK COMMENCING:
………………….
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
PLEASE RECORD REFRIGERATOR
TEMPERATURE Twice daily
(IF ABOVE 8C inform helpdesk 25555)
SIG
SIG
SIG
SIG
SIG
SIG
SIG
Y = ✓ N = X
Y
N
SIG
Y
N
SIG
Y
N
SIG
Y
N
SIG
Y
N
SIG
Y
N
SIG
Y
N
SIG
ALL FOOD STORED IN THE REFRIGERATOR IS
WITHIN THE USE BY DATE
ALL FOOD STORED IN THE REFRIGERATOR IS
LABELLED,DATED
AND COVERED APPROPRIATELY
IS THE BEVERAGE AREA CLEAN?
YELLOW PLASTIC APRONS ARE AVAILABLE FOR
SERVING FOOD AND
BEVERAGES
MANAGERS SIGNATURE
Date Signature
--- PDF page 13 ---
13
Food Safety Patient information leaflet available on E-Library
Food Safety and Hygiene (England) Regulations (2013)
www.legislation.gov.uk/uksi/2013/2996/made/data.pdf (Accessed: 14/11/2022)
Food Standards Agency – Food Handlers – Fitness to Work (2009)
https://www.food.gov.uk/sites/default/files/media/document/fitnesstoworkguide.pdf
(Accessed: 14/11/2022)
NHS (England) Hospital Food Review – FSA evidence package Last updated: : 10 January 2022
https://www.food.gov.uk/research/foodborne-disease/nhs-england-hospital-food-review-fsa-
evidence-package
(Accessed: 14/11/2022)
References
--------------------------------------------------------------------------------
ATTACHMENT: 21_1.pdf
TEXT_FILE: 21_1.pdf.txt
METHOD: pdf_native
OCR_USED: False
PAGES: 21
--------------------------------------------------------------------------------
--- PDF page 1 ---
Version number: 7.0
Trust-wide PPS title: Infection Prevention and Control Assurance Policy
This Trust-wide PPS has been developed/reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
Infection Prevention and Control Policy
eLibrary ID Reference No:
This id will be applied to all new Trust-wide PPSs by
the Quality Department and will be retained throughout
its life span.
OPER-POL-003-10
Newly developed Trust-wide PPSs will be allocated an eLibrary reference number following Trust approval.
Reviewed Trust-wide PPSs must retain the original eLibrary reference number.
The Quality department will progress all new, re-written and reviewed PPSs for final Trust approval.
Version:
(Must be a rounded number, i.e. 6.0,7.0 etc.)
7.0
Title of Approving Committee:
Policy Governance Group
Date Approved:
29 April 2024
Risk Rating:
(this must be applied by the Author prior to being submitted to the
Quality Dept. ( refer to PPS guidance pack on eLibrary)
Moderate
Next Review Date:
(this must be applied by the Author dependant on risk rating or
record alternative date if required to meet national guidance)
28 April 2026
If printed, copied or otherwise transferred from eLibrary, Trust-wide Policies,
Procedures and Strategies will be considered ‘uncontrolled copies’. Staff must
always consult the most up to date PDF version registered on eLibrary.
As a controlled Trust-wide PPS, this record should not be saved onto local or network
drives but should always be accessed from eLibrary.
If you have any queries with regards to the library service, please could you direct
your query to the email address: library@uhcw.nhs.uk.
--- PDF page 2 ---
Page 2 of 21
Version number: 7.0
Trust-wide PPS title: Infection Prevention and Control Assurance Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
Trust-wide PPS to be read in conjunction with:
(List overarching/underpinning strategies, policies and
procedures – refer to PPS Evidence Summary)
Infection Prevention and Control guidance on
UHCW e-Library.
Relevance:
(State one of the following: Governance, Human
Resource, Finance, Clinical, ICT, Health & Safety,
Operational)
Governance
Superseded Trust-wide PPSs (if applicable):
(Should this PPS completely override a previously
approved Trust-wide PPS, please complete the ‘Request
for Removal of PPS’ form and submit to Quality Dept –
please refer to eLibrary and state full title and eLibrary
reference number and the PPS will be removed from
eLibrary)
Infection Prevention and Control Assurance
Framework – V6.0
Author’s Name, Title and email address:
(must not be the same as reviewer)
Fiona Wells Lead Nurse Infection Prevention and
Control
Reviewer’s Name, Title & email address:
(must not be the same as author)
Vicky Williams, Deputy Chief Nursing Officer/
Deputy Director of Infection Prevention and Control
Chief Officer’s Name, Title:
Tracey Brigstock, Chief Nursing Officer/ Director
of Infection Prevention and Control
Title of Group/Department/Specialty:
Infection Prevention and Control
Changes since last version
Detail of Changes
Page No.
Para No.
Title change to Infection Prevention Policy to align to DOH
guidance, removed “assurance framework”
1
-
Scope and introduction re-written to include more recent
references and clarity.
5
-
Details of the document amended, including inclusion of IPC
BAF
6 -12
1
IPC team diagram included
10
-
Monitoring compliance updated to include annual work plan and
annual report requirements
13
-
Definitions added due to detail in report having changed
15
-
IPC reporting structure added as appendix
18
-
Evidence Based Summary
Yes
Version
Consulting & Endorsing Stakeholders,
Committees/Meetings/Forums etc for this version only
List all Consulting & Endorsing Stakeholders for this version, this can
include direct consultation with individuals,
Committees/Forums/Bodies/Groups, refer to guidance pack.
Date
7.0
Infection Prevention and Control Committee
7.0
Patient Safety and Effectiveness Committee
--- PDF page 3 ---
Page 3 of 21
Version number: 7.0
Trust-wide PPS title: Infection Prevention and Control Assurance Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
Policy on a page
Infection Prevention and Control Assurance
Framework
This policy will:
Ensure the Trust complies with the statutory requirements of the Code of Practice for health
and adult social care on the prevention & control of infections & related guidance (DOH
2022).
Effective arrangements are in place for the provision of a full Infection Prevention and
Control (IPC) service including policy and guideline production, surveillance, education and
training, and programme of audit led by an Infection Prevention and Control Team (IPCT).
Responsibility for IPC is embedded throughout the organisation.
All healthcare personnel working within the scope of this policy including partners and
external parties are aware of the rationale and responsibility to maintain high standards of
infection prevention and control at all times
IPC advice is provided by a suitably qualified and resourced team, with administrative and
information technology support.
The IPCT is supported by an adequately resourced and staffed microbiology laboratory
capable of promptly processing and reporting results on specimens sent for investigation.
Multi-professional operational and assurance group structures are in place to advise and
support the IPCT.
Engage with staff to develop systems and processes that lead to sustainable and reliable
improvements in applying infection prevention and control practices, ensuring patient and
public involvement.
--- PDF page 4 ---
Page 4 of 21
Version number: 7.0
Trust-wide PPS title: Infection Prevention and Control Assurance Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
Table of Contents
Paragraph
Number
Description
Page
No.
1.0
Scope
5
2.0
Introduction
5
3.0
Details of Policy
5
4.0
Duties / Responsibilities
6
5.0
Dissemination and Implementation
14
6.0
Training
15
7.0
Monitoring Compliance with Policy
15
8.0
Staff Compliance Statement
16
9.0
Equality & Diversity Statement
17
10.0
Ethical Considerations
17
11.0
Sustainability Impact Assessment
17
12.0
Definitions
17
13.0
References & Bibliography
18
14.0
UHCW Associated PPSs
19
15.0
Appendices
20
--- PDF page 5 ---
Page 5 of 21
Version number: 7.0
Trust-wide PPS title: Infection Prevention and Control Assurance Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
1.0
SCOPE
This policy applies to all individuals employed by University Hospitals Coventry and
Warwickshire NHS Trust (hereafter referred to as the Trust), including Private Finance
Initiatives (PFI) and sub-contractors, students, locum agency and bank staff, and staff
employed on honorary contracts who are involved in Trust business, on or off Trust
premises.
2.0
INTRODUCTION
The Health and Social Care Act (2008) Code of Practice for the NHS on the Prevention
and Control of Infection (DOH 2022) requires all healthcare providers to have clear
arrangements for effective prevention, detection and control of healthcare associated
infection (HCAI).
Effective prevention of infection must be part of everyday practice and be applied
consistently by everyone. For many common infections and infectious diseases, early
recognition and swift action can not only reduce the spread of disease and the associated
impact upon service users, staff, visitors and the wider community.
This policy details the organisational structure, operational systems and assurances which
are in place to ensure that IPC activity is focused, coordinated and communicated
effectively within the Trust meeting Code of Practice requirements.
3.0
DETAILS OF POLICY
IPC is an integral element of the Trust’s integrated governance and risk management
frameworks. It is everyone’s responsibility. All staff must understand their role in the
prevention and control of infection in their area of work. The Trust Board, managers and
--- PDF page 6 ---
Page 6 of 21
Version number: 7.0
Trust-wide PPS title: Infection Prevention and Control Assurance Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
staff are all responsible for establishing, maintaining and supporting a co-ordinated
approach to IPC in all areas of their responsibility.
This policy will ensure that:
3.1 Effective arrangements are in place for the provision of a full infection prevention and
control service including policy production, surveillance, education and training, and audit
led by an Infection Prevention and Control Team (IPCT)
3.2 Responsibility for IPC is embedded throughout the organisation
3.3 IPC advice is provided by a suitably qualified and resourced team with administrative
and information technology support.
3.4 The IPCT is supported by an adequately resourced and staffed microbiology laboratory
capable of promptly processing and reporting results on specimens sent for investigation.
3.5 Multi-professional operational and assurance group structures are in place to advise
and support the IPCT.
3.6 All healthcare personnel working within the scope of this policy are aware of the
rationale and responsibility to maintain high standards of IPC at all times
4.0
DUTIES / RESPONSIBILITIES
The Chief Executive and the Board of Directors are responsible for:
•
Ensuring there are effective and adequately resourced arrangements for IPC
within the organisation.
•
Identifying a board level lead for IPC - Director of Infection Prevention and
Control (DIPC)
•
Ensuring that the role and functions of the DIPC are satisfactorily fulfilled by
appropriate and competent persons as defined by DOH (2004b)
•
Approving IPC annual programme, receiving the IPC annual report and any
other reports regarding the state of IPC within the organisation.
--- PDF page 7 ---
Page 7 of 21
Version number: 7.0
Trust-wide PPS title: Infection Prevention and Control Assurance Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
•
Ensuring that appropriate systems are in place for:
-
Reviewing reports and statistics on the incidence of alert organisms (e.g.
MRSA, Cdiff) outbreaks and incidents
•
Ensuring that clinical responsibility for IPC is effectively devolved to:
-
All professional clinical groups in the Trust
-
Clinical specialties and divisions and, where appropriate, support services
and other similar units.
The Trust’s board level DIPC is the Chief Nurse, supported by the Deputy Chief Nursing
Officer/ Deputy DIPC.
The DIPC has the executive authority and responsibility for ensuring strategy is
implemented to prevent avoidable HCAIs and providing Board assurance in relation to:
•
The organisations performance in relation to HCAI, providing regular reports
including an annual report and delivery of the IPC annual programme of work.
•
Actions taken in response to new and updated legislation, national policies and
guidance ensuring effective policies are in place and audited in relation to
infections/alert organisms and conditions
•
Endorsing and reviewing the terms of reference to ensure that the Infection
Prevention and Control Committee (IPCC) discharges its responsibilities and that
IPC activity, including compliance with the committee’s function to meet with CQC
compliance, is included in the IPC annual report.
•
Ensuring that the IPC annual report is made available to the public. This is
discharged through the public session of the Trust Board and through the Trust
internet site.
•
The DIPC will chair the IPCC and report to the Chief Executive and the Board of
Directors.
Deputy DIPC
The Deputy DIPC will provide support and continuity of strategic leadership for infection
prevention and control. The deputy will deputise in the absence of the DIPC.
Infection Prevention and Control Committee
Given the diverse nature of the subject, most control of infection issues are dealt with
through discussions with the relevant individuals, teams, at the appropriate level within the
--- PDF page 8 ---
Page 8 of 21
Version number: 7.0
Trust-wide PPS title: Infection Prevention and Control Assurance Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
Trust’s existing committee structure, or at the appropriate clinical group or departmental
meetings. This is then noted through IPCC.
IPCC meets monthly and is responsible for:
•
Overseeing the implementation of IPC policies, guidelines and initiatives.
•
Oversight of performance against national standards relating to prevention and
control of infection.
•
Acting on the results of HCAI risk assessments, audit and surveillance results.
•
Ratification of UHCW policies and guidance relating to prevention and control of
infection, ensuring that appropriate consultation has taken place.
•
Monitoring of the infection prevention and control risk register
•
Ensuring adequate allocation of resources to facilitate remedial action.
•
Ensuring that the annual IPC programme is produced.
•
Reviewing national guidance/directives and approving resulting action plans as
applicable to the Trust for implementation and review.
Upward reports from IPCC to the Patient Safety and Effectiveness Committee and Quality
Safety Committee are produced each quarter for reporting to Trust Board (appendix 1).
The Lead Nurse for Infection Prevention and Control has responsibility for
•
Implementing the Infection Prevention & Control Strategy and leading and
managing the IPCT and ensuring the responsibilities above are achieved
•
Providing specialist advice and guidance to DIPC and Deputy DIPC
•
Effective delivery of the Trust Infection Prevention and Control annual work plan
through nursing leadership and service improvement.
•
Supporting the development of monthly, quarterly and annual reports as required
for the Board of Directors
•
Ensuring the completion of the IPC BAF with upward report to Trust board via IPCC
•
Ensuring the provision of a high quality infection prevention service to the Trust.
•
Informing and directly influencing IPC practice throughout the Trust through clinical
decision making and by contributing to operational and strategic planning and
leadership
•
Informing and influencing sepsis practice to the Trust
•
The Infection Prevention and Control Team
--- PDF page 9 ---
Page 9 of 21
Version number: 7.0
Trust-wide PPS title: Infection Prevention and Control Assurance Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
•
Provide expert advice and guidance on all IPC matters including risks and
mitigations
•
Respond appropriately to clinical results, ensure relevant alerts are in place both
electronically and through paper records
•
Be visible in all areas and lead through example
•
Take responsibility for leading and developing the strategic direction of IPC
throughout the Trust
•
Act as the lead for the assurance of IPC
•
Interpret national directives and guidelines at a local level
•
Prepare, review and update evidence-based policies and guidelines
•
Develop and provide relevant on IPC training and education
•
Advise on the management of individual patients with infection
•
Develop and implement surveillance and audit programmes and together with
clinician’s appropriate action plans
•
Advise regarding new builds/re-development of the Trust Estates
•
Ensure that IPC advice is available to the Trust 5 days a week 8-6, with cover
outside of these hours provided via the on call Medical Microbiology staff.
•
Ensure screening and surveillance of alert organisms, audit of compliance against
IPC policies and national guidance such as MRSA screening.
•
The IPCT will liaise directly with clinicians and managers to escalate any concerns
regarding alert infectious conditions, e.g. Clostridiodes difficile (Cdiff) and antibiotic
resistant organisms and positive results associated with food and environmental
conditions, e.g. Legionella, salmonella.
•
Work with the Trust to identify and control outbreaks, liaising with other internal
and external departments.
•
Ensuring the provision of education to all grades of staff working within the scope
of this policy.
•
Liaising with the Occupational Health Department, UK Health Security Agency and
other external services or agencies where applicable.
•
In liaison with other relevant staff preparing, reviewing and updating evidence-
based policies and guidelines in line with relevant NHSE/ UKHSA/ DOH
notifications and/or national guidelines, when available and applicable.
•
Ensure all guidelines and policies are available on the Trust Intranet site.
--- PDF page 10 ---
Page 10 of 21
Version number: 7.0
Trust-wide PPS title: Infection Prevention and Control Assurance Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
•
To participate in Patient Led Assessments of the Care Environment (PLACE)
inspections annually.
•
To participate in Trust committees and working groups providing IPC advice and
guidance
•
Provide clinical leadership, education and training in sepsis to improve recognition
and practice in patient outcomes.
•
To support meeting NHS contractual requirements for IPC and sepsis.
Medical Microbiologists / Virologist and Pathology Services.
•
The Team will work with and be supported by Consultant Microbiologists,
Virologists and laboratory teams to assist in the effective delivery of the IPC service
thus reducing any risk and ensuring there are adequate resources capable of
promptly processing and reporting specimens.
•
Out of hours, the on call Microbiologist will inform the wards of any positive results
and safe management of cases.
•
To provide advice on the management of clinical infections and outbreaks and to
be responsible for highlighting issues to the IPCT for further action.
Clinical Groups are responsible for:
•
Ensuring that every ward/clinical department (where appropriate) has designated
IPC link nurse (or other registered practitioner)
•
Ensure that each ward/ department (clinical and non-clinical) has a designated
individual with ability to undertake hand hygiene and (where appropriate)
respiratory mask fit test cascade.
•
Identifying IPC Medical Leads at group level
•
Ensuring that IPC is included in the personal development plan for the designated
medical lead.
•
Producing and presenting a bi-monthly report for IPCC detailing IPC performance
and providing an associated action plan.
•
Ensuring that IPC is a standing agenda item for clinical group governance meetings
and, where relevant, the following are included:
-
Mandatory training compliance,
-
Outbreak and incidents.
-
Action plans from formal investigations e.g., Cdiff infection MRSA/ MSSA
bacteraemia
--- PDF page 11 ---
Page 11 of 21
Version number: 7.0
Trust-wide PPS title: Infection Prevention and Control Assurance Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
-
Key performance Indicator information shared.
IPC Medical leads
The IPC medical leads will provide group level support in raising the profile of IPC and
acting as a role model. The medical leads will:
•
Provide education and training and working within their group feedback lessons
learnt and any remedial actions.
•
Be responsible for attending QIPs meetings and acting as an IPC representative
with medical colleagues.
•
Work closely with the Group Directors of Nursing and Allied Health Professional
(GDNA) and IPC during times of outbreak/ incident or IPC related issue.
Group Directors of Nursing will:
•
Take responsibility for the ownership of IPC in their areas.
•
Ensure that IPC is incorporated into Group decision-making, service planning,
performance management, project management and other related processes.
•
Establish key IPC risk indicators which are monitored, reviewed and reported
•
Ensure effective healthcare acquired IPC processes are in place.
•
Ensure that, where necessary, HCAI IPC risks are reported on the group risk
register and escalated in accordance with the Trust’s Risk Management Policy.
•
Embed a high standard of IPC practice in all areas to help prevent and reduce
HCAI.
•
Ensure IPC is performance managed within groups through prompt response to
infection incidents and audit results.
•
Ensure escalation and assurance processes are in place.
Matrons
In addition to contributing to the responsibilities as outlined above, Matrons will:
•
Oversee that the domestic, clinical, and non-clinical cleaning responsibilities in
the area are covered.
•
Lead monthly hand hygiene audits, as well as formative rounds and peer review
audits, checking and challenging practice.
•
Lead and drive a culture of cleanliness in clinical areas, monitoring local
compliance, with the estates, facilities, and IPC teams, through clinical
--- PDF page 12 ---
Page 12 of 21
Version number: 7.0
Trust-wide PPS title: Infection Prevention and Control Assurance Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
environmental spot checks and audit, followed by updating the risk register with
migratory actions.
•
Use quality dashboards and league tables for benchmarking and monitoring
cleaning practices.
•
Ensure corridors, walkways and visual display areas are clear, clean and tidy, so
that the organisation’s infrastructure is safe.
•
Monitor standards of cleanliness in clinical areas.
•
Identify IPC training needs to ensure that staff and volunteers are able to work
safely and comply with Trust procedures, including mandatory training
requirement.
•
Ensure implementation of Trust IPC policies, procedures, and guidelines.
•
Ensure there is promotion of IPC awareness responsibilities amongst employees,
service users, contractors and partners.
•
Participate in post infection investigations where required to promote learning and
practice improvement.
The Ward Manager/ department Leaders are responsible for:
•
Monitor standards of cleanliness in clinical areas.
•
Ensure corridors, walkways and visual display areas are clear, clean, and tidy, so
that the organisation’s infrastructure is safe.
•
Ensure implementation of Trust IPC policies, procedures and guidelines.
•
Ensure there is promotion of IPC awareness responsibilities amongst employees,
service users, contractors and partners.
•
Identify IPC training needs to ensure that staff and volunteers can work safely
and comply with Trust procedures, including mandatory training requirement.
•
Ensuring IPC training requirements are discussed in appraisal and included in
personal development plans where appropriate.
•
Participate in post infection investigations where required to promote learning and
practice improvement.
•
Support staff to attend Occupational Health appointments and/or meet risk
assessment needs.
The Link Practitioners for Infection Prevention and Control are responsible for:
•
Contributing to the delivery of the Trust’s IPC annual work plan by monitoring
standards of IPC in clinical practice.
--- PDF page 13 ---
Page 13 of 21
Version number: 7.0
Trust-wide PPS title: Infection Prevention and Control Assurance Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
•
Development and communication of ward/department infection prevention action
plans and regular communication with the IPCT.
•
Undertaking and achieving the IPC competence training programme; as per IPCT
advice.
•
A source of information and guidance of IPC related issues in their area.
Antimicrobial Pharmacist
The Antimicrobial Pharmacist promotes the appropriate use of antimicrobial agents
through education, policy and guidelines. They will participate in IPCC, attend specialty
ward rounds with high antibiotic use, and monitor antimicrobial use across the trust
including point prevalence audits each quarter and on an ad hoc basis as required.
Occupational Health
The Trust Occupational Health Department should:
•
Ensure all staff have access to occupational health service.
•
Have occupational health policies for the prevention and management of
communicable infections in healthcare workers.
•
Offer risk-based screening for communicable diseases and assessment of
immunity to infection after conditional offer of employment.
•
Have arrangements in place for regularly reviewing the immunisation status of
healthcare workers and providing appropriate vaccinations to staff as necessary on
the basis of risk assessment.
•
Have arrangements in place for identifying and managing healthcare staff infected
with hepatitis B, C, HIV and advising about fitness for work, including healthcare
workers who are new to NHS
•
Liaise with the UK advisory panel for health care workers infected with blood borne
viruses when:
-
Advice is needed about fitness to undertake exposure prone procedures
-
When advice on patient notifications exercise
-
When offer of Blood Bourne Virus testing may be needed
•
Have arrangements for risk assessment and appropriate management after
accidental occupational exposure to blood and bodily fluids.
•
Alerting the IPCT of any infectious conditions amongst Trust employees that could
be transmitted during the course of their work.
--- PDF page 14 ---
Page 14 of 21
Version number: 7.0
Trust-wide PPS title: Infection Prevention and Control Assurance Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
•
Participating in the contract tracing of staff exposed to infectious conditions as
applicable.
•
Co-ordinating staff treatment of any infectious disease (treatment maybe source
external to Occupational Health e.g., GP).
All Other Staff
All staff across the Trust have responsibility to ensure they comply with local IPC policies
and guidelines/procedures. They also have a duty to report all infection related incidents
including near misses on Datix according to Trust policy and to inform a member of the
IPCT as soon as possible after an incident has occurred.
Whilst the Trust Board has collective responsibility, effective IPC is the personal
responsibility of every member of staff. The following applies to all Trust employees and
those providing a service or function under a service agreement or contract:
•
IPC responsibilities outlined in job descriptions and discussed as appropriate at
appraisals as aligned to role
•
All employees are responsible for ensuring that they undertake relevant IPC
training available to them
•
All employees are personally accountable for their actions and responsible for
ensuring that they comply with IPC policies
•
All employees must understand their legal duty to take reasonable care of their own
health, safety and security and that of other people who may be affected by their
actions or omissions and for reporting incidents and areas of concern
•
All healthcare professionals are responsible for notifying the IPCT of circumstances
that may lead to outbreaks if infection or a breakdown of IPC procedures
•
Personal and professional codes of practice and responsibility will be adhered to in
all situations
5.0
TRAINING
IPCT will work with the Trust Learning and Development Department to deliver training at
induction and mandatory updates for clinical staff. Infection Prevention and Control
--- PDF page 15 ---
Page 15 of 21
Version number: 7.0
Trust-wide PPS title: Infection Prevention and Control Assurance Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
mandatory training is delivered via e- learning and the results recorded electronically on
the learning management (ESR) system.
Training required to fulfil this policy will be provided in accordance with the Trust’s Training
needs Analysis. Management of training will be in accordance with the Trust’s Mandatory
training policy.
6.0
MONITORING COMPLIANCE
7.1 Monitoring Table
Aspect of
compliance or
effectiveness
being
monitored
Monitoring
method
(i.e. regular
audits/reviews)
Individual/
department
responsible
for the
monitoring
Frequency of
the
monitoring
activity (i.e.
Monthly/
Annually)
Group /
committee
which will
receive the
findings /
monitoring
report
Group /
committee /
individual
responsible
for ensuring
that the
actions are
completed
IPC BAF
Review
Lead Nurse
of IPC
Quarterly
IPCC
IPCC
IPCT is
adequately
supported and
resourced
Annual report
DIPC
Annually
QSC, Trust
Board
DIPC
An
annual
programme is
approved
by
the Board
Annual report
DIPC/ Lead
Nurse
Annually
IPCC, QSC,
Trust Board
DIPC
Annual report
is
produced
and presented
to the Board
Annual report
DIPC/ Lead
Nurse
Annually
QSC,
Trust
Board
DIPC
This policy is
compliant with
new guidance
re
Infection
Prevention
and Control
Review
of
National
guidance
Lead Nurse
of IPC
Annually,
or
when
changes
to
the policy are
made due to
guidance
or
organisational
changes
IPCC
DIPC
Information
available
to
patients
and
the
public
regarding the
Trust's
processes and
arrangements
Review
of
information
provided
to
service users
and public
Lead Nurse
of IPC
Annual
PSEC, IPCC
Director
of
Infection
Prevention
and Control
--- PDF page 16 ---
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Trust-wide PPS title: Infection Prevention and Control Assurance Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
for preventing
and controlling
healthcare
acquired
infections
Audit
programme,
including alert
organisms,
outbreaks and
issues related
to IPC.
Quality/
performance
indicators e.g.
-Number
of
HCAI
infections
-
National
reporting
of
hospital
acquired
infections
-The process
of route cause
analysis
for
HAI
Reporting
of
serious
incidents
through
the
trust systems
and
external
partners.
-Reporting
of
IPC incidents
through Datix
clinical
reporting.
Reports
on
progress
to
address
themes
and
trends
on
areas of non-
compliance.
Lead Nurse
IPC
Monthly
PSEC, IPCC
Director
of
Infection
Prevention
and Control
Quarterly
clinical group
report to IPCC
Performance
report
Clinical
Group/ IPC
medical
lead/ GDNA
Quarterly
IPCC
IPCC
8.0
STAFF COMPLIANCE STATEMENT
All staff must comply with this Trust-wide Policy, Procedure or Strategy and failure to do
so may be considered a disciplinary matter leading to action being taken under the Trust-
s Disciplinary Procedure. Actions which constitute breach of confidence, fraud, misuse of
NHS resources or illegal activity will be treated as serious misconduct and may result in
dismissal from employment and may in addition lead to other legal action against the
individual/s concerned.
--- PDF page 17 ---
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Version number: 7.0
Trust-wide PPS title: Infection Prevention and Control Assurance Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
A copy of the Trust’s Disciplinary Procedure is available from eLibrary.
9.0
EQUALITY & DIVERSITY STATEMENT (Do not delete)
Throughout its activities, the Trust will seek to treat all people equally and fairly. This
includes those seeking and using the services, employees and potential employees. No-
one will receive less favourable treatment on the grounds of sex/gender (including Trans
People), disability, marital status, race/colour/ethnicity/nationality, sexual orientation, age,
social status, their trade union activities, religion/beliefs or caring responsibilities nor will
they be disadvantaged by conditions or requirements which cannot be shown to be
justifiable. All staff, whether part time, full-time, temporary, job share or volunteer; service
users and partners will be treated fairly and with dignity and respect.
10.0
ETHICAL CONSIDERATIONS (Do not delete)
The Trust recognises its obligations to maintain high ethical standards across the
organisation and seeks to achieve this by raising awareness of potential or actual ethical
issues through the PPS consultation and approval process. Authors of PPSs are therefore
encouraged to liaise with the Trust’s Clinical Ethics Forum to seek input where necessary.
11.0
SUSTAINABILITY IMPACT ASSESSMENT (Do not delete)
UHCW NHS Trust is committed to ensuring that the way we provide services minimises
the impact on the environment and the future health of the public e.g. zero waste to
landfill, reducing our carbon footprint and recycling and reuse percentages. The actions
in this policy have been assessed and are in line with the Trust’s Net Zero commitment
and NHS Net Zero target.
12.0
DEFINITIONS
Cdiff
Clostridiodes difficile
CQC
Care Quality Commission
DIPC
Director of Infection Prevention and
Control
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Trust-wide PPS title: Infection Prevention and Control Assurance Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
DoH
Department of Health
GDNA
Group Director of Nursing and Allied
Health Professionals
HCAI
Healthcare associated infections
HCAI
Healthcare Associated Infection
IPC
Infection Prevention and Control
IPC BAF
Infection Prevention and Control Board
Assurance Framework
IPCP
Infection Prevention and Control
Practitioner
IPCT
Infection Prevention and Control Team
MSSA
Meticillin Sensitive Staphylococcus
Aureus
MRSA
Meticillin Resistant Staphylococcus
Aureus
NHSE
National Health Service England
13.0
REFERENCES AND BIBLIOGRAPHY
13.1
The Health & Social Care Act (2008) Code of Practice for the Prevention of Infections
and related guidance, Revised 2022. Department of Health, London <
https://www.gov.uk/government/publications/the-health-and-social-care-act-2008-code-
of-practice-on-the-prevention-and-control-of-infections-and-related-guidance/health-and-
social-care-act-2008-code-of-practice-on-the-prevention-and-control-of-infections-and-
related-guidance>
Department of Health (2008) Board to ward: How to embed a culture of HCAI prevention
in acute trusts
www.dh.gov.uk/prod consumdh/groups/dhdigitalassests/documents/digitalasset/dh
112195
DOH (2004b). Competencies for Directors of Infection Prevention and Control. London:
DH, Available at:
http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/publicationsandstatistics/l
ette rsandcirculars/Dearcolleagueletters/DH_4083982
National infection prevention and control manual (NIPCM) for England (2022) [last
accessed 15th September 2023] NHS England » National infection prevention and control
manual (NIPCM) for England
--- PDF page 19 ---
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Trust-wide PPS title: Infection Prevention and Control Assurance Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
14.0
UHCW ASSOCIATED RECORDS
COP 193
Aseptic non touch technique
CG 930
Clostridiodes difficile
CG 1583
Screening, Prevention and Management of Meticillin
Resistant Staphylococcus aureus (MRSA)
COP 222
Bed And Mattress Cleaning Procedure
COP 209
Body Infestations - Management and treatment of
patients with
COP 96
Cleaning and Disinfection of Non-invasive
Equipment & Computers
CB 10
Community Sepsis Pathway and Screening Tool
CG 2230
Community Sepsis Pathway and Screening tool
Guidance
CG 1885
Food Hygiene Guidelines
CG 1362
Guidelines For the Management of Tuberculosis
COP 211
Home laundering of staff uniforms
CG 334
Isolation Guideline
CG 337
Management of an Outbreak or Incident
COP 915
Management of Multi-Resistant Organisms
COP 954
Management of Norovirus
COP 63
Procedure for the laundering of Soiled Patients
Clothing in the Home Setting
CB 13
Protocol for Management of Neutropenic Sepsis
Pathway
CG 2032
Respiratory Infections Guideline
CG 47
Screening and management of Sepsis in Adults
COP 914
Viral Haemorrhagic Fever (VHF): Acute
Identification and management guide.
OPER-POL-03-10 Infection Prevention and Control Policy
OPER-POL-001-07 Trust Decontamination Policy
OPER-POL-002-10 Hand Decontamination Policy
--- PDF page 20 ---
Version number: 7.0
Trust-wide PPS title: Infection Prevention and Control Assurance Policy
This Trust-wide PPS has been developed/reviewed in accordance with the Trust approved ‘Development & Management of Trust-wide Policies, Procedures and Strategies Procedure
(Clinical and Non-clinical strategies, policies and procedures)’
Appendix 1 IPC reporting Governance Structure
--- PDF page 21 ---
Version number: 7.0
Trust-wide PPS title: Infection Prevention and Control Assurance Policy
This Trust-wide PPS has been developed/reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
--------------------------------------------------------------------------------
ATTACHMENT: 22_1.pdf
TEXT_FILE: 22_1.pdf.txt
METHOD: pdf_native
OCR_USED: False
PAGES: 36
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Version number:
Trust-wide PPS title: Management of Health Care Workers Living with and Working with Blood Borne Viruses, Policy.
This Trust-wide PPS has been developed/reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
Title of Trust-wide PPS:
Management of Health Care Workers Living and Working with Blood
Borne Viruses Policy
eLibrary ID Reference No:
This id will be applied to all new Trust-wide PPSs by
the Quality Department and will be retained throughout
its life span.
H&S-POL-001-11
Newly developed Trust-wide PPSs will be allocated an eLibrary reference number following Trust approval.
Reviewed Trust-wide PPSs must retain the original eLibrary reference number.
The Quality department will progress all new, re-written and reviewed PPSs for final Trust approval.
Version:
(Must be a rounded number, i.e. 6.0,7.0 etc.)
5.0
Title of Approving Committee:
Policy governance Group
Date Approved:
June 2024
Risk Rating:
(this must be applied by the Author prior to being submitted to the
Quality Dept. ( refer to PPS guidance pack on eLibrary)
Moderate
Next Review Date:
(this must be applied by the Author dependant on risk rating or
record alternative date if required to meet national guidance)
June 2026
If printed, copied or otherwise transferred from eLibrary, Trust-wide Policies,
Procedures and Strategies will be considered ‘uncontrolled copies’. Staff must
always consult the most up to date PDF version registered on eLibrary.
As a controlled Trust-wide PPS, this record should not be saved onto local or network
drives but should always be accessed from eLibrary.
If you have any queries with regards to the library service, please could you direct
your query to the email address: library@uhcw.nhs.uk.
--- PDF page 2 ---
Page 2 of 36
Version number: 5
Trust-wide PPS title: Management of Health Care Workers Living with and Working with Blood Borne Viruses Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
Trust-wide PPS to be read in conjunction with:
(List overarching/underpinning strategies, policies and
procedures – refer to PPS Evidence Summary)
Relevance:
(State one of the following: Governance, Human
Resource, Finance, Clinical, ICT, Health & Safety,
Operational)
People Directorate
Superseded Trust-wide PPSs (if applicable):
(Should this PPS completely override a previously
approved Trust-wide PPS, please complete the ‘Request
for Removal of PPS’ form and submit to Quality Dept –
please refer to eLibrary and state full title and eLibrary
reference number and the PPS will be removed from
eLibrary)
Author’s Name, Title and email address:
(must not be the same as reviewer)
Julie Atkins, Senior Specialist Occupational Health
Practitioner
julie.atkins@uhcw.nhs.uk
Reviewer’s Name, Title & email address:
(must not be the same as author)
Alison Evans, Head of Occupational Health
alison.evans@uhcw.nhs.uk
Chief Officer’s Name, Title:
Donna Griffiths
Chief People Officer
Title of Group/Department/Specialty:
People Directorate
Occupational Health Shared Service
Changes since last version
Detail of Changes
Page No.
Para No.
Change Occupational Health Department to Occupational
Health Shared Service (OHSS) and Public Health England
(PHE) to United Kingdom Health Security Agency (UKHSA)
throughout policy.
Change of title: change form “Blood Borne Viruses, Employment
and screening Procedure” to “Management of Health Care
Workers Living and Working with Blood Borne Viruses Policy”.
1
Title
Add RIDDOR
9
Add review by Chief People Officer
9
Removal of Screening Procedures, a separate procedure
/document will replace this.
11-18
Add reference to re-deployment documents.
11
Duties & Responsibilities: addition of Medical Director, Chief
People Officer, Resourcing Team/Recruitment
18
Addition of Patient Notification Exercise (PNE)
18
Addition of other Stakeholders: Locums, Students.
24
Addition: Record Keeping
25
Addition: Confidentiality
27
--- PDF page 3 ---
Page 3 of 36
Version number: 5
Trust-wide PPS title: Management of Health Care Workers Living with and Working with Blood Borne Viruses Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
Changes to Audit/Monitoring of Policy
28
Removal of Appendices: 2-7
Addition of new relevant appendices: 2-8
Evidence Based Summary
(Please state whether Evidence Based Summary is used in the document)
In July 2019 UK Advisory Panel for Healthcare Workers Living with Bloodborne Viruses
(UKAP) published updated integrated guidance that described new recommendations
on the monitoring and clearance of healthcare workers (HCWs) living with hepatitis B
infection, and the investigation of situations where a HCW has been diagnosed with a
bloodborne virus (BBV), based on the evidence base and experience from over 20
years of UKAP investigations.
Over the past 2 years this guidance has been embedded into practice and UKAP
have received helpful feedback on its implementation. The 2020 update contained
changes based on this feedback in order to clarify roles and responsibilities of
stakeholders, and the settings in which the guidance should be applied. The 2021
update contained changes to the recommended monitoring time of HCWs living with
hepatitis B. These changes, detailed in section 7.2, align with national practice (1 to
2) and other international (3 to 5) guidelines.
The 2022 update has new advice regarding reactivation of hepatitis B (rHBV)
following immunosuppression. In cases with resolved hepatitis B, rHBV is becoming
more common due to increasing use of therapeutic immunosuppression for other
conditions. This advice is included in section 6.4 and detailed in section 7.2 of the
UKHSA document.
Version
Consulting & Endorsing Stakeholders,
Committees/Meetings/Forums etc for this version only
List all Consulting & Endorsing Stakeholders for this version, this can
include direct consultation with individuals,
Committees/Forums/Bodies/Groups, refer to guidance pack.
Date
(This table must be complete or the PPS will be returned to the author)
Infection Prevention and Control Committee
April 2024
Patient Safety and Effectiveness Committee
People Directorate
--- PDF page 4 ---
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Version number: 5
Trust-wide PPS title: Management of Health Care Workers Living with and Working with Blood Borne Viruses Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
Policy on a page
Management of Health Care Workers Living
with and Working with Blood Borne Viruses
Policy
•
The overall aim of the policy is to control the risk to patients and staff from
health care workers (HCW) infected with blood borne viruses (BBV), to
control the risk to HCWs from BBV infected patients and to reinforce good
practice.
•
The policy outlines how UHCW NHS Trust will ensure compliance with the
UKHSA’s guidance on health clearance for HCW for BBV (Hepatitis B,
Hepatitis C and Human Immunodeficiency Virus (HIV).
•
Clarification of Roles and Responsibilities within UHCW.
--- PDF page 5 ---
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Version number: 5
Trust-wide PPS title: Management of Health Care Workers Living with and Working with Blood Borne Viruses Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
Table of Contents
Paragraph
Number
Description
Page
No.
1.0
Scope
6
2.0
Introduction
7
3.0
Details of Policy
8
4.0
Duties / Responsibilities
10
5.0
Dissemination and Implementation
17
6.0
Training
18
7.0
Monitoring Compliance with Policy
19
8.0
Staff Compliance Statement
19
9.0
Equality & Diversity Statement
19
10.0
Ethical Considerations
20
11.0
Sustainability Impact Assessment
20
12.0
Definitions
20
13.0
References & Bibliography
21
14.0
UHCW Associated PPSs
24
15.0
Appendices
25
--- PDF page 6 ---
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Version number: 5
Trust-wide PPS title: Management of Health Care Workers Living with and Working with Blood Borne Viruses Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
1.0
SCOPE
(Define the audience to whom this Trust-wide PPS applies.) (Delete upon insertion of text)
1.1 Certain Blood Borne Viruses (BBV) can be transmitted form infected Health Care
Workers (HCW) to patients, and from patients to susceptible Health Care Workers
during clinical procedures. The main viruses of concern are Hepatitis B (HBV),
Hepatitis C (HCV) and Human Immunodeficiency Virus (HIV).
1.2 This policy sets out the Trust approach to managing the risk of transmission of BBV
from staff to patients.
The objectives are:
•
Outline the main areas of risk of transmission of BBV.
•
Outline the responsibilities of the Managers, Occupational Health Service and
Employees.
1.3 This policy applies to all healthcare workers already in employment and those seeking
employment with UHCW NHS Trust and includes substantive, temporary and agency
workers and those on clinical placement. Agencies supplying staff to UHCW must also
comply in full. Education and training establishments must ensure that their staff or
students are compliant with no less rigorous standards. The Occupational Health Shared
Service (OHSS) clients will implement the same guidance from the United Kingdom Health
Security Agency (UKHSA) and the OHSS will liaise with all of its clients who hold contracts
with the OHSS as required to ensure that they are compliant with the same rigorous
standards as well.
1.4 This policy relates to all UHCW healthcare workers with direct patient contact. Basic
control of infection measures provides an important element of BBV infection control and
must be followed by all HCW.
--- PDF page 7 ---
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Version number: 5
Trust-wide PPS title: Management of Health Care Workers Living with and Working with Blood Borne Viruses Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
1.5 After examining the risks, expert UK guidance suggests that formal pre-employment
and “in post” clearance for BBV carriage should be limited to those HCWs involved in
carrying out EPPs, working in exposure prone environments and performing clinical
duties in Renal units or any other settings involving renal dialysis.
1.6 This policy operates in conjunction with UHCW NHS Trust Health Care Worker
Immunisation and Screening Policy, Safe use and disposal of sharps policy and
Management of Health care workers sharps/splash injuries and Post Exposure
procedures for hepatitis B virus (HBV) , hepatitis C virus (HCV) and Human
Immunodeficiency virus (HIV) Policy
2.0
INTRODUCTION
(This section should state why the policy is being developed and must include all relevant national and local guidelines,
statutory requirements or other relevant recommendations. It must also identify the risk(s) the policy will address – refer to
evidence summary for PPSs being reviewed.) (Delete upon insertion of text)
2.1 Blood borne viruses (BBV) are infective agents that can be found in the blood of an
infected person. Information on transmission risk can be found in appendix 1. Blood borne
viruses can, under certain circumstances, be transmitted from patient to healthcare worker
and from healthcare worker (HCW) to patient during exposure prone procedures. (EPPs).
2.2 The Trust has a responsibility to promote general awareness of blood borne viruses in
order to provide a safe working environment for employees and patients as well as to
promote safe working practices. The Trust also has a duty of care in relation to all
employees at occupational risk of contracting blood borne viruses. There is a need for an
effective procedure for screening and health clearance of all staff at risk from contracting
or transmitting blood borne viruses to patients.
This policy will enable the Trust to:
•
Reduce transmission risks to both health care workers and patients in their care.
•
Reduce potential demands on the Trust’s financial resources and emphasise
commitment to our employees and patients.
2.3 This policy assists compliance with the following health and safety legislation:
•
General duties placed upon employers and others by the Health & Safety at Work Act
1974.
• Broad risk assessment requirements of the Management of Health & Safety at Work
Regulations 1992 (updated in 1999)
--- PDF page 8 ---
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Trust-wide PPS title: Management of Health Care Workers Living with and Working with Blood Borne Viruses Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
• Health surveillance and monitoring of microbiological hazards under the
current Control of Substances Hazardous to Health Regulations (COSHH)
2002.
•
RIDDOR: Reporting of Injuries, Diseases and Dangerous Occurrences Regulations
2013.
This policy was reviewed using the expertise of the Chief People Officer, Infection Control
Team, Health & Safety Team and Occupational Health Physician and for the purpose of
external peer review and consultation.
3.0
DETAILS OF POLICY
3.1 This policy applies to all healthcare workers (HCWs) who perform exposure prone
procedures (EPPs) for the first time. This includes existing HCWs who are moving post or
training that involves EPPs and those returning to the NHS dependent on what activities
they have engaged in while away from the NHS.
This policy does not apply to HCWs who are already employed in the Trust with the
exception of those moving to a post requiring performance of EPPs for the first time in their
career.
3.2 In the UK, the policy on the management of healthcare workers (HCWs) infected with
blood borne viruses (BBVs) has evolved over time. This evolution has been informed by
evidence on the risk of HCWs transmitting blood borne viruses to their patients, the
outcomes of patient notification exercises and the recommendations of the Expert Advisory
Groups.
In October 2017, a consolidated guideline incorporating previously existing guidance on
health clearance of healthcare workers and management of healthcare workers living with
BBVs into one document was issued. This guideline, Integrated guidance on health
clearance of healthcare workers and the management of healthcare workers living
with bloodborne viruses (hepatitis B, hepatitis C and HIV) , is regularly updated, with
the most recent iteration being in November 2023.
3.3 This policy updates and replaces the previous UHCW NHS Trust policy “Blood Borne
Viruses, Employment Policy, and Screening Procedure” V4. It will separate the Trust Policy
and the OHSS procedure. It highlights the responsibility of the OHSS, and duties and
--- PDF page 9 ---
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Version number: 5
Trust-wide PPS title: Management of Health Care Workers Living with and Working with Blood Borne Viruses Policy
This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
responsibilities of the People Directorate, Heads of Departments, Management,
Recruitment Department, Health & Safety Team and Health Care Workers.
3.4 The screening procedure will be outlined in an OHSS procedure and used in
conjunction with the UKHSA, Reference: Integrated guidance for management of BBV
in HCW November 2023 (publishing.service.gov.uk)
3.5 The aim of this policy is to control the risk to patients and staff form HCW infected, or
potentially infected, with Blood Borne Viruses (BBVs) by documenting UHCW NHS Trust
requirements and systems for the management of such HCWs. It also aims to control the
risk to HCW form patients and reinforce good practise. It represents the definitive plan for
implementing within the OHSS the UK requirements for protecting patients form Hepatitis
B, C and HIV as outlined in the most recent guidance documents. In addition, the policy
maintains the confidentiality and safe working of all staff infected with BBVs and works
alongside the Management of Health Care Workers sharps and splash injuries/incidents
involving potential exposure to blood borne viruses.
3.6 This policy outlines how UHCW NHS Trust will ensure compliance with the UKHSA
“Integrated guidance on clearance of Health Care Workers and the management of health
care workers living with BBV” document.
3.7 The policy will set out:
•
Responsibilities within UHCW NHS Trust for the delivery of the policy
•
Will outline the ongoing management and support of BBV-infected HCWs
according to the Trusts redeployment procedures under: “Medical & Dental Re-
skilling, Rehabilitation & Remediation Policy” and “Capability & Performance
Procedure”, and Supporting/Managing Attendance processes.
•
Will work alongside the procedure for dealing with incidents involving potential
exposure to BBVs, which allows rapid access for reporting and treating , and
accessing Post Exposure Prophylaxis (PEP) and follow up according to the
“Management of Health Care Workers Sharps/Splash injuries and post exposure
procedures for Hepatitis B virus (HBV), Hepatitis C Virus (HCV) and Human
immunodeficiency virus (HIV) policy.
•
Will highlight the need for subsequent risk assessment and patient notification
exercise if appropriate if the policy is breeched.
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This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
4.0
DUTIES / RESPONSIBILITIES
(State the expectations of staff and specific responsibilities of individual posts and committees. Ideally this should cover
from ‘board to ward’) (Delete upon insertion of text)
4.1 Director of Workforce.
The Director of Workforce has the responsibility to ensure that the policy is published and
is known by UHCW NHS Trust.
The Director of Workforce is responsible for health and safety direction within their
speciality/departments and areas of responsibility, taking in to account of statutory
requirements. They will ensure that Trust policy is implemented and health and health and
safety responsibilities are detailed in agreed job descriptions. Other duties include:
•
Ensuring that management know and accept their individual responsibilities for
health, safety and welfare to meet statutory requirements and best practise.
•
Advising the board of resources required to comply with statutory requirements.
•
Ensuring that adequate communication channels are in place and maintained to
deliver information to the Trust employees.
•
Overseeing the implementation of the Trust Polices and procedures.
•
Ensure that they and all persons reporting to them, are suitably trained to enable
successful implementation of these statutory requirements.
•
Ensure systems are in place to systematically manage and communicate risks.
4.2 Management/Clinical Leads
Managers and Clinical Leads are responsible for ensuring:
•
That Staff are aware of this policy.
•
That the OHSS and Recruitment team are made aware of any HCW whose role
includes EPP work or if working in an exposure prone environment.
•
That Staff involved in exposure prone procedures are aware of the need for routine
infection control measures and safe working practices to prevent transmission of
BBVs in a health care setting. These measures are outlined in the Trust wide
Standard Infection Prevention and control and the Management of Health Care
Workers sharps/splash injuries and post exposure procedures for HBV, HCV and
HIV policy, and the Safe use and disposal of Sharps Policy.
•
That staff are aware of the requirement to report blood and body Fluid
contamination sharps incidents and splash incidents promptly in compliance with
the Trust wide Management of Health Care Workers sharps/splash injuries and
post exposure procedures for HBV, HCV and HIV policy.
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•
Every effort must be made by managers to accommodate employees OHSS
appointments and to ensure their compliance with OHSS requests. Managers will
be informed in writing of any employee who fails to attend/ respond to the OHSS
requests and appropriate action should be taken as necessary.
•
That if they have knowledge of the health status of an infected HCW, they have a
duty to keep such information confidential. They are not legally entitled to disclose
this information unless the individual gives consent, or in exceptional
circumstances, a decision to disclose without consent should be carefully weighed,
as managers taking such action may be required to justify their decision, which may
lead to disciplinary action or legal proceedings if the disclosure is deemed
unjustified.
•
To ensure that all healthcare workers including students carrying out clinical work
are made aware of the guidance and not permitted to participate in exposure prone
procedures until they have been passed fit for these duties by an Occupational
health service. This also applies to academic visitors who may be involved in
exposure prone procedures during their stay on Trust premises.
4.3 Resourcing Team, Medical Resourcing and Temporary Staffing
The protection of both staff and patients begins at the pre-placement stage. Mechanism
should be in place in conjunction with the Human Resources department, to identify new
HCW’s whose role whose role will require EPP clearance or those moving to a new role
which involves EPP to ensure that the necessary checks are carried out relevant to the job
hazard and risk profile.
UKAP has specified that ALL staff planning on undertaking EPPs must undertake an
enhanced health clearance before doing so, without exception.
The Resourcing Teams are responsible for ensuring:
•
That they follow the correct pre-employment health clearance procedure for
HCWs who are already employed but changing posts.
•
That they inform the OHSS of candidates whose duties will include carrying out
exposure prone procedures.
•
That new Candidates must be advised of this policy and informed that
documentary evidence of hepatitis B status, hepatitis C and HIV and Hepatitis B
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Vaccine evidence will be required prior to receiving medical clearance for a
substantive or locum post involving EPP work.
•
That new Candidates may be offered a post “pending” or “in progress”
Occupational Health clearance and other recruitment checks. However, written
occupational health clearance to undertake exposure prone procedures must be
obtained before an appointment can be confirmed, and prior to the candidate
taking up the post.
•
that agencies supplying temporary staff produce adequate documentation
demonstrating satisfactory compliance with Trust policy.
•
EPP Restrictions imposed on HCWs must be adhered to and every effort made to
arrange suitable alternative work should this prove necessary under the Equality
Act 2010 and Trust redeployment procedures.
4.4 Occupational Health Shared Service
The Occupational Health Shared Service is responsible for ensuring:
•
That they provide an appropriate level of counselling prior to blood testing, advice
and information for healthcare workers regarding BBV, hepatitis B vaccination,
blood testing required for EPP and the implications of a positive result.
•
That the HCW is provided with information on their BBV status and will be
encouraged to discuss their condition with their senior manager or professional
lead for the purpose of facilitating alternative duties or other support as necessary.
•
That confidentiality will be preserved as far as reasonably possible.
•
Confidentiality of any HCW infected with a BBV is maintained in line with the
General Data Protection Regulations 2018, Access to Medical Reports Act 1988
and the Trust Confidentiality and Data Protection policy. This responsibility
includes the security of confidential Occupational Health manual and electronic
records.
•
That the process to liaise with the UK Advisory Panel for Health Care Workers
Infected with Blood Borne Viruses (UKAP) as necessary and provide information
about the.
•
The Occupational Health Physician must provide advice when requested on the
NHS Injury Benefits Scheme, which provides temporary or permanent benefits for
all NHS employees who lose remuneration because of an injury or disease
attributable to their NHS employment. Under the terms of the scheme it must be
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This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
established whether, on the balance of probabilities, the injury or disease was
acquired during the course of work.
•
Where the OHSS is made aware that an infected HCW has not followed advice to
modify practice, it should inform an appropriate person in the health care worker's
employing or contracting authority (e.g. Trust Chief Medical Officer or Director of
Public Health). Wherever possible the health care worker should be informed
before information is passed to an employer or regulatory body. This measure
should only be taken if steps have been taken to confirm the facts, as far as is
reasonably practicable and, where possible, the infected HCW should be informed
before this action is taken.
•
Blood for EPP clearance should be an Identified Validated Sample (IVS) and
completed by OHSS Practitioners and sent to the laboratory by OH personnel – not
sent to a phlebotomist unless accompanied by a member of the OH team. Identity
of the HCW will be checked by identity badge, other photo identity (driving licence
or by passport).
•
The OHSS will monitor BBV exposure incidents via Datix and present quarterly
figures in the OHSS Quarterly report to the Health, Safety, Fire committee and
Infection Prevention committee in order to advise on prevention strategies.
•
Patient Notification Exercise (PNE) That the HCW will be advised that senior
management or other relevant professionals may need to be informed e.g. during
patient notification look back exercise.
4.5 Patient Notification Exercises (PNE’s)
Finding that a HCW has performed EPPs while living with HCV, or that the viral load of a
HCW living with HIV or HBV has risen above the cut-off for performing EPPs would not, in
itself, be an indication to trace, notify and offer testing to patients treated by the HCW
(undertake a PNE).
The need for a PNE should be determined on a case-by-case basis taking into
consideration a risk assessment of the HCW’s practice and probity in relation to the risk of
BBV transmission to EPP patients, the relative infectious window period, and significance
of any viral load ‘blip’, in line with the principles in existing guidance. UKAP should be
consulted for advice on undertaking a PNE.
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of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
Further information and guidance on risk assessment and investigation of potential
exposures is available from UKAP.
4.6 Health and Safety Manager
The Trust Health & Safety Manager is accountable to the Executive Director for Safety and
Risk. Their responsibility is to develop, deliver and review safety and risk strategy within
the Trust. Other duties within this policy include:
•
Confirm an incident is reportable under RIDDOR once notification of a RIDDOR
reportable incident has been received form the Line/Departmental Manager.
•
Ensure all confirmed RIDDOR reportable incidents are reported as practicable.
•
Assist Groups, departments and wards to maintain a high consistent standard of
safety and risk management.
4.7. Employee Responsibilities
All HCWs have ethical and legal duties to protect the health and safety of colleagues and
patients. The duties of employees are outlined below:
•
Employees must not rely on their own assessment of the risk they may pose to
patients. Any employee with direct patient contact who knows or suspects that they
may have a BBV must seek medical advice immediately via their GP, GUM centre
or OHSS for further advice and follow up. These employees are required to abide
by the ethical guidelines regarding BBVs issued by the General Medical Council,
General Dental Council, Health Professions Council and the Nursing and Midwifery
Council. The HCW must inform the OHSS immediately if they are found to be
positive for any BBV.
•
Any infected HCW must adhere to the advice given by the OHSS regarding any
modifications or limitations to their duties, which may be necessary for the
protection of patients. Employees should be aware that personal physicians, e.g.
GPs, hospital doctors who are caring for an infected HCW who has not followed
advice to modify their practice, must inform the appropriate regulatory body and
Public Health.
•
At the pre-employment health screening stage, HCWs intending to take
up a position in the Trust that requires the performance of exposure prone
procedures must provide dated, identified validated UK laboratory evidence of their
hepatitis B immunity and hepatitis B surface antigen, hepatitis C and HIV status
and subsequent serological markers or be prepared to be tested. This will be prior
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This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
to receiving OH clearance to undertake EPP or undertake clinical duties in
exposure prone work environments. For those who provide insufficient UK
laboratory evidence of Hepatitis B immunity evidence of a negative surface antigen
result from within the last 12 months is required.
•
Employees must follow general infection control guidelines and adopt safe working
practices to prevent BBV transmission in health care settings in line with Trust
policies and procedures. They should also report any unsafe practices to their line
manager.
•
HCWs involved in exposure prone procedures must respond to compulsory
requests from the OHSS to undergo serological blood tests or appropriate
vaccinations for BBVs.
•
Managers will be informed of failure to respond to OHSS requests and disciplinary
action may result.
•
Therefore, employees should be aware that exposure prone procedures
restrictions will be imposed upon infected HCW who refuse subsequent monitoring
or who do not provide adequate UK documentary evidence of hepatitis B surface
antigen, hepatitis C and HIV status as required at the pre-employment stage.
•
HCWs infected with BBVs must not perform exposure prone procedures and must
follow advice given by the Occupational Health Physician and other
medical specialists involved in their care.
•
Employees or colleagues who know, or have good reason to believe, that an
infected HCW has not followed advice to modify practice should inform an
appropriate person in the health care worker's employing or contracting authority
(e.g. a Consultant Occupational Health Physician, Trust Chief Medical Officer or
Director of Public Health), or where appropriate, the relevant regulatory body.
Wherever possible the health care worker should be informed before information is
passed to an employer or regulatory body. This measure should only be taken if
steps have been taken to confirm the facts, as far as is reasonably practicable and,
where possible, the infected HCW should be informed before this action is taken.
•
Where a member of staff is aware of the health status of an infected HCW there is
a duty to keep such information confidential. They are not legally entitled to
disclose this information unless the individual consents, or in exceptional
circumstances. A decision to disclose without consent should be carefully weighed,
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of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
as persons taking such action may be required to justify their decision, which may
lead to disciplinary action or legal proceedings if deemed unjustified.
4.8 Other Stakeholders
In addition, the following will be responsible for implementation of the policy in relation to
themselves, their staff and their students:
Agencies, education and training establishments and other NHS employers providing staff
and students to work in UHCW NHS Trust, including Volunteers, Clinical Attachments
placements.
4.9 Locums
Locums are subject to the same standard of health checks as applied to NHS employees.
Whilst it is the responsibility of the agency to clear temporary staff for EPPs, the NHS
employer has the responsibility to check they have been cleared. The integrated guidance
states: Providers using locums and agency staff are ultimately responsible for making sure
that HCWs have the necessary health clearance to undertake EPP work
This may be achieved by all locum doctors whose role will require EPP being required to
provide evidence, via their employing agency of the following prior to EPP activities:
An immunisation report from a previous/current OH provider, from another NHS Trust
containing blood results being used for EPP clearance must be on a professional
document which can be verified has originated from the issuing OH department and
detailing the results of IVS serology for Hepatitis B surface antigen & antibody, HIV
antibody and Hepatitis C antibody OR copies of the UK laboratory test results of an IVS
sample for the same.
This evidence should be reviewed by the Occupational Health department for the
healthcare organisation where the locum will be working; with confirmation of EPP
clearance provided to the relevant medical staffing department prior to the locum
undertaking EPP activities or working in EPP environments.
4.10 RECORD KEEPING
As part of the process of ongoing monitoring, responsibility for maintaining the HCW’s
record on the UKAP-Occupational Health Monitoring Register of Blood Borne Virus
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of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
Infected Healthcare Workers (UKAP-OHR), and the assurance of data entry, lies with the
accredited specialist in occupational medicine. Delegated authority may also be given to
specific named individuals within a given occupational health service to undertake these
roles on behalf of the accredited specialist in occupational medicine.
Record-keeping is an essential component of EPP clearance activity. All occupational
health practitioners must comply with Information Governance and Data Protection
Policies in the NHS trust in which they are employed to ensure that data in respect of
HCWs BBV status is managed legally, confidentially, and securely. This applies to both
handwritten and electronic records.
5.0
DISSEMINATION AND IMPLEMENTATION
(Record the method/process of how the dissemination and implementation of this PPS will be executed and record all
underpinning operational policies and procedures developed or to be developed to support this.) (Delete upon insertion of
text)
5.1 The policy will be available on the Trust Intranet / e – library for consultation by all
staff.
As this is a local policy Occupational Health Practitioners will be made aware of changes
to policy or procedure at OHSS team meetings.
The policy will be used in conjunction with an OHSS procedure: using the UKHSA
Integrated guidance on the clearance of Health Care Workers and the management of
Health Care Workers living with BBV’s.
5.2 CONFIDENTIALITY
HCWs BBV status is subject to the same rights of medical confidentiality as any patient in
receipt of medical care or investigation. every effort should be made to avoid disclosure of
the affected workers identity, or information that would allow deductive disclosure.
5.3 Individuals who believe they may have been exposed to BBV infection at work or in
their personal life must seek medical advice and if appropriate undergo diagnostic testing.
Where such testing shows positive results, the HCW must self-refer to the OHSS to review
their fitness to work and may need to cease EPP tasks.
Where accidental exposure to blood and body fluid occurs during work within UHCW NHS
Trust the Management of sharps and splash policy must be followed.
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of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
This policy outlines responsibilities and procedure for dealing with needle stick type injuries
all body fluids splash incidents with healthcare workers.
For HCWs this includes a risk assessment to be carried out by the Line Manager by
completing the sharps contamination management incident form available on the UHCW
intranet the form can be accessed by the policy and on the internet.
Senior managers on departmental heads must ensure that they retain and maintain
documented clearance for all staff carrying out EPP tasks.
EPP staff subject to OHSS following requirements should attend for the required screening
when requested by the OHSS. Where OHSS clearance is withdrawn or where the review
dates are exceeded without any clearance individual must cease EPP work.
OHSS Practitioners should remind any BBV infected HCW under their care to refer
themselves to the OHSS. if they become aware that an infected HCW is performing EPP
or has done so in the past has not followed the professional requirements of this policy to
refer themselves to the OHSS, autumn modify their practise due to BBV infection, the
Commission has a responsibility to inform occupational health.
Occupational health will risk assess the situation and notify the medical director/chief
nurse/ people officer as appropriate. The medical /nurse director will then consider who
else should be notified.
HCWs who have carried out EPP when their BBV status does not meet the requirements
of this policy, have a personal responsibility to EPP and inform the OHSS where they will
be given support and advice.
6.0
TRAINING
(Record all relevant training requirements including training that forms part of the Trust’s mandatory training programme,
the regularity of training as per the Trust’s corporate training needs analysis. (Delete upon insertion of text)
6.1 Occupational Health Practitioners will receive an appropriate level of instruction on
the delivery of pre-employment screening assessment and counselling.
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of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
7.0
MONITORING COMPLIANCE
(Record below how the implementation and effectiveness of the PPS will be monitored and details of corporate or local
procedures to be developed to support this. (Delete upon insertion of text)
7.1 Monitoring Table (Do not delete this table - Must be Completed)
Compliance with EPP clearance should be monitored by Occupational Health departments
and audited regularly as per departmental audit plans. The audit results should be used to
identify any improvements in practice and be reviewed as part of the clinical governance
processes to ensure actions and recommendations are suitable and sufficient.
Aspect of
compliance or
effectiveness
being
monitored
Monitoring
method
(i.e. regular
audits/reviews)
Individual/
department
responsible
for the
monitoring
Frequency
of the
monitoring
activity (i.e.
Monthly/
Annually)
Group /
committee
which will
receive the
findings /
monitoring
report
Group /
committee /
individual
responsible
for ensuring
that the
actions are
completed
Compliance
with screening
standard
Audit 25 EPP
workers
records
Occupational
Health
Annually
Infection
Prevention
and Control
Committee
Infection
Prevention
and Control
Committee
8.0
STAFF COMPLIANCE STATEMENT (Do not delete)
All staff must comply with this Trust-wide Policy, Procedure or Strategy and failure to do
so may be considered a disciplinary matter leading to action being taken under the Trust-
s Disciplinary Procedure. Actions which constitute breach of confidence, fraud, misuse of
NHS resources or illegal activity will be treated as serious misconduct and may result in
dismissal from employment and may in addition lead to other legal action against the
individual/s concerned.
A copy of the Trust’s Disciplinary Procedure is available from eLibrary.
9.0
EQUALITY & DIVERSITY STATEMENT (Do not delete)
Throughout its activities, the Trust will seek to treat all people equally and fairly. This
includes those seeking and using the services, employees and potential employees. No-
one will receive less favourable treatment on the grounds of sex, gender reassignment,
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This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
disability, marital status, race/colour/ethnicity/nationality, sexual orientation, age,
pregnancy and maternity, religion / philosophical or other beliefs, social status, caring
responsibilities, their trade union activities nor will they be disadvantaged by conditions or
requirements which cannot be shown to be justifiable. All staff, whether part time, full-
time, temporary, job share or volunteer; service users and partners will be treated fairly
and with dignity and respect.
10.0
ETHICAL CONSIDERATIONS (Do not delete)
The Trust recognises its obligations to maintain high ethical standards across the
organisation and seeks to achieve this by raising awareness of potential or actual ethical
issues through the PPS consultation and approval process. Authors of PPSs are
therefore encouraged to liaise with the Trust’s Clinical Ethics Forum to seek input where
necessary.
11.0
SUSTAINABILITY IMPACT ASSESSMENT (Do not delete)
UHCW NHS Trust is committed to ensuring that the way we provide services minimises
the impact on the environment and the future health of the public e.g. zero waste to
landfill, reducing our carbon footprint and recycling and reuse percentages. The actions
in this policy have been assessed and are in line with the Trust’s Net Zero commitment
and NHS Net Zero target.
12.0
DEFINITIONS
(List and define short-terms or acronyms used in the document. If there are none, write NONE.) (Delete upon insertion of
text)
12.1 ‘Health care workers’ (HCWs)
Employees and contracted staff, including volunteers, students and trainees, whose
activities involve contact with patients or with blood or other body fluids from patients in a
health care setting
12.2 ‘Hepatitis B infected health care workers’
Employees who are hepatitis B surface antigen positive.
12.3 ‘Exposure Prone Procedures’ EPP
Procedures which carry a risk of occupational injury by exposure of the patient’s open
tissues to the blood of the worker. Procedures include those where the worker’s gloved
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This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
hand may be in contact with sharp instruments, needle tips and sharp tissues, e.g. spicules
of bone or teeth, inside a patients open body cavity, wound or confined anatomical space
where the hands or fingertips may not be completely visible at all times.
12.4 ‘Hepatitis C infected health care workers’
Employees who are hepatitis C RNA positive.
13.0
REFERENCES AND BIBLIOGRAPHY
Record referenced sources of evidence that underpin this procedural document e.g. statute, NHS, other relevant guidance,
information or a professional body and insert bibliography where relevant.) (Delete upon insertion of text)
Reference: Integrated guidance for management of BBV in HCW November 2023
(publishing.service.gov.uk)
integrated-guidance
-for-management-of
Brief Guidance:
Integrated guidance
for management of B
UK Health Departments (1998). Guidance for Clinical Healthcare Workers: protection
against infection with blood-borne viruses. Recommendations of the Expert Advisory
Group on AIDS and the Advisory Group on Hepatitis.
Department of Health (January 2007). Health clearance for tuberculosis, hepatitis B,
hepatitis C and HIV: New healthcare workers’ 2007.
Department of Health (2002). Hepatitis C Infected Health Care Workers. Implementing
Getting Ahead of the Curve: Action on blood-borne viruses.
Department of Health (2002) Good Practice Guidelines for Renal dialysis and Transplant
Units; Prevention and Control of Blood Borne Virus Infection.
Department of Health (June 2004). Hepatitis C: Health Care Professional Information
Pack.
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This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
Department of Health (March 2007). Hepatitis B Infected Health Care Workers and Oral
Antiviral Therapy.
Department of Health (July 2004). Hepatitis C: Action Plan for England.
Department of Health (2007). HIV Infected Health Care Workers: Guidance on the
Management of Infected Health Care Workers and Patient Notification.
Health Service Guidelines HSG (93) 40. Protecting Health Care Workers and Patients
from Hepatitis B and its Addendum issued under cover of EL (96) 77 (26 September
1996).
Health Service Circular (HSC) 2002/020. Hepatitis B Infected Health Care Workers.
Health Service Circular (HSC) 2002/010. Hepatitis C Infected Health Care Workers.
The Management of Health, Safety and Welfare Issues for NHS Staff (The Blue Book),
New Edition, 2005. NHS Employers
The Management of HIV infected Healthcare Workers who perform exposure prone
procedures: updated guidance, January 2014. Public Health England.
Public Health England ‘Integrated guidance on health clearance of healthcare workers
and the management of healthcare workers infected with bloodborne viruses (hepatitis B,
hepatitis C and HIV) October 2017’
Further information can be obtained from the department of Health guidelines of March
2007 " Hepatitis B infected healthcare workers and antiviral therapy"
Health & Social Care Act 2008 (Regulate Activities) Regulations 2014, Regulation 20.
UKHSA (Updated 2021) Integrated guidance on health clearance of healthcare workers
and the management of healthcare workers living with bloodborne viruses (hepatitis B,
hepatitis C and HIV)
https://www.gov.uk/government/publications/bbvs-in-healthcare-workers-health-
clearance-and-management
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This Trust-wide PPS has been developed /reviewed in accordance with the Trust approved ‘Development & Management
of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
UKHSA (Updated 2021) Integrated guidance on health clearance of healthcare workers
and the management of healthcare workers living with bloodborne viruses (hepatitis B,
hepatitis C and HIV) Quick Reference Guide
https://www.gov.uk/government/publications/bbvs-in-healthcare-workers-health-
clearance-and-management
UK Advisory Panel for Healthcare Workers Living with Bloodborne Viruses (UKAP)
https://www.gov.uk/government/groups/uk-advisory-panel-for-healthcare-workers-
infected-with-bloodborne-viruses
UKHSA
(2019)
Hepatitis
B:
the
green
book,
chapter
18
https://www.gov.uk/government/publications/hepatitis-b-the-green-book-chapter-18
NHS Employers (2022) Work Health Assessments
Work health assessments | NHS Employers
BMC Clinical Pathology (2012) Positive hepatitis B surface antigen tests due to recent
vaccination: a persistent problem. Positive hepatitis B surface antigen tests due to recent
vaccination: a persistent problem - PMC (nih.gov)
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14.0
UHCW ASSOCIATED RECORDS and Policy
(List all eLibrary referenced strategies, policies and procedures) (Delete upon insertion of text)
•
Standard infection prevention and control precautions.
•
Safe use and disposal of sharps policy
•
Management of sharps/splash injuries and post exposure procedures for Hepatitis
B virus (HBV), Hepatitis C virus (HCV) and Human immunodeficiency virus (HIV)
Policy.
•
Health Care Worker Immunisation Policy
•
Management of Change Policy
•
Confidentiality and Data Protection Policy
•
Supporting Attendance/Managing attendance policy.
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15.0
APPENDICES
Appendix 1
BLOOD BORNE VIRUS TRANSMISSION RISK
Occupational risks of transmission of blood borne viruses to HCWs arise from the
possibility of exposure to blood and, exceptionally, to certain other body fluids or tissues
from an infected source.
If universal infection control precautions are adopted, any possible risk is confined to
accidental injury i.e. contaminated sharps or body fluid splash.
The risk of transmission of blood borne viruses is greater from patient to HCW than from
HCW to patient. The risk to the HCW for each virus is proportional to the prevalence of
that infection in the population served, the infectious status of the source patient and the
risk of a significant occupational exposure occurring during the procedures undertaken.
The risk of transmission following a significant exposure to an infected source is around:
- 1 in 3 when the source patient is infected with hepatitis B and is ‘e’
antigen positive
- 1 in 30 when the source patient is infected with hepatitis C
- 1 in 300 when the source patient is infected with HIV.
The risk is lowered if the exposure is via a mucous membrane, such as the eyes or mouth
to the region of 1 in 3000.
Not all sources infected with blood borne viruses have had their infections diagnosed. It
is, therefore, important that all blood, body fluids and tissues are regarded as potentially
infectious and universal precautions adhered to.
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of Trust-wide Policies, Procedures and Strategies Procedure (Clinical and Non-clinical strategies, policies and procedures)’
APPENDIX 2
Definitions and examples of Exposure Prone Procedures (EPPs)
Category 1
Procedures where the hands and fingertips of the worker are usually visible and outside
the
body most of the time and the possibility of injury to the worker’s gloved hands from sharp
instruments and or tissues is slight. This means that the risk of the HCW bleeding into a
patient’s open tissues should be remote.
Examples: Local anaesthetic injection in dentistry, removal of haemorrhoids.
Health clearance of healthcare workers and the management of healthcare workers living
with bloodborne viruses.
Category 2
Procedures where the fingertips may not be visible at all times but injury to the worker’s
gloved hands from sharp instruments and or tissues is unlikely. If injury occurs, it is likely
to be noticed and acted upon quickly to avoid the HCW’s blood contaminating a patient’s
open tissues.
Examples: Routine tooth extraction, colostomy.
Category 3
Procedures where the fingertips are out of sight for a significant part of the procedure, or
during certain critical stages, and in which there is a distinct risk of injury to the worker’s
gloved hands from sharp instruments and or tissues. In such circumstances, it is possible
that exposure of the patient’s open tissues to the HCW’s blood may go unnoticed or would
not be noticed immediately.
Examples: Hysterectomy, caesarean delivery, open cardiac surgical procedures.
A series of speciality-specific lists of the most common clinical procedures, classified into
EPP category depending upon the relative risk of bleed-back, has been developed by
UKAP and are available on the UKAP webpage.
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APPENDIX 3
Examples of NON-EPP activities
Non-EPPs are those where the hands and fingertips of the worker are visible and outside
the patient’s body at all times, and internal examinations or procedures that do not involve
possible injury to the worker’s gloved hands from sharp instruments and/or tissues.
These procedures are not considered to be exposure prone provided appropriate infection
prevention and control procedures are adhered to at all times.
Examples are:
•
Venepuncture
•
Minor surface suturing
•
Simple endoscopic procedures
•
Incision of external abscesses
•
Setting up and maintaining intravenous lines or
central lines (provided any skin tunnelling
procedure used for the latter is performed in a non-
exposure prone manner)
•
Routine vaginal or rectal examinations
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APPENDIX 4
Letter template – formal notification of the removal of EPP clearance
"Dear xxx
According to our records you are overdue your exposure prone procedures clearance
(EPP) and following our attempts to recall you we are formally notifying you that you are
not currently health cleared to undertake EPP activities. Your senior manager has been
copied into this notification for your duties to be adjusted as necessary.
If your role requires EPP activity, then you are requested to contact us on xxxxxxx on
receipt of this letter in order to arrange an appointment. If you are no longer working in a
role/staff group in an area that requires EPP clearance, please confirm this by contacting
us on xxxxxxxx in order that we can update your records and remove you from our recall
list.
NB: Exposure prone procedures are ‘where there is an opportunity for HCW to patient
transmission of BBVs where injury to the HCW could result in the worker’s blood
contaminating the patient’s open tissue’.
Examples of EPP procedures include ‘where the HCW’s gloved hands may be in contact
with sharp instruments, needle tips or sharp tissues inside a patient’s open body cavity,
wound or confined anatomical space where the hands or fingertips may not be completely
visible at all times. Sharp tissues may include spicules of bone or teeth’.
An EPP environment is ‘an environment in which there is significant risk of injury to the
healthcare worker, with consequent co-existent risk of contamination of the open tissues
of the patient with blood from the healthcare provider’. This also includes staff undertaking
clinical activity within Renal Units."
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APPENDIX 5
Initial EPP clearance and professional responsibilities leaflet
You have been provided with this information leaflet as it has been identified that your role
will require Exposure Prone Procedure (EPP) clearance.
For clearance purposes you will require serology to test for Hepatitis B (HBV), Hepatitis C
(HCV) and human immunodeficiency virus (HIV). The serology will be taken by the
Occupational Health department and must be an Identity Verified Sample (IVS). You are
required to provide proof of identity with a photograph at the appointment (for example
your trust identity badge, new driver’s licence, passport, or national identity card)
The purpose of this clearance is to provide protection for patients from exposure in the
clinical care setting to HBV, HCV, and HIV. The clearance requirements are not intended
to prevent someone who is living with BBVs from working in the NHS, but rather to restrict
them from working in those clinical areas where their infection may pose a risk to patients
in their care. If you are known to be positive or are found to be positive to HBV, HCV, or
HIV then EPP clearance will depend on further testing and additional advice and guidance
on this will be given to you if applicable.
There are personal benefits for you as well (for example, if positive then earlier diagnosis
can lead to curative or life-prolonging treatment and prevention of onward transmission),
and professionally (for example, avoiding work activities that may pose a risk to your own
health and making career choices appropriate to your infection status).
Confidentiality
Occupational Health records are held separately from other hospital notes and can be
accessed only by occupational health practitioners, who are obliged ethically and
professionally not to release records or information without the consent of the individual.
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You can be reassured that your serology results will only be accessed by authorised
members of the Occupational Health team and will remain confidential. Your employer will
be provided with an outcome that advises only on your EPP clearance status which will
not contain any medical information.
Occupational Health would only ever disclose any medical information in a situation where
it is considered necessary for the purpose of treatment, the prevention of spread of
infection or in the public interest where patients are, or may have been, at risk.
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APPENDIX 6
1. Individuals living with Hepatitis B leaflet. (Credit to Guys and St Thomas NHS
Foundation Trust Occupational Health Department)
Information for HBV (Hepatitis B) infected HCWs who undertake Exposure Prone
Procedures (EPPs) and Renal Dialysis (RD)
Healthcare Workers (HCWs) who are HBV positive and have been cleared by
Occupational Health (OH) to undertake Exposure Prone Procedures (EPPs) or Renal
Dialysis (RD) should be aware that by accepting an offer of employment in an EPP / RD
post, they agree to the following conditions and accept the implications of non-adherence.
Compliance with monitoring
HBV positive HCWs who undertake EPPs / Renal Dialysis must:
•
Attend all OH appointments relevant to their HBV infection, as advised by the
Consultant Occupational Physician (OHP)
•
Consent to OH writing to their manager with regards to their fitness to undertake
EPP / RD if relevant
•
Attend 6 monthly review appointments with OH.
•
Have their blood taken for HBV viral load testing (within the window specified by
OHP) either at OH or another location agreed by OH under Identity Verified (IVS)
procedure.
•
Consent to the registration of their details and monitoring results on the UKAP-
OHR if relevant.
•
Consent to the OHP communicating with their consultant hepatologist on relevant
matters, including the results of quarterly monitoring where appropriate.
•
Inform the OHP and treating HBV consultant as soon as practicable if they miss
treatment doses, stop treatment or other factors that might influence their viral
load and will cease EPP / RD until they have obtained OHP advice.
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•
Inform OH and their treating HBV consultant as soon as practicable if they start
any immunosuppressive treatment or diagnosed with a condition that makes
them immunocompromised.
•
Notify UHCW OHSS if they are changing their work practices (e.g., period of non-
EPP / RD work) or their place of employment.
*If the HCW is prescribed any medication, they should consult with the prescribing
physician and/or pharmacist on potential drug interactions with antiviral treatment and
inform OH and their treating consultant hepatologist
Failure to comply.
If the HCW fails to comply with the monitoring conditions, OH will inform the HCW’s
manager that they are no longer medically fit to undertake EPP / RD, with immediate effect.
Depending on the nature and consequences of non-compliance, other actions may also
be taken.
Accidental body fluid exposures
If the HCW accidentally exposes a patient to their blood, they must immediately inform
their supervisor who will inform the patient’s consultant and OH so that appropriate action
can be taken promptly. The HCW must not approach the patient themselves.
The HCW must attend appointments with OH to have their blood taken for IVS viral load if
they are requested to do so.
APPENDIX 7
1. Individuals living with HIV leaflet. (Credit to Guys and St Thomas NHS
Foundation Trust Occupational Health Department)
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Information for HIV infected HCWs who undertake Exposure Prone Procedures
(EPPs)
Healthcare Workers (HCWs) who are HIV positive and have been cleared by Occupational
Health (OH) to undertake Exposure Prone Procedures (EPPs) should be aware that by
accepting an offer of employment in an EPP post, they agree to the following conditions
and accept the implications of non-adherence.
Compliance with monitoring
HIV positive HCWs who undertake EPPs must:
•
Attend all OH appointments relevant to their HIV infection, as advised by the
Consultant Occupational Physician (OHP)
•
Consent to OH writing to their manager with regards to their fitness to undertake
EPPs if relevant
•
Attend review appointments with the OHP or another OH clinician every 3
months.
•
Have their blood taken for HIV viral load testing (within the window specified by
OHP) either at OH or another location agreed by OHP under IVS procedure.
•
Consent to the registration of their details and monitoring results on the UKAP-
OHR, which will hold them in confidence.
•
Consent to the OHP communicating with their HIV consultant on relevant matters,
including the results of quarterly monitoring.
•
Inform the OHP and treating HIV consultant as soon as practicable if they miss
treatment doses, or are aware of drug interactions* or other factors (e.g.,
diarrhoea) that might influence their viral load and will cease EPP until they have
obtained OHP advice.
•
Notify OH if they are changing their work practices (e.g., period of non-EPP work)
or their place of employment.
*If the HCW is prescribed any medication, they should consult with the prescribing
physician and/or pharmacist on potential drug interactions with cART and inform the OHP
and treating HIV consultant
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Failure to comply
If the HCW fails to comply with the monitoring conditions, OH will inform the HCW’s
manager that they are no longer medically fit to undertake EPPs, with immediate effect.
Depending on the nature and consequences of non-compliance, other actions may also
be taken.
Accidental body fluid exposures
If the HCW accidentally exposes a patient to their blood, they must immediately inform
their supervisor who will inform the patient’s consultant and OH so that appropriate action
can be taken promptly. The HCW must not approach the patient themselves.
The HCW must attend appointments with OH to have their blood taken for IVS viral load if
they are requested to do so.
Professional Responsibilities
All HCWs have an ethical and legal duty to protect the health and safety of themselves
and of others. Therefore, all HCWs must meet the requirements for EPP health clearance
(screening for HBV, HCV, and HIV) where they are undertaking roles which involve EPPs.
At any time during your career, you have a professional duty to seek medical advice and
request further testing if you may have been exposed to HIV, HBV, or HCV, occupationally
or otherwise.
In some circumstances ongoing monitoring will be required following the initial clearance
and you will be required to attend for follow ups when arranged.
If you do not attend for whatever reason your EPP clearance will expire, and you must
cease immediately undertaking any EPP activity until such a time as clearance is re-
instated. It is therefore essential that you attend any appointments and keep a record of
when your next serology review is due.
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APPENDIX 8
Identity Validated Samples (IVS) requirements
•
Proof of identity with a photograph (for example trust identity badge, new driver’s
licence, passport, or national identity card) at the time the sample is taken.
•
The sample of blood should be taken within the Occupational Health service
(exceptions are where this would give rise to duplication of testing, local
arrangements should be made between the treating physician and the
Occupational Health service OR for example, there may be a local agreement
between the OH team and the local phlebotomy service to support where an
individual is difficult to bleed. This must only be undertaken if local training has
been provided to the phlebotomy department with regards to IVS requirements and
the OH service has reassurance of this competency.
•
Samples should be delivered to the laboratory in the usual manner; they must not
be taken to the laboratory by the individual.
•
When results are received from the laboratory, the clinical notes should be checked
to confirm that the sample was sent by the Occupational Health service or under
local arrangements, at the correct date and time and the name and date of birth
match.
NB: Blood results used for EPP clearance (including those submitted at pre-placement)
must be from
a) A UK accredited laboratory and
b) be IVS samples.
Any immunisation history record e.g., from another NHS Trust containing blood results
being used for EPP clearance must be on a professional document which can be verified
has originated from the issuing OH department and clearly documents the results and IVS
status.
OH professionals must check that it is the correct report for the individual by confirming the
correct spelling of the first name and surname, and date of birth.
Any print outs or reports received that do not contain clear information about the source of
the report, (i.e., the originating NHS trust) will require the bloods to be repeated.
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Where an individual moves between NHS Trusts and with the consent of the individual the
Occupational Health department from where the individual is leaving should share EPP
serology results with the new NHS Occupational Health department.
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Screening and Management of Sepsis in Adults
E-Library Reference
CG 47
Version
V6
Approving forum (QIPS or equivalent):
Sepsis Steering Meeting Group
Specialty Clinical Guideline Lead:
Kate Prevc – Lead Nurse for Infection
Prevention and Control, Decontamination
and Sepsis
Kate.prevc@uhcw.nhs.uk
Contributing Author(s) and reviewer(s):
Sarah Bailey- Sepsis Nurse
sarah.bailey@uhcw.nhs.uk
Emma Evans- Sepsis Nurse
emma.evans@uhcw.nhs.uk
Ramesh Ingalagi- Sepsis Nurse
Ramesh.Ingalagi@uhcw.nhs.uk
Lucinda Smart- Sepsis Nurse
Lucinda.Smart@uhcw.nhs.uk
Fiona Wells- Infection Prevention and
Control Nurse and Sepsis Nurse
fiona.wells@uhcw.nhs.uk
Gorana Kovacevic- Consultant in Infectious
Diseases and Sepsis Lead
Gorana.Kovacevic@uhcw.nhs.uk
TRAINEE NURSING ASSOCIATES or NURSING ASSOCIATES - A NEW NURSING ROLE If Registered Nurses or
Student Nurses will be undertaking a role, or carry out procedures in your area, you will now need to consider
the role/input/restrictions for Trainee Nursing Associates/Nursing Associates and refer to them within your
document. If you require any further information please contact Karen Mogan Practice Facilitator
karen.mogan@uhcw.nhs.uk<mailto:karen.mogan@uhcw.nhs.uk>
Department(s) / Primary Speciality:
Infection Prevention and Control
Approval Date:
Expiry Date:
31/3/22
Target Audience:
All clinical staff that have direct contact
with patients.
Superseded UHCW
Clinical Guideline(s):
(if applicable)
Management and Screening of Sepsis in
Adults CG47 version V5
--- PDF page 2 ---
UHCW Associated Records:
Keywords:
Sepsis
Clinical Operating Procedures relating to this guidance (please
list)
- Arterial Blood Gas Sampling (COP 512)
- Obtaining a blood culture sample –
guideline and competency (COP 573)
- Hand Decontamination Policy (OPER-
POL-002-10)
Summary version available
☐
--- PDF page 3 ---
Screening and Management of Sepsis in
Adults
Introduction
Sepsis is a medical emergency and should be
defined as life-threatening organ dysfunction
caused by a dysregulated host response to
infection (Singer et al 2016). Sepsis is a time
critical condition and therefore timely and accurate
diagnosis and management is priority. Each year in
the UK there are more cases of sepsis deaths than
bowel, breast and prostate cancer, HIV and AIDs
combined (The UK Sepsis Trust 2019). Early
intervention with the use of sepsis six pathways can
make a difference in patient’s outcomes. (Levy et al
2018).
Who does it affect?
This guideline applies to all non-pregnant
adults over the age of 16 years and excluding
neutropenic patients.
Purpose of guidance
To enable a face to face evaluation of the
recognition of sepsis, early assessment
using a structured set of observations,
diagnosis and prompt management of
sepsis with appropriate escalation of care,
initial treatment and timely identification of
the source of sepsis.
Summary
Sepsis is a time critical condition and therefore timely and accurate diagnosis and management is priority.
Suspicion of RED FLAG sepsis must be treated with Intravenous (IV) Antibiotics within 1 hour of
recognition unless de-escalated by a clinician and deemed as not sepsis.
All parts of the Sepsis 6 must be completed in one hour of recognition of RED FLAG sepsis unless de-
escalated by a clinician and deemed as not sepsis.
All clinical staff in the Trust must arrange their own sepsis training on the use of the sepsis screening tool
by either a sepsis cascade trainer trained by the sepsis team; or a member of the sepsis team.
All clinical staff in the Trust must make themselves aware of the sepsis protocol within the Trust and the
relevant paperwork required to be filled in the event of caring for a septic patient.
All clinical staff in the Trust must be familiar with the significant morbidity associated with sepsis.
All clinical staff in the Trust should give patient information leaflets to patients who have experienced sepsis
and signpost them if required to a local post sepsis support group; or to empower the patients to know how
to look for signs and symptoms of sepsis and know where to find patient information leaflets.
Please note, all text highlighted blue are hyperlinks to the procedure or guideline listed.
Appendices
Adult Sepsis Screening Tool (Appendix 1)
--- PDF page 4 ---
Guideline clinical content
Clinical Guidelines assist in decision-making; they do not replace clinical judgement. Regardless of
the strength of evidence, it remains the responsibility of the clinician to interpret the application of
the clinical guidance to local circumstances and the needs and wishes of the individual patient.
Where variations of any kind do occur, it is important to document the variations and justification for
them in the patient’s health record. If in doubt, seek senior advice.
Introduction
What is sepsis?
Sepsis is a time critical condition that can lead to organ damage, multi-organ failure septic shock and
eventual death if left untreated. Life-threatening organ dysfunction is due to a dysregulated host
response to an infection. (NICE 2017)
When to screen a patient for sepsis?
People with suspected sepsis require face-to-face assessment to determine whether they need
urgent intervention. Using a structured set of observations for assessing physiological symptoms
should ensure that people at risk of severe illness or death from sepsis receive timely and
appropriate treatment (NICE 2016). Patients MUST be screened using the locally adjusted Adult
Sepsis Screening Tool for patients who are non-pregnant adults over 16 years who are clearly
unwell with any abnormal observations and signs of infection. (Appendix 1)
It is important to remember that if there is an Individual Plan of Care for the Dying Person
pathway in place or there is clinical guidance on specific interventions that may or may not
be wanted or clinically appropriate, including being taken or admitted to hospital +/- receiving
life support, there may be restrictions to treatment.
If an Individual Plan of Care for the Dying Person is in place then the sepsis screening tool needs to
be de-escalated. Please refer to the Individual Plan of the Care for Dying Person for the
management plan.
For further supporting information - West Midlands Palliative Care Guidelines
Screening for sepsis
A diagnosis of sepsis should be considered if a patient presents with a National Early Warning Score
2 (NEWS 2) of 3 in any individual parameter or an aggregate score 5≥ or looks sick, combined with
a presumed source of infection (The UK Sepsis Trust 2019) either acutely unwell within the hospital
or as a new admission (NICE 2017).
AND
If the patient fits the criteria laid out in 1) Please see the criteria for screening. Consider question 2)
Could this be due to an infection? The infections to consider are:
Yes, but source unclear at present
Pneumonia
Urinary Tract Infection
Abdominal pain or distension
Cellulitis/ septic arthritis/ infected wound
--- PDF page 5 ---
Device-related infection
Meningitis
Other (please specify):
If the answer is no to either 1) or 2) then there is no need to complete the pathway; document in
patients’ medical notes and de-escalate the pathway. If the answer is yes to 1) and 2) then continue
to screen for sepsis.
Sepsis is a medical emergency which can be caused by a variety of organisms that we come into
contact with every day; however they do not always make us ill. Sepsis is the body’s dysregulated
reaction to these infections and sepsis is a time critical condition and therefore timely and accurate
diagnosis and management is a priority.
RED FLAG SEPSIS
RED FLAG SEPSIS is considered present if a patient has NEWS 2 of 3 in any individual parameter
or an aggregate score of 5≥ (Royal College of Physicians 2017, The UK Sepsis Trust 2019) with a
proven or highly suspected site of infection and one or more of the following criteria. If you
suspect sepsis and/ or your patient has any signs and symptoms below, they are at a high risk of
severe illness or death from sepsis (NICE 2017):
Responds only to voice/ new confusion/ pain/ unresponsive.
Systolic Blood pressure ≤ 90mmHg (or drop ≥40 from normal).
Heart rate ≥ 130 beats per minute.
Respiratory Rate ≥ 25 per minute.
Needs oxygen to keep SpO2 ≥ 92% (or 88- 92% in hypercapnic respiratory failure patients –
only use scale 2 on NEWS 2 under the direction of qualified clinician)
Non-blanching rash, mottled/ ashen/ cyanotic skin.
Not passed urine in last 18 hours.
Urine output less than 0.5ml/kg/hr if catheterised
Lactate ≥ 2 mmol/L.
Recent Chemotherapy – use neutropenic sepsis pathway.
If any one of the above is present then the patient is considered to have RED FLAG SEPSIS unless
de-escalated by a clinician. Sepsis is a medical emergency. Time is critical and immediate
action is required.
The Sepsis 6 treatment must be commenced and completed within ONE HOUR of
suspicion of sepsis.
Sepsis 6 treatment:
The following treatment is based on NICE recommendations - Sepsis: recognition, diagnosis
and early management NICE guideline [NG51]
SEPSIS 6 treatment is the following:
1) Administer oxygen:
Aim to keep saturations ≥ 94% or new need for 40% oxygen or more to keep sPo2 ≥92%
--- PDF page 6 ---
(88 – 92% if on NEWS 2 scale 2).
See Trust clinical guideline for administering of oxygen - The prescription,
administration and weaning of oxygen therapy for the management of hypoxia in
adults (CG 1682).(click on guideline here to open)
British Thoracic Society Emergency Oxygen Guideline - BTS Guideline for oxygen
use in adults in healthcare and emergency settings
2) Take Blood cultures
At least two sets of blood cultures should be taken when the source of infection is unknown.
Consider sending samples of CSF, urine, sputum and CXR if indicated. Think source
Control. Consider sending FBC’s, CRP, U+Es, LFTs and clotting.
See Trust clinical operating procedure for appropriate taking of blood cultures -
Obtaining a blood culture sample-guideline and competency package (COP 573).
See Trust clinical guideline for suitable for specimen taking - Adult Antibiotic
Guidelines (CG 1168)
See Trust clinical guideline if you have a suspicion of contagious infection – Isolation
Guideline (CG334) (click on guideline here to open)
See Trust operating procedure for hand decontamination – Hand Decontamination
Policy (OPER-POL-002-10)
3) Give IV antibiotics
Please use Trust antibiotic guidelines and consider allergies.
See guidelines here for appropriate antibiotic administration - Adult Antibiotic
Guidelines
See Public Health England guidelines – Start Smart Then Focus
4) Give IV fluids
(use with caution in renal and heart failure)
If patients need IV fluid resuscitation, use crystalloids that contain sodium in the range 130–
154 mmol/l, with a bolus of 500 ml within 15 minutes. Do not exceed 30mls/kg.
If applicable call the Acute Team now if ≥ 2.5L fluid administered with no improvement
– Acute Team contact details below.
See NICE recommendations - Intravenous fluid therapy in adults in hospital Clinical
guideline [CG174]
5) Check serial blood gas lactates
Carry out a venous blood test for the following; blood gas including glucose and lactate
measurement. (NICE 2017)
Monitor the lactate to see if the value is reduced by more than 20% of initial value within
1 hour.
If suspected sepsis and any high risk criteria and lactate over 4mmol/litre, or systolic
blood pressure less than 90 mmHg, call the Acute Team, recheck after each 10ml/kg
fluid challenge.
See guidelines for blood gas sampling – Arterial Blood Gas Sampling (COP 512)
6) Measure urine output
Commence strict fluid balance monitoring and complete hourly.
--- PDF page 7 ---
Is a catheter required? Yes or No?
See Trust clinical guidelines for management of AKI – Acute Kidney Injury (CG 2006)
and Acute Kidney Injury Bundle (CB 5)
See NICE recommendations – Acute Kidney Injury NICE guidelines
PATIENT NOT RESPONDING TO TREATMENT
SEPTIC SHOCK is persisting hypotension requiring vasopressors to maintain a mean arterial
pressure (MAP) of 65 mmHg or more and having a serum lactate level of greater than 2 mmol/l
despite adequate volume resuscitation. (NICE 2017) After the Sepsis 6 treatment has been
delivered and your patient is still experiencing any of the following outlined below; escalation is
required to the Acute Team.
Systolic Blood pressure ≤ 90mmHg (or drop ≥40 from normal).
Reduced level of consciousness despite resuscitation.
Respiratory rate over 25 breaths per minute
Any high risk criteria and lactate over 4 mmol/litre, or systolic blood pressure less than
90 mmHg
The following treatment is based on NICE 2016 recommendations - Sepsis: recognition,
diagnosis and early management NICE guideline [NG51]
Royal College of Physicians recommendations - National Early Warning Score 2
See NICE recommendations - Acutely Ill Patients in Hospital
If the patient is clearly critically ill immediately contact one of the ACUTE TEAM.
ACUTE TEAM:
Critical Care outreach bleep 2909.
Hospital at Night (after 20:00hrs) via HaNbleep.
ITU registrar bleep 1684.
For St Cross Rugby SHO bleep 4127.
AMBER FLAG SEPSIS
AMBER FLAG SEPSIS is considered present if a patient has a NEWS 2 of 3 in one parameter or 5
≥ combined with a proven or highly suspected site of infection. (Royal College of Physicians
2017, The UK Sepsis Trust 2019). If you suspect sepsis and your patient has any of the signs and
symptoms below, they are high risk of severe illness or death from sepsis (NICE 2017):
Relatives concerned about mental status.
Acute deterioration if functional ability.
Immunosuppressed.
Trauma/ surgery/ procedure in the last 6 weeks.
Respiratory rate 21 – 24 breaths per minute or breathing hard.
Heart rate 91 – 130 beats per minute or new arrhythmia.
Systolic Blood Pressure 91 – 100mmHg (or drop ≥40 from normal).
Not passed urine in the last 12 – 18 hours.
Urine output less than 0.5 – 1ml/kg/hr if catheterised
Temperature 36◦C.
Clinical signs of wound, device or skin infection.
--- PDF page 8 ---
If two or more of the amber flag criteria are met the patient must be reviewed within 1 hour by a
doctor and have a lactate taken and bloods sent to identify the presence of AKI.
Send bloods (FBC, U&E’s, CRP, and LFT’s clotting and lactate and blood cultures).
If the lactate is ≥ 2 or an AKI is present; the patient MUST be escalated to RED FLAG SEPSIS.
If lactate ≤ 2 and no AKI is present, repeated structured assessments must be completed hourly and
a senior clinical review within 3 hours of initial identification and are required to make an
antimicrobial prescribing decision upon recognition of deterioration. (NICE 2016)
LOW RISK SEPSIS
If patients with suspected sepsis have no red flag or amber flag criteria met; is displaying normal
behaviour and no non-blanching rash, arrange clinical assessments and manage according to
clinical judgement. If applicable; discharge patient with safety netting advice and patient information
leaflets. (NICE 2016)
De-escalation
If a patient has been screened for sepsis using the Adult sepsis screening tool and is deemed by a
medical clinician to not be septic at that point, the patient must be de-escalated from the Adult sepsis
screening tool. The medical clinician should cross through the pathway, sign and date and write ‘not
septic’ – or fill out the de-escalation box on the bottom of page 2. The pathway then to be filed in the
patients’ medical notes.
A suitable plan for treatment should be written in the medical notes for differential diagnosis.
If the patient was to deteriorate further; they MUST be screened for sepsis again using the Adult
sepsis screening tool.
**It is not necessary to re-screen a patient if the patient is receiving the sepsis 6 treatment and is
not responding to treatment. Escalation of care if appropriate is the main priority at this point.
See NHS England information regarding coding - Improving outcomes for patients with
sepsis - A cross-system action plan
Documentation
Once any Sepsis Screening tool has been commenced this must follow the patient’s journey into the
Emergency Department and filed into the patient’s medical notes upon completion.
Summary
Algorithm for managing suspected sepsis in children and young people aged 12 to 17 years
in an acute hospital setting
Algorithm for managing suspected sepsis in adults and young people aged 18 years and
over in an acute hospital setting
Risk stratification tool for adults, children and young people aged 12 years and over with
--- PDF page 9 ---
suspected sepsis
Definitions
Infection: An infection is where a microorganism such as a bacteria, virus, and parasite that is not
normally present within the body invades the body and multiplies. This may cause no symptoms
and be subclinical; occasionally this may be clinically apparent. (Medicine 2018)
Sepsis: Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated
host response to infection (Shankar-Hari et al 2016).
Septic Shock: Septic shock as persisting hypotension requiring vasopressors to maintain a mean
arterial pressure (MAP) of 65 mmHg or more and having a serum lactate level of greater than 2
mmol/l despite adequate volume resuscitation. (NICE 2016)
Senior Decision Maker: A 'senior clinical decision maker' for people aged 18 years or over should
be someone who is authorised to prescribe antibiotics, such as a doctor of grade CT3/ST3 or above
or equivalent, such as an advanced nurse practitioner with antibiotic prescribing responsibilities,
depending on local arrangements. A 'senior decision maker' for people aged 12–17 years is a
paediatric or emergency care qualified doctor of grade ST4 or above or equivalent. (NICE 2016)
Appropriate Consultant: Appropriate consultant may be the consultant under whom the patient is
admitted or a consultant covering acute medicine, general internal medicine or anaesthetics. (NICE
2016)
Suspected sepsis: Suspected sepsis is used to indicate people who might have sepsis and require
face to face assessment and consideration of urgent intervention. (NICE 2016)
Clinician: A 'clinician' should be a medically qualified practitioner or equivalent who has antibiotic
prescribing responsibilities. (NICE 2016)
Guideline details
End of clinical content
Guideline Governance
Implementation
See above
Training
Clinical and non-clinical staff are able to book sepsis training via ESR on the Trust Intranet.
‘Sepsis Awareness’ is for people who would like to know more about sepsis and the management
of this – any discipline can attend.
‘Sepsis Cascade Trainers Training’ for people who would like to become a cascade trainer and
disseminate sepsis information to their fellow colleagues – any discipline can attend.
‘Link Nurse Meetings’ are available to update sepsis cascade trainers with the most up to date
information with regards to sepsis within the Trust. These meetings should be attended by all link
nurses to be able to provide and disseminate the vital information to their fellow colleagues.
Adhoc training is available on request from the sepsis team for teams/ staff who are unable to attend
the teaching sessions provided; or who would like more specific training to do with their areas and
--- PDF page 10 ---
sepsis. Please make requests via the sepsis team on sepsisnurses@uhcw.nhs.uk
Other useful training – ANTT, AIM course, ILS training, preceptorship training.
Patient Information
Ensure people and their families and carers if appropriate have been informed that they have had
sepsis. Ensure discharge notifications to GPs include the diagnosis of sepsis. (NICE 2016)
Patient information is available to download from the Trust Intranet e-library.
Sepsis: General Information
Sepsis: A Guide for Patients and Relatives
‘Sepsis: General Information’ should be given to patients as safety netting advice to raise
awareness of sepsis and alert people who may be at risk of developing sepsis to the possible signs
and symptoms of sepsis. These signposts patients and their relatives to connect directly with the
best appropriate source of help or advice if they suspect sepsis. It also provides links to sepsis
information and post sepsis support groups which are available if needed.
‘Sepsis: A Guide for Patients and Relatives’ should be given to patients and relatives for
information purposes. The leaflet discusses what sepsis is and how they may have been more at
risk than others developing it. It discusses how sepsis affects the body, how they may feel after and
what the treatment is for sepsis. It also provides links for sepsis information and post sepsis support
groups, which are available if they are needed.
All leaflets given to patients should be discussed with the patients and/ or relatives to enable
questions to be answered and the correct information to be given at the right time.
More information is available from NICE for - Rehabilitation after critical illness in adults
Audit & Monitoring
Aspect being monitored
Monitoring
method
Responsible
department(s)
Frequency
Group / committee
receiving report &
responsible for actions
Screening adult patients for
sepsis
Audit
Sepsis team
Quarterly
ED QIPS, CCG, IPCC,
PPMO, Sepsis Steering
Group, Patient Safety
Committee, Medicines
Management
Committee
Appropriate time to treatment in
adult patients for sepsis
Audit
Sepsis team
Quarterly
ED QIPS, CCG, IPCC,
PPMO, Sepsis Steering
Group, Patient Safety
Committee, Medicines
Management
Committee
End of Governance content
Guideline References
--- PDF page 11 ---
CEBIS Evidence Summary
NICE Evidence
TRIP Database
Google Advanced Search
PubMed
Cochrane Library
References cited in guideline
Grade*
Levy, M. Evans, L. Rhodes, A (2018) ‘The Surviving Sepsis Campaign Bundle: 2018
update’ Intensive Care Medicine [online] available from <
https://link.springer.com/article/10.1007/s00134-018-5085-0> [2 March 2020]
MedicinNet (2018) Medical Definition of Infection [online] available from
<https://www.medicinenet.com/script/main/art.asp?articlekey=12923> [1 March 2019]
National Institute for Health and Care Excellence (2009) Rehabilitation after critical
illness in adults [online] available from <https://www.nice.org.uk/guidance/cg83> [2
April 2019]
National Institute for Health and Care Excellence (2017) Intravenous fluid therapy in
adults in hospital Clinical guideline [CG174] [online] available from
<https://www.nice.org.uk/guidance/cg174> [1 April 2019]
National Institute for Health and Care Excellence (2017) Sepsis: recognition, diagnosis
and early management NICE guideline [NG51] [online] available from
<https://www.nice.org.uk/guidance/ng51> [1 April 2019]
National Institute for Health and Care Excellence (2017) Quality statement 2: Senior
review and antibiotic treatment [online] available from
<https://www.nice.org.uk/guidance/qs161/chapter/Quality-statement-2-Senior-review-
and-antibiotic-treatment> [2 April 2019]
National Institute for Health and Care Excellence (2018) Acute Kidney Injury [online]
available from <https://cks.nice.org.uk/acute-kidney-injury> [15 April 2019]
National Institute for Health and Care Excellence (2019) Acutely Ill Patients in Hospital
[online] available from <https://pathways.nice.org.uk/pathways/acutely-ill-patients-in-
hospital#content=view-node%3Anodes-initial-assessment-and-monitoring> [1 April
2019]
NHS England (2015) Improving outcomes for patients with sepsis A cross-system
action
plan
2015
[online]
available
from
<https://www.england.nhs.uk/wp-
content/uploads/2015/08/Sepsis-Action-Plan-23.12.15-v1.pdf> [1 April 2019]
O’Driscoll, B et al (2017) ‘BTS Guideline For Oxygen Use In Adults In Healthcare and
Emergency Setting’ Thorax An International Journal of Respiratory Medicine [online]
available from <https://www.brit-thoracic.org.uk/document-
library/guidelines/emergency-oxygen/bts-guideline-for-oxygen-use-in-adults-in-
healthcare-and-emergency-settings/> [3 April 2019]
Public Health England (2015) Start Smart-Then Focus Antimicrobial Stewardship
--- PDF page 12 ---
Toolkit for English Hospitals [online] available from <
[1 April 2019]
Royal College of physicians (2017) National Early Warning Score (NEWS) 2 [online]
available from <https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-
score-news-2> [30 March 2019]
Shankar-Hari et al (2016) ‘Developing a New Definition and Assessing New Clinical
Criteria for Septic Shock’. JAMA [online] 315 (8) 775-787 available from
<https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4910392/> [1 April 2019]
Singer, M et al (2016) ‘The Third International Consensus Definitions for Sepsis and
Septic Shock (Sepsis-3)’. JAMA [online] 315 (8) 801-810 available from <
https://www.ncbi.nlm.nih.gov/pubmed/26903338> [1 April 2019]
Steinmo, S et al (2015) ‘Characterising an implementation intervention in terms of
behaviour change techniques and theory: the ‘Sepsis Six’ clinical care bundle’.
Implementation Science [online]10:111 available from
<https://implementationscience.biomedcentral.com/articles/10.1186/s13012-015-0300-
7?report=reader> [1 March 2019]
The UK Sepsis Trust (2019) Clinical [online] available from <
https://sepsistrust.org/professional-resources/clinical/> [1 April 2019]
West Midlands Palliative Care Physicians (2019) Guidelines for the use of drugs in
symptom control [online] available from <http://www.wmcares.org.uk/wmpcp/guide/> [3
April 2019]
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment
_data/file/417032/Start_Smart_Then_Focus_FINAL.PDF
--- PDF page 13 ---
*Grade:- The references are graded through the CEBIS process according to the criteria
outlined below.
Grade of
evidence
Based on
1
Systematic review or meta-analysis
2
Randomised controlled trial/s
3
Controlled study without randomisation (e.g. case controlled) or quasi-experimental
study, such as a cohort study
4
Descriptive studies such as case series and reports.
5
Expert opinion, narrative review
Add any Appendices below
(Please use a “Page Break” before each appendix, and list each clearly in the section on the title
page. Appendices may include a summary, a flowchart, a proforma, or other materials, but its
purpose must be clearly identified)
--- PDF page 14 ---
Appendix 1
--------------------------------------------------------------------------------
ATTACHMENT: 24_1.pdf
TEXT_FILE: 24_1.pdf.txt
METHOD: pdf_native
OCR_USED: False
PAGES: 14
--------------------------------------------------------------------------------
--- PDF page 1 ---
1
University Hospitals Coventry & Warwickshire NHS Trust
Vancomycin Resistant Enterococci Guidelines
E- Library Reference
CG 888
Version
9
Approving forum (QIPS or equivalent):
Infection Prevention Control Committee
Specialty Clinical Guideline Lead:
Dr Natasha Ratnaraja
Contributing Author(s) and reviewer(s):
Dr Natasha Ratnaraja Consultant Microbiologist ,
Natasha.Ratnaraja@uhcw.nhs.uk
Melanie Gallo Infection Prevention and Control Nurse;
Melanie.Gallo@uhcw.nhs.uk
TRAINEE NURSING ASSOCIATES or NURSING ASSOCIATES - A NEW NURSING ROLE If Registered Nurses
or Student Nurses will be undertaking a role, or carry out procedures in your area, you will now need to
consider the role/input/restrictions for Trainee Nursing Associates/Nursing Associates and refer to them
within your document. If you require any further information please contact Karen Mogan Practice Facilitator
karen.mogan@uhcw.nhs.uk<mailto:karen.mogan@uhcw.nhs.uk>
Department(s) / Primary Speciality:
Infection Prevention and Control
Approval Date:
May 2020
Review date:
October 2023
Expiry Date:
April 2024
Target Audience:
All employees of the University Hospitals Coventry and
Warwickshire (UHCW) NHS Trust and all those visiting
UHCW premises such as contractors, agency/bank/locum
staff, students and volunteers where patients are cared
for.
Superseded UHCW
Clinical Guideline(s):
(if applicable)
V8
UHCW Associated Records:
Hand Decontamination Policy (2020) University Hospitals
Coventry and Warwickshire NHS Trust
Cleaning and Disinfection of Non Invasive Equipment
(2019) University Hospitals Coventry and Warwickshire
NHS Trust
Standard Infection Control Precautions (2018) University
Hospitals Coventry and Warwickshire NHS Trust
Isolation Guideline (2020) University Hospitals Coventry
and Warwickshire NHS Trust
Adult Antibiotic Guideline (2017) University Hospitals
Coventry and Warwickshire NHS Trust
--- PDF page 2 ---
2
Antibiotic Prophylaxis in Surgery Guidelines for Adults
(2016) University Hospitals Coventry and Warwickshire
NHS Trust
Trust Waste Policy (2019) University Hospitals Coventry
& Warwickshire NHS Trust
Procedure for the laundering of Soiled Patients clothing in
the home setting guideline (2019) University Hospitals
Coventry & Warwickshire NHS Trust
Keywords:
VRE
Colonisation
Clinical Operating Procedures relating to this
guidance (please list)
None
Summary Version Available
--- PDF page 3 ---
Summary
•
Enterococci are an increasingly common cause of healthcare associated infections caused by Vancomycin- Resistant Enterococci (VRE).
•
Although VRE colonisation appears to be more frequent than true infection, it is essential that transmission of these bacteria is controlled as colonisation
frequently precedes infection.
These organisms can spread within healthcare facilities if standard infection control precautions (SICPs) and transmission based precaution (TBPs) are not
followed. Treatment options may be limited if the patient requires antibiotic therapy. VRE infection may prolong patients’ hospital stay.
•
Acquisition of VRE in hospital is often associated with use of antibiotics and cross transmission via the environment and/or contaminated
hands of healthcare workers
Clinical Guideline Vancomycin Resistant Enterocci Guidelines
Appendices
Appendix 1 VRE Quick Action Guide
Appendix 2 Isolation Risk Assessment
3
Purpose of Guidance
Acquisition of VRE in hospital is often
associated with use of antibiotics and cross
transmission via the environment and/or
contaminated hands of healthcare workers.
The purpose of this guideline is to provide
details on how to reduce the risk of
transmission of VRE within healthcare
settings.
Introduction
Enterococci are a group of bacteria that are
naturally present in the intestinal tract of humans
and normally cause no harm (colonisation).
However, sometimes enterococci can cause
infections in wounds, urine and in more serious
infections in blood. VRE (Vancomycin Resistant
Enterococci) are enterococci that are resistant to an
antibiotic called Vancomycin. VRE are often
resistant to other types of antibiotics and this can
make them more difficult to treat. VRE will not
cause more serious infections than other
enterococci.
Who Does it Affect?
This Guidance Applies to:
This guideline is applicable to all staff Trust wide. It is a staff members’ responsibility to make
themselves aware of the contents of this guideline and to put the guidance into practice. This is
necessary to ensure the safety of patients / clients, all employees and those who visit the care
environment.
NHS providers are required under the Health and Social Care Act 2008 (revised 2015) to ensure that
preventable healthcare associated infections do not occur, as part of maintaining patient quality and
safety. Compliance with this code is a statutory requirement for all healthcare workers and is measured
by the CQC (Care Quality Commission) as part of their inspection process.
--- PDF page 4 ---
4
Guideline clinical content
Clinical Guidelines assist in decision-making; they do not replace clinical judgement. Regardless of the strength of
evidence, it remains the responsibility of the clinician to interpret the application of the clinical guidance to local
circumstances and the needs and wishes of the individual patient. Where variations of any kind do occur, it is important
to document the variations and the reason for them in the patient’s health record. If in doubt, seek senior advice.
EPR update 2023
Please note: The following systems have been replaced by the trust Electronic Patient Record system
(EPR). If any of these systems are identified within the document, please substitute them for the
appropriate EPR alternative system and refer to relevant corresponding EPR procedures.
1. Opera (theatres)
2. Centricity (Critical Care)
3. Wardview
4. Extramed
5. CRRS
6. VitalPack
7. Adastra (CUTC)
8. K2 (maternity portal replaced by PPUK)
9. i.PM
10. Athena (Maternity)
11. SCIT App (replaced by camera capture)
Please contact EPREnquiries@uhcw.nhs.uk if you have any questions about the systems
listed or the EPR system introduced in their place.
On review of this document please ensure the systems listed are removed from the text and
replaced with the relevant EPR system and process.
Introduction
Enterococci are a group of bacteria that are naturally present in the intestinal tract of humans and normally cause no
harm (colonisation). However, sometimes enterococci can cause infections in wounds, urine and in more serious
infections in blood.
VRE (Vancomycin Resistant Enterococci) are enterococci that are resistant to an antibiotic called Vancomycin. VRE
are often resistant to other types of antibiotics and this can make them more difficult to treat. VRE will not cause more
serious infections than other enterococci.
This guideline is necessary to help guide staff on how to prevent transmission of VRE.
Summary
--- PDF page 5 ---
5
Enterococci are an increasingly common cause of healthcare associated infections caused by Vancomycin- Resistant
Enterococci (VRE).
Although VRE colonisation appears to be more frequent than true infection, it is essential that transmission of these
bacteria is controlled as colonisation frequently precedes infection.
VRE colonisation can progress to infection. These organisms can spread within healthcare facilities if standard
infection control precautions (SICPs) and transmission based precaution (TBPs) are not followed. Treatment options
may be limited if the patient requires antibiotic therapy. VRE infection may prolong patients’ hospital stay.
Acquisition of VRE in hospital is often associated with use of antibiotics and cross transmission via the environment
and/or contaminated hands of healthcare workers
Definitions
VRE
Vancomycin Resistant Enterococci
VRE Colonisation
When a person carries VRE but it does not cause them any
harm. This is more common than infection. People who are
colonised do not require treatment.
Colonisation
The presence of micro-organisms without causing signs and
symptoms of infection.
HCW
Health care worker
IPCT
Infection Prevention and Control Team
Guideline details
What infections can be caused by VRE?
•
Urinary Tract Infections
•
Bacteraemia
•
Wound Infections
•
Endocarditis
•
Intravenous device associated infection
--- PDF page 6 ---
6
•
Cholangitis
•
Meningitis
Which patients are at risk of VRE colonisation/infection?
•
Patients who are immuno-compromised such as renal patients, patients in intensive care and neonates.
•
Patients who had previous treatment with vancomycin or combinations of other antibiotics.
•
Patients who had surgical procedures or has invasive medical devices e.g. central venous catheter (CVC) etc.
•
Inpatient stay within Intensive Care Unit
Although this organism is not particularly virulent usually colonising individuals rather than causing infection,
compromised patients can be at risk.
How is VRE spread?
VRE are most commonly spread
•
through direct contact with the patient e.g contaminated hands of HCW or
•
Indirectly from the patient’s care environment e.g. frequently touched surfaces such as lockers or bed tables.
As enterococci including VRE are found in the bowel and passed as faeces, particular care is required if the
patient has loose stools or invasive devices.
Screening for VRE
Currently there is no national requirement to screen for VRE.
VRE is identified in routine clinical specimen where VRE is present e.g. urine, wound swab, blood culture, line tip etc.
The isolation of VRE if present is part of the routine culture and sensitivity process.
Identification of VRE
When identified as VRE, Microbiology Laboratory will inform the Infection Prevention and Control Team (IPCT) during
normal working hours of any positive VRE specimens via the Trust Red Box system.
Out of hours on call Medical Microbiologist will contact the clinical area directly.
Treatment
Clinical judgement is required as to whether the VRE is causing infection. In many instances antibiotic therapy is not
required. Where treatment is indicated, options may be limited.
If patients are showing signs of infection, guidance on antimicrobial management
should be sought from Duty Microbiologist / on call Microbiologist, available via switchboard.
No antibiotic treatment is required for colonisation.
These organisms are part of the faecal flora and, as such, are of particular risk to people with indwelling urinary
catheters and in areas where faecally contaminated items are handled.
Transmission occurs due to poor hand hygiene and following contact with contaminated items in the clinical setting.
In all cases of a positive VRE results, an alert will be placed on CRRS. This will ensure on all future admissions staff in
the Trust are aware of the increased risk in caring for this patient, both in terms of patient placement and in antibiotic
prescribing
Prevention Of The Transmission Of VRE
Please refer to Appendix 1 VRE Quick Action Guide
--- PDF page 7 ---
7
STANDARD PRECAUTIONS APPLY AT ALL TIMES
•
Meticulous attention to hand hygiene and adherence to the 5 moments of hand hygiene is of paramount
importance . Hand gel is effective against VRE except when there has been exposure to bodily fluids, faeces
etc in which case hand hygiene with soap and water is required.
•
Patients found to be positive for VRE should ideally be isolated in a side room to assist in the prevention of
transmission. (Isolation Guidelines 2020).
Where this is not possible, a risk assessment of the patients in the side rooms
must be completed, and documented in the patients nursing notes. If the
patient is considered the lowest risk of transmission on the ward, or the patient
is of high risk of falls, source isolation in a bay can be implemented, taking all
appropriate precautions whilst maintaining patient confidentiality and dignity. Please refer to the isolation
priority system in appendix 2
•
In all cases of a positive VRE result, an alert will be placed on CRRS. This will
ensure on all future admissions staff in the Trust are aware of the increased risk in caring for this patient, both
in terms of patient placement and in antibiotic prescribing.
•
The use of Personal Protective Equipment (PPE) should be implemented as directed in Standard Infection
Prevention and Control Precautions Guideline (2018).
•
Education of staff
•
Educate patients on hand hygiene and good skin care. (Handwashing Decontamination Policy 2020)
•
Antibiotic prescription needs to be reviewed in conjunction with the Medical Microbiologist. If treatment is
required please consult with the duty Microbiologist as the antibiotics used for treatment are on approval by
microbiology only.
Isolation of VRE within the Trust is uncommon but is increasing. It is important that it is taken seriously, and that all
staff maintains best practice to prevent cross infection.
Clinical Investigations
Patients with VRE can undergo investigations in any hospital department, provided the department has been informed
directly in advance by the ward staff.
It is the responsibly of the nurse looking after the patient on the transferring ward to do this.
Patients should be seen promptly, and the time spent waiting in communal areas should be kept to a minimum.
Standard precautions, including adherence to the “WHO five moments”
should be used at all times, by ALL staff.
Equipment, including trolleys, should be decontaminated with Tristel by the member of staff using them before being
used on the next patient.
Theatres
VRE patients undergoing surgery may need different antimicrobial prophylaxis to non-carriers. Please discuss with
Duty Microbiologist (available via Switchboard).
Theatres must be informed directly in advance of the patients VRE status.
This is the responsibility of the transferring ward staff.
Cleaning of theatre surfaces, should be carried out using Tristel after every
case.
--- PDF page 8 ---
8
Air exchanges in theatre are of a sufficient standard no “rest” period is
required between cases
Cleaning
VRE can survive for long periods in dust, so special attention should be paid to
ensuring the cleanliness of horizontal surfaces and dust collecting areas, e.g. beds, bed linen, curtain rails, tables,
sinks, door handles, and ventilators.
Strict attention to cleaning of commodes, using Tristel is to be paid. Disposable bedpans and urinals should be used
or non-disposable, reprocessed in washer/disinfector (Cleaning and Disinfection of Non Invasive Equipment 2019).
Cleaning services personnel should be made aware that the patient is receiving
special precautions so that they can provide the necessary additional cleaning
equipment and fulfil cleaning requirements.
A terminal clean of the side room is required when a VRE patient is discharged or
transferred. If this is from a bay, terminal cleaning of the bed space is sufficient.
Outpatients department, including eye clinic
Strict adherence to the WHO five moments of hand hygiene is required.
Wounds should be covered with a dressing whilst waiting in communal
waiting areas.
There is no need to remove furniture or equipment from consulting rooms.
Surfaces that the patient has been in direct physical contact with, e.g. the
Couch and surfaces the healthcare worker has touched while caring for the patient, should be wiped down with
chlorine dioxide solution (e.g. Tristel)
Equipment
Equipment must be kept to an absolute minimum and designated for the sole use of
the patient in isolation. This includes blood pressure monitoring equipment, tympanic
thermometer, dressing trolley and commode. Equipment may only be used on other
patients after it has received thorough decontamination with chlorine dioxide solution
(e.g. Tristel).
Mattresses
After a patient is discharged the mattress must be thoroughly checked and
decontaminated using chlorine dioxide solution (e.g. Tristel). Dynamic mattresses
should be sent to the mattress library.
Transferring of Patients
Infection Prevention and Control measures should not compromise the patients care
and should not affect the patients freedom to be mobilised or attend other departments for health care related visits.
It is the responsibility of the nursing staff on the transferring ward to make direct
contact with staff on the receiving ward or department (e.g. radiology) to make sure
that they are aware of the patients VRE status in advance of the transfer.
Following a procedure or investigation the area and equipment will require a
decontamination using a chloride dioxide solution (e.g.Tristel).
Porters
--- PDF page 9 ---
9
Transporting a patient with VRE in the hospital on a bed, trolley or in a wheelchair
is a low risk activity. There is no requirement for porters to wear gloves, aprons or
other PPE on transferring patients.
It is of paramount importance however that hand decontamination is performed after contact.
Cleaning of bed, trolley, wheelchair must be performed after the
transportation is complete. Chlorine Dioxide (Tristel) can be found on all
wards and should be utilised.
Laundry
All laundry must be considered contaminated and placed in a red alginate bag inside
a white outer bag. If patients are wearing their own clothing and sent home for laundering then please refer to
Procedure for the laundering of Soiled Patients clothing in the home setting guideline (2019).
Cutlery and Crockery
Ordinary cutlery and crockery can be used, provided that these are washed in an
automated dish-washer after use. Disposable crockery and cutlery are not required.
Under no circumstances should any crockery or cutlery be washed by hand.
Visitors
Visitors are not required to wear protective clothing unless involved in the patient’s
personnel care, when an apron should be worn. Visitors should wash their hands
immediately prior to leaving the isolation room.
Discharge from hospital
Patients with VRE should be discharged promptly from hospital when they are
considered clinically fit. A positive VRE status alone is not a reason to keep the
patient in hospital.
Staff at nursing, convalescent or residential homes should be informed in advance of
discharge of the VRE result but no special measures are required.
In the patient’s own home there are no special measures required by family.
On discharge the General Practitioner (GP) and any other community services
utilised by the patient must be informed of the positive VRE result.
Transportation by Ambulance or Car
Those carriers of VRE when travelling by ambulance or car may be transported
with other individuals as long as all wounds are dressed and they are continent of
urine and faeces. The ambulance crew must be informed and maintain good IPC
standards.
Last offices
No special precautions are needed for VRE positive patients.
Screening staff
Routine screening of staff for carriage of VRE is not required. The IPCT and DIPC in co-ordination with Occupational
Health may implement screening for staff based on the epidemiological pattern of increased isolates within a clinical
area
--- PDF page 10 ---
10
END OF CLINICAL CONTENT
Clinical Guideline Governance
Implementation
Managers are responsible for ensuring that all staff are familiar with this guideline. This can be achieved by
ensuring all staff are aware of the guideline on induction.
Employees are responsible for attending induction training and compliance with Infection Prevention & Control training
in accordance with the trust training needs analysis. They must also know how to access all policies and guidelines
and comply with them.
Training
All Trust staff must complete IPC mandatory training annually.
Patient Information
The VRE patient information leaflet can be located on e-Library
EQUALITY & DIVERSITY STATEMENT
Throughout its activities, the Trust will seek to treat all people equally and fairly. This includes those seeking and
--- PDF page 11 ---
11
using the services, employees and potential employees. No-one will receive less favourable treatment on the grounds
of sex/gender (including Trans People), disability, marital status, race/colour/ethnicity/nationally, sexual orientation,
age, social status, their trade union activities, religion/beliefs or caring responsibilities nor will they be disadvantaged
by conditions or requirements which cannot be shown to be justifiable. All staff, whether part time, full-time,
temporary, job share or volunteer; service users and partners will be treated fairly and with dignity and respect.
Audit & Monitoring
Aspect being
monitored
Monitoring method
Responsible
department(s)
Frequency
Group / committee
receiving report &
responsible for
actions
Prompt isolation of
patients with VRE
positive patients
IPC Datix
IPC & Individual
Departments
As and when
required from datix
IPCC
Quarterly 5 moments
Hand Hygiene Audits
Direct Observation
IPCT
Quarterly
IPCC
END OF GOVERNANCE CONTENT
Guideline References
CEBIS Evidence Summary
References Cited in Guideline
Grade*
Cookson et al (2006) Guidelines for the Control of Glycopeptide Resistant Enterococci
in Hospitals. A report of the combined working party of the Hospital Infection Society,
Infection Control Nurses Association and British Society for Antimicrobial
Chemotherapy, Journal of Hospital Infection, Vol 62 No 1 Pg 621.
5
Department of Health (2015) The Health and Social Care Act 2008, Code of Practice
on the prevention and control of infection and related guidance Available at:
https://www.gov.uk/dh
Loveday, H.P. Wilson J,A. Pratt,M. Golsokhi, A. Tingle, A. Bak, J. Browne, J. PrietoJ.
Wilcoc M. (2014). Epic 3: National Evidence- Based Guidelines for
Preventing Healthcare Associated Infections in NHS Hospitals in England . Journal of
Hospital Infection. 86S1 (2014) S1-S70.
2
Public Health England (2013) Antimicrobial Prescribing and Stewardship Comptencies
Siegel Jane D; Rhinehart Emily; Jackson Marguerite; Chiarello Linda (2007) Guideline
for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare
Settings. The Healthcare Infection Control Practices Advisory Committee.
Last updated July 2019
3, 5
*Grade:- The references are graded through the CEBIS process according to the criteria outlined below.
--- PDF page 12 ---
12
Grade of
evidence
Based on
1
Systematic review or meta-analysis
2
Randomised controlled trial/s
3
Controlled study without randomisation (e.g. case controlled) or quasi-experimental study, such as
a cohort study
4
Descriptive studies such as case series and reports.
5
Expert opinion, narrative review
Add any Appendices below
(Please use a “Page Break” before each appendix, and list each clearly in the section on the title page. Appendices
may include a summary, a flowchart, a proforma, or other materials, but its purpose must be clearly identified)
--- PDF page 13 ---
13
--- PDF page 14 ---
14
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ATTACHMENT: 3.pdf
TEXT_FILE: 3.pdf.txt
METHOD: pdf_native
OCR_USED: False
PAGES: 27
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--- PDF page 1 ---
1
Management of a Healthcare Infection Outbreak or Incident
Related National
Guidance
UKHSA managing outbreaks and incidents 13th February 2023
E-library number
CG 337
Version number
V10
Purpose
The purpose of this policy is to ensure a rapid, well-coordinated
response to an outbreak, verify that there is an outbreak of infection to
investigate the extent and to identify the source. Making efficient use
of all health service resources in order to contain the outbreak, limit
the spread of infection and minimise the disruption of clinical services,
ultimately stopping the outbreak and preventing where possible a
recurrence.
Primary Specialty
Infection Prevention Control and Sepsis
Related
Specialties
Trust Wide
Specialty Clinical
Guideline Lead
Fiona Wells Lead Nurse Infection Prevention and Control and Sepsis
Authors
Lead Author:
Ragbinder Mahal Infection Prevention and Control
and Sepsis Nurse
Mahal.ragbinder@uhcw.nhs.uk
Reviewer(s):
Fiona Wells Infection Prevention and Control and
Sepsis Lead
Fiona.Wells@uhcw.nhs.uk
Approving Forums Infection Prevention Control Committee
Approval Dates
QIPS
August 2023
MMC
Not required
Other (specify)
Review Date
June 2026
Keywords
Infection, isolation, guideline, outbreak, Incident, IPCT, PII, period of
increased incidence, Endemic, Epidemic, Pandemic.
Clinical guideline content: Clinical Guidelines assist in decision-making; they do not replace clinical
judgement. Regardless of the strength of evidence, it remains the responsibility of the clinician to
interpret the application of the clinical guidance to local circumstances and the needs and wishes
of the individual patient. Where variations of any kind do occur, it is important to document the
variations and the reason for them in the patient’s health record. If in doubt, seek senior advice.
Equality and Diversity Statement: Throughout its activities, the Trust will seek to treat all people
equally and fairly. This includes those seeking and using the services, employees and potential
employees. No-one will receive less favourable treatment on the grounds of sex/gender (including
Trans People), disability, marital status, race/colour/ethnicity/nationally, sexual orientation, age,
social status, their trade union activities, religion/beliefs or caring responsibilities nor will they be
--- PDF page 2 ---
2
disadvantaged by conditions or requirements which cannot be shown to be justifiable. All staff,
whether part time, full-time, temporary, job share or volunteer; service users and partners will be
treated fairly and with dignity and respect.
Rationale
Sources of Evidence
NICE Evidence
Google Advanced Search
Cochrane Library
PubMed
Dissemination and related guidance
This will be on e-library to for all staff to access.
Training
• Donning and Doffing Training – with cascade trainers and IPC
• Ready to Care Session – with IPC
• Fit testing- with cascade trainers and IPC
Patient Information
Infection Control – Isolation and Barrier Nursing Patient Information Leaflet
e-Library (uhcw.nhs.uk)
Audit & Monitoring
Audit title
Audit Lead
Monitoring method
and frequency
Committee responsible
National
Standards of
Cleanliness
ISS team and
clinical area
As per ISS timetable
5 moment hand
hygiene audit
Ward manager/
modern matron
Observational hand
hygiene audit
Changes from previous version
Date
Updated information
01/08/2023
New template
01/08/2023
Page 3-8 definitions added, further information added to all sections
from previous guideline.
01/08/2023
New information added:
Page 9 HIATT Tool added, Page 10 assessment and action plan,
Page 11 reporting structure, Page 12 Water system maintenance,
Page 14 Ventilation system maintenance.
01/08/2023
New appendices Page 15-18
--- PDF page 3 ---
3
Contents
Definitions ............................................................................................................................. 3
Introduction .......................................................................................................................... 6
Scope ................................................................................................................................... 6
Roles and Responsibilities .................................................................................................... 7
Clinical guidance ................................................................................................................ 10
Appendices ....................................................................................................................... 155
References ....................................................................................................................... 278
Definitions/Abbreviations
Case
A person (infant to adult) exhibiting symptoms consistent
with the outbreak case definition. This may be a patient or
employee
Cluster
A
cluster
is
a
collection
of
cases
occurring
contemporaneously.
There
is
not
necessarily
any
connection between the cases and, if they are not linked,
outbreak control measures may not be appropriate.
Contact
An exposed individual who might be at risk of developing
the infection.
Exceptional infection
episode
A single case of an infection that has severe outcomes for
an individual patient OR has major implications for others
patients, staff and/or visitors, the organisation or wider
public health.
Incident
A single case of infection, serious illness or adverse event
resulting in, or having potential for harm from an infectious
agent.
Incidence
The number of cases of a disease (or event) occurring in a
specified time
POU filter
Point of Use filter
HCAI
Healthcare Associated Infections (HCAI) is an infection
which is associated with medical care, or treatment, in any
healthcare setting arising. The time frame for attributing an
infection as healthcare associated will vary depending upon
--- PDF page 4 ---
4
the infectious agent and its incubation period.
Index case
The first case of infection to be recognised.
IPCT/IPC
Infection Prevention and Control Team. Infection Prevention
Control
UKHSA
UK Health Security Agency
PII
Period of increased incidence
ICB
Intergrated Care Board
DIPC
Deputy Infection Prevention and Control Nurse
Surveillance
Systematic collection, analysis, and interpretation of data on
specific events and disease, followed by dissemination of
that information to those who can improve the outcomes
TBP
Transmission Based Precautions
WSG
Water Safety Group
Severe or significant
outbreak
Patients linked across multiple bays or wards, prolonged
outbreak with ongoing transmission identified. This also
includes outbreaks which impact on capacity and the
ability to admit or discharge patients into the provider
organisation.
XDR-TB
extensively drug resistant tuberculosis
ALBs
Arm’s Length Bodies
This includes ICB, UKHSA and NHSE regional teams,
where indicated
Mandatory reporting
This column relates to reporting through to UKHSA either
through data capture system or through Notifications of
Infectious Diseases reporting systems
Duty of Candour
Formal regulatory duty of candour as outlined in Health and
Social Care Act 2008 (regulated activities) Regulations
2014: Regulation 20 (CQC regulation 20)
Trusts/providers are still expected to be open and honest
with patients, regardless of whether the legal/regulatory
aspects of DOC are met, this is covered within the patient
communication section of the table.
Incident Reporting
System
This would be your internal incident reporting system, such
as Datix, incident reporting system (IR1) Ulysses etc. The
purpose of reporting IPC incidents through this way is to
support with thematic reviews and provide evidence and
assurance of actions
Patient Safety
These investigations will be automatically carried out where
--- PDF page 5 ---
5
Incident
Investigations (PSII)
there are concerns raised following mortality review. Where
significant concerns are noted during an Infection Control
Review cases will be discussed with Patient Safety Team
for consideration into further investigation.
PSII’s will be reported via the agreed Trust governance
processes, and a copy of any PSII is expected to be shared
at the IPC Committee/Assurance Group. Learning from
these incidents should be shared across the system through
whole health economy/system meetings.
ICR
Infection Control Review
A healthcare infection incident:
• A healthcare associated infection outbreak, defined as two or more linked cases
associated with the same infectious agent, within the same healthcare setting,
over a specified time period; or a higher-than-expected number of cases in each
healthcare area over a specified time period.
• An exceptional infection episode, defined as a single case of an infection that
has severe outcomes for an individual patient OR has major infection
control/public health implications e.g., infectious diseases of high consequence
such as extensively drug resistant tuberculosis (XDR-TB), botulism, viral
haemorrhagic fever, polio, rabies, diphtheria.
• A healthcare infection if there is a high likelihood of exposure of a population to
a hazard (e.g., a chemical, food, water or infectious agent) at levels sufficient
to cause illness.
• A healthcare infection near miss incident, which had the potential to expose
patients to an infectious agent but did not e.g., decontamination failure.
• A healthcare infection exposure incident, defined as an exposure of patients,
staff or the public to a possible infectious agent e.g., via ventilation systems,
water systems or decontamination failure or failure to isolate an infectious
patient.
Outbreak:
The general definition of what constitutes an outbreak in practice is an episode/s of
infection in which there is evidence of spread (clinically, microbiologically, or
epidemiologically) in time or space. This demands immediate action; the Infection
Prevention and Control Team (IPCT) will liaise with other disciplinaries and declare an
outbreak of infection after the evidence has been collected and assessed.
--- PDF page 6 ---
6
Outbreak patterns of occurrence are:
• Endemic: communicable disease such as influenza, diarrhoea and vomiting,
measles, mumps, pneumonia which is characteristic of a particular place, or
among a particular group, or area of interest or activity
• Epidemics: the disease is found to infect a significantly larger number of people
at the same time than is common at that time, and among that population, may
spread through one or several communities (can affect a region in a country or
a group of countries)
• Pandemics: describe global disease outbreaks when epidemics spread
worldwide
Period of Increased Incident:
Period of increased incidence (PII) of infection: two or more cases (at least one of
which occurs ≥48 hours post admission in a 28-day period on one ward). A PII will be
escalated to an outbreak e.g., Clostridiodes difficile infection outbreak, if there are two
or more cases caused by the same strain/typing result related in time and place over
a defined period that is based on the date of onset of the first case (UKHSA 2022).
Introduction
The Trust has an obligation to manage any outbreak of infection or significant incident
to prevent spread and protect patients, staff and visitors. The impact of outbreaks on
the NHS is extensive and it is important that measures to reduce transmission and
control outbreaks do not have a negative impact on patients and their visitors.
The purpose of this policy is to ensure a rapid, well-coordinated response to an
outbreak or incident of any infection (confirmed or suspected), verify that there is an
outbreak of infection, to investigate the extent and to identify the source. Making
efficient use of all health service resources in order to contain the outbreak, limit the
spread of infection and minimise the disruption of clinical services, ultimately stopping
the outbreak and preventing where possible a recurrence.
Scope
The guidance applies to all staff employed by the Trust, including agency, locum and
--- PDF page 7 ---
7
bank staff contracted by the Trust.
Roles and Responsibilities
Early recognition of a potential outbreak or incident is critical to its effective
management and control. This will minimise the impact on patients, visitors, staff,
wider organisation, and public health.
The Chief Executive and the Board of Directors are responsible for:
• Ensuring there are effective and adequately resourced arrangements for
IPC within the organisation, including outbreak management within the
Trust.
The DIPC/ deputy DIPC is responsible for:
• Providing support and continuity of strategic leadership for IPC.
• Ensuring that clinical responsibility for IPC is effectively devolved to:
-
All professional clinical groups in the Trust
-
Clinical specialties and divisions and, where appropriate, support
services and other similar units
• Notify the Chief Executive and Board. Act as a link between IPC, the
outbreak team and Executives.
• Agree the strategy for communication with the media, including information
to be released.
Infection Prevention & Control Team are responsible for:
• Verifying that there is an outbreak of infection.
• Determining the extent of the outbreak and initiate measures to determine the
source and cause.
• Notifying microbiology and/or Virology team, clinical areas, site team and
specialist teams as required.
• Reporting the outbreak to the DIPC and relevant clinical groups and operational
teams.
• Performing a baseline observational audit of the affected area at an early stage
where appropriate.
• Collection of relevant information on affected patients.
--- PDF page 8 ---
8
• Carry out contact tracing as required per infectious agent, advising actions for
patient contacts identified and referring staff contact tracing to occupational
health.
• Advice on control measures to be used for affected patients.
• Regular communication with appropriate staff and external agencies including
NHSE, UKHSA and the ICB.
• Monitoring of agreed control measures.
• Giving adequate notice to Soft FM Service Provider when final clean is required.
• Alerting staff to the need to implement additional actions to contain an outbreak.
• Supporting Ward/Departmental Sister/Charge Nurse with the management of
an outbreak and associated actions.
• Lead Nurse/ Deputy lead: tabling final report as an agenda item at a future
Infection Prevention and Control Committee and others as requested by the
Trust.
Reporting structure:
•
For the majority of incidents/outbreaks the IPCT will coordinate the
outbreak/incident locally
•
IPCT will communicate the result to appropriate staff and make them aware of
the actions being taken.
•
IPCT will ensure senior management including Chief Nursing Officer, and
contracted service managers e.g., ISS and Vinci Estates and Trust
Communications Team are aware.
•
IPCT will inform outside agencies and individuals as appropriate i.e. UKHSA,
ICB team etc.
•
Upwardly reporting with control room/site team involvement (appendix 1)
•
An Incident meeting will be arranged, and relevant internal and external
parties/teams invited, draft meeting agenda (appendix 2).
•
Datix to be completed.
Group triumvirate and IPC Medical leads are responsible for:
• Attending the outbreak/ incident meeting if their clinical area is affected.
• Overseeing implementation of advice given by IPCT and/or outbreak/ incident
group.
• Making contingency arrangements as required to maintain activity during
outbreaks.
--- PDF page 9 ---
9
• Liaison with appropriate staff within the directorate to ensure control measures
are carried out.
Matrons are responsible for:
• Attending the outbreak/ incident meeting if their clinical area is affected.
• Overseeing implementation of advice given by IPCT and/or outbreak/ incident
group
• Managing staffing levels on wards
• Ensuring adequate supplies of equipment are available.
• Ensuring ward staff receive appropriate support.
• Oversight of cleaning of the area prior to re-opening
• Supporting staff on ward/department
• Reporting any breaches to this guidance via the Trust incident reporting and
directly to the IPCT
Clinical ward staff are responsible for:
• Early identification of patients that may have an infection and ensuring
appropriate management, including prompt isolation where required and
adherence to the transmission-based precautions (TBPs).
• Informing the IPCT, Microbiology and Virology of suspected outbreaks. Out of
hours the Duty Matron and clinical site team must also be informed.
• Attending the outbreak/ incident meeting if their clinical area is affected.
• Overseeing implementation of advice given by IPCT and/or outbreak/ incident
group.
• Daily review of bays / wards with outbreak restrictions in their area, and
ensuring the precautions detailed in this guideline are in place, including
checking that there are adequate cleaning staff on the ward.
• Facilitating cleaning of the area prior to re-opening e.g., Signing off a terminal
clean be completed by the performance team, ward manager/nurse in charge
or ISS supervisor for infectious agents that requires a signed off terminal clean.
Nurse equipment clean.
• Out of hours, assessing wards with suspected outbreaks and contacting all
relevant teams (as described above).
• Safe discharges – patients identified with a HCAI, or notifiable disease please
add details to discharge letter/transfer letter to fully inform external facilities (this
could include discharges to adult social care provider or to another hospital).
--- PDF page 10 ---
10
Occupational Health is responsible for:
• Identifying staff contacts
• Confirming suitability of individual members of staff to work in affected areas.
• Liaison with staff members GP were appropriate.
• Alerting the IPCT of any infectious conditions amongst Trust employees that
could be transmitted during the course of their work.
• Participating in the contract tracing of staff exposed to infectious conditions as
applicable.
Communications Team
• Advise and assist in the preparation of communications for the media.
• Liaise closely with Press/Public Relations Officers of partner organisations as
appropriate to ensure that all information is agreed and consistent.
Clinical guidance
Recognition of an outbreak or incident
An outbreak or incident may be identified by several routes depending on its nature
and presentation e.g.
• Ward staff may alert the IPCT to an outbreak of presumptive viral gastroenteritis
or other specific symptoms in patients or staff related to specific infection e.g.,
C. difficile, COVID-19, flu or other respiratory viral infections, scabies.
• Laboratory staff may highlight an outbreak of an organism that exhibits a
specific antimicrobial resistance or whole genome sequence.
• IPCT may notice links between patients with ‘alert’ organisms or healthcare
epidemiologists may identify increases in cases from routine surveillance within
the Trust.
• A national alert about a product or medical device may lead to case finding.
--- PDF page 11 ---
11
• A national alert about a significant infection may trigger case finding or cases
linked to an outbreak outside of the Trust.
• An outbreak may present as either related to a single ‘point source’ e.g., a
contaminated piece of equipment or food or exposure to an infected case or as
a pattern of ongoing transmission.
• If the outbreak or incident involves a notifiable disease or organism (see
Gov.uk) the treating physician or laboratory must notify:
UKHSA West Midlands Health protection Team
If the disease is notifiable by law please click the link http://trustnav/infection-
prevention-control/notification-of-infectious-disease-or-contamination/
Telephone: (In hours) 0344 225 3560 and (Out of hours) 01384 679 031
During a period of increased incidence of disease locally or nationally e.g., Influenza,
measles or norovirus all clinical staff should be alerted to the need to have increased
suspicion of symptoms of the infection and act promptly to report their concerns to
minimise onward transmission.
On suspicion/ confirmation of an outbreak
Staff who suspect two or more people experiencing similar illness who are linked in
time or place, or an increase in background rate of infection will:
• Take immediate action to reduce the risk of cross infection.
• Isolate or cohort patients with similar symptoms based on risk assessment.
• Implement relevant transmission-based precautions (these are additional
measures required to standard precautions).
• Take appropriate samples for laboratory processing.
• Wherever possible, distribute staff to affected and non-affected areas.
• Ensure clear communication to staff on duty regarding their responsibilities.
• Inform senior staff members on duty (person in-charge for that shift).
• Inform the medic responsible for the care of the affected patients.
• Contact the IPCT at the earliest opportunity to enable a risk assessment of the
severity of the situation.
UHCW IPC Team
Telephone: (Mon-Fri 8-6) extension 24791 or bleep 2171
Out of IPCT office hours and during weekends and bank holidays – Please contact the
on-call microbiologist via switchboard.
--- PDF page 12 ---
12
Infection Control Review (ICR)
Suspected outbreaks or incidents are initially investigated by the IPC team and
reported back to the DIPC and relevant clinical groups.
Once alerted to an apparent increase in cases, or other markers of a possible outbreak
or incident, the IPCT will assess the situation. This will include information regarding:
• The number of individuals affected.
• Symptoms/ date commenced/ samples taken.
• Likely source
• Mode of spread
• Healthcare cleaning (National Standards of Cleanliness audit etc)
• Hand hygiene/ PPE/ commode etc.
Based on information gathered:
• No outbreak or incident – increased vigilance in the area, low threshold to
review again where new information becomes available.
• Outbreak or incident that can be managed by the IPCT and multidisciplinary
team (MDT) colleagues within the organisation without the need for a formal
outbreak group - this may include a period of increased incidence (PII).
• Severe or significant outbreak/ incident (including outbreaks which impact on
capacity and the ability to admit or discharge patients into the provider
organisation) require a formal incident management team (IMT).
N.B. It is not possible to be prescriptive about what constitutes the need for a formal
IMT as the variety of potential scenarios is extremely diverse and will be affected by
local factors including the physical environment and resources, the likely transmission
route, the pathogenicity and virulence of spread and the likely impact on patients
related to mortality, morbidity and provision of care. External groups invited to join
the IMT will be UKHSA, NHSE and ICB.
As part of the outbreak or incident management (irrespective of an IMT being formed)
the following methods may be used to facilitate quality improvement.
Thematic Review
A themed review may be useful in understanding common links, themes or issues
within a cluster of investigations or incidents. It will seek to understand key barriers or
facilitators to safety using reference cases (e.g., individual datix incidents or previous
investigations). The IPCT maintains a database of infections that can be used for data
--- PDF page 13 ---
13
comparison to assist with this review, as well as learning derived from the ICR. A
thematic review will be undertaken when an outbreak or cluster of incidents takes
place. Where lessons learnt are identified these will be upwardly reported to
Patient Safety Incident Investigation (PSII)
A PSII offers an in-depth review of a single patient safety incident or cluster of incidents
to understand what happened and how.
After Action Review
AAR is a structured facilitated discussion of an event, the outcome of which gives
individuals involved in the event understanding of why the outcome differed from that
expected and the learning to assist improvement. AAR generates insight from the
various perspectives of the MDT and can be used to discuss both positive outcomes
as well as incidents. It is based around four questions:
• What was the expected outcome? / What was expected to happen?
• What was the actual outcome? / What happened?
• What was the difference between the expected outcome and the event?
• What is the learning?
Process of IMT
See Appendix 2 for Draft Agenda
• At the first meeting, the Chair will ascertain the facts to date and actions
undertaken.
• The Chairperson will lead the discussion and direct and co-ordinate the
management of the outbreak. Options will be fully discussed, using the
expertise of the IMT and decisions taken.
• The nominated administrator will ensure that all discussions and decisions are
accurately recorded and will prepare notes for circulation before the next
meeting, identifying the person(s) responsible for any action agreed.
• At each meeting it will be the responsibility of all full and co-opted members to
provide an update of the situation in their ward or department to form the basis
for further decisions. Members who will be unavoidably absent must ensure that
a senior member of their staff attends the meeting in their place and is fully
briefed beforehand.
--- PDF page 14 ---
14
• All full and co-opted members of the IMT will act in accordance with the
decisions taken at the meetings. They will keep notes of their part in the
management of the outbreak and the actions that they and their staff take.
• Formal consideration throughout the outbreak will be given to the need to
involve the regional or national resources of UKHSA, or to obtain help from
other outside sources, such as NHSEI and the ICB.
• The dissemination of information from the meetings is the responsibility of the
members of the IMT. They should remind their staff not to discuss the outbreak
outside the clinical situation and that patient and staff confidentiality must be
always maintained. The medical and nursing staff on the wards will keep
patients’ relatives informed in the usual way.
• Media enquiries should be referred to the Trust communication team and who
will, if necessary, refer them to the Chief Executive. No information concerning
the outbreak will be released to the media or public from wards or departments,
or by other members of the IMT.
• At the end of each meeting, the date and time of the next meeting will be fixed.
Bed and or Ward Closure
• Beds and/or ward closures may be required where the risk of infection to new
admissions is high and the risk cannot be reduced by routine IPC measures
e.g., hand washing, isolation nursing or cohort isolation nursing.
• The IPC team in consultation with the Consultant Microbiologist or Virologist,
with oversight and awareness of the DIPC will advise when beds and or ward
closures are to be observed.
• A bay/ward/department closure means this area is unable to accept new
admissions or inter ward/ hospital transfers; neither can it discharge patients to
other health or social care premises. Should this occur a Datix must be
completed and rationale for decision taken if this has not been discussed with
the IPC team and/or on-call Microbiologist.
• There is evidence that outbreaks due to norovirus and Clostridiodes difficile can
be controlled by containment in bays/rooms with doors closed and adherence
with IPC procedures rather than entire ward closures. With these organisms it
is likely that the IPC team will recommend bay closures rather than whole ward
closure unless the symptomatic patients are distributed throughout the ward.
• Ongoing review for the need for closure will be undertaken by the IPC team and
will advise when beds and or wards can reopen as soon as it is appropriate.
--- PDF page 15 ---
15
• Once reopening is sanctioned, arrangements for terminal cleaning of the area
will be delegated to the relevant manager and undertaken in advance of
reopening.
Closure of incident/outbreak:
The length of time an outbreak will remain open will depend on several factors
including incubation period of the organism.
Areas for improvement/actions
Where areas for improvement are identified either during Infection Control Review
(ICR) or Patient Safety Incident Investigations (PSII) these will be documented on the
IPC Patient Safety Incident Framework Response Improvement Plan or annual
programme of work which will be monitored through the IPC Committee/Assurance
Group
Appendices
--- PDF page 16 ---
16
Appendix 1 Outbreak update
Date outbreak
suspected
Index case hospital
number
Date of symptom
onset of index case
Infection suspected
(i.e. norovirus,
respiratory illness)
Infection confirmed
(date infection
confiremd) by lab)
Ward(s) affected
Date Areas
affected
Total
number of
symptomatic
patients to
date
Number of
patients
symptomatic
today
Total
number
of
patient
samples
positive*
Number
of
samples
pending
results
Number of
staff
symptomatic
Number
of staff
samples
positive**
Number
of
discharges
due today
Bays
closed to
new
admissions
***
Number
of
closed
beds
***
Comments
Day 0
Day 1
Day 2
Day 3
--- PDF page 17 ---
17
Appendix 2 Draft agenda
1
Introductions and Apologies
2
Summary of Outbreak
2.1 IPC Team:
a. background
b. ward layout/specialty
c. microbiology results
d. audit results and summary of findings
e. service improvement plans
f. areas of good practice
g. epidemic curve
2.2 Ward:
a. Background
b. patient issues
c. staffing issues
d. recent IPC audit compliance/service improvement
plans
e. hand hygiene audit results
3
Domestic Staff Issues
4
IPC Recommendations
5
Conclusion
6
Management of Future Outbreaks and Lessons
Learned
7
Any Other Business
--- PDF page 18 ---
18
--- PDF page 19 ---
19
Appendix 3 PSIRF Actions per organism (DRAFT)
Incident
HCAI Attribution
(HOHA /COHA)
Mandatory
Reporting
(UKHSA)
Incident
Reporting
System
Infection
Control
Review
(ICR)
Regulatory
Duty of
Candor
Patient
Communication
Patient Safety
Incident
Investigation
(PSII)
Individual
complex incident
Internal (Provider)
Governance
External
reported
governance
processes
ICB
governance
Outbreak
No
HOHA/COHA
Deaths.
N/A
Dependent
on
causative
organism
Yes
Case by
case
No
Patients
advised of
outbreak on
declaration.
Discussion/
disclosure to
patients if
admitting to
an
open/ongoing
outbreak
Not routinely
IPC Team
Only if lessons learnt:
• Clinical teams
• IPC operational
Group
• Themes to IPC
Committee
All outbreaks
updated via
Trust Sit rep to
ALBs*
If severe
/significant
outbreak***
IMT expected
with invite to
ALBs
Sitrep
shared for
operational
support
purposes
Assurances
to be gained
through IPC
Committee
Outbreak
HOHA/COHA
Deaths
N/A
Dependent
on
causative
organism
Yes
Yes
Yes
N/A
Not routinely
Unless Part 1 on
death certificate
and Medical
Examiner (ME))
review deems
avoidable
• Clinical teams
• Patient safety team
• IPC team
• IPC Committee
Via Trust Sit
rep to ALBs
If severe
/significant
outbreak***
IMT expected
with invite to
ALBs
Assurances
to be gained
through IPC
Committee
C. difficile
Toxin
positive
All cases
UKHSA
HCAI DCS
Yes
Yes
Not
routinely
Yes - if
CDI result to
be
communicated
to the patient
by clinician
Not routinely
Unless resulting in
death (part 1 on
death certificate),
• Clinical teams
• Bi-weekly HCAI
• IPC Committee
PIIs/Outbreaks
to be reported
via Sit Rep to
ALBs
Thematic
reviews of
community
cases where
indicated
--- PDF page 20 ---
20
Incident
HCAI Attribution
(HOHA /COHA)
Mandatory
Reporting
(UKHSA)
Incident
Reporting
System
Infection
Control
Review
(ICR)
Regulatory
Duty of
Candor
Patient
Communication
Patient Safety
Incident
Investigation
(PSII)
Individual
complex incident
Internal (Provider)
Governance
External
reported
governance
processes
ICB
governance
death or
harm
colectomy, Toxic
Mega Colon,
pseudomembranous
colitis
GP to be
informed of
results,
through
pathology
system or
through
discharge
letters if
inpatient.
can be led
by ICBs and
reported
through
system
governance.
Assurances
to be gained
through IPC
Committee
Invasive
Group A
Strep
Healthcare
Associated
Yes –
notifiable
to UKHSA
(NOIDS)
Yes – if
multiple
cases
Yes
Not
routinely
Yes - if
death or
harm
Result to be
communicated
to the patient
by clinician
Not routinely
Severe/significant
harm or death
reviewed by
Medical examiner
(ME) deems
avoidable.
Only if lessons learnt:
• Clinical teams
• Bi-weekly HCAI
• IPC Committee
If outbreak or
suspected
outbreak –
report to ALBs
If linked to
care home,
community
healthcare
setting as part
of follow up
actions
Assurances
to be gained
through IPC
Committee
All other
NOIDS
No
Care
home
outbreak
Primary
care
related
outbreak
No
Result to be
communicated
to the patient
by clinician
Not routinely
N/A
As above
--- PDF page 21 ---
21
Incident
HCAI Attribution
(HOHA /COHA)
Mandatory
Reporting
(UKHSA)
Incident
Reporting
System
Infection
Control
Review
(ICR)
Regulatory
Duty of
Candor
Patient
Communication
Patient Safety
Incident
Investigation
(PSII)
Individual
complex incident
Internal (Provider)
Governance
External
reported
governance
processes
ICB
governance
Gram-
Negative
Bloodstream
Infection
(GNBSI)
HOHA and COHA
UKHSA
HCAI DCS
Yes
Yes
Not
routinely
Yes - if
death or
harm
Result
communicated
to patients
Not routinely
Only if lessons learnt:
• Clinical teams
• Bi-weekly HCAI
• IPC Committee
ICB via the
NOF/DCS
Assurances
to be gained
through IPC
Committee
All other
UKHSA
HCAI DCS
No
Thematic
review
desirable
– ICB led
decision
No
Results
communicated
to patients –
clinical
team/clinician
Not routinely
N/A
ICB via DCS
GP to be
informed of
results
(discharge
letters)
Thematic
reviews of
community
cases where
indicated
can be led
by ICBs and
reported
through
system
governance.
MRSA
Bacteraemia
HOHA COHA
UKHSA
HCAI DCS
Yes
Yes
Not
routinely
Yes - if
death or
harm
Result to be
communicated
to the patient
by clinician
Death – recorded
as Part 1 on death
certificate or
deemed
avoidable by ME.
Harm – for
example limb
amputation
• Clinical teams
• Bi-weekly HCAI
• IPC Committee
ICB via the
NOF/DCS
Assurances
to be gained
through IPC
Committee
COIA
COCA
UKHSA
HCAI DCS
No
Yes
No
Result to be
communicated
to the patient
by clinician
Harm
Death
N/A
ICB via DCS
GP to be
informed of
results
Thematic
reviews of
community
cases where
indicated
--- PDF page 22 ---
22
Incident
HCAI Attribution
(HOHA /COHA)
Mandatory
Reporting
(UKHSA)
Incident
Reporting
System
Infection
Control
Review
(ICR)
Regulatory
Duty of
Candor
Patient
Communication
Patient Safety
Incident
Investigation
(PSII)
Individual
complex incident
Internal (Provider)
Governance
External
reported
governance
processes
ICB
governance
(discharge
letters)
can be led
by ICBs and
reported
through
system
governance.
MSSA
Bacteraemia
HOHA
COHA
UKHSA
HCAI DCS
Yes
Yes
Not
routinely
Yes - if
death or
harm
Result to be
communicated
to the patient
by clinician
MSSA PVL
bacteraemia – Yes
Death – recorded
as Part 1 on death
certificate or
deemed
avoidable by ME.
Harm – for
example limb
amputation
Only if lessons learnt:
• Clinical teams
• Bi-weekly HCAI
• IPC Committee
ICB via DCS
Assurances
to be gained
through IPC
Committee
COIA
COCA
UKHSA
HCAI DCS
No
Thematic
review
desirable
– ICB led
decision
No
Result to be
communicated
to the patient
by clinician
Not routinely
unless identified
through thematic
reviews
N/A
ICB via DCS
GP to be
informed of
results
(discharge
letters)
Thematic
reviews of
community
cases where
indicated
can be led
by ICBs and
reported
through
system
governance.
HCID
N/A
UKHSA
Yes
YES
Not
Result to be
If processes not
IPC Committee
UKHSA
--- PDF page 23 ---
23
Incident
HCAI Attribution
(HOHA /COHA)
Mandatory
Reporting
(UKHSA)
Incident
Reporting
System
Infection
Control
Review
(ICR)
Regulatory
Duty of
Candor
Patient
Communication
Patient Safety
Incident
Investigation
(PSII)
Individual
complex incident
Internal (Provider)
Governance
External
reported
governance
processes
ICB
governance
NHSE
routinely
communicated
to the patient
by clinician
followed and
patient not
identified exposes
others etc
assurance report with
review of HCID
protocols
• Clinical teams
• IPC/HCAI
operational groups
ICB
NHSE
Notification
through
System
Oversight
and
Assurance
Group
(SOAG)
Legionnaires
disease
Hospital/
healthcare
exposure/source
for infection.
UKHSA
Yes
YES
Not
routinely
Yes - if
death or
harm
Result to be
communicated
to the patient
by clinician
YES
• Clinical teams
• Water Safety Group
• IPC Assurance
Committee
UKHSA
ICB
NHSE
Assurances
to be gained
through IPC
Committee
TB exposure
N/A
UKHSA
Yes, if
healthcare
related. i.e.
patients
exposed on
a ward
No if
community
case
Yes
Not
routinely
Yes - if
death or
harm
Result to be
communicated
to the patient
by clinician
If incorrect
processes result
in the exposure of
others.
Incident to be
managed with an IMT
Review with Clinical
teams
• IPC Committee
If healthcare
exposure (i.e.
HCW) - IMT to
include
UKHSA, ICB,
NHSE
GP to be
informed of
exposure via
discharge
letters
TB team
notification
and follow up
Assurances
to be gained
through IPC
Committee
--- PDF page 24 ---
24
--- PDF page 25 ---
25
Appendix 4 Outbreak report template
Hospital site and Ward
Report completed by
Date
Outbreak declared on
Insert date
Outbreak declared over
Insert date
If applicable –
Number of bed closures and
dates
If applicable –
External bodies informed?
Date
Delete as required
UKHSA/ ICB/ NHSE
Brief description of incident
Action immediately taken.
Recommendations and outcomes following ICR
Compliance with IPC Practices
National Cleaning Standards audit %
Hand hygiene %
Other audit (insert)
Themes identified.
--- PDF page 26 ---
26
Service improvement
--- PDF page 27 ---
27
References
National Infection Prevention and Control Manual, Available at:
https://www.nipcm.hps.scot.nhs.uk/media/1883/2022-06-10-healthcare-infection-
incidents-and-outbreaks-in-scotland-v-20.pdf
Department of Health (2022) The Health and Social Care Act 2008 Code of Practice
on the prevention and control of infections and related guidance. Available at:
Health and Social Care Act 2008: code of practice on the prevention and control of infections -
GOV.UK (www.gov.uk)
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1
National Infection Prevention and Control Manual for England
Related National
Guidance
This document is the national guidance
E-library number
CG 2425
Version number
V1
Purpose
This manual applies to all staff working at UHCW. It outlines
principals in order to prevent infection and avoid transmission of
pathogens within a healthcare setting.
Primary Specialty
Infection Prevention and Control
Related
Specialties
All specialties
Specialty Clinical
Guideline Lead
Tracey Brigstock, Director of Infection Prevention and Control and
Chief Nursing Officer
Authors
Lead Author:
Document produced by NHSE
Document reviewed and amended by:
Katie Jones,
Katie.Jones@uhcw.nhs.uk
Clinical Scientist, Infection Prevention and Control
Reviewer(s):
Fiona Wells,
Fiona.Wells@uhcw.nhs.uk
Lead Nurse, Infection Prevention and Control
Approving
Forums
Infection Prevention and Control Committee
Approval Dates
QIPS
22/05/2024
MPPC
N/A
Other
(specify)
Review Date
30 January 2026
Keywords
Infection Prevention
Infection Control
Hand washing
Infection manual
Face mask
Infection policy
IPC
Standard infection prevention and control precautions
Transmission based precautions
Isolation
Hand hygiene
PPE
Personal protective equipment
Linen
--- PDF page 2 ---
2
Spillage
Waste
AGP
Aerosol generating procedures
Clinical guideline content: Clinical Guidelines assist in decision-making; they do not replace clinical
judgement. Regardless of the strength of evidence, it remains the responsibility of the clinician to
interpret the application of the clinical guidance to local circumstances and the needs and wishes
of the individual patient. Where variations of any kind do occur, it is important to document the
variations and the reason for them in the patient’s health record. If in doubt, seek senior advice.
Equality and Diversity Statement: Throughout its activities, the Trust will seek to treat all people
equally and fairly. This includes those seeking and using the services, employees and potential
employees. No-one will receive less favourable treatment on the grounds of sex/gender (including
Trans People), disability, marital status, race/colour/ethnicity/nationally, sexual orientation, age,
social status, their trade union activities, religion/beliefs or caring responsibilities nor will they be
disadvantaged by conditions or requirements which cannot be shown to be justifiable. All staff,
whether part time, full-time, temporary, job share or volunteer; service users and partners will be
treated fairly and with dignity and respect.
--- PDF page 3 ---
3
Rationale
This NHSE manual for England applies to all staff working at UHCW. It outlines principals
in order to prevent infection and avoid transmission of pathogens within a healthcare
setting.
Dissemination and related guidance
This relates to all existing IPC documents. It will be available on e-library and
communications will share the message to staff groups.
Training
IPC and hand hygiene training mandatory for all clinical staff.
Patient Information
Isolation and Barrier Nursing, VRE, MRSA, ESBL, C. difficile and CPE Patient Information
Leaflets
Audit & Monitoring
Audit title
Audit Lead
Monitoring method
and frequency
Committee responsible
Changes from previous version
Date
Updated information
N/A
--- PDF page 4 ---
4
Introduction
This guidance is necessary to provide staff with the principals of infection prevention and
control in a healthcare setting. This is imperative in order to prevent and control infection at
UHCW. Adherence to this guideline will ensure patient safety relating to infection. Health care
associated infections should be avoided.
Document Link
NHS England » National infection prevention and control
Please explain any deviations from linked guidance in detail:
There are some parts of the guidance where application differs at UHCW. These are outlined
below:
1. Section 1.1 and 2.1: Not all patients in outpatients settings are able to be isolated if
they may have an infection. This is based on local risk assessment due to facilities
available and clinical need.
2. Section 1.3. There is reference to using ‘warm’ water in the document for washing
hands and making up detergent solutions. Cold water can be used to wash hands,
and may be required during boiler breakdowns. Also, at UHCW we use a combined
detergent/disinfectant product called Tristel which must be made up with cold water.
3. Appendix 1 and 2 will not be used at UHCW. These posters do not show a step to
wash the wrist. NHSE are undertaking a literature review to ascertain if there is
sufficient evidence for this to be included. In the interim period we will continue to use
the existing hand wash posters.
4. Appendix 6: UHCW use different posters for donning and doffing which are available
on the IPC web page.
5. Appendix 7: Even if equipment is not contaminated with blood or body fluids, at
UHCW we still recommend cleaning with Tristel rather than a detergent only solution.
6. Appendix 11a: Disseminated shingles. At UHCW we recommend staff wear an FFP3
mask rather than a FRSM when treating a patient with disseminated shingles. Also,
patients who are immunocompromised with shingles should be isolated in a side room
(despite the rash being able to be covered).
References
NHS England » National infection prevention and control
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1
Respiratory Viral Infections Guideline
Related National
Guidance
Infection prevention and control manual for England – NHSE (2023)
UKHSA Covid-19: Information and advice for health and care
professionals (2023)
E-library number
CG 2032
Version number
4
Purpose
Understand and apply the principles of Respiratory Infections
prevention and control by maintaining competence, skills and
knowledge in Infection prevention and Control (IPC).
To reduce the number of patients acquiring Respiratory Infections
and to ensure the correct management of those affected.
Primary Specialty
Infection prevention and control
Related
Specialties
Respiratory
Virology
Specialty Clinical
Guideline Lead
Fiona Wells
Lead Nurse Infection Prevention and Control and Sepsis Team
fiona.wells@uhcw.nhs.uk
Authors
Lead Author:
Fiona Wells
Lead Nurse Infection Prevention and Control and
Sepsis Team
fiona.wells@uhcw.nhs.uk
Reviewer(s):
Lisa Berry
Consultant Virologist
Lisa.berry@uhcw.nhs.uk
Katie Jones
Clinical Scientist
Dr. Judith Drought
Respiratory consultant
Approving
Forums
Infection Prevention Control Committee
Respiratory QUIPS
Approval Dates
QIPS
16/10/2023
MMC
n/a
Other (specify) n/a
Review Date
September 2025
.
--- PDF page 2 ---
2
Keywords
Influenza
Flu
Respiratory Virus
Covid–19
SARS-CoV-2
Standard Precautions
Transmission based precautions
AGP
RSV
FFP3
Droplet precautions
Contact precautions
Airborne precautions
Clinical guideline content: Clinical Guidelines assist in decision-making; they do not replace clinical
judgement. Regardless of the strength of evidence, it remains the responsibility of the clinician to
interpret the application of the clinical guidance to local circumstances and the needs and wishes
of the individual patient. Where variations of any kind do occur, it is important to document the
variations and the reason for them in the patient’s health record. If in doubt, seek senior advice.
Equality and Diversity Statement: Throughout its activities, the Trust will seek to treat all people
equally and fairly. This includes those seeking and using the services, employees and potential
employees. No-one will receive less favourable treatment on the grounds of sex/gender (including
Trans People), disability, marital status, race/colour/ethnicity/nationally, sexual orientation, age,
social status, their trade union activities, religion/beliefs or caring responsibilities nor will they be
disadvantaged by conditions or requirements which cannot be shown to be justifiable. All staff,
whether part time, full-time, temporary, job share or volunteer; service users and partners will be
treated fairly and with dignity and respect.
Rationale
To help to identify, diagnose and manage patients with suspected and confirmed viral
respiratory infections.
Dissemination and related guidance
Available on e-library
Training
Mandatory Infection Prevention and Control Training
Fit testing training
Hand Hygiene training
Donning and doffing
Patient Information
Respiratory Viruses, Isolation and Barrier Nursing, reducing the risk of infection whilst in
hospital and clean hands are caring hands – all patient leaflets available on e-library
--- PDF page 3 ---
3
Audit & Monitoring
Audit title
Audit Lead
Monitoring method
and frequency
Committee responsible
5 Moments for
Hand hygiene
Carolyn Dawson
Quarterly
IPCC
Changes from previous version
Date
Updated information
August 2023
Corrected some typographical errors and punctuation.
Updated version to number 5.
Definitions: Added in reference for list of AGP’s in case of issues with
the hyperlink provided.
Added information on page 7 about the requirement to be fit tested on
masks that are currently available and the option to use a powered
hood if FIT testing fails.
Took out tables of symptoms and made a list (page 8)
Added information on how to take a sample if the patient has a complex
airway.
Changed isolation periods according to national guidance.
Updates appendix 3 to reflect how we manage respiratory infections
according to EMS level.
Changed the references
Changed the title to include ‘viral’
--- PDF page 4 ---
4
Contents
Definitions .............................................................................................................................................. 4
Introduction ............................................................................................................................................ 6
Scope ..................................................................................................................................................... 6
Roles and Responsibilities .................................................................................................................. 6
Clinical guidance .................................................................................................................................. 7
References ............................................................................................................................................ 22
Definitions
AGP (Aerosol
Generating Procedure
Certain medical and patient care activities that can result in
the release of airborne particles (aerosols).
For an up-to-date list see here
The up to date list can also be viewed on the NHSE IPC manual
for England.
AGP’S can increase the risk of transmission of infections.
Incubation Period
The incubation period is the interval between exposure to a
pathogen and the appearance of symptoms.
Infectious Period
The infectious period (or period of communicability) is the
time period over which an infected person can spread the
infection to someone else. This varies by pathogen and
individual
Hierarchy of Controls
The hierarchy of control are used to identify the appropriate
controls with elimination, substitution, engineering controls,
administrative controls and PPE
Routes of transmission
Aerosol
Aerosol transmission occurs through very small infectious
particles being dispersed into the air through breathing,
talking, or coughing. These particles can travel distances >2
metres and hang in the air for prolonged periods of time.
Aerosols may also occur due to AGPs being performed (see
above)
--- PDF page 5 ---
5
Droplet
Droplets may be generated from the respiratory tract during
coughing, sneezing, or talking. If droplets from an infected
person come into contact with the mucous membranes
(mouth or nose) or surface of the eye of a recipient, they can
transmit infection. These droplets remain in the air for a
short period and travel 1−2 metres, so physical closeness is
required for transmission.
Direct Contact
Infectious agents can be inadvertently passed directly from
an infected person (for example after coughing into their
hands) to a recipient who, in the absence of correct hand
hygiene, may then transfer the organism to the mucous
membranes of their mouth, nose or eyes.
Indirect Contact
Transmission takes place when a recipient has contact with
a contaminated object, such as furniture or equipment that
an infected person may have coughed or sneezed on. In the
absence of correct hand hygiene, the recipient may transfer
organisms from the contaminated object to the mucous
membranes of their mouth, nose or eyes.
Standard infection
control precautions
(SICPS)
SICPs are the basic IPC measures necessary to reduce the
risk of transmitting infectious agents from both recognised
and unrecognised sources of infection. Sources of infection
include blood, body fluids secretions or excretions
(excluding sweat), non-intact skin or mucous membranes
and any equipment or items in the care environment that
could be contaminated.
Transmission based
precautions (TBP)
Additional precautions to be used in addition to SICPs when
caring for patients with suspected or confirmed infection or
colonisation
Staff Cohorting
When staff care for one specific group of patients and do not
move between different patient cohorts. Patient cohorts
may include for example symptomatic, asymptomatic and
exposed, or asymptomatic and unexposed patient groups
--- PDF page 6 ---
6
Introduction
Respiratory infections are common and can spread easily between both adults and
children. There are a wide variety of viral causes of respiratory infection including
rhinoviruses, respiratory syncytial virus (RSV), influenza viruses, para-influenza
viruses, and coronaviruses.
The symptoms of respiratory infections are very similar, and it is not always possible
to tell if a patient has COVID-19, Influenza or another respiratory infection based on
symptoms alone.
Most people with respiratory infections will have a relatively mild illness although these
can progress and cause more severe infections and even death.
Scope
This guidance is applicable to all staff that work at UHCW. This will include off site
departments such as Renal Satellite areas, Rugby St Cross and outpatient
departments such as Coventry Urgent Care. This will also include staff that are
employed by Vinci and ISS. This list is not exhaustive.
Viral Respiratory Tract Infections that this guidance is applicable to
• COVID-19 (sars-Cov-2)
• Influenza
• Human parainfluenza viruses (HPIVs)
• Respiratory Syncytial Virus (RSV)
• Coronaviruses
• Human rhinoviruses (HRVs) and enteroviruses (HEVs)
• Human adenoviruses
• Human bocavirus 1 (HBoV1)
• Human Metapneumo Virus (hMPV)
Roles and Responsibilities
Healthcare Workers (HCWs) must:
• Follow this guidance adhere to and follow the principles of Infection
Prevention and Control actions that are outlined in this guideline.
--- PDF page 7 ---
7
• Inform a member of the Infection Prevention and Control Team
(IPCT) if this guidance cannot be followed.
• Ensure they are aware how to use respiratory protection and ensure they are
fit tested for FFP3 masks within the last 2 years. Ensure that the mask that you
have been fit tested on is available for use. If it is not available, the staff member
will require a repeat test on masks that are available at the trust. If a staff
member fails their fit test, they must then receive training to use a powered
hood by contacting the sterile services department.
Infection Prevention and Control Teams (IPCTs) must:
• Keep this guidance up-to-date
• Support the clinical team to undertake a risk assessment where this guidance
cannot be followed.
• Provide education opportunities on this guidance.
Occupational Health must:
• Plan and promote the uptake of staff seasonal influenza and other necessary
vaccinations.
• Provide opportunity for staff to receive their vaccinations during working hours
and support the peer vaccinator programme.
• Provide advise to staff following an exposure incident and returning to work
queries.
Clinical guidance
This guideline outlines the infection prevention and control principles required to
prevent transmission of COVID–19 and other respiratory viruses and minimize
disruption to patient care.
When to take a sample
Symptoms of COVID-19, flu and common respiratory infections include:
• Cough
• Coryzal symptoms
• Fever
• Headache
• Shortness of breath
• Feeling tired or exhausted
• Aches and pains
• Loss of appetite
--- PDF page 8 ---
8
• Diarrhoea, nausea and/or vomiting
• A loss to your sense of smell or taste.
• Acute exacerbation of a chronic lung disease
• Signs and symptoms of lower respiratory infection
• If there is a history of foreign travel, isolate and investigate in line with infections
in the returning traveller. Discuss the case with infectious diseases.
How to take a sample
Request a respiratory viral PCR on the electronic ordering system. Use a sterile dry
swab. See diagram below for how to take a nose and throat swab.
For patients with complex airways (for example, tracheostomy), please ensure
swabs are taken from airway site utilised by patient (for example, tracheostomy site)
instead of sites not involved in air entry. For example, a patient who is fully reliant on
tracheostomy for gas exchange should be swabbed at their tracheostomy site, not
their nose.
--- PDF page 9 ---
9
4. Either place the swab back into the viral transport media
provided (fluid supplied with the swab) or cut swabs into
a single sterile universal container (white topped clear
specimen bottle) using sterile disposable scissors.
5. DO NOT put swab back into agar provided for bacterial
swabs (e.g. charcoal agar).
6. Ensure the sample and request forms are fully labelled.
7. If a lower respiratory tract infection is being considered
also send a sputum sample to the laboratory a full viral
respiratory screen if clinically indicated.
1. Rub the tonsils with the
fabric tip of the swab over
both tonsils. Do this with
good contact on each side 4
times. Carefully remove the
swab so that you don’t
touch the teeth, gums,
tongue or cheeks.
2. Put the same swab gently
into 1 nostril until you feel a
slight resistance (about
2.5cm for adults).
3. Gently wipe the swab
around the inside of the
nostril making 10 complete
circles. No force is needed.
It may feel uncomfortable
but should not be painful.
--- PDF page 10 ---
10
8. Place specimen(s) in a standard
microbiology bag while with the patient.
9. Samples are to then be double bagged and sent to
pathology.
Results
Results will be available on the electronic results system.
Treatment
National guidance for ‘COVID-19 antibody and antiviral treatment’
can be found via this link: Overview | COVID-19 rapid guideline:
managing COVID-19 | Guidance | NICE
National guidance for ‘Influenza: treatment and prophylaxis using
anti-viral agents can be found via this link:
Scenario: Treating influenza | Management | Influenza - seasonal | CKS |
NICE Advice regarding complex cases can be sought from Virology.
Hand Hygiene
Hand hygiene is part of standard infection control precautions and is
the most effective way to prevent transmission by direct contact.
Hand hygiene must be performed as per the WHO Five Moments:
•
before touching a patient
•
before a clean / aseptic procedure
•
after exposure to body fluids
•
after touching a patient
•
after touching the patient’s surroundings
For further information click link for the hand decontamination policy
e-Library (uhcw.nhs.uk)
Respiratory
hygiene and
cough etiquette
(Catch it, Bin it, Kill
it)
Patients should be instructed to follow the recommendations for
respiratory hygiene / and cough etiquette:
•
use a disposable, single use tissue to cover mouth and nose
when coughing, sneezing, wiping or blowing nose
•
dispose of tissues promptly in a bin
•
practice hand hygiene by washing hands with soap and
water, and drying them thoroughly after coughing, sneezing
or using tissues. Antibacterial hand rub may also be used.
•
Patients with suspected or confirmed respiratory infection
should be provided with a FRSM that should be worn in multi
bedded bays and communal areas if this can be tolerated.
FRSM are not required for patients in side rooms unless
another person enters or the room door is required to remain
--- PDF page 11 ---
11
open. If a patient suspected of having a viral respiratory
infection refuses or cannot wear a mask, this must be
documented in their medical notes.
•
All patients transferring to another care area should wear a
surgical face mask (if tolerated) to minimise the dispersal of
respiratory secretions and reduce environmental
contamination.
•
Patients should be provided with a new surgical mask at least
daily or when soiled or damaged. The requirement for
patients to wear a FRSM must never compromise their
clinical care, such as when oxygen therapy is required.
•
Some patients, such as older people or children may require
assistance to contain respiratory secretions.
Patient Movement
Limit the movement of patients outside their isolation room or cohort
area to those necessary for patient management.
If patient movement is necessary, then the patient should, if possible,
wear a fluid resistant surgical face mask to minimise the dispersal of
respiratory secretions and reduce environmental contamination
Safe Management
of Care Equipment
•
Equipment in an isolation or cohort area should be kept to a
minimum.
•
Equipment should, as far as possible, be allocated to each
individual patient or cohort of patients.
•
Disposable, single-use equipment should be utilised where
possible.
•
Reusable equipment must be decontaminated immediately
after patient use and between each patient with Tristel
•
Follow UHCW decontamination policy and equipment specific
manufacturers’ instructions
•
No equipment should be taken out of the room without
decontamination.
•
If advice is required, contact Infection Prevention and Control
Team on extension 24791.
Safe Management
of the Care
Environment
Inc. linen
•
The patient environment should be kept clean, clutter-free and
in a good state of repair
•
Ensure that the rooms of patients with infection are cleaned
daily with Tristel, and are prioritised for frequently touched
surface cleaning (e.g. over-bed tables, lockers, lavatory
surfaces in patient bathrooms, door handles and equipment in
the immediate vicinity of the patient).
•
Touch point cleaning rota is available via the Infection
Prevention and Control Web site. RCA documents and audit
forms | University Hospitals Coventry and Warwickshire NHS Trust
--- PDF page 12 ---
12
•
Linen used for an infectious patient should be bagged
immediately in an alginate liner bag and then placed in a white
plastic linen bag.
•
Terminal clean of all isolation or cohort rooms once patients
are discharged or no longer in isolation.
•
It is essential that all frequently touched surfaces and all
horizontal surfaces are decontaminated after any AGP.
Clearance of infectious particles after AGP is dependent on the
ventilation and air exchange in the room (wait a minimum of 20
minutes after an AGP before cleaning).
•
Ensure weekly / daily cleaning tasks are documented in the
ward cleaning book.
•
If patient was in bay when respiratory virus suspected or
confirmed the bay and bathroom must have a terminal clean
once the patient has placed into isolation
Safe Disposal of
Waste
All waste generated from patients with a confirmed or
suspected respiratory virus should be placed into clinical waste
(orange bag)
Visitors
Visits from patient’s relatives and or/ carers should be encouraged
and supported. If visitors are attending a care area with infectious
patients, they should be made aware of any infection risks and
offered appropriate PPE. This would routinely be a FRSM. Gloves
and aprons are not routinely required unless providing direct patient
care.
Visitors should be instructed on effective hand hygiene.
Visitors should not be present during AGP on infectious patients
unless considered essential following a risk assessment, for example
parent / guardian.
It may be considered appropriate to restrict visiting because of
outbreaks of respiratory infection - this decision will be made on an
individual basis in conjunction with IPC, Clinical Virology, Modern
Matron and the control room. Compassionate visiting will usually
remain in place.
Visitors with respiratory symptoms should not be permitted to enter a
care area. However, if the visit is considered essential for
compassionate (end of life) or other café reasons (for example
parent / child) a risk assessment should be undertaken, and
mitigations put in place to support visiting wherever possible.
PPE required
when caring for
Risk Assessment For PPE
--- PDF page 13 ---
13
patients with a
confirmed or
suspected
respiratory virus
Before undertaking any procedure, staff should assess any likely
blood and bodily fluid exposure risk and ensure PPE worn that
provides adequate protection against the risks associated with the
procedure or task being undertaken.
See appendix 4 for full PPE guidance
Donning and
Doffing of PPE
Click link for correct order of donning and doffing of PPE
National infection prevention and control manual for England
Fit testing for
FFP3 respirator
It is a legal requirement that any HCW required to wear an FFP3
respirator should have undertaken respirator fit testing test prior to
using it.
Where FFP3 respirators are used, it must be able to provide
adequate protection for all individual wearers. A major cause of
leaks is a poor fit. As people come in all sorts of shapes and sizes it
is unlikely that one size of FFP3 respirator will fit everyone.
Fit testing will ensure the equipment selected is suitable for the
wearer and offers the protection that is required.
Every time a FFP3 respirator is donned a fit check must be
undertaken to ensure an adequate seal has been achieved.
Refer to donning FFP3 respirator video and poster link below
which demonstrates how don an FFP3 respirator and how to do
a fit check
https://books.hse.gov.uk/Posters/?DISPLAY=PF&DI=652757
https://www.hse.gov.uk/pubns/disposable-respirator.pdf
In the event of a breach in IPC procedures, such as incorrectly worn
FFP3 respirators during an AGP, staff should be reviewed by
Occupational Health.
--- PDF page 14 ---
14
Duration of
Respiratory
Precautions
As a general rule, the duration of isolation precautions for
hospitalised patients should be continued until resolution of fever
and respiratory symptoms. For prolonged illness, infection
prevention and control measures should be used during the duration
of acute illness until symptoms and signs of respiratory disease have
resolved.
Immunosuppressed/ immunocompromised patients may remain
infectious for a longer period of time than immunocompetent
patients. The decision to discontinue isolation should be based on
clinical assessment of the patient’s condition, and a repeat viral
respiratory swab should be sent to test for on-going viral shedding.
Please discuss step-down of isolation requirements with Virology
and IPCT if required.
The decision to de –escalate a patient from isolation must be
documented in the patient’s notes by the clinician documenting the
reasons why.
Contact Tracing
Depending upon the virus causing an infection, contact tracing may
be required.
For Influenza specific information, please see this link -
https://assets.publishing.service.gov.uk/government/uploads/system/
uploads/attachment_data/file/1058443/ukhsa-guidance-antivirals-
influenza-11v4.pdf
COVID-19 contacts will be noted on CRRS handover and verbally
communicated, however no follow up is required unless the patient
becomes symptomatic.
Environmental
ventilation
(Hierarchy of
controls)
Open windows for 10 minutes every hour
In the event of a respiratory virus outbreak IPC will ask for the
estates department to check that all ventilation in the outbreak area
is working as it should
Isolation for
patients with
suspected or
confirmed
respiratory virus
Single side room
Patients with a known or suspected respiratory tract infection should
be placed in a single side room, ideally with ensuite facilities.
The door to the room should be kept shut at all times.
--- PDF page 15 ---
15
The area must be clearly labelled as an isolation area, a purple hand
must be used to signify a patient with a respiratory viral illness.
Staff entering the room should be kept to a minimum.
Strict attention to standard and respiratory precautions should be
exercised always.
Cohorting of patients with a Respiratory Tract Infection (RTI)
If a single room is not available and the respiratory pathogen is
known, then patients can be cohorted with other patients with a
confirmed RTI caused by the same pathogen, after a documented
risk assessment considering the possibility of co-infection with other
pathogens. Risk based decisions should be made with clinical teams
alongside site management, infection prevention and virology
colleagues.
If single rooms are in short supply and laboratory confirmation of
the pathogen is awaited, after a documented risk assessment, it
may be feasible to prioritise patients with cough and sputum
production for single room placement.
Please refer to isolation priority system located in UHCW Isolation
guideline (2022) on e - library to free up a side room if required.
https://uhwebapps.uhcw.nhs.uk/eLibrary/filecon/download.aspx?Doc
=121230&DocReturn=/elibrary/&VERI=6jjprqf3
When undertaking a local risk assessment to decide the best patient
placement to reduce cross-transmission, it may be reasonable to
assume that patients admitted with complications of influenza, i.e. who
have
had
symptoms
for
3−4
days,
and
who
are
not
immunocompromised, are less infectious than those who are admitted
with new influenza-like symptoms.
If respiratory patients are cohorted together, ensure patients are at
least two metres apart from each other.
Discharge
Discharge to own home
If patient is deemed medically fit for discharge by the medical team
then patients can be discharged to their home even if they are still in
the infectious period of their infection.
Discharge home with a package of care
--- PDF page 16 ---
16
If a patient is deemed medically fit for discharge by the medical team
then patients can be discharged to their own home with a package of
care as long as the infectious status is communicated to the care
team prior to discharge
Discharge to care facility such as nursing home / residential
home
The decision to discharge a medically fit patient to a care facility
must be made in conjunction with the care facility and whether they
can facilitate isolation until the patient is no longer deemed
infectious.
De-escalating patients following a confirmed respiratory virus
1. COVID-19: de-escalating isolation precautions in non-immunocompromised
patients
For inpatients with COVID-19, isolation should continue for 5 days after the onset of
symptoms (or their first positive COVID-19 test if they do not have any symptoms),
provided the clinical criteria below have been met.
Clinical criteria:
•
Clinical improvement with at least some respiratory recovery
•
Absence of fever (temperature greater than 37.8°C) for 48 hours without the
use of medication
•
no underlying severe immunosuppression
A cough or a loss of, or change in, normal sense of smell or taste (anosmia), may
persist in some individuals for several weeks, and are not considered an indication of
ongoing infection when other symptoms have resolved.
Before stepping down isolation of the patient, ensure there are no other
infections for which This guidance does not apply if there are any additional
indications for ongoing isolation and transmission-based precautions (for
example MRSA carriage, C. difficile etc).
--- PDF page 17 ---
17
COVID-19: de-escalating isolation precautions in severely
immunocompromised patients
It is possible for severely immunocompromised patients to remain infectious for
prolonged periods, even if they do not display any symptoms. The isolation period for
these patients whilst in hospital should be at least 10 days.
In severely immunocompromised patients’ resolution of symptoms should not be
used as a marker of decreased infectiousness and these patients should be isolated
in side rooms, cubicles or cohorted until until they have:
-
Completed a full 10 days of isolation.
-
Been afebrile for at least 48 hours.
-
A negative COVID-19 PCR result, taken no less than 10 days after symptom
onset. If the patient did not have any symptoms, then the PCR swab should
be done at least 10 days after their first positive Covid-19 test. If this swab
returns positive or indeterminate for COVID or any other respiratory viruses,
please discuss with clinical virology prior to step down ext. 25471.
2. Influenza
For patients who are not immunocompromised:
Patients can be removed from isolation/cohort areas after 5 days of Tamiflu if
asymptomatic and they have been apyrexial for 48 hours.
For patients who are immunocompromised:
Immunocompromised patients require a negative Influenxa PCR prior to de-
escalation. If any further advice is required, please discuss with the clinical virology
team.
3. Other respiratory viruses
Patients should be isolated until symptom resolution.
4. Exceptions to isolation durations
In extremis, a risk assessment can be carried out to remove patients from isolation
earlier if required after discussion with virology (see appendix 3).
--- PDF page 18 ---
18
Appendix 1
Isolation door signage
Signage should be displayed to control entry into isolation or cohort areas; this should be
done by using the coloured hands system:
•
The red hand is used to indicate that the patient has an infection and extra
precautions are required
•
The blue hand is used for neutropenic patients who require protective isolation
•
The purple hand is used for patients who have a respiratory viral infection
Examples of signage:
--- PDF page 19 ---
19
Appendix 2
Requirements for PPE use for respiratory and non-respiratory patients, including when
carrying out AGPs, are shown in the table below. If an area is under outbreak control
measures, universal wearing of FRSM will be required.
--- PDF page 20 ---
20
Appendix 3: Bed management on identifying a symptomatic case in a bay. NB At all EMS levels CEV patients should be prioritized for side room capacity
Inpatient symptomatic in a bay
EMS Level
1 and 2
•
Move patient to side room
•
Close beds to new admissions into the bay until results return from the index case.
•
Terminal clean
•
If positive for FLU A, FLU B, COVID or RSV assess contacts as per their risk of developing severe influenza and (if relevant) offer prophylaxis
for Flu A. Screen any patients who display symptoms.
•
If the PCR is negative, clinically review if isolation is still required. Open beds once terminal clean has happened.
EMS Level
3
•
Move to a side room if possible and ask for a terminal clean of the bay.
•
If moving to a side room is not possible, the patient can remain in the bay. Request all patients wear a mask if they are able. Close beds to
new admissions in bay until PCR results return.
•
Open windows and air scrubber to be used where possible.
•
If positive for FLU A, FLU B, COVID, RSV assess contacts for immunosuppression and (if relevant) offer prophylaxis for Flu. Screen any
patients who display symptoms.
•
Open beds
•
Patients with a confirmed respiratory viral infection can be managed in a respiratory cohorted bay (same virus) or side room. If the patient is
immunocompromised, they require a side room.
•
If the PCR is negative, clinically review if isolation is still required.
•
If EMS level 3 and position is deteriorating – on call manager/ site can discuss with IPC and virology to look at other actions to support
capacity and flow on a case by case basis.
EMS Level
4
•
Move to a side room if possible and ask for a terminal clean of the bay.
•
Patient remains in the bay if no side room available. Request all patients wear a mask if they are able.
•
Beds remain open to new admission into the bay.
•
Windows to be open and air scrubbers to be used where possible
•
If positive for FLU A, FLU B, COVID, RSV assess contacts for immunosuppression and (if relevant) offer prophylaxis. Screen any patients
who display symptoms.
•
Index case can be managed in a respiratory cohorted bay (same virus) or side room. If immunocompromised, they require a side room.
•
If negative, clinical review to decide if isolation is required.
•
On call manager/ site discuss with IPC/ virology regarding levels of risk and other actions to support (i.e. moving Influenza patients before day
5 case by case basis)
--- PDF page 21 ---
21
Page is blank
--- PDF page 22 ---
22
References
Guideline References
CEBIS Evidence Summary
(NICE Guidelines, and other National Guidance. Other national guidance may include those issued
by speciality college, patient safety agency, monitoring agencies, or other external governing
bodies )
References Cited in Guideline
Grade*
Infection Control Manual for England: NHS England » National infection prevention
and control
UKHSA (2021) Seasonal influenza: guidance, data and analysis - Seasonal
influenza: guidance, data and analysis - GOV.UK (www.gov.uk)
UKHSA (2021) guidance on use of antiviral agents for the treatment and
prophylaxis of seasonal influenza
Influenza: treatment and prophylaxis using anti-viral agents - GOV.UK (www.gov.uk)
UKHSA (2019) Seasonal influenza: guidance for adult critical care units
https://www.gov.uk/government/publications/seasonal-influenza-managing-cases-in-
critical-care-units
COVID-19 advice for health care professionals (2023). COVID-19: information and
advice for health and care professionals - GOV.UK (www.gov.uk)
UKHSA Covid – 19: Personal protective equipment use for aerosol generating
procedure 10th January 2020 updated 27th May 2022
https://www.gov.uk/government/publications/covid-19-personal-protective-
equipment-use-for-aerosol-generating-procedures
UKHSA Covid -19: Personal Protective equipment use for non aerosol generating
procedure 10th January 2020 updated May 2022
https://www.gov.uk/government/publications/covid-19-personal-protective-
equipment-use-for-non-aerosol-generating-procedures
--------------------------------------------------------------------------------
ATTACHMENT: 6.pdf
TEXT_FILE: 6.pdf.txt
METHOD: pdf_native
OCR_USED: False
PAGES: 34
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--- PDF page 1 ---
1
Guidelines For Screening, Prevention of and Management of Meticillin –
Resistant Staphylococcus aureus (MRSA) in adult, paediatric and neonatal
patients
Related National
Guidance
Health and Social Care Act 2008- Code of practice on the prevention
and control of infections and related guidance
E-library number
CG 1583
Version number
V9
Purpose
The purpose of this guideline is to minimise the risk to patients of
infection or colonisation with MRSA.
Primary Specialty
Infection Prevention and Control
Related Specialties N/A
Specialty Clinical
Guideline Lead
Fiona Wells,
Infection Prevention Control and Sepsis
Fiona.Wells@uhcw.nhs.uk
Authors
Lead Author:
Emma Evans
Sepsis Nurse
Emma.evans@uhcw.nhs.uk
Reviewer(s):
Maddy Winterton,
Antibiotic Pharmacist
Madeleine.winterton@uhcw.nhs.uk
Approving Forums Infection Prevention Control Committee
Medicines Management Committee
Approval Dates
QIPS
12/07/2023
MMC
03/10/2023
Other (specify)
Review Date
16/11/2025
Keywords
MRSA
Bacteraemia
Decolonisation
Hibiscrub
Octenisan
Clinical guideline content: Clinical Guidelines assist in decision-making; they do not replace clinical
judgement. Regardless of the strength of evidence, it remains the responsibility of the clinician to
interpret the application of the clinical guidance to local circumstances and the needs and wishes
of the individual patient. Where variations of any kind do occur, it is important to document the
variations and the reason for them in the patient’s health record. If in doubt, seek senior advice.
Please note: The following systems have been replaced by the trust Electronic Patient Record
system (EPR). If any of these systems are identified within the document, please substitute them
for the appropriate EPR alternative system and refer to relevant corresponding EPR procedures.
1. Opera (theatres)
2. Centricity (Critical Care)
3. Wardview
4. Extramed
5. CRRS
6. VitalPack
--- PDF page 2 ---
2
7. Adastra (CUTC)
8. K2 (maternity portal replaced by PPUK)
9. i.PM
10. Athena (Maternity)
11. SCIT App (replaced by camera capture)
Please contact EPREnquiries@uhcw.nhs.uk if you have any questions about the systems
listed or the EPR system introduced in their place.
On review of this document please ensure the systems listed are removed from the text
and replaced with the relevant EPR system and process.
Equality and Diversity Statement: Throughout its activities, the Trust will seek to treat all people
equally and fairly. This includes those seeking and using the services, employees and potential
employees. No-one will receive less favourable treatment on the grounds of sex/gender (including
Trans People), disability, marital status, race/colour/ethnicity/nationally, sexual orientation, age,
social status, their trade union activities, religion/beliefs or caring responsibilities nor will they be
disadvantaged by conditions or requirements which cannot be shown to be justifiable. All staff,
whether part time, full-time, temporary, job share or volunteer; service users and partners will be
treated fairly and with dignity and respect.
Rationale
The rationale for screening for MRSA colonisation is:
•
To identify colonised individuals from the time of admission
•
To minimise transmission to other patients
•
To enable decolonisation treatment to be prescribed promptly
•
To ensure that they receive appropriate empirical treatment for infection, taking into
account of patient’s MRSA carriage
•
To ensure, where indicated, that they receive appropriate surgical prophylaxis
•
This guideline provides a local implementation of the national guidance set out in
“Implementation of modified admission MRSA screening guidance for NHS (2014)”
(Department of Health 2014)
Dissemination and related guidance
This guideline has been discussed at Infection Prevention Control Committee. This has
also be added to e-library.
Training
Training will be provided to trust staff by the IPCT and IPC link nurses via ward-based
training sessions. Education is also offered at preceptorship and medical student training
sessions. Mandatory training is provided via the ESR system.
Patient Information
Meticillin-Resistant Staphylococcus aureus (M R S A) Information for patients and relatives
Audit & Monitoring
Audit title
Audit Lead
Monitoring method
and frequency
Committee responsible
MRSA
Elective/emergency
IPC
Comparing Elective and
emergency admission
Nursing and Midwifery
--- PDF page 3 ---
3
screening
compliance
data with microbiology
lab screening results
Ward compliance
with MRSA QAG
IPC
IPC review the QAG on
commencement and
then weekly
Infection Prevention and
Control Committee
Changes from previous version
Date
Updated information
November 2023
All of the document has been placed into the new format guidelines.
November 2023
Page 6, table 1.1 – changes to the text to ensure clarity.
November 2023
There has been references added to refer staff to the relevant
documents throughout the guideline.
November 2023
Page 8, table 1.3 refers staff to appendix 10 – the UHCW high risk
areas.
November 2023
Page 11, this text has been added. For patients with eczema,
dermatitis or other skin conditions, attempts should be made to treat
the underlying skin condition. Advice on suitable eradication protocols
for these individuals should be sought from a consultant
dermatologist. Consider alternatives (e.g. octenidine) where mupirocin
and chlorhexidine are not feasible.
November 2023
Page 11, added. On NNU a patient in an incubator is deemed as in
isolation.
November 2023
Page 14, added. 1.6.7 MRSA decolonisation upon discharge:
Decolonisation is not usually required when the patient is discharged
unless clinically indicated.
Contents
Definitions ............................................................................................................................................... 4
Introduction ............................................................................................................................................ 4
Scope ....................................................................................................................................................... 5
Roles and Responsibilities ....................................................................................................................... 5
Clinical guidance ..................................................................................................................................... 6
Appendices ............................................................................................................................................ 17
References ............................................................................................................................................ 17
--- PDF page 4 ---
4
Definitions
Introduction
Meticillin Resistant Staphylococcus aureus (MRSA) is a strain of Staphylococcus aureus that is
resistant to all penicillin and its derivatives e.g. flucloxacillin, amoxicillin, co-amoxiclav, piperacillin –
tazobactam (Tazocin) as well as cephalosporins and carbapenem antibiotics. Many strains of MRSA
are also resistant to quinolones e.g. ciprofloxacin, macrolides e.g. erythromycin, clarithromycin and
clindamycin. This resistance makes infection with MRSA difficult to treat and significantly increases
the risk to patients.
Clinical infection with MRSA (including MRSA bacteraemia/blood infection) occurs either from the
persons own resident MRSA colonisation or by cross-infection from another person. It is important
to identify if an individual is colonised with MRSA on admission to hospital to minimise the risk and
spread of infection to themselves and other patients.
The zero-tolerance approach to MRSA was reiterated in Everyone Counts: Planning for patients
2014 / 2015 to 2018/ 2019 and this approach remains a priority for the NHS. Before April 2018 all
MRSA blood stream infections (BSI) cases underwent a formal post – infection review. From April
2018 this requirement will be modified so that formal reviews must only be undertaken for
organisations with the highest rates of infections. UHCW is excluded from undertaking a formal PIR,
however all MRSA BSI should still be subject to a robust clinical review, regardless of the
requirement for PIR. Trusts must continue to undertake patient safety reviews on all cases to identify
best practice and areas for improvement / learning (NHS improvement 2018).
MRSA
Meticillin Resistant Staphylococcus aureus
Bacteraemia
The presence of bacteria in the blood
HCAI
Healthcare Acquired Infection
Colonised
Individual carries the bacteria on their skin or in their nose but have
no signs of symptoms of infection.
Screening
A test that looks solely for the presence of an organism –
in this case MRSA.
Transient carriage
Presence of bacteria on a person without infection for a short period of
time e.g. on hands before washing.
IPC
Infection Prevention Control
UKHSA
UK Health Security Agency
PIR
Post Infection Review
QIPS
Quality Improvement and Patient Safety
NICU
Neonatal Intensive Care Unit
TC
Transitional Care
IPCT
Infection Prevention Control Team
IPCN
Infection Prevention Control Nurse
BSI
Blood stream infection
QAG
Quick Action Guide
CRRS
Clinical Results Reporting System
EPR
Electronic Patient Record System
--- PDF page 5 ---
5
MRSA bacteraemia is considered by the Government as unacceptable for a patient to acquire MRSA
bloodstream infection within a healthcare setting. UHCW has adopted this zero-tolerance approach
through a combination of good hygienic practice, appropriate use of antibiotics, improved techniques
in the care and use of medical devices as well as adherence to best practice guidance (NHS England
2014).
Scope
The guidance applies to all staff (temporary or permanent) working in all locations managed by
University Hospital Coventry and Warwickshire NHS Trust. This includes volunteers, contractors,
students and/or trainees.
Roles and Responsibilities
What are the duties and responsibilities of the staff that will be utilising this guidance:
1. Doctors: To prescribe correct decolonisation where appropriate for the patients identified as
requiring this treatment.
2. Staff who screen the patients: To ensure that the correct process is undertaken in order to
collect accurate samples and ensure safe delivery to the laboratory for testing.
3. Nurses and Doctors: To ensure the correct decolonisation is prescribed and given to the
patient. To ensure that the patient is aware of the clinical diagnosis and has been given
relevant information with regards to MRSA. Nurses to escalate any issues that arise
appropriately.
4. Pharmacists: To ensure prescriptions are in line with clinical guidance and supply the
medication in a timely manner.
--- PDF page 6 ---
6
Clinical guidance
Type
Process
All emergency adult admissions to high-risk areas
(see ‘High Risk Areas – appendix 10 and Sample
Sites’). Patients must be swabbed in this category
when they are moved onto a high-risk area.
And
All previously known positive for MRSA for any
admission areas
(Include any patient that has been an inpatient in
any other hospital, include episodes in hospital or
clinical setting abroad)
MRSA screen within 48hours of admission.
And if
previously known MRSA positive only, completion
of the Infection Prevention and Control Quick
Action Guide – Appendix 2.
Elective patients attending Pre-Operative
Assessment Clinic (POAC) to be assessed using
appendix 1 for screening requirements.
(Include any patient that has been an inpatient in
any other hospital, include episodes in hospital or
clinical setting abroad)
MRSA screening monitoring is undertaken from at
least 18 weeks before the surgery is performed.
Regular / repeat attendees to be screened as per
local guidance.
Renal, oncology or haematology outpatients clinics
(Include any patient that has been an inpatient in
any other hospital, include episodes in hospital or
clinical setting abroad)
MRSA screen within 48hours of admission.
And if
previously known MRSA positive only, completion
of the Infection Prevention and Control Quick
Action Guide – Appendix 2.
Standard Infection Prevention and Control Precautions must be adopted on all patients
regardless of their diagnosis.
MRSA positive patients
(Include any patient that has been an inpatient in
any other hospital, include episodes in hospital or
clinical setting abroad)
All patients will be informed of the result. Inpatients
will be informed via ward staff. Outpatient team,
GP’s, patient and the consultant caring for the
patient will be informed by the IPC team (Appendix
4 - 8). The Consultant performing surgery will also
be informed.
These patients will be treated with appropriate
decolonising agents. Patients presenting with a
MRSA positive screen alerted on CRRS should be
started on decolonisation on admission, irrelevant
of any negative screen results or the year it was
taken and a Quick Action Guide Commenced
(QAG) (Appendix 2&3)
MRSA positive patients must only be transferred to
wards/departments when adequate arrangements
have been made to cater for these patients in the
receiving ward and an appropriate risk assessment
has been documented.
1.1
--- PDF page 7 ---
7
1.2 Who to Screen:
Adult Patients
Emergency Admissions
(including transfers from other healthcare
providers)
(Include any patient that has been an inpatient in
any other hospital, include episodes in hospital or
clinical setting abroad)
All emergency adult inpatient admissions to high-
risk areas. Any patient transfers to high-risk areas
will be screened as soon as possible, within 48
hours of admission (see ‘High Risk Areas –
appendix 10 and Sample Sites’). Patients must be
swabbed in this category when they are moved
onto a high-risk area.
Elective Admissions
(including day cases)
(Include any patient that has been an inpatient in
any other hospital, include episodes in hospital or
clinical setting abroad)
MRSA screening in advance of surgery allows
decolonisation treatment to be started before the
operation and greatly reduces the risk of MRSA
infection of the wound.
The screen will be taken when the patient attends
for their pre-operative assessment appointment.
If an elective high-risk patient fails to have their
screen taken during the pre-admission phase, they
should follow the same protocol as emergency
admissions.
Regular Outpatient Attendees
Including but not limited to:
•
Dialysis patients
•
Oncology patients
•
Haematology patients
(Include any patient that has been an inpatient in
any other hospital, include episodes in hospital or
clinical setting abroad)
Will require MRSA screens to be performed on a
regular basis which has been deemed by the
respective specialities due to the presence of
invasive devices and increased healthcare
interventions/attendances.
General Critical Care (GCC)
Cardiothoracic Critical Care (CTCC)
(Include any patient that has been an inpatient in
any other hospital, include episodes in hospital or
clinical setting abroad)
All patients admitted to these areas will be
screened on admission, either being transferred
internally within the trust or transferred from
another hospital, and then at weekly intervals until
discharge. GCC and CTCC routinely decolonise all
of their patients during their stay.
Paediatric Admissions (Excluding Neonates)
Emergency and Elective Admissions
(Include any patient that has been an inpatient in
any other hospital, include episodes in hospital or
clinical setting abroad)
Paediatric admissions are excluded from routine
screening unless they fulfil any of the following
criteria in which case they should be screened as
soon as practical on admission (or prior to
admission if an elective case)
•
Are known to have been infected or
colonised with MRSA in the past
•
Have been transferred from another
hospital
Neonates
Neonates
(Include any patient that has been an inpatient in
any other hospital, include episodes in hospital or
clinical setting abroad)
All neonates admitted to Neonatal Intensive Care
Unit (NICU) or Transitional Care (TC) will be
screened on admission to the ward area, including
on transfer from another hospital, and then at
weekly intervals until discharge. See appendix 3.
--- PDF page 8 ---
8
1.3 High risk areas and sample sites
High Risk Areas
Adults
•
Please see appendix 10 for high-risk areas
Nose and Groin
(Other samples to be screened.
Any open wound, ulcer, area of broken skin,
Sputum if patient has productive cough)
High Risk Areas
Neonates
•
Neonates see appendix 3 for management
Nose
Umbilical
Groin
Urine and Sputum Samples:
•
Routine screening of urine for MRSA is not required.
MRSA isolated from urine or from sputum may represent colonisation, however if infection is
clinically indicated, treatment with antibiotics maybe required – please see Side Room Priority
Isolation Guidance in Isolation Guideline CG 334 for management.
•
Advice can be sought from the on call/Duty Microbiologist.
1.4 How to screen a patient
When swabs are taken from dry parts of the body (e.g. the nose), the swab must be moistened prior to
sampling using the sterile water or sterile saline.
A minimum of 2 swabs should be taken for recommended MRSA screening specimens. 1 swab to be used
for each site (nose, throat, axilla, groin (or perineum) and rectum).
Swabs taken from wounds with high levels of exudate do not need to be moistened first.
1.Gain patient consent
A full explanation must be given to the
patient/carers and consent obtained for
screening
2. Decontaminate hands
To prevent cross contamination
3. Moisten swabs using sterile water or Saline
For patient comfort and improved
technique
4. Rub and rotate the swab on the skin, one swab is sufficient
to use in both nostrils. Swabs should be taken from the
following sites:
To ensure surface area coverage
--- PDF page 9 ---
9
•
nose: carefully place swab into nasal vestibule (not the
middle nor back of the nose) and rotate around 5 times
(5 seconds). One swab can be used for both nostrils.
•
groin: in the fold between the perineum and the thigh,
swab should be rolled around several times
•
any skin lesions / PEG (percutaneous endoscopic
gastrostomy) sites / catheter sites/ drain sites
•
consider the throat, especially in suspicion of prolonged
carriage
5. Place swab back in charcoal tube and label with patient
details
For correct transportation of media
6. Decontaminate hands
To prevent cross contamination
7. Using the clinical results reporting system (CRRS) print e-
request and document in nursing notes
CRRS/ EPR is the Trust result
reporting system. Documentation
assists communication and
accountability.
•
Please note: when swabs are sent as an “MRSA screen”, the laboratory places the swabs together.
This means that it will not be possible to determine precisely which site was positive.
Therefore, if a patient has a lesion or wound which looks clinically infected, a separate swab for
culture and sensitivity must be sent to the laboratory in addition to screening the site for MRSA.
•
Wound Swabs - If a patient presents with a wound which is clinically indicative of infection, a swab
may be taken to test for MRSA infection. The wound swab must be taken after the wound has been
cleaned.
If a wound swab is positive for MRSA, a nasal and groin swab (if not already done on admission)
should be taken at this time to test for colonisation.
MRSA isolated from non-inflamed skin or ulcers, or from other sites where there are no clinical indications
of infection implies MRSA carriage/colonisation rather than infection and should be managed without
systemic antibiotic treatment.
Skin wounds that demonstrate signs of infection and from which MRSA is isolated on culture, may require a
course of systemic antibiotic therapy. Advice should be sought from the on call/duty Microbiologist.
For patients with eczema, dermatitis or other skin conditions, attempts should be made to treat the
underlying skin condition. Advice on suitable eradication protocols for these individuals should be sought
from a consultant dermatologist. Consider alternatives (e.g. octenidine) where mupirocin and chlorhexidine
are not feasible.
--- PDF page 10 ---
10
1.4.1 Patient Refusal of Procedure:
A patient can decline to have an MRSA screen. If a patient initially refuses to be screened, they should be
informed that it is UHCW policy and given the MRSA information leaflet. This can be found on the Trusts e-
Library. If the patient continues to refuse, this should be clearly documented in the patient’s clinical notes.
However, the patient’s clinical management will not be compromised and they will need to have the same
management as a MRSA carrier and decolonisation should be commenced.
1.4.2 Results:
Positive MRSA results are sent to the Infection Prevention and Control Team (IPC) daily. An alert will be
placed the result on CRRS/ EPR if not previously alerted from another admission. If they are previously
known the alert will be updated to reflect the new result. This will inform all future admissions of the
patient’s MRSA status.
1.4.3 Emergency Screens
If the patient is an inpatient then the IPC will inform
a trained nurse on the appropriate ward and the
patient will be managed according to the QAG (see
appendix 2).
If the patient has been discharged home before
result is known and is a new positive result the IPC
will inform the General Practitioner (GP) and the
patient of the result (see appendix 4 & 5)
1.4.4 Elective Screens
The IPC will inform the patient, their GP and the
listed surgical Consultant of the positive result and
advise on decolonisation and antibiotic prophylaxis
if needed for the surgery. An FP10 completed with
an approved MRSA decolonisation stamp on the
prescription will be sent by post to the patient by
the IPC if required for decolonisation. The
prescription has been approved by MMC (appendix
9)
Negative MRSA screens prior to the surgical
intervention are not required as long as 5 days of
decolonisation has been completed prior to
surgery. Day of surgery is counted as day 5. If the
patient undergoes decolonisation therapy, use
appendix 2 for patient management. Do not delay
a surgical procedure if the patient still tests
positive.
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11
1.5 Isolation:
MRSA positive patients should be isolated in a side room, instructing them to stay in their room and keep
the door closed. If the door cannot be kept closed document the reason for this on the QAG. An isolation
notice should be attached to the side room door which can be found in Isolation Guideline V11 CG 334
University Hospitals Coventry and Warwickshire NHS Trust as an appendix.
On NNU a patient in an incubator is deemed as in isolation.
If a side room not available, please risk assess the patient. Depending on where the MRSA is located, the
patient can possibly be nursed in a bay using Standard Infection Control Precautions– please see Side
Room Priority Isolation Guidance in Isolation Guideline CG 334 for management.
1.6 Decolonisation:
Any patient with a previously MRSA colonisation/infection should be treated in the same way as a patient
with a new positive MRSA screen, regardless of any intervening screens or the time elapsed since the
original positive. Products to be ordered through pharmacy or stock utilised on the ward and re-ordered
accordingly.
If the patient undergoes decolonisation therapy, use appendix 2 for patient management. Do not delay a
surgical procedure if the patient still tests positive.
The following products should be used for decolonisation:
For adults/ paediatrics inpatients only
Site
First Line Treatment
Second Line Treatment (first
line in patients who are pre-op
and requiring decolonisation)
Nasal
Mupirocin 2% (Bactroban) nasal
ointment
Three times a day to both nostrils
(For 5 days, stop for 2 days and
then rescreen as per appendix
2). Please follow the guidance
on this appendix for further
treatment, dependant on results.
* if Bactroban is out of stock then
please use second line
treatment.
** If Bactroban and Octenisan
are not suitable for the patient,
please speak to IPC or
Microbiology.
Octenidine (Octenisan MD) nasal
gel
Twice a day to both nostrils
(For 5 days, stop for 2 days and
then rescreen as per appendix
2). Please follow the guidance on
this appendix for further
treatment, dependant on results.
Antimicrobial Body Wash
Chlorhexidine 4% (Hibiscrub)
once a day applied all over the
body. Twice a week to the hair.
Positive and negative screen
result continue
*Hibiscrub/Octenisan until patient
discharged.
Octenisan once a day applied all
over the body. Twice a week to
the hair. Positive and negative
screen result continue
*Hibiscrub/Octenisan until patient
discharged.
--- PDF page 12 ---
12
For neonatal inpatients only
Site
First Line Treatment
Second Line Treatment
Nasal
Mupirocin 2% (Bactroban) nasal
ointment 3 times a day to both
nostrils as per BNFc.
(For 5 days, stop for 2 days and
then rescreen as per appendix 3.
Please follow the guidance on
this appendix for further
treatment, dependant on results.)
Please speak to
Microbiology/IPC for second line
alternative, if patient unable to
tolerate Bactroban or if
Bactroban not available.
Antimicrobial Body Wash
Octenisan once a day applied all
over the body. Twice a week to
the hair. Positive and negative
screen result - continue.
*Octenisan continued until
patient discharged.
Care and consideration should be given where patients are pre-term. Where further advice is required,
microbiology/IPC team should be consulted about this. Patient information leaflets should be given to
either the patient if able or the respective next of kin or carer/ parent.
1.6.1 Nasal products: Apply to the end of a finger or cotton wool bud and position inside both nostrils.
Gently squeeze the nostril to ensure coverage. Nasal decolonisation should be used according to the
instructions of the particular agent. The suppliers of Octenisan nasal gel and Octenisan wash can be
obtained from General Stores at UHCW.
*NB If patient self applies ask them to wash hands afterwards
1.6.2 Antimicrobial body wash: Apply to a dry disposable cloth and rub onto damp skin. Do not dilute.
Wash off Hibiscrub after 2-3 minutes or Octenisan after 1 minute
•
For patients with skin disorders, e.g. psoriasis or eczema, dermatology advice should be sought
before prescribing treatment.
•
For patients with known hypersensitivity to chlorhexidine (Hibiscrub), Octenisan may be used as an
alternative.
•
For patients with Mupirocin resistance use Octenisan nasal gel.
•
For neonates please see instructions illustrated in appendix 3.
1.6.3 Elective admissions
An initial period of decolonisation should commence as soon as the positive result is known and should
continue for five days. A second period of decolonisation should commence four days prior to admission.
Use of an antimicrobial body wash should continue until discharge. Use of the nasal product should be
limited to two five-day cycles, with a two day break, as set out in the QAG (appendix 2).
--- PDF page 13 ---
13
1.6.4 Emergency admissions
Decolonisation should commence immediately upon admission. Use of an antimicrobial body wash should
continue until discharge. Use of the nasal product should be limited to two five day cycles, with a two day
break, as set out in the QAG (Appendix 2).
1.6.5 MRSA decolonisation in General Critical Care: All patients require decolonisation regimen started
on admission and documented on the drug kardex.
1.6.6 MRSA decolonisation in Renal Haemodialysis: Renal haemodialysis patients who are currently an
outpatient follow a local regimen for MRSA decolonisation and re-screening based on their patient need.
Please refer to the Renal Unit MRSA screening guideline.
1.6.7 MRSA decolonisation upon discharge: Decolonisation is not usually required when the patient is
discharged unless clinically indicated.
1.7 Antimicrobial Prescribing
Appropriate and responsible antimicrobial prescribing is an essential element of any programme attempting
to control MRSA.
Advice should be sought from the duty Microbiologist before systemic treatment is prescribed. Please see
the Trust ‘Adult Antibiotic Guideline’ CG 1168 and ‘Antibiotic Prophylaxis in Surgery Guidelines 2022’ CG
1935 for further information.
Duration of therapy will vary depending on source of infection and clinical response. Advice on duration
should be sought from the Duty Microbiologists.
1.7.1 Theatres: MRSA patients undergoing surgery may need different antimicrobial prophylaxis to non-
carriers, refer to Trust ‘Antibiotic Prophylaxis in Surgery Guidelines 2022 CG 1935’ or discuss with Duty
Microbiologist.
--- PDF page 14 ---
14
1.8 The MRSA Quick Action Guide (QAG)
The MRSA QAG is a checklist that provides evidence that the decolonisation regime has been followed. In
addition to this is provides advice on re-screening after days 1 to 5 have been completed, and
recommencement of decolonisation. Versions are available for:
Adults/ Paediatrics (appendix 2)
Neonates (appendix 3)
The MRSA QAG must be used whenever a patient has a positive or presumptive positive MRSA screen or
is admitted having previously had a positive screen.
If the patient self-administers, or / carers use the wash, they can complete the form.
•
Adults/ Paediatrics (appendix 2)
•
Neonates (appendix 3)
If patients are self-caring with the decolonisation, education must be provided by the nurse in order to
ensure they are aware of correct decolonisation and rationale. Patients must be provided with patient
leaflets.
1.9 Transmission and Prevention
Clinical infection with MRSA (including MRSA bacteraemia/ blood infection) occurs either from the persons
own resident MRSA colonisation or by cross-infection from another person. Transmission may occur due
to poor hand hygiene, or following contact with contaminated items in the clinical setting.
Hand hygiene is of paramount importance. Adherence to the World Health Organisations (WHO) 5
moments for Hand Hygiene and use of the correct hand decontamination procedure (Ayliffe technique) is
vital to reduce transmission (Hand Decontamination Policy 2018).
Alcohol hand gel is effective against MRSA. When there has been exposure to bodily fluids, hand hygiene
with soap and water is required.
1.10 Personal Protective Equipment (PPE)
--- PDF page 15 ---
15
The use of PPE should be implemented as directed in ‘Standard Infection Prevention and Control
Precautions’ (2018) Guideline.
For appropriate PPE for porters please see ‘Transferring of Patients’ section.
1.10.1 Visitors wearing PPE: Visitors are not required to wear protective clothing unless involved in the
patient’s personal care, when an apron should be worn. Visitors should wash their hands immediately prior
to entering the room and prior to leaving the isolation room or bed space if the patient is in the bay.
1.11 Environmental Cleaning
MRSA can survive for long periods in dust, so special attention should be paid to ensuring the cleanliness
of horizontal surfaces and dust collecting areas, e.g. beds, curtain rails, tables, sinks, door handles and
ventilators and incubators. Incubators are to be cleaned in accordance with COP ‘The Incubator and the
Preterm baby Procedure’ V8.
Cleaning services personnel should be made aware that the patient is receiving special precautions so that
they can provide the necessary additional cleaning equipment and fulfil cleaning requirements. The patient
isolation/ cohort bay must be decontaminated at least daily with Tristel.
A terminal clean of the side room is required when an MRSA patient is discharged or transferred. If the
patient is transferred from a bay, a terminal clean of the bed space is sufficient.
It is the responsibility of the nursing staff to clean items such as blood pressure equipment, drip stands and
pumps prior to removal from the room or bed area. Tristel should be used for this.
Following a procedure or investigation, the area and equipment will require a decontamination using a
chloride dioxide solution (e.g. Tristel).
Theatres: cleaning of theatre surfaces should be carried out using chlorine dioxide solution (e.g. Tristel)
after every case.
--- PDF page 16 ---
16
1.12 Transferring of Patients
Screening
Infection Prevention Control measures should not compromise the patient’s care and should not affect the
patient’s freedom to be mobilised or attend other departments for health care related visits.
It is the responsibility of the nursing staff on the transferring ward to make direct contact with staff on the
receiving ward or department (e.g. radiology) to make sure that they are aware of the patients MRSA status
in advance of the transfer.
1.12.1 Porters transferring a patient: Transporting a patient with MRSA in the hospital on a bed, trolley
or wheelchair is a low-risk activity. There is no requirement for porters or staff to wear gloves, aprons or
other PPE on transferring patients. It is of paramount importance however that hand decontamination is
performed after contact.
1.12.2 Theatre: theatres must be informed of the patients MRSA status immediately prior to transfer. This
is the responsibility of the transferring ward staff. Patients with MRSA can be nursed in recovery post-
surgery. The trolley and bed space should be cleaned thoroughly with chlorine dioxide solution (e.g.
Tristel) following the patients return to the ward.
1.12.3 Travelling by vehicle:
MRSA carriers requiring transport by ambulance (e.g. between UHCW and St Cross) may be transported
with other patients so long as any wounds, ulcers etc are covered securely with an occlusive dressing and
the ambulance crew adhere to standard infection prevention control precautions.
Outpatients may be transported in cars without posing a risk to the driver or other passengers as long as
such wounds are covered.
1.13 Laundry:
All laundry must be considered contaminated and placed in a red alginate bag inside a white outer bag.
For patients/ relatives that wish to take home soiled clothing, please refer to the COP ‘Guidance for the
laundering of Patient’s Soiled Clothing in the Home Setting’ V8 which is located on the e-library.
--- PDF page 17 ---
17
1.14 Cutlery and Crockery:
Ordinary cutlery and crockery can be used, provided that these are washed in an automated dishwasher
after use. Disposable crockery and cutlery are not required. Under no circumstances should any crockery
or cutlery be washed by hand.
1.15 Staff screening:
The decision whether staff should be screened will be made at the discretion of the Director of Infection
Prevention Control (DIPC) and IPCS team, in conjunction with Occupational Health. This is a decision
made on clinical judgement and risk assessment, if there is a MRSA outbreak or clusters of cases within
their clinical areas.
Swabs should be taken at the beginning of the work shift. Do not take swabs immediately after the staff
member has come off duty as they may be transiently colonised in a number of sites.
Appendices
•
Guidance for the laundering of Patient’s Soiled Clothing in the Home Setting COP 63 V9 University
Hospitals Coventry and Warwickshire NHS Trust
•
Adult Antibiotic Guideline CG 1168 V17.1 University Hospitals Coventry and Warwickshire NHS
Trust
•
Antibiotic Prophylaxis in Surgery Guidelines 2022 CG 1935 V4 University Hospitals Coventry and
Warwickshire NHS Trust
•
Standard Infection Control Precautions CG 885 V11 University Hospitals Coventry and
Warwickshire NHS Trust
References
CEBIS Evidence Summary
(NICE Guidelines, and other National Guidance. Other national guidance may include those issued by speciality
college, patient safety agency, monitoring agencies, or other external governing bodies )
Referral ID: Q 12558 completed on 26/06/2023
--- PDF page 18 ---
18
References Cited in Guideline
Grade*
UK Standards for Microbiology Investigations | Issued by the Standards Unit, Public Health
England Bacteriology | B 29 | Issue no: 7 | Issue date: 26.05.20 | Page: 7 of 18
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file
/887595/B_29i7.pdf
Surgical site infections: prevention and treatment, NICE guideline [NG125]
https://www.nice.org.uk/guidance/ng125/chapter/Recommendations#nasal-decolonisation
Coia JE et al. Working Party Report (2006). Guidelines for the control and prevention of meticillin
resistant Staphylococcus aureus (MRSA) in healthcare facilities. Journal of Hospital Infection 63S
S1-S44.
epic3 National Evidence-Based Guidelines for Preventing Healthcare Associated Infections in
NHS Hospitals in England Journal of Hospital Infection 2014 86: supplement 1
1
Health and Social Care Act 2008- Code of practice on the prevention and control of infections and
related guidance (DH 2010).
5
Department of Health (2006). Screening for Meticillin-resistant staphylococcus aureus (MRSA)
colonisation. A strategy for NHS trusts: a summary of best practice. London: Department of
Health
5
Implementation of modified admission MRSA screening guidance for NHS (2014)
Department of Health expert advisory committee on Antimicrobial Resistance and Healthcare
Associated Infection (ARHAI)
NHS England (2014) Guidance on the reporting and monitoring arrangements and post
infection review process for MRSA bloodstream infections from April
2014 version 2
The Journal of Hospital Infection (2021) Joint Healthcare Infection Society (HIS) and Infection
Prevention Society (IPS) guidelines for the prevention and control of meticillin-resistant
Staphylococcus aureus (MRSA) in healthcare facilities
https://www.journalofhospitalinfection.com/article/S0195-6701(21)00360-1/fulltext
NHS Improvement (2018) Update on the reporting and monitoring arrangements and post –
infection review process for MRSA bloodstream infections
National Health Service (2022) National infection prevention and control manual for England V2
*Grade:- The references are graded through the CEBIS process according to the criteria outlined below.
Grade of
evidence
Based on
1
Systematic review or meta-analysis
2
Randomised controlled trial/s
3
Controlled study without randomisation (e.g. case controlled) or quasi-experimental study, such
as a cohort study
--- PDF page 19 ---
19
4
Descriptive studies such as case series and reports.
5
Expert opinion, narrative review
Add any Appendices below
•
Guidance for the laundering of Patient’s Soiled Clothing in the Home Setting COP 63 V9 University
Hospitals Coventry and Warwickshire NHS Trust
•
Adult Antibiotic Guideline CG 1168 V17.1 University Hospitals Coventry and Warwickshire NHS
Trust
•
Antibiotic Prophylaxis in Surgery Guidelines 2022 CG 1935 V4 University Hospitals Coventry and
Warwickshire NHS Trust
•
Standard Infection Control Precautions CG 885 V11 University Hospitals Coventry and
Warwickshire NHS Trust
--- PDF page 20 ---
20
Appendix 1 Pre-operative assessment tool
Version 2- June 2023
Patient attends Pre-op
assessment (POAS)
POAS nurse checks alert
status on CRRS
POAS provides decolonisation
products
POAS screens patient for
MRSA (within 18 weeks of
surgery) if outside of this time
period – assess patient for risk
factors for MRSA
POAS screens patient for
MRSA
Previously alerted
Not previously alerted
Prescription for decolonisation
products sent by IPCN, with
letter informing of result
Positive screen
Decolonisation for 5 days after
receiving regime, and a further
5 days up to and including day
of surgery
No action required
Negative screen
--- PDF page 21 ---
21
--- PDF page 22 ---
22
--- PDF page 23 ---
23
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24
--- PDF page 25 ---
25
Appendix 4 Elective letter to the patient
Date
Name
Address
Dear,
Whilst attending the clinic for your pre-operative
assessment swabs were taken to check for
MRSA.
Your swabs results have shown that you are MRSA positive. Do not be alarmed by
this finding as many people are MRSA positive and come to no harm.
We are sending you enclosed with this letter, a prescription of the required
treatments which can be taken to any local pharmacy for dispensing.
Please apply a 5 day course of treatment (hair and body washes and nose
ointment) on the receipt of the therapy. It is best that this happens as soon as
practicably possible.
Please start a further treatment 4 days prior to the surgery date and take
the products to hospital to be used on the day of surgery as well.
(You should have enough of both drugs to use for both treatments. Please
check the date of expiry of the drugs before use)
When you attend the hospital for your surgery or procedure please inform the nurse in
charge on the day that you were/ are MRSA positive. On admission it would be helpful
if you could bring your completed decolonisation record with you to show the nursing
team. The decolonisation record is enclosed with this letter.
Should you need to discuss this matter any further you can contact the Infection
Prevention and Control Team on 02476 964791.
Yours sincerely
--- PDF page 26 ---
26
Infection Prevention & Control
University Hospital Coventry & Warwickshire
Clifford Bridge Road,
Coventry
CV2 2DX
--- PDF page 27 ---
27
Appendix 5 Elective letter to the GP
Date
Dr
Address
Dear Dr xxx
Re: …………… PID ……………. DOB …………….. NHS no ……………….
This is just to inform you that this patient, who we believe to be registered with your practice,
has recently been found to be MRSA positive on a routine screen done at the pre-operative
assessment clinic. We have sent a letter to the patient informing the MRSA result and
advising on decolonisation regimen (see below). Patient has also been sent a FP10
prescription for decolonisation therapy (body wash and a nasal ointment) which can be taken
to any Pharmacy for dispensing.
Decolonisation treatment regime:
As soon as result known
Octenisan body wash once a
day for 5 days (twice a week
wash the hair also)
Octenisan
nasal ointment twice a
day for 5 days
5 days before and
including day of scheduled
elective procedure
Octenisan body wash once a
day for 5 days (twice a week
wash the hair also)
Octenisan
nasal ointment twice a
day for 5 days
Please could you make a note of this patient’s MRSA status on your records?
--- PDF page 28 ---
28
If they do present with an infection after surgery, or at some time in the future, which might
be staphylococcal in origin, please take this into account when prescribing treatment.
As you know, MRSA is a variant of S. aureus which is resistant to meticillin, one of the fore-
runners, a narrow spectrum penicillin used in susceptibility testing as a surrogate marker for
flucloxacillin.
MRSA is always resistant to:
•
Flucloxacillin
•
Amoxicillin and co-amoxiclav (Augmentin)
•
The cephalosporins, including cephalexin.
It is nearly always resistant to the macrolides including erythromycin and clarithromycin
and quinolones such as ciprofloxacin. Please discuss with on duty Microbiologist on
02476965446/5487 for advice on antibiotic therapy if needed. If patient needs hospital
admission, particularly to one of the higher risk areas, including to a general or more
specialist surgical ward, they may be put into a side room.
Should you need to discuss this matter any further you can contact the Infection Prevention
and Control team on 02476 96 4791.
Yours sincerely
Infection Prevention & Control
University Hospital Coventry & Warwickshire,
Clifford Bridge Road,
Coventry
CV2 2DX
--- PDF page 29 ---
29
Appendix 6 Elective letter to UHCW Trust Consultant in charge of patients
care
Date
Dear Colleague
Re:
PID DOB
NHS no
In accordance with DH policy this patient was screened for MRSA and found to be
positive.
This patient should now have at least a 5 day course of MRSA decolonisation. (Octenisan
nasal gel and Octenisan body wash)
Additionally 5 days prior to and including the day of surgery the patient should re-start the
same decolonisation regimen.
A letter advising decolonisation therapy with the regime and a prescription for the therapy
has been sent to the patient. The patient’s GP has also been made aware of this.
Please follow the relevant Trust Guidelines or contact the Medical Microbiologist for further
advice if required.
MRSA is thought to be no more likely to cause an infection than a sensitive strain of
Staphylococcus aureus. Thus for operations / procedures that would not normally require
antibiotic prophylaxis, this should still be the case, even if the patient is MRSA positive.
Where the infective risk for a surgical procedure routinely requires antibiotic prophylaxis
then the antibiotic cover should be extended to include MRSA (see surgical prophylaxis
guidelines to support this).
If the above measures are implemented (decolonisation and antibiotic prophylaxis where
indicated) then the risk to the individual patient of acquiring a MRSA infection is minimal and
the overall rate of infection should be no higher than the expected rate for that procedure /
operation. However the risk cannot be completely removed- sensitive Staphylococcus
aureus infections can occur despite antibiotic prophylaxis and the same holds true for
MRSA.
--- PDF page 30 ---
30
Thank you for your assistance in the matter.
Yours sincerely
Infection Prevention & Control
University Hospital Coventry & Warwickshire
Clifford Bridge Road
Coventry
CV2 2DX
Tel: 02476 964791
--- PDF page 31 ---
31
Appendix 7 Emergency letter to the patient
Date
Name
Address
Dear
During your recent admission to UHCW NHS Trust you were
screened for MRSA in accordance with Department of Health
requirements. Please be aware that you have been found to be MRSA positive but you
were discharged before this information was available. We have also told your GP directly
about this result.
MRSA stands for Meticillin-Resistant Staphylococcus Aureus. Staphylococcus aureus is a
type of germ carried on the skin and in the nose or throat of about one third of the population;
MRSA is just one kind of this germ which is resistant to some antibiotics.
Should you ever need a course of antibiotics to treat what might be a Staphylococcus aureus
infection; your doctor will need to take this into account.
When you go to your doctor, please can you make sure that you tell him/her that you are a
MRSA carrier so they can ensure you receive the right treatment.
If you are worried, please call the Infection Prevention and Control Team at University Hospital
Coventry and Warwickshire for advice on 02476 96 4791.
There is also some good information on the NHS Choices website- please see:
http://www.nhs.uk/Conditions/MRSA/Pages/Introduction.aspx
Yours sincerely
Infection Prevention & Control
University Hospital Coventry & Warwickshire
Clifford Bridge Road
Coventry
CV2 2DX
02476 964791
--- PDF page 32 ---
32
Appendix 8 Emergency letter to the GP
Date
Dr
Address
Dear,
Re: DOB HOSP NO , NHS No
608 490 1905
Your patient was screened for MRSA on admission to UHCW in accordance with the current
Department of Health requirements, and was found to be positive.
The patient has also been informed directly of this result.
If this patient presents to you with an infection which is likely to be caused by Staphylococcus
aureus, please can you take this into account.
MRSA will definitely not be sensitive to commonly used drugs including flucloxacillin, co-
amoxiclav (augmentin), cephalexin, and is usually also resistant to ciprofloxacin and
erythromycin and other macrolides.
There are usually other oral options available, depending on the situation. Please call the duty
clinical microbiology team via the UHCW switchboard if a discussion would be helpful about
an individual case
Yours sincerely
Infection Prevention & Control
University Hospital Coventry & Warwickshire
Clifford Bridge Road
Coventry
CV2 2DX
02476 964791
--- PDF page 33 ---
33
Appendix 9 Approved MRSA decolonisation stamp
--- PDF page 34 ---
34
Appendix 10 UHCW high risk areas
UHCW High Risk Areas
MRSA screening compliance will now *only* be reported against the following HIGH RISK
areas/ unit:
Speciality
IPM Ward
Code
Ward
Description
Emergenc
y
Admission
s
Elective
Inpatient
Admissio
n
Elective
Day Case
Admission
s
All Intensive
Care Units
and High
Dependency
Units (adult/
paediatric
ICUs,
Neonatal
units,
Coronary
Care Units)
CTCC
Cardiothoracic
Critical
Care
(Ward 11a)
Yes
Yes
NA
GCC
General
Critical
Care
Unit
Yes
Yes
NA
CCU
Coronary
Care Unit
Yes
Yes
NA
NNU
Neonatal Unit
Yes
Yes
NA
Haematology
/ Oncology/
Bone Marrow
Transplant
ACRC
Arden Cancer
Centre
NA
Yes
Yes
ACC
Chemotherap
y Suite
Yes
Yes
Yes
34
Haematology
Yes
Yes
NA
34DC
Haematology
Day Unit
NA
Yes
Yes
35
Oncology
(Cancer)
Yes
Yes
NA
Neurology
43
Neurosurgery
Yes
Yes
NA
43NECU
Neuro
Enhanced
Care Unit
Yes
Yes
NA
Renal/
Dialysis
50
Renal Ward
Yes
Yes
NA
50DU
Renal Day
Unit
Yes
Yes
Yes
Cardiac
10ECU
Cardiology
Enhanced
Care Unit
Yes
Yes
NA
11
Cardiothoracic Yes
Yes
Yes
Vascular
22a
Vascular
Yes
Yes
NA
Orthopaedics
/ Trauma
52
Orthopaedics
Yes
Yes
NA
53
Major trauma
Yes
Yes
NA
53MTEC
U
Major trauma
Enhanced
Care unit
Yes
Yes
NA
CEDM
Cedar Trauma Yes
Yes
No
--------------------------------------------------------------------------------
ATTACHMENT: 7.pdf
TEXT_FILE: 7.pdf.txt
METHOD: pdf_native
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PAGES: 14
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--- PDF page 1 ---
1
Clinical Operating Procedure
Procedure Title:
Clinical operating procedure for the cleaning and disinfection of
non-invasive equipment and computers
Procedure Ref No:
COP 96
Expiry date:
October 2022
Version Number:
V9
Summary statement /scope of the procedure:
Clinical operating procedure for the cleaning and disinfection of non-invasive
equipment and computers.
Recommendations for procedure content:
Clinical operating procedures should detail clear and explicit recommendations for practice
and behaviour specific instructions; what, who, when, where and how. This will increase the
likelihood of adoption of the procedure.
1. SCOPE
These guidelines set out what is meant by cleaning, disinfection, and sterilisation and the level
of decontamination that is required for specific equipment before and after use, prior to service
and repair, and for assessment prior to equipment being condemned.
Care equipment can be categorised into different groups
Re-useable
Single patient use
Single use
IT equipment
This document will look at the cleaning and disinfecting of the above equipment
2. INTRODUCTION
.
Current evidence suggests that a contaminated environment plays an important role in the
spread of microorganisms and if the environment is not decontaminated on a regular basis it
may act as a reservoir for potential pathogens (Weber et al 2010) The National Patient Safety
Agency (NPSA) (2009) suggested that risk and cleaning frequencies should be established for
all equipment.
Decontamination is a process which reduces, removes, or destroys contamination to ensure
that infectious agents or other contaminants cannot reach a susceptible site in sufficient
quantities to cause infection or any other harmful response.
Decontamination can involve cleaning, disinfection and/or sterilisation as required and
according to the infection risk.
• Cleaning is defined as ‘a process which physically removes infectious agents and the organic
matter on which they thrive but does not necessarily destroy infectious agents”. MHRA (2010)
--- PDF page 2 ---
2
• Disinfection is defined as a process used to reduce the number of viable microorganisms but
which may not necessarily inactivate some infectious agents. (MHRA 2010)
• Sterilisation is defined as a process to make an object free from viable micro-organisms. The
processes for sterilisation are specified in BS EN ISO 14937:2009.
Decontamination should take place
At regular pre planned times as per cleaning schedule
Between each patient use
After exposure to bodily fluids
Before service or repair
Before disposal
There should be safe systems in place to ensure that any risks associated with
decontamination facilities and processes are adequately managed.
3. STATEMENT OF INTENT
In line with the Health and Social Care Act 2008 code of practice (DOH 2009), all healthcare
organisations must provide and maintain a clean and appropriate environment for equipment to
be stored and cleaned/decontaminated. This will:
Raise public and patient confidence that cleanliness standards continue to rise
Assist in reducing the risk of healthcare associated infection (HCAI) cross
contamination.
Make cleaning a part of everyday work on the ward/unit.
4. DEFINITIONS
EQUIPMENT
Any device or machine which is used in the treatment, care, or diagnosis of patients
(Note: equipment may contain disposable items or consumables which need to be regarded as
potentially contaminated and should be treated accordingly)
CORRECTIVE WORK
Servicing activity which is required to restore equipment to a safe and fully functional status
INVESTIGATIVE WORK
Any inspection or test that is required to verify a performance factor that ensures the
equipment meets the required criteria
SCHEDULED MAINTENANCE
The maintenance or medical equipment that is conducted on an area by area basis by prior
arrangement with equipment users, and where such services activity is planned within a
regular time cycle.
PLANNED MAINTENANCE
Maintenance of medical equipment where individual equipment items are assigned an
identified time and functional check based on a maintenance schedule.
HAZARDOUS SUBSTANCES
A full definition is given in the Control of Substances Hazardous to Health (COSHH) and the
Dangerous Substances and Explosive Atmosphere regulations (DSEAR). The user should also
consult the trust Health and Safety Policy. Briefly, a hazardous substance in terms of this policy
includes.
--- PDF page 3 ---
3
Biological agents likely to cause disease of harm in humans (e.g. viruses, bacteria,
toxins directly arising from biological agents etc.)
Hazardous chemical agents (e.g. harmful, irritant, corrosive, toxic, flammable,
carcinogens etc.)
Hazardous substances that are not necessarily chemicals (e.g. santisers)
Radioactive substances
HAZARD ROUTE
The main route of entry into the body which can include but is not limited to:
Inhalation skin contact (superficial reactions)
Skin absorption (systemic reactions)
Mucus membrane absorption (nose, mouth) and sensitive areas (eyes)
Puncture or laceration with accompanying contamination
Ingestion (mainly via contamination of hands which then contact mucus membrane)
5. DUTIES/RESPONSIBILTIES
RESPONSIBILTIES
It is the responsibility of the user of the equipment to ensure it is decontaminated after each
use.
MANAGEMENT RESPONSIBILTIES
It is the responsibility of the ward manager to ensure all staff has received the appropriate
training on how to use the disinfectants and detergents.
All wards should have an infection control link nurse who will keep up to date with the current
products being used and will be able to cascade this information.
A nominated person will also be a cascade trainer for the Dekomed machine and will complete
competency checklists for each member of staff to be kept by the ward manager.
STAFF RESPONSIBILITIES All staff have a responsibility to be up to date with all Infection
Prevention and Control mandatory training, it is the staff member’s responsibility to be
competent to use all disinfectants and detergents and to know how to appropriately load and
check the Dekomed.
6. DETAILS OF THE DOCUMENTCLEANING
Cleaning is the primary method of decontamination; it removes dirt using soap and water to
remove a high proportion of all micro-organisms and the organic material which they thrive on.
A poor cleaning technique can cause a negative effect and may spread the micro-organisms
over a larger area therefore increasing contamination risk.
Cleaning uses friction to remove the dirt from surfaces and is a pre-requisite to any disinfection
process (Booth 2000)
A surface should be visibly clean and all soiling removed before disinfection can take place.
Equipment (e.g. BP cuffs, pulse oximeters) requires cleaning between each patient use.
DISINFECTION
Disinfection reduces the number of vegetative bacteria, viruses and fungi to a level that is
unlikely to cause infection. It does not remove or destroy all bacterial spores.
Disinfection will only be effective once all visible signs of soiling have been removed by
cleaning.
Disinfection of equipment or the environment is required if a patient is in isolation or in an
outbreak situation.
DETERGENTS
--- PDF page 4 ---
4
Detergents are surface active agents that are characterised by frothing caused by ionic and
non-ionic components. They are used to break down organic matter. The appropriate type of
detergent should be selected for the equipment to be cleaned.
DISINFECTANTS
Disinfectants are substances which are capable of killing micro-organisms. The use of
disinfectant is to reduce the number of micro- organisms on a surface, thereby decreasing the
risk of contamination. Disinfectants are ineffective against soil.
Disinfection and detergent solutions must be made up according to company guidelines; they
must be fresh and appropriately diluted. Incorrect mixing can lead to the ineffectiveness of the
product.
NB Never mix different products
THEMAL DECONTAMINATION
The Dekomed machine uses thermal disinfection which allows a high-level disinfection. The
internal water and steam process prevents unpleasant odours and bacterial growth inside the
machine. All internal services are washed and the water tank, piping, outlet chamber and
articles being processed are disinfected in each cycle. The temperature of the machine will be
over 90 degrees Celsius for 3 minutes or more. The efficiency of the machine is thought to be
better than human decontamination. However the machine requires correct loading in order for
optimum decontamination.
IMPORTANT INFORMATION REGARDING DISINFECTANTS AND DETERGENTS
Do not use chlorine releasing agents such as Haz Tabs granules or tablets, on acidic
bodily fluids such as vomit or urine as this can cause a rapid release of a toxic level of
chlorine.
Always refer to COSHH instructions displayed on product label
Use appropriate personal protective equipment (PPE) when using these products and
the use of a visor is recommended if there is a risk of splash (UHCW Standard
Precautions Policy 2018)
In the event of a splash into the eyes or onto the skin, rinse immediately with running
water, inform your line manager. Complete on-line datix form and attend Occupational
health between the hours of 9-5 Monday to Friday and ED at all other times.
All disinfectants should be stored in a locked cupboard.
For further advice please contact the infection prevention and control team on
extension 24791
--- PDF page 5 ---
5
The following table provides details of the usages of cleaning and disinfectant
products.
PRODUCTS USED
AT UHCW
DILUTION
INDICATION FOR USE
Sani Cloth Active
Per wipe
To be used on medical devices e.g. bladder scanner
probe
Detergent Wipes
Per wipe
To clean small surfaces areas. e.g. dressing trolleys,
PDA, computer key board and mouse
Disinfectant
Haz Tab Tablets
10,000p.p.m Chlorine solution
Add four Haz – Tab tablets to
the small 1 litre diluter bottle
provided and fill to the line with
cold water.
Disinfection of dried blood spillages.
Disinfection of small wet blood spillages
Use PPE Leave on spillage for minimum of 2 minutes.
Wipe up with paper towels and dispose of directly into
non-infectious waste or clinical waste if from an isolation
room
Blood stained computer key boards and mouse must be
decontaminated with Haz tab prior to cleaning with
detergent wipe
DO NOT USE DIRECTLY ON URINE / VOMIT SPILLS.
Disinfectant
Haz Tab granules
(can only be used
on wet blood
spillage)
Sprinkle over neat spill until all
moisture is completely
absorbed.
Disinfection of large blood spillages i.e. more than 30mls.
Use PPE -Leave on spill for minimum of two minutes until
gel like substance is formed. Wipe up with paper towels
and dispose of directly into non-infectious waste or clinical
waste if from an isolation room
DO NOT USE DIRECTLY ON URINE / VOMIT SPILLS.
Detergent and
chlorine
disinfection.
Tristel Jet (chlorine
dioxide )
Tristel Fuse
(solution) One fuse
sachet for surfaces
marked 5 or 1 litre/s
to produce 5 or 1
litre/s of working
solution.
1,000 ppm chlorine solution
(Tristel)
Spray directly onto surface or
onto a damp cloth and use a
damp cloth to spread. Contact
time is 1 minute.
Fold the sachet in half and
hold away from the body.
Squeeze one side of the
sachet to burst contents
through centre seal. Contents
will start to turn yellow, which
confirms that solution is being
activated. Prepare dilutor
container with 5 litres of cold
water. Cut a corner of the
sachet. Pour the contents of
the sachet into five litres of
cold water.
Use dosette bottle and wipe to
clean surfaces. Contact time 1
mintue
Cleaning and disinfection for daily barrier cleans, terminal
cleans, and outbreak cleans.
Examples of usage Tristel Jet/Fuse:
Whole bed spaces including:
Bed and mattress covers, lockers, bed tables (Tristel fuse
only)
Couches
Commodes
Work surfaces
Sterile dressing trolleys
IV poles
Pulse oximeters
Keyboards Operating theatre tables and environment
Incubators.
This is not an exhaustive list.
Disinfectant
(Alcohol Wipes)
70% Isopropyl alcohol solution
Disinfection of dressing trolley after cleaning with
detergent.
Radiological probes- These wipes must not be used for
general environmental cleaning
Sani- cloth CHG
2%
70% alcohol + 2%
Chlorhexidine (CHG)
Cleaning and disinfection of mobile electronic devices e.g.
vital pack iPod
--- PDF page 6 ---
6
DECONTAMINATION OF NON INVASIVE EQUIPMENT
All equipment should be risk assessed to ensure adequate decontamination takes place; the
NPSA has identified four risk categories
Very high
High
Significant
Low
And cleaning frequencies should be matched accordingly.
Cleaning alone is often an adequate method of decontamination for a wide range of non-
invasive items Wilson (2001). As stated previously equipment should be cleaned between
patient use Smith et al (2008) and prior to storage. Once cleaned these items should be have a
signed and dated label attached, this is in line with High Impact Intervention N8 (DOH 2010).
UHCW advocates the use of “green means clean” tape which should be signed, dated and
labelled as to where the equipment was cleaned and by whom.
Where possible decontaminated equipment should be stored separately from used items and
away from areas where cleaning is taking place to reduce risks of contamination (DOH2009)
EQUIPMENT BEING RETURNED FOR SERVICE
Employees and external contractors can be exposed to transmission of infection or varying
degrees of chemical contamination, therefore it is essential all equipment due for repair or
replacement is decontaminated.
Equipment being returned for service or repair to any of the hospital departments must be
decontaminated, and any exposure to hazardous material a formal decontamination procedure
should take place.
The procedure must be recorded on the equipment decontamination certificate (appendix 1).
The certificate must be authorised by the ward/unit manager and attached to the piece of
equipment prior to being released to the person who will undertake the work with an estimation
of the likelihood of contamination remaining after the decontamination process. (These
certificates will be kept for 5 years)
Failure to supply a decontamination certificate will result in suspension of repair or service of
said item until the decontamination process has been identified.
ITEMS SUBJECT TO SCHEDULED MAINTENANCE
At times a department will service or undertake a scheduled maintenance of a piece of
equipment in a clinical environment. A permit to work form (appendix 2) is required to
safeguard the personnel undertaking the work.
RISK ASSESMENT AND SERVICING
Persons, who undertake work on residually contaminated equipment such as blood gas
equipment will be responsible for their own risk assessment, however trust staff has a
responsibility to ensure that:
They are aware of action to be taken if a hazard were to be released
They know the parts of equipment that can pose a greater contamination risk
They know the mode of transmission if a hazard were to be released – e.g. blood
borne, droplets.
--- PDF page 7 ---
7
They are aware of the nature of any residual hazard and the harm that this may cause
The hazard may be either biological or chemical.
On receipt of the information the engineer will be responsible for his/her own health and safety
using the above information to undertake his/her own risk assessment.
If risk cannot be mitigated or sufficiently controlled they reserve the right to suspend work until
the equipment is appropriately decontaminated, or a satisfactory method of work can be
established.
TYPES OF EQUIPMENT
Equipment can be classified as reusable, single patient use and single use.
Reusable- This means that the equipment may be reused subject to appropriate
decontamination.
Single patient use- This means the equipment may be used more than once for the same
patient, however, manufacturers’ instructions must be adhered to regarding suitability of
decontamination.
Single use- This means that the equipment may be used once only and then disposed of.
Items labelled single use can be identified by this sign.
Single use items must not be reused, or decontaminated because of the following;
•Cannot guarantee effective decontamination.
•Lack of knowledge of the suitability of cleaning and disinfection process.
•Absorption of the cleaning or disinfection agents into the single use item, which may then
transfer to the patient during use.
•Absence of quality assurance procedures to confirm that reprocessed devices have not
deteriorated during reprocessing e.g. plastic materials may become brittle, lose flexibility or
crack.
The reprocessing of single use items can lead to patient’s infection, injury or unnecessary
exposure to harmful substances, which has serious implications for the trust.
All staff should make sure they adhere to the manufacturer’s guidelines on decontamination
and all of the instructions should be filed and all staff involved in decontamination should have
access.
IT equipment - All computer equipment including PC’s, screens, workstations on wheels,
printers, faxes and IPODS, should be clean and dust free at all times, this is the responsibility
of the staff using the equipment, and cleaning should take place with a detergent wipe.
Consequences to the user and the Trust If Single use items are reprocessed:
•Prosecution for a criminal offence under the Health and Safety at Work Act 1974
•If products are found to be defective/exposure to civil liability to pay damages for any injuries
caused under the Consumer Protection Act 1987
Acquisition and Procurement
Any items of new equipment to be purchased must:
Be fit for intended purpose
Be compatible with existing equipment
Easy to clean.
Have complete and clear instructions for decontamination from the manufacturer
--- PDF page 8 ---
8
Table 2. Equipment Required for Decontamination of Non-Invasive Equipment
ACTION
RATIONALE
A. Always refer to manufacturers’ instructions for
decontaminating the equipment
To ensure appropriate use and compatibility of
product to equipment and ensure integrity of
equipment.
B. Identify piece of equipment to be
decontaminated and put on personal protective
equipment, i.e. gloves, and plastic apron. (Full-
face visor if splashing is anticipated).
To protect uniform, face and hands from
contamination and minimise the potential risk for
cross infection.
C.Select a 5 litre Tristel container and fill with cold
water to the fill line. Using a Tristel fuse sachet,
fold the sachet in half and at arm’s length
squeeze the sachet until an audible pop sound is
heard. Mix components of the sachet together by
squeezing the sachet from hand to hand. Then
locate the perforated edge and tear, empty the
contents of the sachet into the water contained
within the 5 litre container. The 5 litre solution i.e.
water and fuse is now viable for 24 hours after
which time it must be discarded and fresh
solutions made up. NB ensure all containers are
labelled and dated. Decant required amount of
prepared solution into a blue bowl for cleaning
Or
Using Tristel jet solution moisten a damp
disposable cloth, squirt jet solution onto the cloth
and then apply directly to the piece of equipment
Allow equipment to dry for at least 1 minute
For terminal or discharge cleans as detergent and
a disinfectant solution is required
To ensure product has had sufficient contact time
with equipment in order to be effective
Please note no electrical equipment should be put through the Dekomed washer
EXEMPTIONS TO THE EQUIPMENT DECONTAMINATION POLICY
In certain situations there may be occasions when procedures outlined in the policy may cause
delays or practical difficulties in operating an efficient maintenance service for example:
Fixed radiological or radiotherapy equipment may require continuous adjustment by a
maintenance engineer during a session, therefore it may not be practical to issue a new
certificate every time the engineer touches the equipment
Equipment may fail whilst connected to a patient, under this situation it is permissible not to
operate the decontamination system providing:
There is prior agreement between the departmental/ward manager or the user and the
maintenance department/repair/service company
The department /ward manager must inform the service engineer prior to the handling of the
equipment of any hazard that may prevail whilst working on the equipment. The service
engineer must take all possible precautions whilst maintaining, servicing and repairing the
equipment, which can include the wearing of PPE.
REPORTING OF EQUIPMENT DEFECTS OR HAZARDS
Accidents or defects relating to medical equipment be reported to the Medical & Healthcare
Products Regulatory Agency (MHRA) at the DOH in accordance with must DB2010 (01) where
they involve products and materials which could put individuals at risk. This will allow
appropriate Hazard notices and safety notices to be issued on a national basis.
Reports should be channelled through the appropriate department:
--- PDF page 9 ---
9
Non-medical equipment -The Director of Estates
Medical equipment -MEBS department
Computer equipment- ICT services
NHS supplies based at UHCW for consumables
Consumable medical supplies, if not able to be decontaminated, must be contained within a
sealable bag available for HSDU and kept on the ward with the completed certificate. The
supplies department at UHCW must then be contacted prior to the item being dispatched.
It is illegal to send contaminated items through the post
Where contamination may damage the article, prior notification and agreement with the carrier
may be required before dispatch. The packaging should be sufficiently robust to withstand
transport and should ensure the contents of the inner pack cannot contaminate the outer one.
i.e. by direct contact or leakage. The package should be labelled with a notice “Danger of
Infection”
All dangerous goods sent by road must comply with the ARD2009 and The Carriage of
Dangerous Goods and use the transportable pressure Equipment Regulations 2009. Any
dangerous goods to be sent by road or courier must be consigned or approved for
consignment by the Trust’s Dangerous Goods Safety Advisor (DGSA)
7. DISSEMINATION AND IMPLEMENTATION
These revised guidelines are available to review on the E-Library and will be disseminated via
training.
8. TRAINING
The revised guidelines are part of mandatory Infection prevention & control training. All staff
must complete this update on a yearly basis booking via ESR. It is an individual staff member’s
responsibility to maintain their own mandatory updates.
Link Nurses will be able to cascade training to staff and if more in-depth training is required
please contact the IPC team.
9. MONITORING COMPLIANCE
Aspect of
compliance
or effective
ness being
monitored
Monitoring
method
Individual
department
responsible
for the
monitoring
Frequency
of the
monitoring
activity
Group/committee
which will receive
the
findings/monitoring
report
Group/
committee/individual
responsible for
ensuring that the
actions are
completed.
The process
of delivery of
standard
infection
prevention &
control
precautions
to all staff
within the
Standard Infection Prevention & control precautions are monitored in line with
the mandatory training policy.
--- PDF page 10 ---
10
trust and
follow up of
non-
attendance
The process
for ensuring
staff are
aware of the
need to
practice
standard
infection,
prevention &
control
precaution’s
is that
training is
given to all
trust staff
groups and
follow up of
non-
attendance
is followed
Review of
the local
audits
Infection
prevention
and control
team
Annual
Infection
prevention
&control
committee trust
board
Infection prevention
& control committee
10. APPENDICES
APPENDICES
APPENDIX 1
UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST
Equipment Decontamination Certificate
Hospital:
Ward/Dept:
Location:
Equipment No.
Job No.
Description of Equipment and area contaminated:
ALL EQUIPMENT MUST BE SOCIALLY CLEAN BEFORE RETURN FOR
SERVICE / REPAIR
Has the equipment been exposed internally or externally to?
Blood, body fluids, and or, pathological samples?
YES
NO
Other Biohazards?
YES
NO
Chemicals or other substances hazardous to health?
YES
NO
--- PDF page 11 ---
11
Are there any inaccessible parts likely to be contaminated?
Give details here:
e.g. Internal filters etc.
Has the Equipment been cleaned & decontaminated?
YES
NO
I declare that I have taken all reasonable steps to ensure the accuracy of this
information:
Signature
Print name
Date
(Ward / Dept Authorised Signatory)
APPENDIX II
UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST
AREA PERMIT TO WORK CERTIFICATE
SCHEDULED MAINTENANCE ACTIVITY
Hospital
Ward Department
Dates Activity Planned
Service Organisation
Service Engineers
Specific Area(s) where
maintenance activity to take place
Description of equipment types
and models etc.
--- PDF page 12 ---
12
If the Reviewer and Author is the same person please tick box
If the Reviewer and Author is not the same person please provide the Reviewer
details below
Reviewer Name:
Martha Bird
Reviewer Job Title:
Infection Prevention and Control Nurse
Reviewer email address:
Martha.bird@uhcw.nhs.uk
Approved by:
Simon Lambert
Date Approved:
28/10/2019
Primary Specialty:
To be allocated by Quality & Effectiveness Department upon
This is to indicate that equipment within the designated area(s) is in an appropriate condition
and state of cleanliness for scheduled maintenance to be undertaken. Equipment identified for
repair within MEBS facilities will be subject to separate ‘Permit to Work’ policy as applied to
individual items of equipment.
Signature
Print name
Date
Ward/department Authorised Signatory
Does this Clinical
Operating Procedure relate
to a Clinical Guideline?
No Yes
(if Yes, please detail )
Author Name:
Fiona Wells
Author Job Title:
Fiona Wells Infection prevention and Control Nurse
Author email address:
Fiona.wells@uhcw.nhs.uk
TRAINEE NURSING ASSOCIATES or NURSING ASSOCIATES - A NEW NURSING ROLE
If Registered Nurses or Student Nurses will be undertaking a role, or carry out
procedures in your area, you will now need to consider the role/input/restrictions for
Trainee Nursing Associates/Nursing Associates and refer to them within your
document. If you require any further information please contact Karen Mogan Practice
Facilitator karen.mogan@uhcw.nhs.uk<mailto:karen.mogan@uhcw.nhs.uk>
--- PDF page 13 ---
13
receipt
Secondary Specialty:
To be allocated by Quality & Effectiveness Department upon
receipt
Other Specialty:
To be allocated by Quality & Effectiveness Department upon
receipt
Are there any UHCW documents related to this topic area Yes
No
University Hospitals Coventry and Warwickshire NHS Trust (2018) Standard Precautions
References
Provide full references for any literature utilised in the development of this clinical operating
procedure, if applicable
Category of
evidence
(See Table 1.)
Booth, C (2000) The Principles of Decontamination. Nursing Times Vol. 96(38):2.
D
Clarkson D, Scheduled maintenance of Medical Equipment IDP89
Department of Health (2009) The Health and Social Care 2008: Code of Practice for the
NHS on the prevention and control of healthcare associated infections and related
guidance. London: Crown Copyright.
D
Department of Health (2009) High Impact Intervention No.8. Care Bundle to improve
the cleaning and decontamination of clinical equipment. Saving Lives: reducing
infection, delivering clean and safe care. London: Crown Copyright.
D
Fleming, M (2000) New Standards for Cleanliness. Nursing Times Supplement. Vol. 96
(38): 10-11.
D
Great Britain, (2004), Control of Substances Hazardous to Health (COSHH) regulations
statutory Instruments 2004 3386, London Stationary Office.
Great Britain (2002) The dangerous substances and explosive Atmospheres (DSEAR)
Regulations statutory Instruments 2002 2776, London Stationary Office
Great Britain (1974) Health & Safety at Work Act Chapter 37 ( 1074), London Stationary
Office
Great Britain (1987) Consumer Protection Act , London Stationary Office
Great Britain (2010) Reporting Adverse Incidents and Disseminating Medical Device
Alert- DB2010 (01), Medicines and Healthcare Products Regulatory Agency
Great Britain (2009) The carriage of Dangerous Goods and use of transportable
pressure Equipment regulations 2009, Statutory Instruments 2009 1348 , London, the
Stationary Office
Medicines and Healthcare Regulatory Agency (2006) SN 2001 (28) – Compatability of
--- PDF page 14 ---
14
Medical Devices and Reprocessing Equipment with Decontamination Agents.
www.mhra.gov.uk/Publications/Safetywarnings/MedicalDevicesAlerts/Safety
Notices/con2025047.
National Patient Safety Agency (2009) Nation Reporting and Learning Service. The
Revised Healthcare-Cleaning Manual. National Audit Office (2000) The Management
and Control of Hospital Acquired Infection in Acute NHS Trusts in England. London:
The Stationary Office.
D
Medicines and Healthcare products Regulatory Agency. Sterilization, disinfection and
cleaning of medical equipment: guidance on decontamination from the Microbiology
Advisory Committee (the MAC manual): Part 1 principles. London: MHRA; 2010.
D
Smith, R. C; Robinson, C; Darlington, N. P; Infection Prevention and Control Team
(2008) Policy on Medical and Computer Equipment Decontamination Prior To service
and Repair.
D
Wilson, J. (2001) Infection Control In Clinical Practice. London: Bailliere Tindall.
D
Weber DJ, Rutala WA. The role of the environment in transmission of clostridium
difficile infection in healthcare facilities. Infection control and hospital epidemiology
2011; 32(3):207-9
D
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ATTACHMENT: 8.pdf
TEXT_FILE: 8.pdf.txt
METHOD: pdf_native
OCR_USED: False
PAGES: 22
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--- PDF page 1 ---
1
Clinical Operating Procedure
A Clinical Operating Procedure is defined as:
A set of instructions that describe the method for carrying out clinical tasks or
activities to ensure efficiency, consistency and safety.
Procedure Ref
No:
COP 222
Review date:
October 2023
Expiry date:
April 2024
Version
Number:
V9
Procedure
Title:
Bed And Mattress Cleaning Procedure
Summary statement /scope of the procedure:
All patients admitted to University Hospitals Coventry and Warwickshire NHS
Trust have the right to be admitted into a clean bed space and trust employees
have a responsibility to deliver this. All parts of the bed (including mattresses
such as static or dynamic) and bed frame, wheels and castors should be visibly
clean with no blood or body substances, dust, dirt, debris, adhesive tape or
spillages (National Patient Safety Agency 2007). They must be cleaned and
checked between each patient episode. It is the responsibility of all employees
to ensure that no bed or mattress leaves their area that has not been cleaned.
Recommendations for procedure content:
--- PDF page 2 ---
2
Please note: The following systems have been replaced by the trust Electronic Patient Record system (EPR). If
any of these systems are identified within the document, please substitute them for the appropriate EPR
alternative system and refer to relevant corresponding EPR procedures.
1. Opera (theatres)
2. Centricity (Critical Care)
3. Wardview
4. Extramed
5. CRRS
6. VitalPack
7. Adastra (CUTC)
8. K2 (maternity portal replaced by PPUK)
9. i.PM
10. Athena (Maternity)
11. SCIT App (replaced by camera capture)
Please contact EPREnquiries@uhcw.nhs.uk if you have any questions about the
systems listed or the EPR system introduced in their place.
On review of this document please ensure the systems listed are removed from the
text and replaced with the relevant EPR system and process.
All patients admitted to University Hospitals Coventry and Warwickshire NHS Trust
have the right to be admitted into a clean bed space and trust employees have a
responsibility to deliver this. All parts of the bed (including mattresses such as static
or dynamic) and bed frame, wheels and castors should be visibly clean with no blood
or body substances, dust, dirt, debris, adhesive tape or spillages (National Patient
Safety Agency 2007). They must be cleaned and checked between each patient
episode. It is the responsibility of all employees to ensure that no bed or mattress
leaves their area that has not been cleaned.
The purpose of this procedure is to identify a process for ensuring beds and
mattresses are decontaminated appropriately following the discharge of a patient and
prior to it being used for the next patient.
It is the responsibility of the ward manager and modern matron to ensure that this
standard is achieved. The use of the word bed also refers to cots, trolleys and
couches. This procedure seeks to implement a coordinated approach to
decontamination of vacant bed spaces, beds, mattresses, trolleys etc. This Clinical
Operating Procedure does not apply to theatres bed/ trolleys or emergency admission
trolleys.
1.1 Cleaning of the Mattresses:
In order to clean the mattress effectively; whether the mattress is static or dynamic.
--- PDF page 3 ---
3
The mattress needs to be examined to see if the integrity of the mattress is in
accordance with manufacturer’s guidance and Medicines & Healthcare products
Regulatory Agency. Please see ‘Mattress Integrity’ section for guidance on what to
look for.
The mattress needs to be cleared of all equipment and bed linen in order to effectively
decontaminate it. The mattress should be cleaned with chlorine dioxide disinfectant
solution (Tristel) by applying the solution to a cloth and wiping the product over the
equipment (appendix 4). The product must not be directly added to the equipment as
this can destroy/harm the equipment. If the mattress is not staying with the bed frame
then a separate cleaning tape is to be applied to the mattress once completed. Stating
when and who cleaned the bed and mattress so this is ready for the next patient to
use.
1.1.2 Pressure Relieving Cushions:
The same cleaning process should be applied to pressure relieving cushions as
mattress decontamination.
•
Ward areas will socially clean PR Mattresses with ‘Tristel’.
•
Roll-up and place PR Mattresses inside the plastic bag.
•
Attach decontamination certificate to the outside of the bag so it is: clearly visible.
•
Boxes (Pumps) again need to be fully cleaned with ‘Tristel’ and then placed on
top of the bag or by its side (Not inside the bag).
The mattress should then be left in the back service delivery corridor not on the main
street for collection.
1.1.3 Cleaning of the Bed Frame and Rails:
Bed frames and rails also need to be examined to see if the integrity of the equipment
is in accordance with manufacturer’s guidance and Medicines & Healthcare products
Regulatory Agency and that the product is not faulty. Please see ‘Bed Frame/ Rails
--- PDF page 4 ---
4
Integrity’ section for guidance on what to look for.
The bed frame and rails should also be cleaned with chlorine dioxide disinfectant
solution (Tristel) by applying the solution to a cloth and wiping the product over the
equipment. The product must not be directly added to the equipment as this can
destroy/harm the equipment. The bed frame must be raised in order to clean
underneath the bed also, including the base, wheels and head and foot of the frame.
Once effectively decontaminated, cleaning tape is to be applied to the bed frame once
completed stating when and who cleaned the bed and mattress so this is ready for the
next patient to use.
--- PDF page 5 ---
5
1.2 Mattress Integrity:
Checking the beds integrity prior to decontamination: Mattress covers can become
damaged at any time during use or storage, for example from: needle stick; strike-through;
damage from sharp objects; abrasion during handling, transport or movement;
inappropriate cleaning and decontamination procedures. The same process should be
applied to pressure relieving cushions when looking at the integrity of the equipment.
Foam mattresses after a period of time of compression and moisture can cause serious
infections for our patients. There is a known documented connection between damaged,
contaminated mattresses and outbreaks of bacterial infections. Infections can complicate
illnesses, cause distress for patients and their families and lead to death.
In accordance with Medicines & Healthcare products Regulatory Agency Ref:
MDA/2010/002. Bed mattresses need to comply with this regulation to check the
following:
• Inspect the exterior surface of each mattress cover for signs of damage, such as
holes or cuts.
• Remove the cover and inspect its inside surface and the mattress core for staining
or contamination.
• Safely dispose of any covers showing signs of damage or staining.
• Arrange for contaminated mattress cores to be either: cleaned and decontaminated
in accordance with the manufacturer’s instructions; or safely disposed of.
• Ensure that a frequent inspection regime is established for all mattresses before
and during use.
• Distribute the attached poster within your organisation. (appendix 1)
1.3 Bed Frame/ Rails Integrity:
Manufacturers should specify what bed and bed rail devices should be used, cleaned and
maintained so that they remain in good working order and continue to be safe to use. Medicines
& Healthcare products Regulatory Agency (2021).
Bed rails should be maintained in accordance with the manufacturer’s recommendations in the
instructions for use. Examples of common types of damage include:
• Adjusters, clamps and fixings can wear, work loose, crack, deform or be missing
completely, giving rise to unwanted free play which can increase important gaps.
• Material fatigue can also occur. Bed occupants who rattle the bed rails can exacerbate
this tendency.
• Telescopic components can become loose or jammed, discouraging correct
adjustment.
• Plastic components can degrade due to age, exposure to light and some cleaning
--- PDF page 6 ---
6
chemicals.
• Poor transport and storage can also cause damage to components.
• Duvets, blankets, sheets and valances may need to be removed to check these areas
properly.
All bed frames should be examined for any corrosion
1.4 Additional cleaning:
In addition to the bed space clean, all isolation rooms, bays and all equipment associated with
the discharge/transfer of patients with alert organisms must also undergo disinfection with chlorine
dioxide solution (Tristel). This will be requested as a terminal clean and will include changing of
soft furnishings such as curtains. This is requested via the help desk and is a responsibility of
both ISS and healthcare staff.
NB A terminal clean will be carried out to the same standard whether or not patients are in the
area. If a bay area is to be terminally cleaned, it may not be reasonable or practicable to vacate
the area.
1.5 Glossary
Discharge clean – When a patient vacates a bed space. This is undertaken by the Trust
staff.
Barrier Clean – Routine cleaning of a room that has an infected or reverse – barrier
nursed patient(s). This is undertaken by ISS under the right instruction from Trust staff.
If the room has had a patient with an infection that requires barrier nursing then disposable
cloths are to be used with Tristel. If the patient is not barrier nursed due to infection then
microfiber cloths are to be used with Tristel and placed into a bag for laundering ready for
the next use.
Terminal Clean – Clean required when a barrier room (or cohort bay) is vacated or when
an infected patient is no longer infected. This may also follow the opening of a ward when
an outbreak is over, or a bay if a patient has been transferred out into a side room for
reasons of Infection Prevention and Control.
Hydrogen Peroxide Vapour (Fogging Clean). Carried out by the Performance team &
requested as a pre-fogging terminal clean via the Help desk Ext 25555 & then by
contacting the Performance team (Bleeps 2129/4723/2635/1840).
Fogging cleans are to be used in the following situations:-
• To disinfect rooms when a patient with Clostridium difficile becomes
48 hours asymptomatic.
• To disinfect side rooms when there is evidence of an outbreak of Clostridium
--- PDF page 7 ---
7
difficile or with other organisms
• When a patient with a multi resistant organism has vacated a room
• This service is available seven days a week Monday-Friday 8-2pm & Weekends 8-
12pm. Outside these hours, if the fogging cannot be completed then a terminal
clean should be requested and signed off by a senior staff member. If a room can
be kept vacant then fogging can be completed the following day.
• Note that once fogging has been commenced the room will be out of action for 3 hours
** Please note: If the patient is moved to a different bed space and remains an inpatient, in
order to have a ‘Fogging Clean’ – please ensure the bed is changed for the patient. This
is to ensure the bed is decontaminated effectively from spores for future use.**
The bed space checklist for each type of clean can double as an audit tool and as an aid to Private
Finance Initiative (PFI) collaboration. It is intended to be used to reassure the next patient that a
clean has taken place of the bed and space before they occupy the bed. It can be laminated and
used as a checklist and if the department choose to this can be documented in any admission
paperwork. It will also be used as an aide memoire for all staff.
1.6 Mattress Audit (appendix 2)
To ensure that mattresses are fit for purpose and clinically effective for the patient; it is
recommended that mattresses are checked between 6 and 12 monthly.
Audit Protocol
How do you check your mattresses in accordance with Invacare Mattress Auditing Criteria? Use
the points below to record your findings in Appendix 2.
Column 3: Mattress Type
It is important to identify the type of mattress in use, and whether or not the mattress has specific
features that may affect the outcome of the audit. Also take note if the mattress has an installation
date or batch number.
Column 4: Mattress Depth
Measure the depth of the mattress at the edge with a ruler. The foam mattresses (not including
foam overlays) should be at least 5”/13cm in depth.
Column 5: Cover Condition
The tester should scrutinize the general appearance of the mattress cover, both internally and
externally, looking for visible evidence of wear and tear.
This might include:
I.
Damage – for example splits, tears or punctures
II.
Cover breakdown
III.
Broken seams
IV.
Staining along zip lines (zip leakage)
V.
Staining of the interior cover or foam *
VI.
Staining of exterior of cover
VII.
Noting whether the cover is appropriate for the type of mattress
--- PDF page 8 ---
8
•
Selected mattresses have inner surfaces light in colour to facilitate audit inspection and to
help clearly identify any staining or bacterial growth. HOWEVER remember to take extra care
when looking for stains on dark or patterned mattress covers.
In the event of the cover failing the audit on points VI) or VII), only the cover needs to be replaced.
To avoid significant risk of pressure damage or friction to the patient, it is imperative that the new
mattress cover fits correctly. Selected mattress manufacturers produce mattress covers that are
fully detachable which helps aid inspection. It also allows ease of removal for laundering in cases
of heavy contamination, whilst offering a cost benefit of allowing the replacement of individual
parts rather than the whole mattress.
Mattresses should be marked accordingly to indicate that only the cover needs replacing. This
should be marked on the mattress using the code ‘RC’ indicating Replace Cover.
Column 6: Foam Condition
a)
Mattress Contamination
Unzip the mattress cover and examine the inner foam core for evidence of the following:
I.
Dampness, together with staining of the interior cover
II.
Staining
III.
Malodour, other than the foam smell that accompanies a new mattress
IV.
Foam exposed
b)
Bottoming Out
In line with RCN Guidelines for mattress auditing protocols, the ‘Fist Test’ is used to determine
whether the foam core of the mattress has ‘bottomed out’. This is where the base of the bed can
be felt through the mattress during testing. This procedure should be carefully followed to ensure
that all mattresses that do not comply with the recommended depth and foam condition are
identified. This will potentially prevent further use where their pressure reducing capabilities may
be compromised due to the present condition of the mattress.
To undertake the ‘Fist Test’:
I.
Make sure the top of the mattress is level with the tester’s greater trochanter;
II.
With the mattress cover in situ;
III.
Stand at the side of the bed;
IV.
Link hands to form a fist, keep elbows straight
V.
Lean forward with body weight and push the fist into the mattress along the seven points
below
--- PDF page 9 ---
9
The mattress should be marked accordingly to indicate whether the whole mattress needs
replacing or just the cover/inserts. If the cover and 1 insert require replacing, ‘RC1’ should be
marked on the mattress. Should the cover and 2 inserts require replacing, ‘RC2’ should be marked
on the mattress. If the mattress is condemned and requires complete replacement, the code ‘C’
should be marked on the mattress. These codes are then also used in the final mattress audit
report to provide consistent analysis and results.
POINTS TO REMEMBER
1.
Every new mattress should be allocated a number and a note made of the day it was put
into service – selected mattress manufacturers have audit boxes printed on their mattress covers
to aid this protocol.
2.
The date is usually located on the cover and also on the foam near the zip opening.
It is found to be unnecessary to condemn the whole mattress, only the contaminated individual
parts of the mattress need to be replaced.
Column 7: Audit Recommendation/ Report:
Please use the codes in the chart below, Code for recommendation: Audit outcome
Code
Recommendation
RC
Replace cover
RC1
Replace cover and 1 insert
RC2
Replace cover and 2 inserts
C
Condemn
U
Untested
--- PDF page 10 ---
10
Bed space checklist for discharge cleans.
Ward
Room number
Bay
Side room
Dear Patient
Infection Prevention and Control is taken very seriously by UHCW NHS Trust and we aim to ensure that
your bed and surrounding area has been thoroughly cleaned
Action.
Responsibility
Tick as cleaned or
reason for omission.
Locker empty and checked. Including wash bowl
Trust staff
Suction checked and replaced as necessary
Trust staff
O2 supply checked and replaced as necessary
Trust staff
Bed frame cleaned with chlorine dioxide disinfectant
(Tristel)
Trust staff
Mattress to be cleaned and checked for ingress and
bottoming out on the static mattresses. Replace as
necessary (refer to pg 6 & 8) Place UHCW nurses
green and white cleaning tape on
zip tie when cleaned, sign and date clearly
Trust staff
Check and clean pillows ensure all seams of pillow are
secure. Dispose of any with integrity breaches.
Trust staff
All items cleared from bedside locker/ trolley.
Trust staff
Locker/bedside trolley all surfaces inside and out ,
patient line equipment etc to be washed with chlorine
releasing agents
Trust staff
Bed rails, head and base, patient call bell cleaned with
chlorine dioxide disinfectant (Tristel)
Trust staff
Clean bedside chair, check integrity of cushion by
unzipping. Clean with chlorine dioxide disinfectant
(Tristel).
Trust staff
Wash bowls to be put through deko med bed pan
washer, washbowls not to be stored in dirty utility when
clean
Trust staff
Alcohol gel supplies checked and replenished.
Trust staff
Put green and white nursing cleaning tape with name
and date clearly on bed frame as well as the mattress.
Trust staff
Form left for next patient / relative to complete.
Trust staff
Cleaned by
PRINT NAME
I am happy with the standard of cleanliness of my bed and space □
I am not happy with the standard of cleanliness of my bed and space □
Comments:
--- PDF page 11 ---
11
Bed/Bay space checklist for terminal cleans.
Unoccupied Room
Ward
Room number
Bay
Side room
UHCW NHS Trust takes infection Prevention and Control very seriously and we aim to ensure that your bed
and surrounding area has been thoroughly cleaned.
For a terminal clean washing should be undertaken using chlorine dioxide) releasing cleaning agents Tristel.
It may not be possible for all patients to leave the room for all terminal cleans e.g. post Noro virus or MRAB
or if a patient develops diarrhoea in a bay. The same standard of clean is expected
NB Cleaning of a terminal room and barrier clean requires single use items for each area.
Action.
Responsibility Completed if not why not?
Locker empty and checked. Including washbowl.
Trust staff
Wash bowls put through deko med bedpan washer.
Wash bowls not to be stored in dirty utility
Trust staff
Suction checked and replaced as necessary
Trust staff
O2 supply checked (unconnected) replaced as necessary
and cleaned
Trust staff
Alcohol gel supplies checked and replenished.
Trust Staff
Bed frame cleaned with chlorine dioxide disinfectant
(Tristel)
Trust Staff
Mattress to be cleaned and checked for ingress and
bottoming out. Replace as necessary (refer to pg 6 & 8)
Place UHCW nurses green and white cleaning tape on
zip tie when cleaned, sign and date clearly
Trust Staff
Check and clean pillows ensure all seams of pillow are
secure. Dispose of any with integrity breaches.
Trust staff
Clean pressure relieving cushion and check integrity,
replace if required
Trust Staff
Replace headphones on bedside entertainment system
Trust staff
Replace fire blanket under the mattress.
Trust Staff
Ensure alcohol gel is at the base of the bed
Trust Staff
Form left for next patient/relative or performance
management team to complete.
Trust staff
Cleaned by
PRINT NAME
I am happy with the standard of cleaning □
I am not happy with the standard of cleaning □
Comments:
--- PDF page 12 ---
12
Bed/Bay space checklist for terminal cleans
Occupied Room
Ward
Room number
Bay
Side room
UHCW NHS Trust takes Infection Prevention and Control very seriously and we aim to ensure that your bed
and surrounding area has been thoroughly cleaned. For a terminal clean washing should be undertaken
using chlorine releasing cleaning agent, Tristel. It may not be possible for all patients to leave the room for
all terminal cleans e.g. post Noro virus or MRAB. The same standard of clean is expected.
NB Cleaning of a terminal room and barrier clean requires single use items for each area.
Action.
Responsibility
Completed if not why not?
Locker cleared and checked.
Trust staff
Wash bowls put through deko med bedpan washer.
Wash bowls not to be stored in dirty utility.
Trust staff
Suction checked and replaced as necessary BP cuffs etc
removed or replaced
Trust staff
O2 supply cleaned, checked (unconnected) and replaced
as necessary
Trust staff
Alcohol gel supplies checked and replenished.
Trust Staff
Bed frame cleaned with chlorine dioxide disinfectant
(Tristel)
Trust Staff
Mattress to be cleaned and checked for ingress and
bottoming out. Replace as necessary (refer to pg 8 & 9)
Clean with chlorine dioxide disinfectant (Tristel) Place
UHCW nurses green and white cleaning tape on zip tie
when cleaned, sign
and date clearly
Trust Staff
Check and clean pillows ensure all seams of pillow are
secure. Dispose of any with integrity breaches.
Trust staff
Clean propad cushion and check integrity, replace if
required
Trust Staff
Replace headphones on bedside entertainment system
Trust staff
Replace bed linen and change patients clothing.
Trust Staff
Replace fire blanket under the mattress.
Trust Staff
Ensure alcohol gel is at the base of the bed
Trust Staff
Cleaned by
PRINT NAME
I am happy with the standard of cleaning □
I am not happy with the standard of cleaning □
Comments:
--- PDF page 13 ---
Ward/ Department staff to check mattress on
discharge of patients
OR
When Patient Transferred onto an Alternative Type of
Mattress
If Mattress and pressure relieving cushion
intact/ not damaged and/or stained and no
ingress, continue use after cleaning with
chlorine dioxide disinfectant (Tristel). If soft
form mattress not required place UHCW nurses
green and white tape on zip tie and store safely
for use at a later date.
If stains/ damage noted, inform equipment store on Ext
25041 or bleep 2976. Clean mattress (static or
dynamic) with Tristel, place decontamination certificate
on mattress.
Log call on ISS help desk and porters will bring
mattress to equipment store
Make this request explicit when calling the FM help
desk
Cover and Foam Damaged and/or
Stained
Action: Dispose of both items in
designated bag as clinical waste and
equipment store will replace both.
Contact 25555 Helpdesk, to obtain yellow and
black striped, clinical waste mattress/curtain
bag, take to waste hold.
All parts of Mattress or pressure
relieving cushion. Damaged Stained
and or ingress Action: condemn whole
mattress or pressure relieving cushion
and equipment store will issue a new
replacement
Cover Damaged and/ or stained with
ingress.
Action: Dispose of cover in designated
bag as clinical waste and equipment
store will replace cover with a new one.
--- PDF page 14 ---
Bed needs repair or is surplus to requirements
Repair
Surplus to requirements
Yes
Clean bed frame with Tristel. Place completed decontamination
notice on the bed frame. Log call on help desk.
Mattress to be cleaned with Tristel jet or fuse, it must be
checked for ingress, if none found follow procedure above.
Clean mattress and bed frame with Tristel jet or fuse.
Place UHCW nurses green and white cleaning tape on the
bed frame and the Mattress zip tie.
Store mattress safely for use at later date.
Cover and Foam Damaged and/or
Stained
Action: Dispose of both items in
designated bag as clinical waste and
equipment store will replace both.
Cover Damaged and/ or stained with
ingress.
Action: Dispose of cover in designated
bag as clinical waste and equipment
store will replace cover with a new one.
All parts of Mattress or pressure
relieving cushion. Damaged Stained
and or ingress Action: condemn whole
mattress or pro pad and equipment
store will issue a new replacement
Contact 25555 Helpdesk, to obtain yellow and
black striped bag, clinical waste
mattress/curtain bag, take to waste hold.
NB Any bed that is to be stored within the trust should be properly decontaminated following use. Once this bed is required, again it may
need to be cleaned using chlorine dioxide disinfectant (Tristel). Cleanliness is the responsibility of all staff.
--- PDF page 15 ---
If the Reviewer and Author is the same person please tick box
If the Reviewer and Author is not the same person please provide the Reviewer
details below
Reviewer Name:
Emma Evans
Reviewer Job Title:
Infection Prevention Control and Sepsis Nurse
Reviewer email address:
Emma.evans@uhcw.nhs.uk
Approved by:
Infection Prevention and Control Committee
Date Approved:
April 2021
Primary Specialty:
IPCC
Secondary Specialty:
N/A
Other Specialty:
N/A
Are there any UHCW documents related to this topic area Yes
No
If yes please provide Title
References
National Patient Safety Agency (2007) The national specifications for cleanliness in the NHS: a
framework for setting and measuring performance outcomes
Medicines & Healthcare products Regulatory Agency (2010) Medical Device Alert, Ref:
MDA/2010/002
Medicines & Healthcare products Regulatory Agency (2014) All types of bed mattresses -
contamination through damaged mattresses or covers https://www.gov.uk/drug-device-
alerts/medical-device-alert-all-types-of-bed-mattresses-contamination-through-damaged-
mattresses-or-covers
Medicines & Healthcare products Regulatory Agency (2021) Bed rails: management and safe
use https://www.gov.uk/guidance/bed-rails-management-and-safe-use
Does this Clinical
Operating Procedure relate
to a Clinical Guideline?
No Yes
(if Yes, please detail )
Author Name:
Fiona Well
Author Job Title:
Modern Matron Infection Prevention & Control
Author email address:
Fiona,wells@uhcw.nhs.uk
TRAINEE NURSING ASSOCIATES or NURSING ASSOCIATES - A NEW NURSING ROLE
If Registered Nurses or Student Nurses will be undertaking a role, or carry out
procedures in your area, you will now need to consider the role/input/restrictions for
Trainee Nursing Associates/Nursing Associates and refer to them within your
document. If you require any further information please contact Karen Mogan Practice
Facilitator karen.mogan@uhcw.nhs.uk<mailto:karen.mogan@uhcw.nhs.uk>
--- PDF page 16 ---
Appendix 1:
MHRA poster
--- PDF page 17 ---
Appendix 2
Mattress Audit form
1
2
3
4
5
6
7
Date
Ward area/
bay and bed
number
Mattress
Type
Mattress
Depth
Cover
Condition
Foam
Condition
Audit
Recommend
ation/ Report:
Place Code
Below
--- PDF page 18 ---
Appendix 3
--- PDF page 21 ---
Appendix 4
--- PDF page 22 ---
Appendix 5
--------------------------------------------------------------------------------
ATTACHMENT: 9.pdf
TEXT_FILE: 9.pdf.txt
METHOD: pdf_native
OCR_USED: False
PAGES: 15
--------------------------------------------------------------------------------
--- PDF page 1 ---
1
Clinical Operating Procedure
Procedure Title:
Management
of
Multi-Resistant
Organisms,
Carbapenemase
Producing Enterobacteriaceae (CPE), Multi Resistant Acinetobacter
baumanni (MRAB) and Extended Spectrum Beta-Lactamases (ESBL)
Procedure Ref No:
COP 915
Review date:
October 2023
Expiry date:
April 2024
Version Number:
V1
Summary statement /scope of the procedure:
Multi-drug Resistant Organisms (MRO) are now endemic in healthcare facilities in many countries.
The prevalence of MRO is increasing and there are areas in the UK in which MRO are considered
widespread.
The ability of these organisms to acquire resistance to virtually all antimicrobial agents presents
both a therapeutic problem and a hazard of cross infection in the healthcare setting.
It is therefore important to identify patients who are at risk of colonisation and infection of MRO, and
to ensure strict Infection Prevention and Control (IPC) precautions are in place.
Gram negative bacteria are a large, heterogeneous group of organisms. This document will
consider MRO
•
Carbapenemase Producing Enterobacteriaceae (CPE)
•
Multi Resistant Acinetobacter baumanni (MRAB) and
•
Extended Spectrum Beta-Lactamases (ESBL)
Guiding Principles of MRO management
1.Transmission and Prevention
MRO can be spread by person-to-person contact, contact with contaminated surfaces, or exposure
in the environment (by colonised medical equipment).
Careful attention to infection control procedures, such as, hand hygiene and environmental
cleaning, can reduce the risk of transmission.
Once this organism becomes established in a unit, it can be extremely difficult to eradicate, so
preventing it from becoming established is very important.
--- PDF page 2 ---
2
Patients colonised with MRO and experiencing diarrhoea are at
particularly high risk of transmitting the organisms to others and/or contaminating the environment.
2.Patient Risk Group
Known risk factors for colonisation and/or infection with MRO include:
Patients with underlying medical conditions
Elderly patients
Patients who have taken antibiotics
Previously hospitalised individuals
Those who are most susceptible are
Immunosuppressed
In intensive care
3.Staff working with MRO patients
Staff caring for patients with confirmed or suspected MRO should do so with strict adherence to
standard infection prevention control precautions and use of PPE must be maintained.
Where practically possible see all other patients prior to those with confirmed or suspected MRO.
Transporting a patient with a MRO in the hospital on a bed, trolley or in a wheelchair is a low risk
activity. There is no requirement for porters to wear gloves, aprons or other PPE on transferring
patients.
4.Mattresses
After a patient is discharged the mattress must be thoroughly checked and decontaminated using
chlorine dioxide solution (e.g. Tristel) Dynamic mattresses should be sent to the mattress library.
5.Transferring of Patients
Infection Prevention and Control measures should not compromise the patients care and should not
affect the patient’s freedom to be mobilised or attend other departments for health care related
visits.
It is the responsibility of the nursing staff on the transferring ward to make direct contact with staff on
the receiving ward or department (e.g. radiology) to make sure that they are aware of the patients
MRO status in advance of the transfer.
6.Laundry
All laundry must be considered contaminated and placed in a red alginate bag inside a white outer
bag. Please refer to Procedure for the laundering of Soiled Patients Clothing in the Home Setting
Guideline (2016) for further details.
7.Cutlery and Crockery
Ordinary cutlery and crockery can be used. Disposable crockery and cutlery are not required.
Under no circumstances should any crockery or cutlery be washed by hand.
8.Visitors
Visitors are not required to wear protective clothing unless involved in the patient’s personnel care,
when an apron should be worn. Visitors should wash their hands immediately prior to leaving the
isolation room and should not wander around the ward and visit other patients.
9.Last offices
No special precautions are needed for MRO positive patients.
--- PDF page 3 ---
3
--- PDF page 4 ---
4
Management of Extended Spectrum Beta Lactamase (ESBL)
Patient previously known ESBL positive OR Newly diagnosed with ESBL
Outpatients department, including eye clinic
Inpatient
Strict adherence to the WHO five moments of
hand hygiene is required
Wounds should be covered with a dressing whilst
waiting in communal waiting areas
There is no need to remove furniture or
equipment from consulting rooms
Surfaces that the patient has been in direct
physical contact with, e.g. the couch, should be
wiped down with chlorine dioxide solution (e.g.
Tristel)
Appendix A
Theatres
May need different antimicrobial
prophylaxis to non-carriers
Cleaning of theatre surfaces, should be
carried out using Tristel after every case
Air exchanges in theatre are of a
sufficient standard no “rest” period is
required between cases
If clinically appropriate place at the end of
the list
--- PDF page 5 ---
5
Management of Multi Resistant Acinetobacter baumanni (MRAB)
Patient previously known MRAB positive OR Newly diagnosed with MRAB
Outpatients department, including eye clinic
Inpatient
Strict adherence to the WHO five moments of
hand hygiene is required
Wounds should be covered with a dressing whilst
waiting in communal waiting areas
There is no need to remove furniture or
equipment from consulting rooms
Surfaces that the patient has been in direct
physical contact with, e.g. the couch, should be
wiped down with chlorine dioxide solution (e.g.
Tristel)
Appendix B
Theatres
Appendix D
May need different antimicrobial
prophylaxis to non-carriers
Cleaning of theatre surfaces, should be
carried out using Tristel after every case
Air exchanges in theatre are of a
sufficient standard no “rest” period is
required between cases
If clinically appropriate place at the end of
the list
Hydrogen Peroxide Vapour (Fog)
--- PDF page 6 ---
6
Management of Carbapenemase Producing Enterobacteriaceae (CPE)
Patient suspicion of CPE, previously known CPE positive OR Newly diagnosed with CPE
Outpatients department, including eye clinic
Inpatient
Strict adherence to the WHO five moments of
hand hygiene is required
Wounds should be covered with a dressing whilst
waiting in communal waiting areas
There is no need to remove furniture or
equipment from consulting rooms
Surfaces that the patient has been in direct
physical contact with, e.g. the couch, should be
wiped down with chlorine dioxide solution (e.g.
Tristel)
For Pre-Operative Assessment Service please refer to
POAS CPE Clinical Operating Procedure (2020)
Appendix C
Appendix E
Theatres
Appendix D
Appendix E
May need different antimicrobial
prophylaxis to non-carriers
If clinically appropriate place at the end of
the list
Air exchanges in theatre are of a
sufficient standard no “rest” period is
required between cases
--- PDF page 7 ---
7
--- PDF page 8 ---
8
--- PDF page 9 ---
9
--- PDF page 10 ---
10
--- PDF page 11 ---
11
--- PDF page 12 ---
12
--- PDF page 13 ---
13
Appendix D
Theatre Management Guidance for MRAB and CPE
1
• Remove all non-essential equipment from theatre
2
• Bleeps and personal items will not to be taken into theatre
3
• Bring airway essentials and anaesthesia drugs into theatre
4
• Designate outside circulator to avoid contamination of outside area
5
• If involved in direct patient contact don a long sleeved gown. Apron sufficent for non-
direct contact
6
• Medium/ High indiviuduals prepare for recovery in theatre
• Low risk individuals can be managed as per normal practice
7
• Instruments and devices should be decontaminated in the normal manner in accordance
with the manufacturer’s advice
8
• Trays sent to SSD in normal way
9
• All clinical waste to be dealt with in the normal manner
--- PDF page 14 ---
14
Appendix E
--- PDF page 15 ---
15
If the Reviewer and Author is the same person please tick box
If the Reviewer and Author is not the same person please provide the Reviewer details below
Reviewer Name:
Dr. Steve Laird
Reviewer Job Title:
Consultant Microbiologist
Reviewer email address:
Steve.Laird@uhcw.nhs.uk
Approved by:
Infection Prevention and Control
Date Approved:
April 2021
Primary Specialty:
Infection Prevention and Control
Secondary Specialty:
N/A
Other Specialty:
N/A
Are there any UHCW documents related to this topic area Yes
No
If yes please provide Title
Does this Clinical
Operating Procedure relate
to a Clinical Guideline?
No Yes
(if Yes, please detail )
Author Name:
Fiona Wells
Author Job Title:
Infection Prevention and Control
Author email address:
Fiona.Wells@uhcw.nhs.uk
TRAINEE NURSING ASSOCIATES or NURSING ASSOCIATES - A NEW NURSING ROLE
If Registered Nurses or Student Nurses will be undertaking a role, or carry out
procedures in your area, you will now need to consider the role/input/restrictions for
Trainee Nursing Associates/Nursing Associates and refer to them within your
document. If you require any further information please contact Karen Mogan Practice
Facilitator karen.mogan@uhcw.nhs.uk<mailto:karen.mogan@uhcw.nhs.uk>