Calderdale and Huddersfield NHS Trust
Contents
1. uniform from microorganisms and implement infection prevention and control precautions to prevent further spread Infection Prevention and Control Precautions a Hand Hygiene and Hand Care Hand decontamination is the single most important measure in infection control Effective hand decontamination can significantly reduce infection rates WHO 2009 WHO 2009 02 Hand hygiene should be undertaken immediately before and directly after any patient contact or procedures including those defined as social contact Hands should be decontaminated before and after all procedures and before and after removing gloves or any other PPE Hands should be washed immediately if contaminated with blood or body fluids using soap and water and then dried thoroughly A suitable hand moisturiser should be available for use in wards and departments and used as required Hands should be free from organic material or dirt if using an alcohol gel the solution must be allowed to evaporated and hands to dry Staff with chronic skin lesions or infected skin conditions to hands or forearms must seek advice from the Occupational Health Department before commencing work Existing cuts lesions or any other breaks in the skin should be covered with a waterproof dressing and replaced when necessary see below Page 6 of 26 UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control Nurse b All HSCWs who carry2. vomit and urine should be removed with paper towels first and then clean the area with a chlorine releasing agent e g Tristel Fuse using paper towels discarding all waste and protective clothing into the appropriate waste stream Any floor surface that has been cleaned and remains wet must have the appropriate Yellow warning sign in place Page 11 of 26 UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control Nurse i Accidental Spillages Protective clothing must be worn prior to dealing with any spillage of blood and or body fluids Ensure adequate ventilation prior to using disinfection solutions or granules Spillage from domestic waste clear bag waste Clean up with dustpan and brush or mop and place in fresh clear bag for disposal Spillage from offensive waste bags clinical waste bags tiger stripe bags orange bags sharps containers or laboratory waste bags Inform the appropriate departmental manager immediately A full risk assessment must be made prior to cleaning up spillages from the Orange waste bags as masks may need to be worn Follow guidelines below and complete an incident report form e Clinical Waste Spillage wearing disposable apron and gloves together with any other appropriate PPE having made a thorough risk assessment carefully place the waste into another same type bag Clean the contaminated area with paper towels followed by a chlorine rele
3. Guidelines on Hand Hygiene in Health Care First Global Patient Safety Challenge Clean Care is Safer Care Chapter 7 WHO 2009 02 Save Lives Clean your Hands guide to implementation A Guide to the Implementation of the WHO Multimodal Hand Hygiene Strategy Part 1 Page 15 of 26 UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control Nurse Appendix 1 Cytotoxic Drug Spillage It is essential that all staff working in areas which handle liquid or powdered cytotoxics are aware of the procedure All cytotoxic spills should be dealt with immediately and a clinical incident form completed The contents of the kit should be checked regularly to ensure everything as outlined below is enclosed The aim is to reduce risks of contamination and spread THE SPILLAGE MUST BE CLEANED UP EFFECTIVELY AND ALL CONTAMINATION DISPOSED OF SAFELY SPILLAGE ONTO FLOORS BENCHES ETC 1 Isolate the area Call for assistance and warn others around you Do not leave the spill unguarded 1 Women who are or think they may be pregnant must not attempt to clean up the spillage Obtain help from another member of staff 1 Obtain cytotoxic drug spillage kit these are located available as follows OAseptic Dispensing Unit CRH amp HRI OWd12 Wd3 OPD HRI Macmillan unit CRH iEmergency cupboard CRH Contents Berner Cytotoxic Spill Kit 1 pair blue latex gloves 1 pair yellow over gloves 1
4. Nurse Hawker J Begg N Blair Reintjes R Weinberg J 2005 Communicable Disease Control Handbook 2 edition Blackwell London Health and Safety Sharp Instruments in Healthcare Regulation 2013 Guidance for employers and employees Health and Safety Executive Crown Available at www hse gov uk pubns hsis7 htm Needlestick Injuries Document available at http www nhsemployers org SiteCollectionDocuments Needlestick Injury 22 02 2011 doc NICE 2012 NICE clinical guideline 139 Infection Prevention and control of healthcare associated infections in primary and community care NICEO Manchester NPSA Based on My 5 moments for Hand Hygiene WHO 2009 NMC 2008 The Code Professional Code of Conduct for Nurses and Midwives Nursing and Midwifery Council London RCN 2009 Infection Prevention and Control Minimum Standards RCN London RCN 2012 Essential practice for infection prevention and control Guidance for nursing staff RCN London Peate 2008 Body fluids part 1 infection control British Journal of Healthcare Assistants 2008 Vol 02 No 01 Thomas V ed 2011 Fundamental Aspects of Infection Prevention and Control Quay Books London Chapter 7 UK Health Departments 1998 Guidance for Clinical Health Care Workers Protection against infection with blood borne viruses Recommendations of the Expert Advisory Group on AIDS and the Advisory Group on Hepatitis London DH WHO 2009
5. measures CAS No EINECS No Wt Vol Symbol 10049 04 4 233 162 8 0 01 0 0125 ClO 2605 79 0 0 002 HO Chlorine dioxide generator OES of 0 3ppm short term 0 1ppm long term Non toxic Rinse eyes with water Wash affected area with water Do not induce vomiting Give water to drink Seek medical advice where necessary Non flammable Accidental release measures Environmental precautions Clean up method Clothing for disposal Environmental precautions required but product is biodegradable under OECD conditions operational 6 1995 Flush to drain with water or soak up onto inert material and dispose of with clinical waste Wear appropriate gloves and apron This document conforms with Regulation 6 of the Chemicals Hazard Information and Packaging Supply Regulations 2002 CHIP3 Tristel User Manual Section 4 Master File January 2008 Revision Number 005 2 Page 19 of 26 UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control Nurse Tristel Fuse for Surfaces Working Solution Safety Data Sheet Handling and storage Handling guidelines Storage guidelines Safe handling in accordance with label instructions Not to be mixed with other chemicals Keep from children Store out of direct sunlight Single Use solution Exposure controls personal protection Personal protection Skin contact Eye contact Inhalation Ingestion Avoid eye conta
6. of the Deceased Section S Tuberculosis Section T Multi Resistant Organism Policy NICE Clinical Guideline 2 2003 Infection Control Prevention of Healthcare Associated Infections in Primary and Community Care NICE London NICE 2011 NICE public health guidance 36 Prevention and control of healthcare associated infections Quality improvement guide NICEO Manchester RCN 2013 Infection prevention and control available at http www rcn org uk support rcn_ direct online advice a z2 infection_prevention_and _control infection_prevention_and_control Tristel Fuse for Surfaces Working Solution Safety Data Sheet see appendix 3 Wilson J 2006 Infection Control in Clinical Practice 3 Edition Bailliere Tindall London References and Bibliography Calderdale and Huddersfield NHS Foundation Trust 2013 Personal Protective Equipment PPE for Influenza Available on the Trust intranet via the IPC web link entitled Influenza sub heading Personal Protective Equipment DH 2008 The Health and Social Care Act Code of practice for the NHS on the prevention and control of healthcare associated infections and related guidance epic2 National Evidence Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England Journal of Hospital Infection 2007 65 Supplement p S18 Page 14 of 26 UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control
7. the risk of sharps injuries and blood borne infections and to achieve the safest possible working environment within a hospital or other healthcare environment It is a legal requirement from 11 May 2013 that all NHS Trusts or settings where healthcare is delivered should comply with this Directive Any HSCWs including community staff who may require further advice should refer to see Section M Sharps Policy of the Infection Control Policies and Guidelines Manual For other legislation but which is not solely limited to these please see section 10 Associated documentation further reading h Spillages of Blood and Body Fluids Protective clothing must be worn prior to dealing with any spillage of blood and or body fluids Ensure adequate ventilation prior to using disinfection solutions or granules Procedure for spillages of blood or blood stained body fluids see also appendix 2 e Cover spillage with disposable paper towels In the event of large spillages soak up the majority with paper towels and place into the appropriate waste stream taking care not to cause any new spillages then apply further paper towels to area e Make up chlorine releasing agent e g Tristel Fuse Impregnate paper towels or disposable j cloths with the Tristel and clean the area thoroughly before discarding paper towels j cloths and worn PPE into appropriate waste stream e Allow to dry thoroughly e Decontaminate hands Spillages of faeces
8. 2015 Review Lead Infection Prevention amp Control Nurse 10 appropriate waste stream e g Pharmaceutical Liquid bin Otherwise decontamination using Tristel would be required Training and Implementation Training sessions delivered by the Infection Prevention and Control Team are available to all Trust staff i e Induction Right from the Start and Beyond the Basics There are targeted training sessions Link Infection Prevention and Control Practitioners in departments and wards across the trust who will then cascade the information to colleagues within their area or department Ad hoc targeted session can also be provided following discussion with the IPCT Trust Equalities Statement Calderdale and Huddersfield NHS Foundation Trust aims to design and implement services policies and measures that meet the diverse needs of our service population and workforce ensuring that none are placed at a disadvantage over others We therefore aim to ensure that in both employment and services no individual is discriminated against by reason of their gender gender reassignment race disability age sexual orientation religion or religious philosophical belief marital status or civil partnership Monitoring Compliance with this Procedural Document All clinical policies are subject to compliance with Standard Precautions and monitoring compliance would be dealt within that specific policy Clinical audits i e Rapid Assurance
9. TIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control Nurse Tri stel Appendix 2 Management of blood bodily fluid spillages Put on PPE gloves and apron Using absorbent material Conti wipe or paper towel soak up the spill removing as much as physically possible Discard the soiled wipes to clinical waste bag Apply Tristel Fuse or Jet to the contaminated surface and leave to dry Do not rinse Discard PPE and used cloths to clinical waste bag Page 18 of 26 UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control Nurse Tristel Fuse for Surfaces Working Solution Safety Data Sheet Product Name Tristel Fuse for Surfaces Working Soluti Product Code FUS SUR Type of product Manufacturer Telephone Number Fax Number Emergency Number Chemical type High level disinfecting and sporicidal solution for surfaces Tristel Solutions Limited Lynx Business Park Fordham Road Snailwell Cambs CB8 7NY 44 0 1638 721500 44 0 1638 721911 44 0 7798 805692 out of business hours Mild Oxidising Solution Appendix 3 Revision Number FUS SUR SDS 006 Publication Date 19 02 08 Composition Ingredients Chlorine dioxide in aqueous solution Surfactant Decamine Oxide Water Hazards identification First aid measures Inhalation Eye contact Skin contact Ingestion Fire fighting
10. UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control Nurse Calderdale and Huddersfield NHS NHS Foundation Trust Section C Standard Precautions Version 5 Important This document can only be considered valid when viewed on the Trust s Intranet If this document has been printed or saved to another location you must check that the version number on your copy matches that of the document online Page 1 of 26 UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control Nurse Document Summary Table Unique Identifier Number C 47 2013 Status Ratified Version 5 Implementation Date June 2002 Current Last Review February 2006 July 2008 April 2011 April 2013 Dates Next Formal Review April 2015 Sponsor Infection Prevention amp Control Director Author Infection Prevention amp Control Nurse Where available Trust Intranet Target audience All Staff Ratifying Committees Executive Board 25 July 2013 Consultation Committees Committee Name Committee Chair Date Infection Prevention amp Control Consultant June 2013 Committee Microbiologist Infection Prevention amp Control Doctor Other Stakeholders Consulted All Calderdale and Huddersfield NHS Foundation Trust Infection May 2013 Prevention and Control Nurses Does this document map to ot
11. anyone who undertakes any degree of care to a patient or service user or who comes into contact with their environment HCAI Is an infection caused by any infectious agent acquired as a consequence of a person s treatment or that which is acquired by a HSCW in the course their daily duties Pathogen Any microorganism capable of causing disease or infection Page 5 of 26 UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control Nurse 4 Duties Roles and responsibilities The Chief Executive is responsible for ensuring that there are effective infection control arrangements in the Trust Nursing staff must always comply with Nursing and Midwifery Code of Professional Conduct The Code and delegate to those only who are competent for that delegated task All other registered HSCWs must abide by their own Professional Code together with the Trust s policies and procedures Risk Assessment All HCWs must carry out a risk assessment on the possible exposure to blood and body fluids and the risk of substances containing harmful organisms during the course of their duties HCWs should always as a minimum implement standard infection prevention and control precautions to reduce the risk of transmission of such organisms and minimise the spread of infection HSCWs with direct clinical and environmental contact must also assess the risk of contamination to their own clothing
12. asing agent e g Tristel Fuse solution Tristel Fuse is sufficient to use where there is visible blood Place protective clothing and all paper towels into same type bag seal and dispose of immediately e Sharps Container Spillage Always wear a disposable apron and gloves For broken or partially open containers place into a larger sharps bin where possible e Medicine Spillages Any spilled medicine and all items used in the cleaning process e g gloves paper towels clothes mop heads etc must be placed into the correct waste stream e Hazardous spillage For full information on cytotoxic spillage process and kit please refer to appendix 1 http intranet cht nhs uk formulary Web Formulary Files pdf doc files etc MMC 113 Cytotoxic Drug Spillage May 2011 pdf Please refer to the Medicine Code section 17 using this link http nww cht nhs uk index php id 4848 amp cat 3 Spillages onto carpeted areas wearing disposable apron and gloves soak up the excess fluid with a disposable cloth and clean the area with detergent and hot water This may need repeating several times to remove all spillage The carpet should be steam cleaned at the first available opportunity If a dust pan and brush is used the dust pan will require a thorough clean using Tristel The brush may be contaminated with glass articles chemicals and would therefore require disposing of in the Page 12 of 26 UNIQUE IDENTIFER NO C 47 2013 Review Date April
13. checklist RAC Quality Improvement Audits Hand Wash Roadshow ad hoc Infection Prevention and Control Audits These audits and other relevant audits are an ongoing process Furthermore it is the responsibility of all clinical staff to comply with this policy senior clinical staff and managers are asked to lead by example Continued failure by an individual to adhere to this policy may be managed under the Trust s disciplinary policy Associated Documents Further Reading CHFT 2013 Infection Prevention and Control 7 Card Pocket Set Francis R QC 2013 Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry The Stationery Office London Epic2 National Evidence Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England Journal of Hospital Infection 2007 65 Supplement General Policies Principles for Uniform and Non Uniform Staff version 3 Page 13 of 26 UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control Nurse 11 Waste Disposal Policy Medicine Code Medicine Code 17 Medicines no longer required Return or disposal http nww cht nhs uk index php id 4848 amp cat 3 Infection Control Policies amp Guidelines Section F Decontamination Policy Section G Aseptic Technique Policy Section H Hand Hygiene Section M Management of Clinical Sharps Injuries and Exposure to Blood and High Risk Body Fluids Section P Care
14. ct and prolonged skin contact Gloves and apron recommended Low risk No known hazard Low risk No known hazard Low risk Low risk substantial ingestion may cause discomfort to mouth and digestive tissues Physical and chemical properties Physical state Appearance and odour Evaporation rate Boiling point Freezing point Volatile by weight Solubility in water 20 C pH Specific gravity Liquid Light yellow with mild odour As water 100 degrees centigrade As water Not known Soluble 5 5 approximately 1 005 20 Revision Number FUS SUR SDS 006 Publication Date 19 02 08 This document conforms with Regulation 6 of the Chemicals Hazard Information and Packaging Supply Regulations 2002 CHIP3 Tristel User Manual Section 4 Master File January 2008 Revision Number 005 3 Page 20 of 26 UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control Nurse Tristel Fuse for Surfaces Working Solution Safety Data Sheet Stability and reactivity Decomposes to simple salt solution Hazardous decomposition products None under normal use Chlorine donors and oxygen produced if heated Toxicological information LD50 oral rat Irritation to skin rabbit Irritation to eyes rabbit Sensitisation guinea pig Ecological information Disposal considerations Packaging Contaminated packaging Product Transport info
15. d plastic aprons cannot be worn e g X ray alternative clothing must be water resistant and cleanable e Eye Protection Eye protection must be available in all areas for use when there is a risk of blood body fluids secretions or excretions splashing into the eyes These Page 9 of 26 UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control Nurse should be decontaminated after use and stored clean If single use then dispose of immediately into the appropriate waste stream f Masks Surgical face masks should be worn when there is a risk of contamination of the mouth and nose by splashes of blood body fluids secretions and excretions Respirators FFP3 masks should be worn for all procedures that create an aerosol e g air power tools bronchoscopy open airway management or some respiratory diseases Respirators FFP3 masks may be recommended with certain respiratory diseases e g multi drug resistant TB and influenza For further information on the usage of masks please refer to Section S Tuberculosis of the Infection Control Policies and Guidelines Manual If a patient is suspected to have or is confirmed to have flu Seasonal or pandemic a surgical mask is sufficient to wear upon entering the patient or service users side room and for performing most medical and nursing tasks If however aerosol generating procedures are to be performed e g bronchoscopy CPR nebuli
16. d Infection Prevention amp Control Nurse 3 Definitions Body Fluids Any fluid found in produced by or excreted from the human body which includes blood urine faeces saliva tears breast milk CSF semen vaginal fluid amniotic fluid pleural fluid peritoneal fluid bile digestive juices vomit pus other infected discharges and serous fluid Definition of Contact a Social Contact Social contact may be defined as a physical contact occurring between HSCWs patients or service user that may occur in a non intimate social setting e g a simple handshake b Direct Clinical Contact Direct contact is more than would be expected in a social environment and involves close contact with a patient or service user and or their immediate environment including physical examinations performed on ward rounds Direct clinical contact that involves contact with open wounds invasive devices e g urinary catheters chest drains peripheral venous catheters PEGs and other vulnerable sites significantly increases the risks of cross transmission and infection c Indirect Contact Indirect contact includes contact with equipment used for patients and with a patient s immediate environment Policies and procedures are in place regarding cleaning and decontamination of such items please see Section F of the Infection Prevention amp control Policies amp Guidelines HSCW Health care worker and or Social Care Worker may be defined as
17. d dispose of with clinical waste Wear appropriate gloves and apron This document conforms with Regulation 6 of the Chemicals Hazard Information and Packaging Supply Regulations 2002 CHIP3 Tristel User Manual Section 4 Master File January 2008 Revision Number 005 5 Page 22 of 26 UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control Nurse Tristel Fuse for Surfaces Activator amp Base Safety Data Sheet Product Name Triste Fuse for Surfaces Activator Solution Handling and storage Handling guidelines Storage guidelines Safe handling in accordance with label instructions Not to be mixed with other chemicals Keep from children Store out of direct sunlight Shelf life two years see product for expiry date Exposure controls personal protection Personal protection Skin contact Eye contact Inhalation Ingestion Avoid eye contact and prolonged skin contact Gloves and apron Recommended Low risk No known hazard Low risk No known hazard Low risk Low risk substantial ingestion may cause discomfort to mouth and digestive tissues Physical and chemical Properties Physical state Appearance and odour Evaporation rate Liquid Clear colourless solution no odour As water Boiling point 100 degrees centigrade Product Name Tristel Fuse for Surfaces Base Solution Handlin
18. e Ecological information No known adverse effects from normal use Disposal considerations Packaging Can be disposed of as normal waste in accordance with local authority regulations Contaminated May be disposed of safely packaging under normal conditions in accordance with local authority regulations This document conforms with Regulation 6 of the Chemicals Hazard Information and Packaging Supply Regulations Page 24 of 26 UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control Nurse 2002 CHIP3 Tristel User Manual Section 4 Master File January 2008 Revision Number 005 7 Tristel Fuse for Surfaces Activator amp Base Safety Data Sheet Product Name Triste Fuse for Surfaces Activator Solution Disposal considerations continued Product Solution to be disposed of in accordance with spillage instructions as explained in accidental release measures Transport information No special conditions apply non hazardous Regulatory information Not a licensed medicine Other information Safety phrases 2 Keep out of reach of children 24 25 Avoid contact with skin and eyes 50 Do not mix with other chemicals Revision Number FUS SUR SDS 006 Publication Date 19 02 08 Product Name Tristel Fuse for Surfaces Base Solution Disposal considerations continued Product Solution to be disposed of in accordance with spillage ins
19. ents or suggested further reading are provided together with the most recent references available Page 26 of 26
20. es Tristel Fuse COSHH Summary of Document Page 3 of 26 Page OoODOANDOOOAaAA 16 17 18 25 UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control Nurse 1 Introduction Standard precautions are essential components in reducing the risk of transmission of infectious conditions micro organisms in any healthcare setting These precautions should be applied as standard principles by all health and social care workers HSCW to the care of all patients at all times Standard precautions regard all blood and body fluids to be potentially infected They should also be followed when coming into contact with patients intact skin and with the patient s immediate environment These precautions include the use of personal protective equipment PPE the safe handling and disposal of sharps managing blood and bodily fluids handling and disposal of waste and hand hygiene Standard precautions apply to both non uniform and uniform wearing staff including any HSCW attending a patient in their own home or any healthcare setting in the course of their daily duties who may or may not be employed by the Trust e g care home staff assessing patients District Nurses social workers Guidance contained within this policy and within Section H Hand Hygiene Policy of the Infection Control Policies amp Guidelines Manual should be followed It is generally recognised that many patients
21. g and storage Handling guidelines Storage guidelines Revision Number FUS SUR SDS 006 Publication Date 19 02 08 Safe handling in accordance with label instructions Not to be mixed with other chemicals Keep from children Store out of direct sunlight Shelf life two years see product for expiry date Exposure controls personal protection Personal protection Skin contact Eye contact Inhalation Ingestion Avoid eye contact and prolonged skin contact Gloves and apron recommended Low risk No known hazard Low risk No known hazard Low risk Low risk substantial ingestion may cause discomfort to mouth and digestive tissues Physical and chemical Properties Physical state Appearance and odour Evaporation rate Boiling point Page 23 of 26 Liquid Pale green mild odour As water 100 degrees centigrade This document conforms with Regulation 6 of the Chemicals Hazard Information and Packaging Supply Regulations 2002 CHIP2 UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control Nurse Tristel User Manual Section 4 Master File January 2008 Revision Number 005 6 Tristel Fuse for Surfaces Activator amp Base Safety Data Sheet Product Name Triste Fuse for Surfaces Activator Solution Physical and chemical Properties continued Freezing point As water Volati
22. her Regulator requirements Regulator details Regulator standards numbers etc Document Version Control Version 5 This document includes community use of these precautions The Trust Equality Statement has also been updated Version 4 The document has been redesigned to ensure that all new and revised procedural documents are set out to a Trust wide format and the content of which includes a minimum set of criteria which include The training requirements for implementation Monitoring arrangements for the document Equality impact of the document In addition the monitoring arrangements for this document have been included Page 2 of 26 UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control Nurse Contents Section Oe eS Sie Se Document Summary Table Contents Introduction Purpose Definitions Duties Roles and Responsibilities Risk Assessment Infection Prevention amp Control Precautions Hand Hygiene and Hand Care Personal Protective Equipment PPE Gloves Plastic Aprons Eye Protection Masks g Safe Handling and Disposal of Sharps h Spillages of Blood and Body Fluids i Accidental Spillages Training and Implementation Trust Equalities Statement Monitoring Compliance with this Policy Associated Documents Further reading References and bibliography Appendices Cytotoxic Drug Spillage Tristel Spillag
23. le Not known by weight Solubility in water Soluble 20 C pH 11 5 13 approximately Specific gravity 1 025 20 C Stability and reactivity No decomposition if stored and used as directed Hazardous None under normal use decomposition products Chlorine donors and oxygen produced if heated Toxicological information Animal studies No known risks to skin Exposure Human studies No known risks to skin exposure Ecological information No known adverse effects from normal use Disposal considerations Packaging Can be disposed of as normal waste in accordance with local authority regulations Contaminated May be disposed of safely packaging under normal conditions in accordance with local authority regulations Revision Number FUS SUR SDS 006 Publication Date 19 02 08 Product Tristel Fuse for Name Surfaces Base Solution Physical and chemical Properties continued Freezing point As water Volatile Not known by weight Solubility in water Soluble 20 C pH 1 5 3 5 approximately Specific gravity 1 020 20 C Stability and reactivity No decomposition if stored and used as directed Hazardous None under normal use decomposition products Not compatible with alkaline substance and chlorine donors Toxicological information Acute oral LD50 gt 4000 mg kg Animal studies No known risks to skin exposure Human studies No known risks to skin Exposur
24. ot a substitute for hand washing they should be put on immediately before a task is to be performed If extra items are required during an episode of patient care e g dressings that are not immediately to hand PPE should be removed discarded into the appropriate waste stream hands decontaminated and the required items obtained prior to continuing with patient care Gloves should be worn as single use items Remove gloves immediately following completion of a task or episode of care and dispose into the appropriate waste stream Gloves should be changed between caring for different patients or between different care or treatment activities for the same patient If known or highly suspected risk of infection gloves must be disposed of through the orange waste stream Page 8 of 26 UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control Nurse e Sterile gloves low protein should be worn for all operative and invasive procedures that require an aseptic technique ANTT e Non sterile gloves low protein should be worn for non sterile procedures when contact with blood or body fluids is possible Non sterile gloves can be worn when performing an aseptic non touch technique see Aseptic Policy Section G e Special gloves are required for use with certain chemicals Seek advice from the manufacturer of the Chemical and comply with COSHH e Staff with a known or suspected latex allergy mus
25. out social or direct clinical contact with patients or service users or who work within the healthcare environment should adhere to Section H Hand Hygiene Policy of the Infection Control Policies and Guidelines Manual e Cover cuts and abrasions with waterproof dressings Keep nails short clean and unvarnished Not wear false nails including extensions shellac minx overlays etc e Not wear wrist jewellery Not wear rings the only exception being a plain wedding band Be Bare Below the Elbow All HCWs including non uniformed staff who carry out direct clinical contact which involves contact with open wounds invasive devices or other vulnerable sites must adhere to the above and also e Remove outer clothing i e white coat jacket e Roll sleeves up above the elbow e Putona plastic disposable apron and any other appropriate PPE e f wearing a tie tuck this under the plastic apron The next sections of the Policy discuss the use of protective clothing This applies to all uniformed and non uniformed HSCWs who are undertaking any patient service user contact Further information on the dress code can be found under General Policies for the Principles of Uniform and Non Uniform Staff version 3 Personal Protective Equipment PPE PPE should be selected on the basis of a risk assessment of the transmission of micro organisms to the patient and the risk of contamination of HSCWs clothing and skin by blood body fluids
26. pair goggles 1 pair overshoes 1 gown 1 face mask 2 chemosorb pads 3 cleaning cloths 2 Waste bags ties Please note that sharps must not be picked up by hand 1 Put on the protective clothing plastic apron disposable overshoes double gloves mask and safety goggles Powders Gently cover the spilled material with moistened paper towels to avoid raising a dust Pour on sufficient water to dissolve the powder then treat as for a liquid below Liquids Cover the spillage with sufficient paper towels to absorb the liquid Transfer paper towels to the heavy duty clinical waste bag 1 Wash the affected surface with detergent and water using paper towels and dry to avoid leaving a slip hazard 1 Place All the waste including ALL items contained in the spillage kit and any other items that were used in the cleaning process into the waste bag and seal Place this bag inside the large bag marked 18 01 08 1 This bag must then be placed into a hazardous purple liquid bin Wash hands thoroughly with soap and water Complete an incident report form Obtain replacement spillage kit from pharmacy NB must be booked out on the pharmacy computer system For guidance on disposal of medicinal waste refer to Medicines Code Section 17 http nww cht nhs uk index php id 4848 amp cat 3 Page 16 of 26 UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control Nurse Page 17 of 26 UNIQUE IDEN
27. rmation Regulatory information Not a licensed medicine Other information Safety phrases 2 Keep out of reach of children 50 Do not mix with other chemicals gt 5 000 mg kg Negative Negative Negative Presents no known hazards to the environment Can be disposed of as normal waste in accordance with local authority regulations May be disposed of safely under normal conditions in accordance with local authority regulations Solution to be disposed of in accordance with spillage instructions as explained in accidental release measures No special conditions apply non hazardous Revision Number FUS SUR SDS 006 Publication Date 19 02 08 This document conforms with Regulation 6 of the Chemicals Hazard Information and Packaging Supply Regulations CHIP3 Tristel User Manual Section 4 Master File January 2008 Revision Number 005 4 Page 21 of 26 UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control Nurse Tristel Fuse for Surfaces Activator amp Base Safety Data Sheet Product Name Triste Fuse for Surfaces Activator Solution Chemical Type Sodium salt solution Composition information on ingredients Major 2 1 Sodium chlorite solution in ingredients de mineralised water Hazards No specific hazards Identification Contact with acids liberates chlorine dioxide First aid measures Inhalation Non toxic Eye contact Rinse eyes wi
28. secretions excretions This can be by direct or indirect contact with the patient service user and or their immediate environment All PPE together with any waste produced must be disposed of into the appropriate waste stream For further information on the disposal of PPE please refer to the Waste Disposal Policy available on the Trust s intranet Hand hygiene must be performed prior to and following removal of all PPE The following visual risk assessment is available within the pocket card set Page 7 of 26 UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control Nurse Personal Protective Equipment Risk Assessment Assess the risk of task A Contact with blood body fluids high risk of splashing Single use gloves aprons eye mouth protection Single use gloves aprons No gloves aprons Single use aprons Gloves must be worn for e invasive procedures e contact with sterile sites e contact with non intact or skin mucous membranes e all activities that have been assessed as carrying a risk of exposure or involve direct contact with blood body fluids secretions and excretions handling contaminated instruments when in contact with a patient or their environment who is known or highly suspected to have Clostridium Difficile c Gloves Hands should always be decontaminated before putting gloves on and after their removal Gloves are n
29. sed therapy a FFP3 mask is advised For further information on the usage of masks FFP3 and surgical masks with influenza please refer to the IPC web page CHFT 2013 A limited emergency supply of FFP3 masks is available from the Infection Control cupboards located outside Old Ward 10 Calderdale Royal Hospital key held by site co ordinator and Infection Prevention and Control Nurses and outside the Pathology Dept at Huddersfield Royal Infirmary key from security staff on the front desk The ordering and stock levels of the FFP3 masks are the sole responsibility of the manager for that healthcare setting All PPE together with any waste produced must be disposed of into the appropriate waste stream Hands should always be decontaminated before and after removal of any PPE g Safe Handling and Disposal of Sharps Sharps that are handled incorrectly and not disposed of adequately are extremely dangerous It is the responsibility of the user to dispose of their sharps device safely immediately after use This means the sharps container should be portable enough to take to the site of the intended procedure and be designed specifically to allow sharp instruments and needles to be disposed of safely and easily at the point of use Page 10 of 26 UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control Nurse In May 2013 a European Sharps Directive was introduced with the aim of reducing
30. service users visitors or staff who are not obviously ill may be carrying potentially harmful micro organisms in their blood other body fluids or on their skin which may present an infection hazard to other patients service users and to HCSW s with whom they come into contact The implementation of precautions upon diagnosis of infection may not prevent cross transmission Therefore in order to protect staff and patients service users we must consider all blood and body fluids from all patients i e adults children and neonates to be infected and incorporate measures to minimise the risk of exposure into everyday practices The DH 2008 states Effective prevention and control of Health Care Associated Infection HCAI has to be embedded into everyday practice and applied consistently by everyone It is particularly important to have a high awareness of the possibility of HCAI in both patients and healthcare workers to ensure early and rapid diagnosis This should result in effective treatment and containment of the infection Effective action relies on an accumulating body of evidence that takes account of current practices Purpose These guidelines describe the processes and rationales that need to be undertaken to minimise the risk of cross transmission of potentially harmful micro organisms between patients HSCW s or other service users Page 4 of 26 UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lea
31. t not use latex gloves and must contact Occupational Health as soon as possible for advice Latex gloves must not be used if the patient has or is suspected of having a latex allergy Alternative gloves can be provided for those with allergies In December 2012 the Trust standardised gloves all non sterile gloves are now nitrile If however staff are allergic to this type of glove they must contact Occupational Health as soon as possible for advice d Plastic Aprons Disposable plastic aprons must be worn when there is a risk that clothing or uniform may become contaminated from the environment blood body fluids secretions and excretions with the exception of sweat Full body fluid repellent gowns should be worn where there is a risk of extensive splashing of blood body fluids secretions and excretions onto the skin of staff Uniforms clothing that becomes contaminated must be laundered at the earliest opportunity Please note only the Trust s laundry should be used for staff uniforms irrespective of contamination Disposable plastic aprons are single use items and must only be used for one procedure or episode of patient care i e bed making handling linen If during patient contact it is realised extra items are required from a cupboard PPE must be removed and discarded prior to collection of the item and fresh PPE to be worn prior to continued patient episode During procedures where protection from splashes is required an
32. th water Skin contact Wash affected area with water Ingestion Do not induce vomiting give milk or water to drink Seek medical advice where necessary Fire fighting measures Non flammable Accidental release measures Environmental Environmental precautions Precautions required but product is biodegradable under OECD conditions operational 6 1995 Clean up method Flush to drain with water or soak up onto inert material and dispose of with clinical waste Clothing for Wear appropriate gloves and disposal apron Revision Number FUS SUR SDS 006 Publication Date 19 02 08 Product Tristel Fuse for Name Surfaces Base Solution Chemical Type Organic acid blend Composition information on ingredients Major 5 solution of citric acid with ingredients preservatives and 20 surfactant Decamine Oxide in de mineralised water Hazards No specific hazards Identification First aid measures Inhalation Eye contact Skin contact Ingestion Non toxic Rinse eyes with water Wash affected area with water Do not induce vomiting give milk or water to drink Seek medical advice where necessary Fire fighting measures Non flammable Accidental release measures Environmental Precautions Environmental precautions required but product is biodegradable under OECD conditions operational 6 1995 Clean up method Flush to drain with water or Clothing for disposal soak up onto inert material an
33. tructions as explained in accidental release meansures Transport information No special conditions apply non hazardous Regulatory information Not a licensed medicine Other information Safety phrases 2 Keep out of reach of children 24 25 Avoid contact with skin and eyes Do not mix with other chemicall This document conforms with Regulation 6 of the Chemicals Hazard Information and Packaging Supply Regulations 2002 CHIP3 Tristel User Manual Section 4 Master File January 2008 Revision Number 005 7 Page 25 of 26 UNIQUE IDENTIFER NO C 47 2013 Review Date April 2015 Review Lead Infection Prevention amp Control Nurse Summary of document This revised policy provides a rationale as to why Standard Precautions are important to the safety and wellbeing of primarily our patients but also to attending care givers It gives clear guidance on the precautions required by all healthcare workers and social care workers HSCW attending a patient in the course of their daily duties whether employed by the Trust or other healthcare or social care agencies work forces Clear definitions are provided so that there is no ambiguity or misunderstanding Standard precautions include e Risk assessment Hand hygiene Personal protective equipment Gloves Plastic aprons Eye protection Masks Safe handling and disposal of sharps Spillages of blood and body fluids Accidental spillages Links to all associated docum
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