Good Practice in Infection Prevention and Control
As part of its Wipe it out campaign the Royal College of Nursing has revised its guidance on good practice in infection prevention and control. This new updated guidance emphasises they key roles that nursing staff and other health care workers in the NHS and independent sector have in helping to reduce the prevalence of health care associated infections (HCAIs).
Every health care worker plays a vital part in helping to minimise the risk of cross infection - for example, by making certain that hands are properly washed, the clinical environment is as clean as possible, ensuring knowledge and skills are continually updated and by educating patients and visitors.
This publication includes information on the general principles of infection prevention and control, including standard infection prevention and control practice, decontamination, achieving and maintaining a clean clinical environment, what to do in the event of an invasive injury/accident, and the importance of good communication. Two small sections give guidance on variant Creutzfeldt Jakob Disease (vCJD) and methicillin-resistant Staphylococcus aureus (MRSA). There is also a Useful Information section with signposts to initiatives and policies being implemented around the UK.
The general principles of infection prevention and control (standard precautions)
Standard precautions (formerly known as universal precautions) underpin routine safe practice, protecting both staff and clients from infection. By applying standard precautions at all times and to all patients, best practice becomes second nature and the risks of infections are minimised.
- Achieving optimum hand hygiene.
- Using personal protective equipment.
- Safe handling and disposal of sharps.
- Safe handling disposal of clinical waste.
- Managing blood and bodily fluids.
- Decontaminating equipment.
- Achieving and maintaining a clean clinical environment.
- Appropriate use of indwelling devices.
- Managing accidents.
- Good communication - with other health care workers, patients and visitors.
1. Hand Hygiene
Hand hygiene is widely acknowledged to be the singly most important activity for reducing the spread of disease, yet evidence suggests that many health care professionals do not decontaminate their hands as often as they need to or use the correct technique which means that areas of the hands can be missed. The diagram on page 5 demonstrates the hand hygiene procedure that should be followed when washing with soap and water or using an alcohol hand gel or rub.
Hands should be decontaminated before direct contact with patients and after any activity or contact that contaminates the hands, including following the removal of gloves. While alcohol hand gels and rubs are a practical alternative to soap and water, alcohol is not a cleaning agent. Hands that are visibly dirty or potentially grossly contaminated must be washed with soap and water and dried thoroughly. Hand preparation increases the effectiveness of decontamination. You should:
- keep nails short, clean and polish free
- avoid wearing wrist watches and jewellery, especially rings with ridges or stones
- artificial nails must not be worn
- any cuts and abrasions should be covered with a waterproof dressing
Remove your wristwatch and any bracelets and roll up long sleeves before washing your hands (and wrists). In addition, bear in mind the following points:
Adequate hand washing facilities must be available and easily accessible in all patient areas, treatment rooms, sluices and kitchens. Basins in clinical areas should have elbow or wrist lever operated mixer taps or automated controls and be provided with liquid soap dispensers, paper hand towels and foot-operated waste bins (NHS Estates, 2002). Alcohol hand gel must also be available at ‘point of care’ in all primary and secondary care settings (National Patient Safety Agency (2004).
All health care workers should bring any lack of, or inappropriately placed facilities to the notice of their managers (or matron). They also have a duty of care to patients and themselves and must use facilities provided to prevent cross infection.
Improper drying can recontaminate hands that have been washed. Wet surfaces transfer organisms more effectively than dry ones and inadequately dried hands are prone to skin damage. Disposable paper hand towels of good quality should be used to ensure hands are dried thoroughly. Hand towels should be conveniently placed in wall mounted dispensers close to hand washing facilities.
2. Using personal protective equipment
Personal protective equipment (PPE) is used to protect both yourself and your patient from the risks of cross-infection. It may also be required for contact with hazardous chemicals and some pharmaceuticals. PPE includes items like gloves, aprons, masks, goggles or visors. In certain situations such as theatre, it may also include hats and footwear
Gloves should be worn whenever there might be contact with blood and body fluids, mucous membranes or non intact skin. They are not a substitute for hand washing. They should be put on immediately before the task to be performed, then removed and discarded as soon as the procedure is completed. Hands must always be washed following their removal.
The choice of glove should be made following a suitable and sufficient risk assessment of the task, the risk to the patient and risk to the health care worker (ICNA, 2002). Nitrile or latex gloves should be worn when handling blood, blood-stained fluids, cytotoxic drugs or other high risk substances.
Polythene gloves are not suitable for use when dealing with blood and/or blood and body fluids, ie. in a clinical setting. Neoprene and nitrile gloves are good alternatives for those who are sensitive to natural rubber latex. These synthetic gloves have been shown to have comparable in-use barrier performance to natural latex gloves in laboratory and clinical studies. Vinyl gloves can be used to perform many tasks in the health care environment, but are not appropriate when handling blood, blood-stained fluids, cytotoxic drugs or other high risk substances. Please check the local policy for your workplace.
Disposable plastic aprons
These should be worn whenever there is a risk of contaminating clothing with blood and body fluids and when a patient has a known infection, for example, direct patient care, bed making or when decontaminating equipment. You should discard them as soon as the intended task is completed and then wash your hands. They must be stored safely so that they don’t accumulate dust which can act as a reservoir for infection. Impervious gowns should be used when there is a risk of extensive contamination of blood or body fluids.
Masks, visors and eye protection
These should be worn when a procedure is likely to cause blood and body fluids or substances to splash into the eyes, face or mouth. Masks may also be necessary if infection is spread by an airborne route - for example, multi drug resistant tuberculosis or severe acute respiratory syndrome (SARS) - see information on the Health Protection Agency website (www.hpa.org.uk). You should ensure that this equipment fits correctly, is handled as little as possible and changed between patients or operations. Masks should be discarded immediately after use.
3. Safe handling and disposal of sharps
Sharps include needles, scalpels, stitch cutters, glass ampoules and any sharp instrument. The main hazards of a sharps injury are hepatitis B, hepatitis C and HIV. Second only to back injuries as a cause of occupational injuries amongst health care workers, between July 1997 and June 2002, there were 1,550 reports of blood-borne virus exposures in health care workers - of which 42 per cent were nurses or midwives.
To reduce the risk of injury and exposure to blood-borne viruses, it is vital that sharps are used safely and disposed of carefully, following your workplace’s agreed policies on safe working procedures. Your employer should provide targeted education and awareness training for all health care workers.
Some procedures have a higher than average risk of causing injury. These include intra-vascular cannulation, venepuncture and injection. Devices involved in these high-risk procedures are:
- IV cannulae.
- winged steel - butterfly - needles.
- needles and syringes.
- phlebotomy needles.
You should ensure that:
- sharps are not passed directly from hand to hand.
- handling is kept to a minimum.
needles are not broken or bent before use or disposal.
- syringes or needles are not dismantled by hand and are disposed of as a single unit.
- needles are never re-sheathed.
- staff take personal responsibility for any sharps they use and dispose of them in a designated container at the point of use. The container should
- conform to UN standard 3291 and British Standard 7320.
- sharps containers are not filled by more than two thirds and are stored in an area away from the public.
- sharps trays with integral sharps bins are in use.
- sharps are disposed of at the point of use.
- sharps boxes are signed on assembly and disposal.
- sharps are stored safely away from the public and out of reach of children.
- staff are aware of inoculation injury policy.
If you notice that any of the above procedures are not being followed properly by colleagues you should seek advice from your infection control team who will provide education for staff on safe use and disposal of sharps.
Innovative products are available that can reduce the risk of sharps injuries. While they may be more expensive, their cost can be offset against the savings achieved in reducing sharps injuries. Guidance on the most appropriate evaluated safety devices is available from the NHS Purchasing and Supply Agency.